* The author's new ball forceps are very successful with ball-bearing balls and marbles.

[FIG. 89.—Schema illustrating the use of the lip of the bronchoscope in disimpaction of foreign bodies. A and B show an annular edema above the foreign body, F. At C the edematous mucosa is being repressed by the lip of the tube mouth, permitting insinuation of the hook, H, past one side of the foreign body, which is then withdrawn to a convenient place for application of the forceps. This repression by the lip is often used for purposes other than the insertion of hooks. The lip of the esophagoscope can be used in the same way.]

Extraction of Soft Friable Foreign Bodies from the Tracheobronchial Tree.—The difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps space. There is usually in these cases an abundance of purulent secretion which further hinders the work. The great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view, must always be kept in mind. Extremely delicate forceps with rather broad blades are required for this work. The fenestrated "peanut" forceps are best for large pieces in the large bronchi. The operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal, yet not so firmly as to crush them. Nipping off an edge by not inserting the forceps far enough is also to be avoided. Small fragments under 2 mm. in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping. It is, however, never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled, for these may be aspirated into small bronchi, and cause multiple abscesses. A hook may be found useful in dealing with round, friable, foreign bodies; and in some cases the mechanical spoon or safety-pin closer may be used to advantage. The foreign body is then brought close to, but not crushed against the tube mouth.

[174] Removal of animal objects from the tracheobronchial tree is readily accomplished with the side-curved forceps. Leeches are not uncommon intruders in European countries. Small insects are usually coughed out. Worms and larvae may be found. Cocaine or salt solution will cause a leech to loosen its hold.

Foreign bodies in the upper-lobe bronchi are fortunately not common. If the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps (Fig. 90), guided by the collaboration of the fluoroscopist. These forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus. Full-curved coil-spring hooks will reach high, but must be used with the utmost caution, and the method of their disengagement must be practiced beforehand.

Penetrating Projectiles.—Foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus (see Bibliography, 43)

[FIG. 90.—Schematic illustration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. T, Trachea; UL, upper-lobe bronchus; LB, left bronchus; SB, stem bronchus. These forceps are made to extend around 180 degrees.]

RULES FOR ENDOSCOPIC FOREIGN BODY EXTRACTION

1. Never endoscope a foreign body case unprepared, with the idea of taking a preliminary look. 2. Approach carefully the suspected location of a foreign body, so as not to override any portion of it. [175] 3. Avoid grasping a foreign body hastily as soon as seen. 4. The shape, size and position of a foreign body, and its relations to surrounding structures, should be studied before attempting to apply the forceps. (Exception cited in Rule 10.) 5. Preliminary study of a foreign body should be from a distance. 6. As the first grasp of the forceps is the best, it should be well planned beforehand so as to seize the proper part of the intruder. 7. With all long foreign bodies the motto should be "Search, not for the foreign body, but for its nearer end." With pins, needles, and the like, with point upward, search always for the point. Try to see it first. 8. Remember that a long foreign body grasped near the middle becomes, mechanically speaking, a "toggle and ring." 9. Remember that the mortality to follow failure to remove a foreign body does not justify probably fatal violence during its removal. 10. Laryngeally lodged foreign bodies, because of the likelihood of dislodgment and loss, may be seized by any part first presented, and plan of withdrawal can be determined afterward. 11. For similar reasons, laryngeal cases should be dealt with only in the author's position (Fig. 53). 12. An esophagoscopy may be needed in a bronchoscopic case, or a bronchoscopy in an esophageal case. In every case both kinds of tubes should be sterile and ready before starting. It is the unexpected that happens in foreign body endoscopy. 13. Do not pull on a foreign body unless it is properly grasped to come away readily without trauma. Then do not pull hard. 14. Do no harm, if you cannot remove the foreign body. 15. Full-curved hooks are to be used in the bronchi with greatest caution, if used at all, lest they catch inextricably in branch bronchi. [176] 16. Don't force a foreign body downward. Coax it back. The deeper it gets the greater your difficulties. 17. The watchword of the bronchoscopist should be, "If I can do no good, I will at least do no harm."

Fluoroscopic bronchoscopy is so deceptively easy from a superficial, theoretical, point of view that it has been used unsuccessfully in cases easily handled in the regular endoscopic way with the eye at the proximal tube-mouth. In a collected series of cases by various operators the object was removed in 66.7 per cent with a mortality of 41.6 per cent. In the problem of a pin located out of the field of bronchoscopic vision, the fluoroscopist will yield invaluable aid. An extremely delicate forceps is to be inserted closed into the invaded bronchus, the grasp on the object being confirmed by the fluoroscopist. It is to be kept in mind that while the object itself may be in the grasp of the forceps, the fluoroscope will not show whether there may not be included in the forceps' grasp a bronchial spur or other tissue, the tearing of which may be fatal. Therefore traction must not be sufficient to lacerate tissue. If the foreign body does not come readily it must be released, and a new grasp may then be taken. All of the cautions in faulty seizure already mentioned, apply with particular force to fluoroscopic bronchoscopy. The fluoroscope is of aid in finding foreign bodies held in abscess cavities. The fluoroscope should show both the lateral and anteroposterior planes. To accomplish this quickly, two Coolidge tubes and two screens are necessary. Fluoroscopic bronchoscopy, because of its high mortality and low percentage of successes, should be tried only after regular, ocularly guided, peroral bronchoscopy has failed, and only by those who have had experience in ocularly guided bronchoscopy.



[177] CHAPTER XVI—FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS

The sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis, pulmonary abscess, and fibrous changes. The symptoms of tuberculosis may all be presented, but tubercle bacilli have never been found associated with any of the many cases that have come to the Bronchoscopic Clinic.* The history of repeated attacks of malaise, fever, chills, and sweats lasting for a few days and terminated by the expulsion of an amount of foul pus, suggests the intermittent drainage of an abscess cavity, and special study should be made to eliminate foreign body as the cause of the condition, in all such cases, whether there is any history of a foreign body accident or not. Bronchoscopy for diagnosis is to be done unless the etiology can be definitely proven by other means. In all cases of chronic chest disease foreign body should be eliminated as a matter of routine.

* One exception has recently come to the Clinic. 12

The time of aspiration of a foreign body may be unknown, having possibly occurred in infancy, during narcosis, or the object may even enter the lower air passages without the patient being aware of the accident, as happened with a particularly intelligent business man who unknowingly aspirated the tip of an atomizer while spraying his throat. In many other cases the accident had been forgotten. In still others, in spite of the patient's statement of a conviction that the trouble was due to a foreign body he had aspirated, the physician did not consider it worthy of sufficient consideration to warrant a roentgenray examination. It is curious to note the various opinions held in regard to the gravity of the presence of a bronchial foreign body. One patient was told by his physician that the presence of a staple in his bronchus was an impossibility, for he would not have lived five minutes after the accident. Others consider the presence of a foreign body in the bronchus as comparatively harmless, in spite of the repeated reports of invalidism and fatality in the medical literature of centuries. The older authorities state that all cases of prolonged bronchial foreign body sojourn died from phthisis pulmonalis, and it is still the opinion of some practitioners that the presence of a foreign body in the lung predisposes to the development of true tuberculosis. With the dissemination of knowledge regarding the possibility of bronchial foreign body, and the marvellous success in their removal by bronchoscopy, the cases of prolonged foreign body sojourn should decrease in number. It should be the recognized rule, and not the exception, that all chest conditions, acute or chronic, should have the benefit of roentgenographic study, even apart from the possibility of foreign body.

Often even with the clear history of foreign-body aspiration, both patient and physician are deluded by a relatively long period of quiescence in which no symptoms are apparent. This symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum, finally by bronchiectasis and pulmonary abscess, chronic sepsis, and invalidism.

Pathology.—If the foreign body completely obstructs a main bronchus, preventing both aeration and drainage, such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months, or even in a few weeks, in the case of irritating foreign bodies such as peanut kernels and soft rubber. Very minute, inorganic foreign bodies may become encysted as in anthracosis. Large objects, however, do not become encysted. The object is drawn down by gravity and aspirated into the smallest bronchus it can enter. Later the negative pressure below from absorption of air impacts it still further. Swelling of the bronchial mucosa from irritation plus infection completes the occlusion of the bronchus. Retention of secretions and bacterial decomposition thereof produces first a "drowned lung" (natural passages full of pus); then sloughing or ulceration in the tissues plus the pressure of the pus, causes bronchiectasis; further destruction of the cartilaginous rings results in true abscess formation below the foreign body. The productive inflammation at the site of lodgement of the foreign body results in cicatricial contraction and the formation of a stricture at the top of the cavity, in which the foreign body is usually held. The abscess may extend to the periphery and rupture into the pleural cavity. It may drain intermittently into a bronchus. Certain irritating foreign bodies, such as soft rubber, may produce gangrenous bronchitis and multiple abscesses. For observations on pathology (see Bibliography, 38).

Prognosis.—If the foreign body be not removed, the resulting chronic sepsis or pulmonary hemorrhage will prove fatal. Removal of the foreign body usually results in complete recovery without further local treatment. Occasionally, secondary dilatation of a bronchial stricture may be required. All cases will need, besides removal of the foreign body, an antituberculous regimen, and offer a good prognosis if this be followed.

Treatment.—Bronchoscopy should be done in all cases of chronic pulmonary abscess and bronchiectasis even though radiographic study reveals no shadow of foreign body. The patient by assuming a posture with the head lowered is urged to expel spontaneously all the pus possible, before the bronchoscopy. The aspirating bronchoscope (Fig. 2, E) is often useful in cases where large amounts of secretion may be anticipated. Granulations may require removal with forceps and sponging. Disturbed granulations result in bleeding which further hampers the operation; therefore, they should not be touched until ready to apply the forceps, unless it is impossible to study the presentation without disturbing them. For this reason secretions hiding a foreign body should be removed with the aspirating tube (Fig. 9) rather than by swabbing or sponge-pumping, when the bronchoscopic tube-mouth is close to the foreign body. It is inadvisable, however, to insert a forceps into a mass of granulations to grope blindly for a foreign body, with no knowledge of the presentation, the forceps spaces, or the location of branch-bronchial orifices into which one blade of the forceps may go. Dilatation of a stricture may be necessary, and may be accomplished by the forms of bronchial dilators shown in Fig. 25. The hollow type of dilator is to be used in cases in which the foreign body is held in the stricture (Fig. 83). This dilator may be pushed down over the stem of such an object as a tack, and the stricture dilated without the risk of pushing the object downward. It is only rarely, however, that the point of a tack is free. Dense cicatricial tissue may require incision or excision. Internal bronchotomy is doubtless, a very dangerous procedure, though no fatalities have occurred in any of the three cases in the Bronchoscopic Clinic. It is advisable only as a last resort.



[181] CHAPTER XVII—UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES

The limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. When localization by means of transparent films, fluoroscopy, and endobronchial bismuth insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane. With foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. At the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. The nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. The blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility.

The possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote; and the lesions established may result fatally even after the expulsion of the object. Pulmonary abscess formation and rupture into the pleura should not be awaited, for the foreign body does not often follow the pus into the pleural cavity. It remains in the lung, held in a bed of granulation tissue. Furthermore, to await the development is to subject the patient to a prolonged and perhaps fatal sepsis, or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process. The recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy, so that this operation is to be considered when bronchoscopy has failed. Bronchoscopy can be considered as having failed, for the time being, when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it; but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today. Before considering thoracotomy months of study of the mechanical problem are advisable. It is probable that any foreign body of appreciable size that has gone down the natural passages can be brought back the same way.

In the event of a foreign body reaching the pleura, either with or without pus, it should be removed immediately by pleuroscopy or by thoracotomy, without waiting for adhesive pleuritis.

The problem may be summarized thus: 1. Large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy. 2. The development of bronchoscopy having subsequently solved the problems presented by previous failures, it seems probable that by patient developmental endeavor, any foreign body of appreciable size that has gone down through the natural passages, can be bronchoscopically removed the same way, provided fatal trauma is avoided.

At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies have been removed.



CHAPTER XVIII—FOREIGN BODIES IN THE ESOPHAGUS

Etiology.—The lodgement of foreign bodies in the esophagus is influenced by: 1. The shape of the foreign body (disc-shaped, pointed, irregular). 2. Resiliency of the object (safety pins). 3. The size of the foreign body. 4. Narrowing of the esophagus, spasmodic or organic, normal, or pathologic. 5. Paralysis of the normal esophageal propulsory mechanism.

The lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature; a large bolus of food, poorly masticated and hurriedly swallowed, may, however, become impacted in a perfectly normal esophagus.

Carelessness is the cause of over 80 per cent of the foreign bodies in the esophagus (see Bibliography, 29).

Site of Lodgement.—Almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax. A physiologic narrowing is present at this level, produced in part by muscular contraction, and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture. If dislodged from this position the foreign body usually passes downward to be arrested at the next narrowing or to pass into the stomach. The esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold. Such, however, is almost never the case. The cricopharyngeus muscle functionates in starting the foreign body downward as if it were food; but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor.

Symptoms.—Dysphagia is the most frequent complaint in cases of esophageally lodged foreign bodies. A very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. Intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-passages by food arrested by the foreign body. Dyspnea may be present if the foreign body is large enough to compress the trachea. Cough may be excited by reflex irritation, overflow of secretions into the larynx, or by perforation of the posterior tracheal wall, traumatic or ulcerative, allowing leakage of food or secretion into the trachea. (See Chapter XII for discussion of symptomatology and diagnosis.)

Prognosis.—A foreign body lodged in the esophagus may prove quickly fatal from hemorrhage due to perforation of a large vessel; from asphyxia by pressure on the trachea; or from perforation and septic mediastinitis. Slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia. Sooner or later, if not removed, the foreign body causes death. It may be tolerated for a long period of time, causing abscess, cervical cellulitis, fistulous tracts, and ultimately extreme stenosis from cicatricial contraction. Perichondritis of the laryngeal or tracheal cartilages may follow, and result in laryngeal stenosis requiring tracheotomy. The damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal. If the foreign body becomes dislodged and moves downward, the danger of intestinal perforation is encountered. The prognosis, therefore, must be guarded so long as the intruder remains in the body.

Treatment.—It is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie. Sounding the esophagus with bougies to determine the level of the obstruction, or to palpate the nature of the foreign body, is unnecessary and dangerous. Esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus, except for urgent reasons. The level of the stenosis, and usually the nature of the foreign body, can thus be decided. Blind instrumentation is dangerous, and in view of the safety and success of esophagoscopy, reprehensible.

If for any reason removal should be delayed, bismuth sub-nitrate, gramme 0.6, should be given dry on the tongue every four hours. It will adhere to the denuded surfaces. The addition of calomel, gramme 0.003, for a few doses will increase the antiseptic action. Should swallowing be painful, gramme 0.2 of orthoform or anesthesin will be helpful. Emetics are inefficient and dangerous. Holding the patient up by the heels is rarely, if ever, successful if the foreign body is in the esophagus. In the reported cases the intruder was probably in the pharynx.

External esophagotomy for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists. It has been the observation in the Bronchoscopic Clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way, unless it has already perforated the esophageal wall, in which event it is no longer a case of foreign body in the esophagus. The mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent, while that of esophagoscopy is less than two per cent, if the foreign body has not already set up a serious complication before the esophagoscopy. Furthermore, external esophagotomy can be successful only with objects lodged in the cervical esophagus and, moreover, it has happened that after the esophagus has been opened, the foreign body could not be found because of dislodgement and passage downward during the relaxation of the general anesthesia. Should this occur during esophagoscopy, the foreign body can be followed with the esophagoscope, and even if it is not overtaken and removed, no risk has been incurred.

Esophagoscopy is the one method of removal worthy of serious consideration. Should it repeatedly fail in the hands of two skillful endoscopists, which will be very rarely, if ever, then external operation is to be considered in cervically lodged foreign bodies.



[187] CHAPTER XIX—ESOPHAGOSCOPY FOR FOREIGN BODY

Indications.—Esophagoscopy is demanded in every case in which a foreign body is known to be, or suspected of being, in the esophagus.

Contraindications.—There is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies, even in the presence of aneurism, serious cardiovascular disease, hypertension or the like, although these conditions would render the procedure inadvisable. Should the patient be in bad condition from previous ill-advised or blind attempts at extraction, endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved. It is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the passage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient. Moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false passage into the mediastinum or overriding the foreign body is great. Water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. The esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder: Rx. Anesthesin...gramme 0.12 Bismuth subnitrate...gramme 0.6 Calomel, gramme 0.006 to 0.003 may be added to each powder for a few doses to increase the antiseptic effect. If the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done. This will give time for nature to repair the damage and render the removal of the object more certain and less hazardous. Perforation of the esophagus by the foreign body, or by blind instrumentation, is a contraindication to esophagoscopy. It is manifested by such signs as subcutaneous emphysema, swelling of the neck, fever, irritability, increase in pulsatory and respiratory rates, and pain in the neck or chest. Gaseous emphysema is present in some cases, and denotes a dangerous infection. Esophagoscopy should be postponed and the treatment mentioned at the end of this chapter instituted. After the subsidence of all symptoms other than esophageal, esophagoscopy may be done safely. Pleural perforation is manifested by the usual signs of pneumothorax, and will be demonstrated in the roentgenogram.

ESOPHAGOSCOPIC EXTRACTION OF FOREIGN BODIES

It is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look. Everything likely to be needed for extraction of the intruder should be sterile and ready at hand. Furthermore, all required instruments for laryngoscopy, bronchoscopy or tracheotomy should be prepared as a matter of routine, however rarely they may be needed.

Sponging should be done cautiously lest the foreign body be hidden in secretions or food accumulation, and dislodged. Small food masses often lodge above the foreign body and are best removed with forceps. The folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. If the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great.

"Overriding" or failure to find a foreign body known to be present is explained by the collapsed walls and folds covering the object, since the esophagoscope cannot be of sufficient size to smooth out these folds, and still be of small enough diameter to pass the constricted points of the esophagus noted in the chapter on anatomy. Objects are often hidden just distal to the cricopharyngeal fold, which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object, so that the contact at the side of the tube is not felt as the tube passes over the foreign body (Fig. 91). The chief factors in overriding an esophageal foreign body are: 1. The chute-like effect of the plica cricopharyngeus. 2. The chute-like effect of other folds. 3. The lurking of the foreign body in the unexplored pyriform sinus. 4. The use of an esophagoscope of small diameter. 5. The obscuration of the intruder by secretion or food debris. 6. The obscuration of the intruder by its penetration of the esophageal wall. 7. The obscuration of the intruder by inflammatory sequelae.

[FIG. 91.—Illustrating the hiding of a coin by the folding downward of the plica cricopharyngeus. The muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has passed over the foreign body. Other folds may in rare instances act similarly in hiding a foreign body from view. This overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall.]

The esophageal speculum for the removal of foreign bodies is useful when the object is not more than 2 cm. below the cricoid in a child, and 3 cm. in the adult. The fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found. The author's down-jaw forceps (Fig. 22) are very useful to reach down back of the cricopharyngeal fold, because of the often small posterior forceps space. The speculum has the disadvantage of not allowing deeper search should the foreign body move downward. In infants, the child's size laryngoscope may be used as an esophageal speculum. General anesthesia is not only unnecessary but dangerous, because of the dyspnea created by the endoscopic tube. Local anesthesia is unnecessary as well as dangerous in children; and its application is likely to dislodge the foreign body unless used as a troche. Forbes esophageal speculum is excellent.

MECHANICAL PROBLEMS OF ESOPHAGOSCOPIC REMOVAL OF FOREIGN BODIES

The bronchoscopic problems considered in the previous chapter should be studied.

The extraction of transfixed foreign bodies presents much the same problem as those in the bronchi, though there is no limit here to the distance an object may be pushed down to free the point. Thin, sharp foreign bodies such as bones, dentures, pins, safety-pins, etcetera, are often found to lie crosswise in the esophagus, and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made (Fig. 92). Should the intruder be grasped in the center and traction exerted, serious and perhaps fatal trauma might ensue.

[191] [FIG. 92.—The problem of the horizontally transfixed foreign body in the esophagus. The point, D, had caught as the bone, A, was being swallowed. The end, E, was forced down to C, by food or by blind attempts at pushing the bone downward. The wall, F, should be laterally displaced to J, with the esophagoscope, permitting the forceps to grasp the end, M, of the bone. Traction in the direction of the dart will disimpact the bone and permit it to rotate. The rotation forceps are used as at K.]

[FIG. 93.—Solution of the mechanical problem of the broad foreign body having a sharp point by version. If withdrawn with plain forceps as applied at A, the point B, will rip open the esophageal wall. If grasped at C, the point, D, will rotate in the direction of F and will trail harmlessly. To permit this version the rotation forceps are used as at H. On this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal.]

The extraction of broad, flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in Fig. 93.

Extraction of Open Safety-pins from the Esophagus.—An open safety pin with the point down offers no particular mechanical difficulty in removal. Great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. The coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. An open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. A roentgenogram should always be made in the plane showing the widest spread of the pin. It is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. It may be best to close the safety pin with the safety-pin closer, as illustrated in Fig. 37. For this purpose Arrowsmith's closer is excellent. In other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the Tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. The rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. The sense of touch will aid the sense of sight in the execution of this maneuver (Fig. 87). When the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. In certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. This, however, is a dangerous method and applicable in but few cases. It is better to disengage the point by downward and inward rotation with the Tucker forceps.

Version of a Safety Pin.—A safety pin of very small size may be turned over in a direction that will cause the point to trail. An advancing point will puncture. This is a dangerous procedure with a large safety pin.

Endogastric Version.—A very useful and comparatively safe method is illustrated in Figs. 94 and 95. In the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus passed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost. It can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. Only very small safety-pins can be withdrawn through the esophagoscope.

Spatula-protected Method.—Safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. The keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. Instruments and foreign body are then removed together. Often the pin point will catch in the light-chamber where it is very safely lodged. If the pin be then pulled upon it will straighten out and may be withdrawn through the tube.

[FIG. 94.—Endogastric version. One of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach, where they are turned and removed. The first illustration (A) shows the rotation forceps before seizing pin by the ring of the spring end. (Forceps jaws are shown opening in the wrong diameter.) At B is shown the pin seized in the ring by the points of the forceps. At C is shown the pin carried into the stomach and about to be rotated by withdrawal. D, the withdrawal of the pin into the esophagoscope which will thereby close it. If withdrawn by flat-jawed forceps as at F, the esophageal wall would be fatally lacerated.]

Double pointed tacks and staples, when lodged point upward, must be turned so that the points trail on removal. This may be done by carrying them into the stomach and turning them, as described under safety-pins.

The extraction of foreign bodies of very large size from the esophagus is greatly facilitated by the use of general anesthesia, which relaxes the spasmodic contractions of the esophagus often occurring when attempt is made to withdraw the foreign body. General anesthesia, though entirely unnecessary for introduction of the esophagoscope, in any case may be used if the body is large, sharp, and rough, in order to prevent laceration through the muscular contractions otherwise incident to withdrawal.* In exceptional cases it may be necessary to comminute a large foreign body such as a tooth plate. A large smooth foreign body may be difficult to seize with forceps. In this case the mechanical spoon or the author's safety-pin closer may be used.

* It must always be remembered that large foreign bodies are very prone to cause dyspnea that renders general anesthesia exceedingly dangerous especially in children.

[FIG. 95.—Lateral roentgenogram of a safety-pin in a child aged 11 months, demonstrating the esophageal location of the pin in this case and the great value of the lateral roentgenogram in the localization of foreign bodies. The pin was removed by the author's method of endogastric version. (Plate made by George C. Johnston )]

The extraction of meat and other foods from the esophagus at the level of the upper thoracic aperture is usually readily accomplished with the esophageal speculum and forceps. In certain cases the mechanical spoon will be found useful. Should the bolus of food be lodged at the lower level the esophagoscope will be required.

Extraction of Foreign Bodies from the Strictured Esophagus.—Foreign bodies of relatively small size will lodge in a strictured esophagus. Removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body passing the first one lodges at the second. Still more difficult is the case when the second stricture is considerably below the first, and not concentric. Under these circumstances it is best to divulse the upper stricture mechanically, when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body.

Prolonged sojourn of foreign bodies in the esophagus, while not so common as in the bronchi is by no means of rare occurrence. Following their removal, stricture of greater or less extent is almost certain to follow from contraction of the fibrous-tissue produced by the foreign body.

Fluoroscopic esophagoscopy is a questionable procedure, for the esophagus can be explored throughout by sight. In cases in which it is suspected that a foreign body, such as pin, has partially escaped from the esophagus, the fluoroscope may aid in a detailed search to determine its location, but under no circumstances should it be the guide for the application of forceps, because the transparent but vital tissues are almost certain to be included in the grasp.

[197] Complications and Dangers of Esophagoscopy for Foreign Bodies. Asphyxia from the pressure of the foreign body, or the foreign body plus the esophagoscope, is a possibility (Fig. 91). Faulty position of the patient, especially a low position of the head, with faulty direction of the esophagoscope may cause the tube mouth to press the membranous tracheo-esophageal wall into the trachea, so as temporarily to occlude the tracheal lumen, creating a very dangerous situation in a patient under general anesthesia. Prompt introduction of a bronchoscope, with oxygen and amyl nitrite insufflation and artificial respiration, may be necessary to save life. The danger is greater, of course, with chloroform than with ether anesthesia. Cocain poisoning may occur in those having an idiosyncrasy to the drug. Cocain should never be used with children, and is of little use in esophagoscopy in adults. Its application is more annoying and requires more time than the esophagoscopic removal of the foreign bodies without local anesthesia. Traumatic esophagitis, septic mediastinitis, cervical cellulitis, and, most dangerous, gangrenous esophagitis may be present, caused by the foreign body itself or ill-advised efforts at removal. Perforation of the esophagus with the esophagoscope is rare, in skillful hands, if the esophageal wall is sound. The esophageal wall, however, may be weakened by ulceration, malignant disease, or trauma, so that the possibility of making a false passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening. To avoid entering a false passage previously created, is often exceedingly difficult, and usually it is better to wait for obliterative adhesive inflammation to seal the tissue layers together.

Treatment.—Acute esophagitis calls for rest in bed, sterile liquid food, and the administration of bismuth powder mentioned in the paragraph on contraindications. An ice bag applied to the neck may afford some relief. The mouth should be hourly cleansed with the following solution: Dakin's solution 1 part Cinnamon water 5 parts. Emphysema unaccompanied by pyogenic processes usually requires no treatment, though an occasional case may require punctures of the skin to liberate the air. Gaseous emphysema and pus formation urgently demand early external drainage, preferably behind the sternomastoid. Should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable. Prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected. Foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae. In the serious degrees of esophageal trauma, particularly if the pleura be perforated, gastrostomy is indicated to afford rest of the esophagus, and for alimentation. A duodenal feeding tube may be placed through an esophagoscope passed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly passed stomach tube would be very likely to enter, with probably dangerous results.



[199] CHAPTER XX—PLEUROSCOPY

Foreign bodies in the pleural cavity should be immediately removed. The esophageal speculum inserted through a small intercostal incision makes an excellent pleuroscope, its spatular tip being of particular value in moving the lung out of the way. This otherwise dark cavity is thus brilliantly illuminated without the necessity of making a large flap resection, an important factor in those cases in which there is no infection present. The pleura and wound may be immediately closed without drainage, if the pleura is not infected. Excessive plus pressure or pus may require reopening. In one case in which the author removed a foreign body by pleuroscopy, healing was by first intention and the lung filled in a few days. Drainage tubes that have slipped up into the empyemic cavity are foreign bodies. They are readily removed with the retrograde esophagoscope even through the smallest fistula. The aspirating canal keeps a clear field while searching for the drain.

Pleuroscopy for Disease.—Most pleural diseases require a large external opening for drainage, and even here the pleuroscope may be of some use in exploring the cavities. Usually there are many adhesions and careful ray study may reveal one or more the breaking up of which will improve drainage to such an extent as to cure an empyema of long standing. Repeated severing of adhesions, aspiration and sometimes incision of the thickened visceral pleura may be necessary. The author is so strongly imbued with the idea that local examination under full illumination has so revolutionized the surgery of every region of the body to which it has been applied, that every accessible region should be thus studied. The pleural cavity is quite accessible with or without rib-resection, and there is practically no risk in careful pleuroscopy.



[201] CHAPTER XXI—BENIGN GROWTHS IN THE LARYNX

Benign growths in the larynx are easily and accurately removable by direct laryngoscopy; but perhaps no method has been more often misused and followed by most unfortunate results. It should always be remembered that benign growths are benign, and that hence they do not justify the radical work demanded in dealing with malignancy. The larynx should be worked upon with the same delicacy and respect for the normal tissues that are customary in dealing with the eye.

Granulomata in the larynx, while not true neoplasms, require extirpation in some instances.

Vocal nodules, when other methods of cure such as vocal rest, various vocal exercises, etcetera have failed may require surgical excision. This may be done with the laryngeal tissue forceps or with the author's vocal nodule forceps. Sessile vocal nodules may be cured by touching them with a fine galvanocautery point, but all work on the vocal cords must be done with extreme caution and nicety. It is exceedingly easy to ruin a fine voice.

Fibromata, often of inflammatory genesis, are best removed with the laryngeal grasping forceps, though the small laryngeal punch or tissue forceps may be used. If very large, they may be amputated with the snare, the base being treated with galvanocautery though this is seldom advisable. Strong traction should be avoided as likely to do irreparable injury to the laryngeal motility.

Cystomata may get well after simple excision or galvanopuncture of a part of the wall of the sac, but complete extirpation of the sac is often required for cure. The same is true of adenomata.

[202] Angiomata, if extensive and deeply seated, may require deep excision, but usually cure results from superficial removal. Usually no cauterization of the vessels at the base is necessary, either to arrest hemorrhage or to lessen the tendency to recurrence. A diffuse telangiectasis, should it require treatment, may be gently touched with a needle-pointed galvanocaustic electrode at a number of sittings. The galvanonocautery is a dangerous method to use in the larynx. Radium offers the best results in this latter form of angioma, applied either internally or to the neck.

Lymphoma, enchondroma and osteoma, if not too extensively involving the laryngeal walls, may be excised with basket punch forceps, but lymphoma is probably better treated by radium.* True myxomata and lipomata are very rare. Amyloid tumors are occasionally met with, and are very resistant to treatment. Aberrant thyroid tumors do not require very radical excision of normal base, but should be removed as completely as possible.

In a general way, it may be stated that with benign growths in the larynx the best functional results are obtained by superficial rather than radical, deep extirpation, remembering that it is easier to remove tissue than to replace it, and that cicatrices impair or ruin the voice and may cause stenosis.

* In a case reported by Delavan a complete cure with perfect restoration of voice resulted from radium after I had failed to cure by operative methods. (Proceedings American Laryngological Association, 1921.)



[203] CHAPTER XXII—BENIGN GROWTHS IN THE LARYNX (Continued)

PAPILLOMATA OF THE LARYNX IN CHILDREN

Of all benign growths in the larynx papilloma is the most frequent. It may occur at any age of childhood and may even be congenital. The outstanding fact which necessarily influences our treatment is the tendency to recurrences, followed eventually in practically all cases by a tendency to disappearance. In the author's opinion multiple papillomata constitute a benign, self-limited disease. There are two classes of cases. 1. Those in which the growth gets well spontaneously, or with slight treatment, surgically or otherwise; and, 2, those not readily amenable to any form of treatment, recurrences appearing persistently at the old sites, and in entirely new locations. In the author's opinion these two classes of case represent not two different kinds of growths, but stages in the disease. Those that get well after a single removal are near the end of the disease. Papillomata are of inflammatory origin and are not true neoplasms in the strictest sense.

Methods of Treatment.—Irritating applications probably provoke recurrences, because the growths are of inflammatory origin. Formerly laryngostomy was recommended as a last resort when all other means had failed. The excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for papillomata is mentioned only to be condemned. Fulguration has been satisfactory in the hands of some, disappointing to others. It is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. Radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. In my experience, however, I have never seen a cure of papillomata which could be attributed to the radiation. I have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. In other most unfortunate cases I have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. Possibly the disastrous results were due to overdosage; but I feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. Multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. In cancer we have an infiltrating process that has no limits short of life itself.

Endolaryngeal extirpation of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility. If, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway. Obstructed respiration introduces into general anesthesia an enormous element of danger. Concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the Bronchoscopic Clinic, that repeated superficial removals with blunt non-cutting forceps (see Chapter I) will so modify the soil as to make it unfavorable for repullulation. The removals are superficial and do not include the subjacent normal tissue. Radical removal of a papilloma situated, for instance, on the left ventricular band or cord, can in no way prevent the subsequent occurrence of a similar growth at a different site, as upon the epiglottis, or even in the fauces. Furthermore, radical removal of the basal tissues is certain to impair the phonatory function. Excellent results as to voice and freedom from recurrence have always followed repeated superficial removal. The time required has been months or a year or two. Only rarely has a cure followed a single extirpation.

If the child is but slightly dyspneic, the obstructing part of the growth is first removed without anesthesia, general or local; the remaining fungations are extirpated subsequently at a number of brief seances. The child is thus not terrified, soon loses dread of the removals, and appreciates the relief. Should the child be very dyspneic when first seen, a low tracheotomy is immediately done, and after an interim of ten days, laryngoscopic removal of the growth is begun. Tracheotomy probably has a beneficial effect on the disease. Tracheal growths require the insertion of the bronchoscope for their removal.

Papillomata in the larynx of adults are, on the whole, much more amenable to treatment than similar growths in children. Tracheotomy is very rarely required, and the tendency to recurrence is less marked. Many are cured by a single extirpation. The best results are obtained by removal of the growths with the laryngeal grasping-forceps, taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue. Radical resection or cauterization of the base is unwise because of the probable impairment of the voice, or cicatricial stenosis, without in anyway insuring against repullulation. The papillomata are so soft that they give no sensation of traction to the forceps. They can readily be "scalped" off without any impairment of the sound tissues, by the use of the author's papilloma forceps (Fig. 29). Cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning. A gentle hand might be trusted with the cup forceps (Fig. 32, large size.)

Sir Felix Semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths. Therefore, no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths. Indeed there is much clinical evidence elsewhere in the body, and more than a little such evidence as to the larynx, to warrant the removal of benign growths, repeated if necessary, as a prophylactic of cancer (Bibliography, 19).



[207] CHAPTER XXIII—BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE

Extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. True primary growths of the tracheobronchial tree, though not frequent, are by no means rare. These primary growths include primary papillomata and fibromata as the most frequent, aberrant thyroid, lipomata, adenomata, granulomata and amyloid tumors. Chondromata and osteochondromata may be benign but are prone to develop malignancy, and by sarcomatous or other changes, even metaplasia. Edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered.

Symptoms of Benign Tumors of the Tracheobronchial Tree.—Cough, wheezing respiration, and dyspnea, varying in degree with the size of the tumor, indicate obstruction of the airway. Associated with defective aeration will be the signs of deficient drainage of secretions. Roentgenray examination may show the shadow of enchondromata or osteomata, and will also show variations in aeration should the tumor be in a bronchus.

Bronchoscopic removal of benign growths is readily accomplished with the endoscopic punch forceps shown in Figs. 28 and 33. Quick action may be necessary should a large tumor producing great dyspnea be encountered, for the dyspnea is apt to be increased by the congestion, cough, and increased respiration and spasm incidental to the presence of the bronchoscope in the trachea. General anesthesia, as in all cases showing dyspnea, is contraindicated. The risks of hemorrhage following removal are very slight, provided fungations on an aneurismal erosion be not mistaken for a tumor.

Multiple papillomata when very numerous are best removed by the author's "coring" method. This consists in the insertion of an aspirating bronchoscope with the mechanical aspirator working at full negative pressure. The papillomata are removed like coring an apple; though the rounded edge of the bronchoscope does not even scratch the tracheal mucosa. Many of the papillomata are taken off by the holes in the bronchoscope. Aspiration of the detached papillomata into the lungs is prevented by the corking of the tube-mouth with the mass of papillomata held by the negative pressure at the canal inlet orifice.



CHAPTER XXIV—BENIGN NEOPLASMS OF THE ESOPHAGUS

As a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen, but true benign tumors of the esophagus are rare affections. Keloidal changes in scar tissue may occur. Cases of retention, epithelial and dermoid cysts have been observed; and there are isolated reports of the finding of papillomata, fibromata, lipomata, myomata and adenomata. The removal of these is readily accomplished with the tissue forceps (Fig. 28), if the growths are small and projecting into the esophageal lumen. The determination of the advisability of the removal of keloidal scars would require careful consideration of the particular case, and the same may be said of very large growths of any kind. The extreme thinness of the esophageal walls must be always in the mind of the esophagoscopist if he would avoid disaster.



[210] CHAPTER XXV—ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX

The general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. The facility, accuracy and thoroughness afforded by skilled, direct, laryngeal operation offers a means of lessening the incidence of cancer. To a much greater extent the facility, accuracy, and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis. Well-planned, careful, external operation (laryngofissure) followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx; and it is a cure only in those intrinsic cases in which the growth is small, and is located in the anterior two-thirds of the intrinsic area. By limiting operations strictly to this class of case, eighty-five per cent of cures may be obtained.* In determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached. It is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method, for the reason that the full extent of the growth cannot be appreciated when viewed only from above, and the necessary radical removal cannot be accurately or completely accomplished.

* The author's results in laryngofissure have recently fallen to 79 per cent of relative cures by thyrochondrotomy.

Malignant disease of the epiglottis, in those rare cases where the lesion is strictly limited to the tip is, however, an exception. If amputation of the epiglottis will give a sufficiently wide removal, this may be done en masse with a heavy snare, and has resulted in complete cure. Very small growths may be removed sufficiently widely with the punch forceps (Fig. 33); but piece meal removal of malignancy is to be avoided.

Differential Diagnosis of Laryngeal Growths in the Larynx of Adults.—Determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities, namely, 1. Lues. 2. Tuberculosis, including lupus. 3. Scleroma. 4. Malignant neoplasm.

In the Bronchoscopic Clinic the following is the routine procedure: 1. A Wassermann test is made. If negative, and there remains a suspicion of lues, a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks; during which time no potassium iodid is given, lest its reaction upon the larynx cause an edema necessitating tracheotomy. If no improvement is noticed lues is excluded. If the Wassermann is positive, malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury, because, for instance, a leutic or tuberculous patient may have cancer; a tuberculous patient may have lues; or a leutic patient, tuberculosis. 2. Pulmonary tuberculosis is excluded by the usual means. If present the laryngeal lesion may or may not be tuberculous; if the laryngoscopic appearances are doubtful a specimen is taken. Lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty. 3. In all cases in which the diagnosis is not clear a specimen is taken. This is readily accomplished by direct laryngoscopy under local anesthesia, using the regular laryngoscope or the anterior commissure laryngoscope. The best forceps in case of large growths are the alligator punch forceps (Fig. 33). Smaller growths require tissue forceps (Fig. 28). In case of small growths, it is best to remove the entire growth; but without any attempt at radical extirpation of the base; because, if the growth prove benign it is unnecessary; if malignant, it is insufficient.

Inspection of the Party Wall in Cases of Suspected Laryngeal Malignancy.—When taking a specimen the party wall should be inspected by passing a laryngoscope or, if necessary, an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus. If this region shows infiltration, all hope of cure by operation, however radical, should be abandoned.

Radium and the therapeutic roentgenray have given good results, but not such as would warrant their exclusive use in any case of malignancy in the larynx operable by laryngofissure. With inoperable cases, excellent palliative results are obtained. In some cases an almost complete disappearance of the growth has occurred, but ultimately there has been recurrence. The method of application of the radium, dosage, and its screening, are best determined by the radiologist in consultation with the laryngologist. Radium may be applied externally to the neck, or suspended in the larynx; radium-containing needles may be buried in the growth, or the emanations, imprisoned in glass pearls or capillary tubes, may be inserted deeply into the growth by means of a small trocar and cannula. For all of these procedures direct laryngoscopy affords a ready means of accurate application. Tracheotomy is necessary however, because of the reactionary swelling, which may be so great as to close completely the narrowed glottic chink. Where this is the case, the endolaryngeal application of the radium may be made by inserting the container through the tracheotomic wound, and anchoring it to the cannula.

The author is much impressed with Freer's method of radiation from the pyriform sinus in such cases as those in which external radiation alone is deemed insufficient.

The work of Drs. D. Bryson Delavan and Douglass M. Quick forms one of the most important contributions to the subject of the treatment of radium by cancer. (See Proceedings of the American Laryngological Association, 1922; also Proceedings of the Tenth International Otological Congress, Paris, 1922.)



[214] CHAPTER XXVI—BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA

The trachea is often secondarily invaded by malignancy of the esophagus, thyroid gland, peritracheal or peribronchial glands. Primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy. Peritracheal or peribronchial malignancy may produce a compressive stenosis covered with normal mucosa. Endoscopically, the wall is seen to bulge in from one side causing a crescentic picture, or compression of opposite walls may cause a "scabbard" or pear shaped lumen. Endotracheal and endobronchial malignancy ulcerate early, and are characterized by the bronchoscopic view of a bleeding mass of fungating tissue bathed in pus and secretion, usually foul. The diagnosis in these cases rests upon the exclusion of lues, and is rendered certain by the removal of a specimen for biopsy. Sarcoma and carcinoma of the thyroid when perforating the trachea may become pedunculated. In such cases aberrant non-pathologic thyroid must be excluded by biopsy. Endothelioma of the trachea or bronchus may also assume a pedunculated form, but is more often sessile.

Treatment.—Pedunculated malignant growths are readily removed with snare or punch forceps. Cure has resulted in one case of the author following bronchoscopic removal of an endothelioma from the bronchus; and a limited carcinoma of the bronchus has been reported cured by bronchoscopic removal, with cauterization of the base. Most of the cases, however, will be subjects for palliative tracheotomy and radium therapy. It will be found necessary in many of the cases to employ the author's long, cane-shaped tracheal cannula (Fig. 104, A), in order to pipe the air down to one or both bronchi past the projecting neoplasm.

It has recently been demonstrated that following the intravenous injection of a suspension of the insoluble salt, radium sulphate, that the suspended particles are held in the capillaries of the lung for a period of one year. Intravenous injections of a watery suspension, and endobronchial injections of a suspension of radium sulphate in oil, have had definite beneficial action. While as yet, no relatively permanent cures of pulmonary malignancy have been obtained, the amelioration and steady improvement noted in the technic of radium therapy are so encouraging that every inoperable case should be thus treated, if the disease is not in a hopelessly advanced stage.

In a case under the care of Dr. Robert M. Lukens at the Bronchoscopic Clinic, a primary epithelioma of the trachea was retarded for 2 years by the use of radium applied by Dr. William S. Newcomet, radium-therapist, and Miss Katherine E. Schaeffer, technician.



[216] CHAPTER XXVII—MALIGNANT DISEASE OF THE ESOPHAGUS

Cancer of the esophagus is a more prevalent disease than is commonly thought. In the male it usually develops during the fourth and fifth decades of life. There is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors. In the female the condition often occurs at an earlier age than in the male, and tends to run a more protracted course, preceeded in some cases by years of precancerous dysphagia.

Squamous-celled epithelioma is the most frequent type of neoplasm. In the lower third of the esophagus, cylindric cell carcinoma may be found associated with a like lesion in the stomach. Sarcoma of the esophagus is relatively rare (Bibliography 1, p. 449).

The sites of the lesion are those of physiologic narrowing of the esophagus. The middle third is most frequently involved; and the lower third, near the cardia, comes next in frequency. Cancer of the lower third of the esophagus preponderates in men, while cancer of the upper orifice is, curiously, more prevalent in women. The lesion is usually single, but multiple lesions, resulting from implantation metastases have been observed (Bibliography 1, p. 391). Bronchoesophageal fistula from extension is not uncommon.

Symptoms.—Malignant disease of the esophagus is rarely seen early, because of the absence, or mildness, of the symptoms. Dysphagia, the one common symptom of all esophageal disease, is often ignored by the patient until it becomes so marked as to prevent the taking of solid food; therefore, the onset may have the similitude of abruptness. Any well masticated solid food can be swallowed through a lumen 5 millimeters in diameter. The inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia. When the stenosis becomes so severe that the fluid intake is limited, rapid decline occurs from water starvation. Pain is usually a late symptom of the disease. It may be of an aching character and referred to the vertebral region or to the neck; or it may only accompany the act of swallowing. Blood-streaked, regurgitated material, and the presence of odor, are late manifestations of ulceration and secondary infection. In some cases, constant oozing of blood from the ulcerated area adds greatly to the cachexia. If the recurrent laryngeal nerves are involved, unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough, dyspnea, aphonia, and possibly septic pneumonia.

Diagnosis.—It has been estimated that 70 per cent of stenoses of the esophagus in adults are malignant in nature. This should stimulate the early and careful investigation of every case of dysphagia. When all cases of persistent dysphagia, however slight, are endoscopically studied, precancerous lesions may be discovered and treated, and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal. Luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests, supplemented in rare instances by biopsy. Aneurysm of the aorta must in all cases of dysphagia be excluded, for the dilated aorta may be the sole cause of the condition, and its presence contraindicates esophagoscopy because of the liability of rupture. Foreign body is to be excluded by history and roentgenographic study. Spasmodic stenosis of the esophagus may or may not have a malignant origin. Esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain. It is to be especially remembered, however, that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth. Fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue.

The esophagoscopic appearances of malignant disease, varying with the stage and site of origin of the growth, may present as follows:— 1. Submucosal infiltration covered by perfectly normal membrane, usually associated with more or less bulging of the esophageal wall, and very often with hardness and infiltration. 2. Leucoplakia. 3. Ulceration projecting but little above the surface at the edges. 4. Rounded nodular masses grouped in mulberry-like form, either dark or light red in color. 5. Polypoid masses. 6. Cauliflower fungations.

In considering the esophagoscopic appearances of cancer, it is necessary to remember that after ulceration has set in, the cancerous process may have engrafted upon it, and upon its neighborhood, the results of inflammation due to the mixed infections. Cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane. The significant signs at this early stage are: 1. Absence of one or more of the normal radial creases between the folds. 2. Asymmetry of the inspiratory enlargement of lumen. 3. Sensation of hardness of the wall on palpation with the tube. 4. The involved wall will not readily be made to wrinkle when pushed upon with the tube mouth.

In all the later forms of lesions the two characteristics are (a) the readiness with which oozing of blood occurs; and (b) the sense of rigidity, or fixation, of the involved area as palpated with the esophagoscope, in contrast to the normally supple esophageal wall. Esophageal dilatation above a malignant lesion is rarely great, because the stenosis is seldom severely obstructive until late in the course of the disease.

Treatment.—The present 100 per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study. The relief or circumvention of the dysphagia requires early measures to prevent food and water starvation. Bouginage of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability, and is attended with the great risk of perforating the weakened esophageal wall.

Esophageal intubation may serve for a time to delay gastrostomy but it cannot supplant it, nor obviate the necessity for its ultimate performance. The Charters-Symonds or Guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope. The tube must be changed every week or two for cleaning, and duplicate tubes must be ready for immediate reinsertion. Eventually, a smaller, and then a still smaller tube are needed, until finally none can be introduced; though in some cases the tube can be kept in the soft mass of fungations until the patient has died of hemorrhage, exhaustion, complications or intercurrent disease.

Gastrostomy is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. Surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst. The operation should be done before inanition has made serious inroads. As in the case of tracheotomy, we always preach doing it early, and always do it late. If postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach.

Radiotherapy.—Radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. No permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. The combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases.

The dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. Two fundamental points are to be considered, however. The radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. The dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. If the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. It is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (Fig. 95)

Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer.



[221] CHAPTER XXVIII—DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX

The diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. No anesthetic, local or general, should be used, for the practised endoscopist can complete the examination within a minute of time and without pain to the patient. The technic for doing this should be acquired by every laryngologist. Anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria, and especially because of the dyspnea so frequently present in laryngeal disease. To attempt general anesthesia in a dyspneic case is to invite disaster (see Tracheotomy). It is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa, so that the first glance should include an estimation of the color of the mucosa, which, as a result of the engorgement, deepens with the prolongation of the direct laryngoscopy.

Chronic subglottic edema, often the result of perichondritis, may require linear cauterization at various times, to reduce its bulk, after the underlying cause has been removed.

Perichondritis and abscess, and their sequelae are to be treated on the accepted surgical precepts. They may be due to trauma, lues, tuberculosis, enteric fever, pneumonia, influenza, etc.

Tuberculosis of the larynx calls for conservatism in the application of surgery. Ulceration limited to the epiglottis may justify amputation of the projecting portion or excision of only the ulcerated area. In either case, rapid healing may be expected, and relief from the odynphagia is sometimes prompt. Amputation of the epiglottis is, however, not to be done if ulceration in other portions of the larynx coexist. The removal of tuberculomata is sometimes indicated, and the excision of limited ulcerative lesions situated elsewhere than on the epiglottis may be curative. These measures as well as the galvanocautery are easily executed by the facile operator; but their advisability should always be considered from a conservative viewpoint. They are rarely justifiable until after months of absolute silence and a general antituberculous regime have failed of benefit.

Galvanopuncture for laryngeal tuberculosis has yielded excellent results in reducing the large pyriform edematous swellings of the aryepiglottic folds when ulceration has not yet developed. Deep punctures at nearly a white heat, made perpendicular to the surface, are best. Care must be exercised not to injure the cricoarytenoid joint. Fungating ulcerations may in some cases be made to cicatrize by superficial cauterization. Excessive reactions sometimes follow, so that a light application should be made at the first treatment.

Congenital laryngeal stridor is produced by an exaggeration of the infantile type of larynx. The epiglottis will be found long and tapering, its lateral margins rolled backward so as to meet and form a cylinder above. The upper edges of the aryepiglottic folds are approximated, leaving a narrow chink. The lack of firmness in these folds and the loose tissue in the posterior portion of the larynx, favors the drawing inward of the laryngeal aperture by the inspiratory blast. The vibration of the margins of this aperture produces the inspiratory stridor. Diagnosis is quickly made by the inspection of the larynx with the infant diagnostic laryngoscope. No anesthetic, general or local, is needed. Stridorous respiration may also be due to the presence of laryngeal papillomata, laryngeal spasm, thymic compression, congenital web, or an abnormal inspiratory bulging into the trachea of the posterior membranous tracheo-esophageal wall. The term "congenital laryngeal stridor" should be limited to the first described condition of exaggerated infantile larynx.

Treatment of congenital laryngeal stridor should be directed to the relief of dyspnea, and to increasing the nutrition and development of the infant. The insertion of a bronchoscope will temporarily relieve an urgent dyspneic attack precipitated by examination; but this rarely happens if the examination is not unduly prolonged. Tracheotomy may be needed to prevent asphyxia or exhaustion from loss of sleep; but very few cases require anything but attention to nutrition and hygiene. Recovery can be expected with development of the laryngeal structures.

Congenital webs of the larynx require incision or excision, or perhaps simply bouginage. Congenital goiter and congenital laryngeal paralysis, both of which may cause stertorous breathing, are considered in connection with other forms of stenosis of the air passages.

Aphonia due to cicatricial webs of the larynx may be cured by plastic operations that reform the cords, with a clean, sharp anterior commissure, which is a necessity for clear phonation. The laryngeal scissors and the long slender punch are often more useful for these operations than the knife.



[224] CHAPTER XXIX—BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI

The indications for bronchoscopy in disease are becoming increasingly numerous. Among the more important may be mentioned: 1. Bronchiectasis. 2. Chronic pulmonary abscess. 3. Unexplained dyspnea. 4. Dyspnea unrelieved by tracheotomy calls for bronchoscopic search for deeper obstruction. 5. Paralysis of the recurrent laryngeal nerve, the cause of which is not positively known. 6. Obscure thoracic disease. 7. Unexplained hemoptysis. 8. Unexplained cough. 9. Unexplained expectoration.

Contraindications to bronchoscopy in disease do not exist if the bronchoscopy is really needed. Serious organic disease such as aneurysm, hypertension, advanced cardiac disease, might render bronchoscopy inadvisable except for the removal of foreign bodies.

Bronchoscopic Appearances in Disease.—The first look should note the color of the bronchial mucosa, due allowance being made for the pressure of tubal contact, secretions, and the engorgement incident to continued cough. The carina trachealis normally moves slowly forward as well as downward during deep inspiration, returning quickly during expiration. Impaired movement of the carina indicates peritracheal and peribronchial pathology, the fixation being greatest in advanced cancer. In children and in the smaller tubes of the adult, the lengthening and dilatation of the bronchi during inspiration, and their shortening and contraction during expiration are readily seen.

Anomalies of the Tracheobronchial Tree.—Tracheobronchial anomalies are relatively rare. Congenital esophagotracheal and esophagobronchial fistulae are occasionally seen, and cases of cervicotracheal fistulae have been reported. Congenital webs and diverticula of the trachea are cited infrequently. Laryngoptosis and deviation of the trachea may be congenital. Substernal goitre, aneurysm, malignant growths, and various mediastinal adenopathies may displace the trachea from its normal course. The emphysematous chest fixed in the deep voluntary inspiratory position produces in some cases an elevation of the superior thoracic aperture simulating laryngoptosis (Bibliography r, pp. 468, 594).

Compression Stenosis of the Trachea and Bronchi.—Compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. Less frequently, enlarged mediastinal tuberculous, leukemic, leutic or Hodgkin's glands compress the airway. The left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle. Compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing.