T 1 3 2 1 Tr aclieo - Bronclioscopy, 
 190^ Esopliagoscopy and 
 
 rjbevalier Jackson^ M.D*
 
 -I'll—l'^Wl 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 ./ 
 
 Tracheo-Bronchoscopy, 
 
 Esopnagoscopy and 
 
 Gastroscopy. 
 
 BY 
 
 CHEVALIER JACKSON, M. D. 
 
 Laryngologist to the Western Pennsylvania Hospital, tlie Eye and 
 Ear Hospital, and the Montefiore Hospital. 
 
 WITH FIVE COLORED PLATES AND MANY 
 ILLUSTRATIONS. 
 
 ST. LOUIS, MO.: 
 
 THE LARYNGOSCOPE COMPANY. 
 
 1907.
 
 COPYRIGTED 1907 
 
 BY Chevalier Jackson.
 
 TO THIC 
 
 Father of Bronchoscopv, 
 
 Professor Gustav Killiax, 
 
 as a token of esteem, 
 
 this book is dedicated. 
 
 \^ 
 
 6242S7
 
 Bicnedieal 
 Library 
 
 (^07 
 
 Preface. 
 
 The )«ime has L-ome when not onlv the profession hnl also the pubnc 
 demands tliat every Iar\-ngologist shall be expert at the removal of for- 
 eign bodies from the trachea, bron:iii, esophagus and stomach. The day 
 has come when the treatment of diseased organs, especially chronically 
 diseased organs, without looking at them is regarded as a groping in the. 
 dark that i^ pennissible onl\- in organs that cannot be safely examined. 
 
 The eso|)hagus has lieen for some years granted, though somewhat 
 grudgingly, a place among the organs to be examined. The trachea and 
 l>ronchi, owing to the initiative of Professor Gustav Killian, have been 
 recently accorded a place also. Lastly it has been the author's privilege to 
 demonstrate the ease with which the stomach may be examined by 
 endoscopy. 
 
 At the present time, the only available information in the English 
 language on these subjects is the reports of cases scattered through the 
 journals. These reports do not give working data li\' which the student 
 mav learn how to proceed. This book is intended to furnish this informa- 
 tion, and is not in any sense exhaustive. It is preliminary to a complete 
 work, which the author has in preparation. 
 
 While the author realizes that there are men more capable of writing 
 on the subjects, yet. as they have not done so, this little book is offered 
 with a full realization of its shortcomings, but also with the assurance 
 that every assertion therein, not attributed to someone else, is the result 
 of practical experience. 
 
 Thanks are due to Dr. Jnhn W". Boyce and Dr. Ellen J. I'attersoii 
 for aid. 
 
 Chev.\lier J.\cksox. 
 
 Pittsburgh. Pa.. ]\larch. 1907.
 
 Introduction. 
 
 P.\- direct larvnn;oscopy is meant the direct examination of the interior 
 of the larynx, in contradistinction to indirect laryngoscopy by which a 
 reflected image of the larvnx is examined. Direct laryngoscopy is prac- 
 ticed with the aid of various instruments which serve to drag out of the 
 way the anatomical structures which ordinarily obstruct the view. 
 
 By tracheo-bronchoscopy is meant the inspection of the interior of the 
 trachea and bronchi with the aid of tubes which serve as specula, bring- 
 ing into view successively the various passages, by pushing aside struct- 
 ures that would obstruct the view, or dragging the passages into a new 
 position where they will be in the direct line of vision. 
 
 ^^'llen the tiilies are introduced through the natural passages, the 
 procedure is spoken of as upper tracheo-bronchoscopy, as distinguished 
 from lower tracheo-bronchoscopy in which the tubes are passed through 
 a tracheotomy wound. 
 
 By esophn.goscopy is meant the inspection of the interior of the esoph- 
 agus with the aid of long tubes which serve as specula. It is almost al- 
 ways practiced through the natural passages. 
 
 By gastroscopv is meant the inspection of the interior of the stomach 
 by means of tubes wdiich serve as specula. It is usually practiced through 
 the natural passages, though it is occasionally done through an abdominal 
 wound or fistula.
 
 Contents 
 
 Part I. 
 tuaciii-:ii-i:ronchoscoi*y. 
 
 Chapter I. Historical Xdtes. 
 
 Cliapter II. Jnstruniciits. 
 
 Chapter III. Acquiring Skill. 
 
 Chapter I\'. Technic. 
 
 Chapter \'. Direct Laryngoscopy. 
 
 Chapter \1. Anatomy of the Tracheo-bronichial Tree, Topographi- 
 
 cally. Radiographically and Endoscopicallv Consid- 
 ered. 
 
 Chapter ATI. Tracheo-briinchiiscoi)y in Diseases of the Trachea and 
 Bronchi. 
 
 Chapter A III. Tracheo-bronchoscopy Upper and Lower, for the Di- 
 agnosis and Extraction of Foreign Ilodies. 
 
 Part II. 
 
 ESOPHAGOSCOrV. 
 
 lntr( iduction. 
 
 .\natomical Notes on the Esophagus. 
 
 Xormal Esophagoscopic Appearances. 
 
 Technic of Esophagoscopy. 
 
 Diseases and Anomalies of the Esophagus. 
 
 Stenotic Diseases of the Esophagus. 
 
 Acute Inflammations. 
 
 Cicatricial Stenoses. 
 
 Neoplastic Stenoses. 
 
 Spastic Stenoses. 
 
 Compression Stenoses. 
 Chapter XV. Non-Stenotic Diseases of the Esophagus. 
 
 Diverticula. 
 
 Diffuse Dilatations. 
 
 Chapter 
 
 IX. 
 
 Chapter 
 
 X. 
 
 Chapter 
 
 XL 
 
 Qiapter 
 
 NIL 
 
 Chapter 
 
 XIII. 
 
 Chapter 
 
 XIV.
 
 COXTEXTS— Continued. 
 
 Tntlanmiations and Ulceration?. 
 Paralyses and Pareses. 
 Neuroses. 
 Chapter XVI. Foreign Bodies in the Esophagus. 
 
 Part III. 
 
 GASTROSCOPY. 
 
 Chapter X\'II. History. 
 
 Chapter X\'III. Usefulness of Gastroscopy. 
 
 Chapter XIX. Instruments for Gastroscopy. 
 
 Chapter XX. Technic of Gastroscopy. 
 
 Chapter XXI. Area of the Stomach Explorable by Gastroscopy. 
 
 Chapter XXII. Difikulties, Dangers and Contraindications. 
 
 Giapter XXIII. Gastroscopic Appearances.
 
 Part I
 
 CHAPTER I. 
 Historical Notes. 
 
 Bozini in 1807 examined the npper end of the esophagus. 
 
 \'oltolini and Waldenberg, in i860, and Stocrck, in 1861, devised 
 esophageal spccida iisini;- the laryngeal mirror. 
 
 Kussmaul, in 1868, did the first esophagoscopy worthy of the name, 
 using a Desormeaux urethroscope elongated to 43 cm. He diagnosticated 
 a carcinoma of the thoracic esophagus and approache<l the cardia. His 
 tube was rigid and he used the "sword swallowing" position. 
 
 Trouve, in 1873, designed a "polyscope" consisting of a tube having 
 a window, and titted with prisms and lenses constituting an optical aiipa- 
 ratus. This was used by Ledentu and Raynaud for esophagoscopy. 
 
 Alikulicz, in 1881, with the aid of Mr. Leiter, -designed an esopha- 
 goscope consisting of a tube into which an optic apparatus was slid after 
 the removal of the mandrin used to facilitate introduction of the tube into 
 the esophagus. He also examined the stomach with an elongated form 
 of his esophagoscope by adding an angle and an additional prism. 
 
 Gottstein, in 1891, advocated esophagoscopy under cocain anesthe- 
 sia. Prior work having been all done under either general anesthesia or 
 morphin narcosis, mostly the latter. 
 
 Von Acker, in icjo2, reported the tirst cases of tracheoscopy worthy 
 of the name. 
 
 Mikulicz, in i8y6, reported successful cases of tracheoscopy. 
 
 Kirstein, in 1897, described tracheoscopy as well as his now well 
 known direct laryngoscojiy. For the latter he used at tirst a tubular 
 spatula. 
 
 Killian, in 1897, removed a foreign body from a bronchus and dem- 
 onstrated the feasibility of upper bronchoscopy. Later he developed 
 lower bronchoscopy. These were the greatest steps in endoscopy. 
 
 Coolidge, in 1899, reported the removal of a fragment of a trache- 
 otom\- canula from the right bronchus of a man. 
 
 \'. .Schrotter and Piniazek, in 1901, reported some excellent work in 
 lower tracheoscop}- and hronchosco]iy.
 
 14 HISTORIC. I L XOTES. 
 
 Einhiirn. in uj02, devised an esiiphagosco])e having an auxiliary tube 
 made in the wall of the main tube. In the auxiliary tube was inserted a 
 light carrier wliieh served as a double conducting wire to carry current tn 
 the electric lamp which it carried to the distal end of the tube. 
 
 Guisez. in 1903. removed a nail from a tertiary bronchus. 
 
 Ingals, in 1904. used a separate light carrier in a Killian tube ami 
 removed a pin from a bronchus of a woman. 
 
 Chevalier Jackson, in 1904. combined the lighting principle of the 
 Einhorn esojihagoscope with the tube of Killian. and in 1905 he designed 
 a bronchoscope in which, in addition to the auxiliary canal, a drainage 
 canal was placed. In 1906 he described a gastroscope he had devised and 
 reported a series of 14 cases in which he had obtained results of value 
 from gastroscopv. including 12 cases with lesions, one in which a lesion 
 could be positively excluded and one case of extraction of a foreign body 
 from the stomach. 
 
 TTie foregoing is not by any means a complete review of the history 
 of the subject. Only a few of the more notable events are given. The 
 reader interested in the history is referred to the almost complete bil)- 
 Jiography appended.
 
 CHAPTER II. 
 Instruments. 
 
 The instruments in use t.vilay for tracheo-bronchoscopy and esopha- 
 goscopy may be divided into two classes : • , • , 
 
 I Those without hghting apparatus, consistmg of a tube mto whicli 
 hcrht is projected irom an independent source of hght, usually a head 
 lamp These instruments are simple and very satisfactory for short tubes. 
 For very long tubes great skill and much practice are required, and be- 
 yond 50' cm. they are impracticable on account of the loss of light through 
 distance, bubbles of secretion, etcetera. The object, be it normal, path- 
 ologic or foreign substance, is too feebly illuminated to throw back a 
 strong image. All of these disadvantages are overcome by great skill. 
 Killian and von Schrotter, who have clone the greatest amount of upper 
 bronchoscopic work, which requires long tubes of small diameter, use this 
 
 form of tube. 
 
 2. In the other class of instruments the light is at the distal extrem- 
 ity o7 the tube where its full power is available practically without loss 
 through distance, and where its obliquity renders visible otherwise unob- 
 servable details. Einhorn atid Glucksman have used this form for the 
 esophagus, and the author has perfected a bronchoscope and a gastro- 
 scope which utilize the great advantages of this plan of illumination. 
 
 INDEPENDEXT ILI.UM IX.^TORS. 
 
 KirstcinS headlamp (Fig. i) is the most used form. It consists 
 practically of a combination of a Wendell C. Phillips electric headlight 
 and a miniature form of the ordinary forehead mirror. The parallel rays 
 emerging from the lens instead of being projected directly toward the 
 objec't are caught upon a small mirror set at 45° which reflects the rays 
 parallel with the line of vision of the observer's eye, the mirror having a 
 small aperture which is placed in front of the pupil. 
 
 The headlight of Giiisec (Fig. 2), consists essentially of three Phil- 
 lips headlights clustered around the visual aperture of the disc on whicR
 
 ]6 
 
 ILLVMIXATORS. 
 
 they arc mounted, the axes of the lamps converging slightly. The liglit 
 from this apparatus is excellent, the heat very slight, and annoying ran- 
 dom rays are absent. There is a disc to obstruct the view of the left eye, 
 useful for those unaccustomed to ignore the image of the left eye while 
 using the riHit. 
 
 Fig. 1 — Kirstein's headlamii ami autosfoiie. 
 
 The clcctroscol'C of Cnspcr is virtually a handlamp form of its suc- 
 cessor. Kirstein"s headlamp, a prism occupying the place of the mirror. 
 Half of the orifice of the tube is occluded by the cap of the lamp, thus in- 
 terfering with instrumentation : but for demonstration and for the intro- 
 duction of unilluminated tubes which are to be used later with the head- 
 lamp, it is useful.
 
 TUBIiS. 
 
 TrUKS. 
 
 Kirstcin used orisjinally a tulnilar spatula attacliod to a Casper's 
 handlamp for direct laryugoscopy. but afterward abandoucd the tulndar 
 form for an open spatula with a hood at the proximal end. 
 
 Killian uses the tubular fnnii ( l-'itr- 3) "'itli the Kirstcin head- 
 
 Flti. i. — Killiau'!! split tubular siialula.
 
 18 
 
 SPECULA. 
 
 light. He has designed a most ingenious spHt tube spatula (Fig. 4) 
 to facilitate the introduction of tubes into the trachea, the two halves of 
 the split spatula being separated for removal of the spatula after the ilistal 
 end of the bronchoscope has passed the glottis. Six tubular spatulse, 
 3 sizes solid and 3 split, are listed by the manufacturer, F. L. Fischer, 
 Freiburg im Breisgau. 
 
 Alosher has devised a most ingenious speculum (Fig. 5) for work 
 
 ^ 
 
 Fic. 5. — Mosher"s esophageal speculuui aail iiistriiraouts for llie surgery of the 
 upper end of Uie esophagus.
 
 srr.crL.L 
 
 19 
 
 about tlic upper cuil of the esnplKiL^us. U is used witli the Kirstein or 
 Phillips headhght. or even w itli the forehead niirrnr, if for any reason this 
 should be necessary. 
 
 The autb.or uses a self-illuniinatiuii' tubular s]K-euluni (Fig. (>) hav- 
 ing a drainage tube made in its wall which maintains the lield of observa- 
 tion, clean and free from secretion, and prevents the necessity for interrup- 
 
 I''lG. 7. — AiiUior's separable speculum for passing tironchoscopes. 
 Handle. A B. is onl.v used on tlie sitting patient. 
 
 tion for the patient to expectorate, the constant desire to do which is the 
 source of more discomfort to the patient than any other part of direct lar- 
 yngoscopy. For the introduction of tubes he uses a split spatula pat- 
 terned after the ingenious device of Killian. but having it separable in the 
 other direction, so as to avoid wounding the mucosa. (Fig. 7) It is made 
 in two forms, one is self-illuminated, the other is not.
 
 20 
 
 INSTRUMENTS 
 
 Fig. S. — .Mikulicz's psophagosoope, maudrin aud (ui'.\t to bottojii) "practice 
 liougio." Tlic liandle portion i.-. a Caspar liandlamp. 
 
 Fig. 0. — Rosenheim".s esophagoscope. mandrin forceps and cotton liolder.
 
 IXSTKL'MBXTS. 
 
 ■n 
 
 1 U„rv-linped hou.^ie. li. Tube with mandrin in place. :'.. ( ottou holdeu 4 
 1. lM)i.\ uppeci )oi.„ii i„i„rerl curette S, !>. li>. H. Fofceps :a\vs. 
 
 and 7. Forceps. 5. Forceps handle. (,. .Jointed curette. ., 
 
 12. Leiter's paneloctroscope attached to luhe. 
 
 10 II 12 '3 I" 
 
 7 8 9 10 II 
 
 I il ^0 ^R ^^B 
 
 ^^^ ^^^ ^^n 
 
 .••■jmwiiwt^**'^"*""^' 
 
 forcep. for removal of specimens. S. Coiuaatel toiop. 
 
 10 to IC. Sounds and foreign body hooks. 1.. (ott.m lu.ld.i.
 
 99 
 
 TUBES. 
 
 Mikiilic", whose work is mainly esophageal, uses straight metallic 
 tubes, the distal ends of which are cut off slantingly. (Fig. 8.) They 
 are fitted with a mandrin tipped with a soft rubber pilot. Tlie inside of 
 the tube is Ijlackened to prevent annoying roHections. For illumination 
 he uses the Casper handlamp. 
 
 Rosciihciiii uses a similar tube and illuminalnr. (Fig. 9.) 
 J'oii Hacker for the esophagus uses a similar tube but uses the Leiter 
 panelectroscope, a half open cylindroid box with mirrors. (Fig. 10.) 
 
 Fio 11'. — Killian"^; bronclioscope and (below) Kirstein's esophagoscope with wiiuliiw. 
 
 Starck's esophageal tubes, shown in h'igure 11, have no fitted man- 
 drin, a form of esophageal sound being used as a pilot. 
 
 Kil Han's tubes (Fig. 12) are designed especially for the trachea and 
 bronchi, the svstematic exploration of which dates from Killian"s original 
 demonstrations. He uses straight rigid tubes of plated copper, graduated 
 in centimeters outside, and highly polished inside. They all fit into a uni- 
 versal handle. (Fig. 13.) The sizes of Killian's tubes for bronchoscopy 
 
 Fig. 33. — Uuiversal handle to fit Killian's tubes. 
 
 to be had in the shops vary from 7 to 9 mm. in diameter and 14 to 52 cm. 
 long. For esophagoscopy the sizes are from ii to 13 mm. in diameter, 
 and from 19 to 52 cm. long. Including both esophagoscopes and bron- 
 choscopes 18 sizes are listed, besides the 6 tubular spatulje. All of these 
 are not essential, but for the best work and to be prepared to meet all 
 emergencies, the largest possible assortment should be on hand, so that 
 the tube of shortest length and largest diameter possible may be used, for 
 the technical difficidties varv inverseh' to the size.
 
 TUBES. 
 
 23 
 
 Killian uses the Kirsk'in lK'a(ll:iiii|) fur ilkiminatidn. X'on SchrrittiT 
 designed a bronchoscope (Fig-. 14) the chief advantage of which is that 
 the tubes fit in a universal handle, so that after passing a second tulje 
 through the first, the handle may be removed fmm the first and attached 
 to the second and thus onl\ one handle is in use at a time. 
 
 Fig. 14. — von Sohrijtter's hrouclioscope. 
 A. Bi'oiiclioseii|iic tube. B. Dotacliable liantlle. which can he removed, leaving 
 onl.v the c.vlimlrical part of tlie tuhe and attaclied to a second tube passed throngh tlie 
 lirst. 
 
 Einhorn's esophagoscope (Fig. 15) consists of a straight tube without 
 lip or ring or thickening at the distal end. In the wall of the tube is made 
 a small auxiliary tube in which a light carrier is inserted, carrying the 
 light to the distal end of the instrument. A mandrin locked by a pin is 
 fitted, presenting a conical end for insertion. 
 
 Fii;. 1."). — Kiuhorn's esophago.scope and mandrin. 
 
 Ingals uses a Killian tube in which he inserts a little lamp on a light 
 carrier (Fig. 16), removing the light carrier before he inserts a mop or 
 a forceps. Tlie light being removed, the forceps are inserted, and the 
 foreign body or specimen is seized by the sense of touch and the memory
 
 24 
 
 TUBUS. 
 
 of its pDsitinii, ilic depth (if insertion licinn;- known liv liavin,^;- a provionsly 
 placc(l mark, as h\ a niljljer hand, on the forceps shank, showing the 
 length of the particular tnbe used. 
 
 The author's tubes (Fig. 17) are ilUiniinated liy a small "cold" lamp 
 carried down to the extremity by a light carrier. The chief advantages 
 of this form of illumination are these: 
 
 I. The light being in the tube is always illuminating the object, re- 
 .gardless of the movements of patient or operati ir. 
 
 I'or this reason. i)rolonged practice, as with the headlamps and unil- 
 
 J''i(;. IG. — Ir.sals' lirouehoscope. 
 A. Killiau liilit. B. Iiii^als' light ciirrier. 
 
 luminated tulies. is not necessary. True, the lamp occasionally gets smeared 
 with blood, but it requires no more time to withdraw the light carrier and 
 clean the lamp than it does to clean off the mirror or lenses of a head- 
 lamp which are Ijcdaubed every tinue the patient coughs, and when thus 
 bedaulx'd the light is dimmed. The constant readjustment of a headlamp 
 consumes nuich time, as each time a piece of sterile gauze nuist be picked 
 up to handle it with in order not to infect the hands. 
 
 2. There is no urgent need of selecting the shortest ])Ossible tube. 
 Tlie illumination is as good and the \'iew as good through an 80 cm. gas- 
 
 T" 
 
 FUi. 17 
 
 Author's bruiichoscopc. csoiiliagoscope au<l ga-stroscoye. 
 
 troscope as through a tube of one-foiu-th this length. For this reason, 
 lower tracheo-bronchoscopy, with the necessity of tracheotomy, is less 
 often required. 
 
 3. A great advantage is the obliquity of the light, due to the location 
 of the lamp at one side of the orifice of the tube. Every photographer 
 knows that light from back of the camera makes a flat picture, and every 
 opthalmologist knows that details of corneal lesions, invisible with direct 
 light, show up plainly with oblique illumination. The darker shades of 
 red do not throw back rays strongly, so that in case of a long tube, with
 
 .ICCnSSORV IXSTRCMRXrS. 
 
 2.-) 
 
 llu- liglit at onr rnd and a dark ivd nl)ji'ct at tlio oilier, the liiilit traveliiiL; 
 twice the tiihal length, the greatest skill and the utmost perfection dl ev- 
 ery detail of apparatus are absolutely essential for results. 
 
 4. .-\ small bubble or mass of secretion, or an instrument introduced 
 into the tube does not cut off any light as the light is beyond. 
 
 These points make it possible for the surgeon to do good work with 
 these tubes without the long arduous preliminary jiractice necessary with 
 the headlight and uiullumiuated tube, though these have other ad\-an- 
 tages once the skill is acc|uired. especiall\- in cases where large and short 
 tubes can be used. Each tube is fitted with its own handle which is a 
 great saving of time, as compared to attaching a handle e\er\ time a lube 
 of different size is inserted. 
 
 The tubes for general use are fitted with an auxiliary drainage canal 
 which maintains a dr> , clean condition at the distal end oi the tube. 
 Occasionallv a tube is needed without this auxiliary drainage, but oul\- 
 
 l-'u.. LS. — Antlior's secrftiou-:\s|iii;ilcir. 
 
 rarely, as in case of passing a narrow stricture. The secretion is pumped 
 out by the negative pressure maintained in the bottle with the aspirating 
 syringe (Fig. 18), the rubber tubing connected with the bottle being 
 slipped over the outlet of tlie drainage canal. Should the drainage canal 
 become obstructed, which very rarely happens, an extra drainage tube is 
 run in and out as needed, being connectable to the same asjiirator. These 
 extra drainage tubes are useful for blowing in medicaments or bismuth 
 oxide for Roentgen rav localization, b'or bronchoscopy drainage is not 
 often necessary. 
 
 ACCKSSORV INSTKCMENTS. 
 
 Forccf^s. The forceps of Coolidge ( Fig. 19) are exceedingly satis- 
 factory. The tube is pushed over the jaws by a trigger action and the 
 large handle will be very convenient to most operators. Starck's forceps 
 (Fig. 11) are actuated by pushing a thumb Initton and are good.
 
 26 
 
 FORCEPS. 
 
 Fig. lU. — C'ooliilge's forceps 
 
 Fig. 20. — Killian's toiveps antl manner of holding it. 
 
 Fio. 21. — Killian's .stronger forceps anil varions .iaws, tlie threatled one being an 
 expanding form for the extraction of hollow foreign bodies.
 
 FORCIiPS. 2( 
 
 Kalian's forceps (Fig. 20) are made in t\\ i styles of mechanism and 
 Will be found to do their' work ijerfectly. The) arc excecdino-ly conven- 
 ient to those accnstomcd to the tin,L;er-lever aclinn >>\ Dr. .Mnrrcll .Macken- 
 zie. A stronger pattern is shown in 1-ig. 21. 
 
 G:==C 
 
 I-'K,. 2"-!. — Aiitlior's forceps. 
 
 The author's in-eference is for tlie light, convenient, ringed handle 
 (Fig. 22) we are all so much accustomed to manipulate in the hemostat. 
 The'tuhe is pushed over the jaws, the jaws are n..t drawn into the tube. 
 
 ''■'>5!!^ 
 
 r-'iG. 2o. — Author's I'orci'iis, oiu-vimI .i,T\\> 
 
 the 
 
 thus they do not retreat from their bite. As with all tube torceps, 
 strength of grip of this instrument is astonishmg. Different lengths of 
 canuhe and ''differently formed jaws are made to fit one handle. The 
 
 !''«:. 24.— Aiillior's forrcps. ciippiil .jaws. 
 
 form shown in h'lgure 27, is for going down alongside a |iin or ncedl.- and 
 grasping it sidewise, or reaching around a turn or bend, or sidewise past 
 the end of the tube. Tliese are also made with cupped extremities like 
 Fig. 24, for the biting out of a specimen laterally from a wall. Either cup- 
 ped or serrated they will b.' found exceedingly useful for biting off a pa-
 
 28 
 
 ACCESSORY IXSTRCMHXTS. 
 
 jiillciiiia or other neoj)lasin from the anterior commissure of the larynx, 
 and similar jnirposcs. as will also the pimch forceps (Fig. 25). 
 
 Cotton carriers with roughened ends are too uncertain. It is ainioy- 
 ing to have the di>ssil slip off. and still more so is the delay occasionally 
 necessary for a prolonged search for it. Mikulicz has devised a very in- 
 genious claw end to hold the cotton. Coolidge uses the most comfortably 
 
 i'J(j U-j. — Author's forceps, rinicli jaws for excision of a speciun'ii. U'lie lower 
 instrument is a tent carrier to work in forceps liaudle. 
 
 safe device (Fig. 26). The slip collar screws down on the spring jaws 
 so that thoy cannot lose the dossil. 
 
 The author uses these exclusively for bronchoscopic work, though 
 for the esophagus and stomach where there is no risk from, or delay in 
 removing, the lost mop, the author uses the simple slide which does not 
 screw, small gauze sponges being used instead of cotton, which is pront 
 
 soiisa 
 
 Fig. iMj. — Coolidae's cotton lioliler. 
 
 to leave threads that interfere with vision. About a dozen carriers are 
 needful for rajiid work. 
 
 ( )f the other accessory instruments, various hooks, probes, etc., are 
 useful. 
 
 Alosher has devised a most ingeniou.= safety pin closer (Fig. 2j). It 
 consists of a ring which is passed clown below the open pin ; then the pin 
 
 Flc. 27. — Moslier's safet.v |)iu closer. 
 
 is pushed in spring-end first by the little pronged instrument. To facili- 
 tate passing the ring below the pin, the author has arranged a stem that 
 permits of introducing the instrument with the ring in the same plane as 
 the stem. ,\fter the ring has passed the pin, moving the handle turns the 
 ring to a right angle with the stem. ( Fig. 28. ) 
 
 For endolarvngeal surgerv, such as the incision of edematous masses,
 
 Acciissni^y ixsriu witixis. 
 
 •29 
 
 (lixisimi of stenotic webs, openinj;' of abscesses, ami similar work it will 
 be found necessary to bave at least one knife. (Fitj. 29.) 
 
 A mouth g-ag is a most important accessory, b'ergusou's (Fig. 30) 
 has given tbe author most satisfaction. .\ long cleanins.'' wire for the 
 
 >'■-,' \ 
 
 ^■> 
 
 Flu. 1!^. — Till? aiitliur's safety piu clustT. 
 
 canals, extra lamps, sterile vaseline, small gauze strips about 4x6 cm. in 
 size and folded into sponges, a steel centimeter rule and battery complete 
 tbe outfit. 
 
 Comiuercial lighting circtiits should never lie used iVir lighting the 
 
 Fig. -'•). — Aiuliur's lar.vii;;i'al kiiifi'. 
 
 lamps. .Ml rheostats ha.vc one live side which may be "grounded" tlirrmgh 
 the patient, involvmg great danger, even if of no more than no volts 
 pressure, on account of the good contact with the moist mucosa, through- 
 out the length, of the tube. Dry batteries (Fig. 31 ) involve no risk what- 
 
 FlG. .30. — Fersiisou's moutli sas. 
 
 ever and with intelligent care are perfectU" satisfactory. The box should 
 have a rheostat for regulation of the current. If much work is to be done 
 a storage battery (Fig. 32') will be found conveniuit.
 
 30 
 
 BATTERIES. 
 
 If the operator does not wear g-lasses habitually, it will be necessary 
 to have spectacles with plain eyes of larsje size for the prevention of infec- 
 
 KiG. ol. — Eight-cell dry battery for euilnsidijy. 
 
 Fig. o2. — Four-cell storage battery for eudoscopy. 
 
 tion from coughed out secretions, which shoot out like projectiles from 
 the tubes. 
 
 A list of instruments is here appended for convenience:
 
 LIST ()/•■ IXSTRL'MHXrS. 31 
 
 LIST OF TXSTR^^[F.^■TS. 
 
 TUBICS. 
 
 The author's tubes are made in the following sizes: 
 lo mm. X 53 cm. eso|)hagoscopc for adults. 
 
 7 
 
 " >^45 ' 
 
 
 
 
 children. 
 
 7 
 
 " X40 • 
 
 bronchosco])c 
 
 
 
 adults. 
 
 8 
 
 " X 20 ' 
 
 ' tracheoscope 
 
 
 
 adults. 
 
 5 
 
 •' X 14 ' 
 
 . It 
 
 
 
 children. 
 
 5 
 
 •■ X30 ■ 
 
 bronchoscope 
 
 
 
 adults. 
 
 5 
 
 ■■■' >^45 • 
 
 i t> 
 
 
 
 children. 
 
 12 
 
 ■' X 17 ' 
 
 ■ tubular specul 
 
 luni. 
 
 
 12 
 
 ■■ X f7 • 
 
 separable 
 
 
 
 for adults 
 
 10 
 
 " X70 ■ 
 
 S'astroscope for 
 
 adults. 
 
 If rigid economy nnist be practiced, much good work can be done 
 with a 7 mm. x 45 cm. esophagoscope, a 5 mm. x 30 cm. bronchoscope, and 
 a 12 mm. X 17 cm. separable speculum. The 7 mm. x 45 cm. esophago- 
 scope can be used in the adult trachea and main bronchi, but if used in the 
 latter, the absence of lateral openings must be remembered. Lateral open- 
 ings are a disadvantage in an esophagoscope. He who expects to work- 
 to the best advantage with any and every case encountered will need the 
 entire set. For bronchosco])y tubes with drainage are not often needed. 
 
 The diameters of the tubes as here given are of the cylindrical tubes 
 before the canals are uiade in the walls. These canals bulge outward 
 slightly, thus increasing one diameter, though this need not be taken into 
 account as the resiliency of the passages more than compensates for it. 
 
 Killian"s tubes are made in the following sizes : 
 
 For bronchoscopy, adults 9 mm. x 18 cm. 
 
 " 
 
 " 
 
 9 ' 
 
 ■ X25 
 
 ii 
 
 9 
 " 9 ' 
 children 7 ' 
 
 " >;35 
 
 " X41 
 
 ' >^ 13 
 
 ^t 
 
 ( 
 
 7 
 
 " x 18 
 
 n 
 
 ti 
 a 
 
 7 
 7 
 
 " X23 
 
 " x28 
 
 esophagoscopy 
 
 adults 
 
 7 
 1 1 
 
 " X35 
 • X19 
 
 *' 
 
 
 II 
 
 " X32 
 
 C4 
 
 •' 
 
 1 1 
 
 " -^45 
 
 (( 
 
 a 
 
 II 
 
 " X52 
 
 a 
 
 a 
 
 13 
 
 " X19 
 
 it 
 
 a 
 
 13 
 
 " X 24 
 
 it 
 ti 
 
 ti 
 
 a 
 
 13 
 13 
 
 " X32 
 
 " X42 
 
 t ( 
 
 a 
 
 13 
 
 " X52
 
 32 .-ICCRSSORIHS. 
 
 For esoj)hagoscopy in children the y mm. bronchoscopes are used. 
 
 One universal handle for all tubes. 
 
 Tube spatulas, three sizes. 
 
 Tube spatulre, split, three sizes. 
 
 The following list of accessories will be found to contain the essen- 
 tials : 
 
 ACCESSORIES. 
 
 Aspirator and tuljing". 
 
 3 mm. X ()0 mm. extra drainage tube. 
 
 3 ■■ >^40 
 
 4 •■ x84 ' 
 
 I forceps 25 cm. canula and 4 jaws. 
 
 I ■■ .VS 4 " 
 
 I " 60 " ■' ■■ 4 " 
 
 I " 84 4 " 
 
 yi doz. sponge holders 2^ cm. long. 
 
 i^ '• •■' •• 66 ■' ■' 
 
 I " •• ■■ 84 " " 
 
 I hook and probe 25 cm. long. 
 
 I " '• ()0 '■ 
 
 I ■■ •• 84 •■ " 
 
 I Lister-Killian hook 23 cm. long. 
 
 I '■ ■■ '■ 60 ■■ 
 
 I •' •• " 84 " " 
 
 I safetv pin closer, 3 mm. ring, 30 cm. long. 
 
 I "■' •• •■ 10 •■ •■' 60 •■ " 
 
 I Sajous laryngeal sponge forceps, (curved) 
 
 I .Laryngeal knife. 
 
 I ■' cautery electrode and cord. 
 
 1 " galvanic electrode (monopolar) and cord. 
 y2 doz. extra lamps. 
 
 2 wires for cleaning canals. 
 
 I sterilizing tube for packing sterilized extra lamps. 
 Eye glasses for the protection of operator's eyes. 
 I double bronchoscopic battery and conducting cords. 
 I extra battery cord.
 
 CHAPTER III. 
 Acquiring 5i<:ill. 
 
 As bronchoscdin- with the avera,c:e laryngologist or surgeon is rela- 
 tivelv a rare procedure, some prehminary practice is advisable. If Killian 
 tubes with the Kirstein headhght are used considerable preliminary train- 
 ing will be necessary to keep the light projx'rly directed down the lube, 
 and the general physician or surgeon, who has had no experience whatever 
 with even the ordinary head mirror, will find that long preliminary prac- 
 tice is necessary in order to see anything. With the distally illuminated 
 tubes anyone can see clearly. line author has frequently had physicians 
 totally unfamiliar with tube work, discuss appearances at their first exami- 
 nation in a way that revealed the fact that they had obtained good clear 
 views. Nevertheless, some practice is, of course, necessary. Endoscopy 
 is in no case like looking through an opera glass. Many details require 
 attention. Lights are to be cleaned and readjusted, secretions to be con- 
 tended with, cough and reflexes to be combatted. 
 
 The first step should be the technical management of the miniature 
 electric lights and the batteries. If possible, this should be acquired by 
 instruction. If not possible, the details may be worked out by experiment. 
 After burning out a few lamps, the current strength they will stand is soon 
 learned. If too strong it will shorten the life of the lamp even if it does 
 not immediately burn it out. All lamps, whether used in tubes or on head- 
 lamps, must be adjusted by watching the filament. It will never do to 
 start using the tube and then run up the rheostat until the ojierator thinks 
 he is getting enough light on the object. This will mean no end of trouble. 
 Every lamp will stand just so much, and no more. This amount gives 
 what is called full illumination. It is not easy to describe, further than to 
 say that it is the point where the filament seems to grow thicker and turn 
 white, just beginning to lose the yellow. \\'hen first commencing to glow, 
 it is red. As the rheostat is run up, it turns to yellow, and then to white. 
 \\'hen just commencing to turn white is the point of full illumination.
 
 34 TESTING LIGHTS. 
 
 If pushed to intense dazzling whiteness, it is overilluminated and will 
 soon burn out ; while if only yellow, with the filament plainly visible, it is 
 underilluminated and useless. Until this is thoroughly mastered, it is use- 
 less to attempt endoscopy. Many utter failures have been due to rushing 
 into endoscopv on the living without a full mastery of the purely mechani- 
 cal details of the instruments. 
 
 Some practical experience in the location of electrical troubles is ex- 
 ceedingly useful and can only be acquired b}' practical experience with elec- 
 trical api^aratus. An automobile ignition experience may help. A skill- 
 ful experienced operator will quickly locate the cause of "no light" where 
 the inexperienced will give uji in despair. All electrical apparatus turned 
 out for medical work, including that for endoscopv is too flimsv. The 
 wires are too fine, the switches and rheostats too delicate. Of course, 
 even if perfect in construction, wear and also damage by transportation, 
 rough handling, sterilization, and other things will cause broken circuits, 
 short circuits, and "no light." The best way is to have a definite routine 
 for locating trouble. The following order is a good one: 
 
 1. See if your switch is on and the rheostat where it ought to be, 
 pressing the levers to see if they have sprung away from contact. 
 
 2. Test all contacts and connections by screwing home the lamp, 
 twisting the bayonet catch, screwing down the thumb nuts on the binding 
 posts. 
 
 3. Next try a new light carrier that lighted uy ])ro])erly before. If 
 this lights u[), the trouble is in the previously used light carrier or lamp, 
 which of the two being quickly located by trying a new lamp. If the light 
 carrier which worked perfectly before, fails to light up, trv a new cord, or 
 if this is not at hand, close the circuit from one binding post to the other 
 through the light carrier. 
 
 If at any time, the light flashes on again, note where you were touch- 
 ing the apparatus at the time, as there is likely a loose connection at the 
 point, brought into contact by your touch. 
 
 These tletails are soon learned and are necessary with any endoscopic 
 apparatus, unless an electrician be available in the operating room. 
 
 The location of "no light" troubles with the Ivirstein headlamp is 
 much the same. First, see if the current is on by turning on one of the 
 room illuminating lamps. Tlien test the Kirstein lamp to see if it is screw- 
 ed home, or, if the glass looks blackened on its interior surface, trv a new 
 one. Next, test the cord as before described, then the switch, then the 
 binding posts and rheostat. Usually the commercial lighting circuit is 
 used, and rheostats for this purpose as made at the present day are flimsy 
 and subject to constant disorder. Two or more are necessary as at least 
 one will be always at the factory for repairs. Tliere is no need for Ibis to
 
 .icurih'ixa SKILL. 
 
 85 
 
 be the case, but such seems to be the condition of meiiico-electrical nianu- 
 faeturing to-day. Doubtless there would be less trouble, too, if physi- 
 cians were better skilled in electrical mechanics. 
 
 After the details of batteries and lights have been mastered some fa- 
 miliarity with the manii)ulations may be gained from tubal exaiuinations 
 of the interior of the clenched fist, pushing the tube ilnwii ihrnugh it from 
 the upper (radial) side. 
 
 The rubber manikin of Killian (big. S3) is '^■^"''}' "seful for i)r;ictice, 
 being ingeniously designed to sinudate actual obstacles to the intn.KJuction 
 
 1' IG. ;!3. — Killiau's niniiikia for practiuin^' lii-ouchoscnpy anil esophagoscopy. 
 
 of a tube through the natural passages. The dog offers a convenient ani- 
 mal subject for ]nactice. Chloretone hypodermaticallv in doses of I 
 gramme is a convenient anesthetic for the dog. The author's preference 
 is for scopolamine gr. i/ioo (0.00065 gm-) with morphin gr. 1/2 
 (0.0324 gm.) given hypodermatically one hour before, and repeated, if 
 there be no signs of oncoming stupor, twenty minutes before the time for 
 practice.
 
 36 .-ICOUIRIXG SKILL. 
 
 Much available material is wasted about the average clinic. Cases of 
 gfoitre that complain of dys]jnoea, justify tracheoscopy, and any case of 
 goitre which by its size demands o])eration should be tracheoscopized for 
 tlie information yielded. Cases complaining of difficulty in swallowing 
 are neglected or sent to the general medical or gastro-enterologic clinic, 
 when in reality it is the plain duty of the laryngologist to find out by direct 
 laryngoscopy, and by esophagoscopy idiy they cannot swallow. Patients 
 wearing tracheal canulse would be the better for a tracheoscopic watcii 
 upon their endotracheal condition. Mucosal inflammations and ulcera- 
 tions, perichrondrial and chondrial diseases could be detected and cured. 
 A]\ this material is at the present writing wasted in all the clinics of this 
 country, to say nothing of the neglect of the patients' best interests.
 
 CHAPTER IV. 
 
 Technic of Direct Laryngoscopy and Tracheo- 
 bronchoscopy. 
 
 General Considerations. 
 
 Asepsis. It cannot be too strongly emphasized that the strictest de- 
 tails of aseptic technic must be followed out. Tliis will limit infective 
 risks to those organisms already present in the mucosa. If this be not 
 (lone, sooner or later, the operator will have upon his conscience the bur- 
 den of having inoculated a fellow creature with syphilis. di])htheria. ery- 
 sipelas, tuberculosis or other infection. 
 
 In regard to the field of operation, absolute asepsis is impossible, but 
 the mouth, the most septic portion of the tract, can be put in a relatively 
 clean condition. 
 
 A definiti; routine position, of all tallies, instruments, liatteries, assist- 
 ants and nurses should be followed, otherwise all is confusion, which is not 
 conducive to good work. Ouiet, orderly ])roc.?dure is essential. Sterile 
 caps should be worn as well as gowns, to {)revent infection of instruments 
 in passing them to and fro, especially the long instruments, particularly 
 when an assistant or the operator stoops, kneels or sits. 
 
 llie patient is clothed in a sterile gown if the sitting [josture is used; 
 or covered with the usual sterile sheet and towels if examined in dorsal 
 decubitus. Either way he should wear a sterile rubber cap pulled well 
 down over the ears. 
 
 StcriIi.':aflon. All instruments except the light carriers, battery cords 
 and aspirator can be boiled. The light carriers should be immersed in 
 alcohol before using and a stock of lamps already sterilized shoufd be 
 packed in glass sterilizing tubes. The battery cords are rubber covered 
 so they can be wiped with mercuric bichloride solution. The a.spirator is 
 immersed in 5 ])er cent, carbolic acid solution, which is also pumi)ed 
 through it a luimlier of times. It is then rinsed in sterile water.
 
 38 BRONCHOSCOPY. 
 
 If, during the course of an upper bronchoscopy, it is decided to do a 
 lower bronchoscopy, everything should be resterihzed before opening the 
 trachea, provided there is time. Sterile tracheotomy instruments should 
 be at hand on a separate table where they will not get soiled while work- 
 ing with the bronchoscopes through the mouth, and where they are reail}' 
 for immediate use. If, as will occasionally happen, an immediate trach- 
 eotomy is required, it is an advantage to have an assistant who has not 
 been contaminated with the mouth, or the instruments used therein, to 
 stab the trachea. In any case there will be ample time to resterilize all 
 tracheo-bronchoscopic instruments before introducing them into the 
 trachea, and it is utterly unjustifiable except in dire emergency to intro- 
 duce through a tracheotomy wound, the instruments soiled in the mouth. 
 It may be argued that in upper bronchoscopy the tubes are introduced 
 through the mouth, but they are introduced through a split spatula and no 
 great amount of infective material need be carried downward. Besides, 
 one great advantage of lower bronchoscopy is its asepsis, and this advan- 
 tage will be lost if instruments infected in the mouth be used without re- 
 sterilization. 
 
 During an examination the small lights require cleansing frequently, 
 the light carrier being withdrawn for the purpo:-e. \\ ith trained help this 
 requires but a moment. Occasionally it will be found that the ciu'rent 
 requirements of the lamps vary, and a little readjustment of the rheostat 
 is necessary for a fresh lamp. For rapid work, it is imperativelv necessary 
 to have a trained assistant who is thoroughly familiar with all the appara- 
 tus, and also a nurse who is trained to keep the lamps and tubes clean and 
 in good order while working, so that the operator has nothing to do but to 
 observe, while armed sponge holders, forceps, probes, hooks, fresh light 
 carriers with lights properly illuminated are handed to him as called for. 
 
 A stock of extra miniature lamps should be kept sterile, packed in 
 glass sterilizing tubes with a wad of cotton between each lamp, so that a 
 single extra lamp can be taken out when needed without infecting the 
 others more deeply placed. In this way the extra lamps are always ready 
 and never need sterilizing but the once. 
 
 Unilluminated tubes should never be boiled as boiling soon dulls the 
 brilliancy of their interior polish. 
 
 Preparation of the patient. Foreign body cases will often be dealt 
 with without pre]5aration of the patient. Where there is time, as there 
 usuallv is in most other cases, and in many foreign body cases, it is best 
 to insist upon proper preparation. A purge should be given, and no food 
 allowed for 6 hours for tracheo-bronchoscopy. 8 hours for esophagos- 
 copy and 12 hours for gastroscopy. Even in direct laryngoscopy the pres- 
 ence of the instrument in the pharynx may excite vomiting if there be food
 
 DIRECT LARYXGOSCOPy. 39 
 
 in the stomach. The possiljlc need for general anesthesia also renders 
 fasting- necessary in a Ux-ally anesthetized case. If the patient has just 
 eaten.and delay is inadvisable, lavage of the stomach is called for. 
 
 The nearest approach to oral asepsis is imperative. Whenever practi- 
 cable the teeth should be put in the best of condition by the dentist. 
 
 The patient is then, directed to brush his teeth with soap and chalk 
 and to rinse his mouth every two hours with thirty per cent alcohol. As 
 shown recently by Dr. A. \\'adsworth. alcohol is the most efficient oral 
 antiseptic. A more eligible preparation, as advocated by Wadsworth, is 
 made bv adding sodium bicarlx>nate and chloride in normal salt propor- 
 tions and spirits of chloroform and oil of wintergreen as flavoring to the 
 
 alcohol. 
 
 The patient should wash his face thoroughly with soajj and water, be- 
 mg particularlv thorough with beard or mustache if he have these ; and he 
 should rinse first with water and then with i :iooo perchloride of mercur_\- 
 sohition. 
 
 DIRRCT L.VRYNGOSCOPY. 
 
 Anesthesia. For ordinary routine work either in the consulting room 
 or in the operating room, local anesthesia is sufficient. A 4 per cent 
 
 Fn;. 34. — Sajous' cotton liolilins forcin» for prelimhinr.v oocainizntioii of the 
 larynx and pliar.vnx. 
 
 solution of cocain is applied w ith a mop of cotton held in the Sajous for- 
 ceps (Fig. 34). After waiting a few moments, the laryngeal speculum 
 (Fig. 6) is introduced until the epiglottis appears and a more accurate 
 apphcation is made to the epiglottis and all tissues in its neighborhood. 
 Then the instrument is passed posteriorly to the epiglottis, bringing into 
 view the interior of the larynx and the introitus esophagi, which are swept 
 over with a 20 per cent solution. Cotton mops may be used for this. 
 
 For operative work, where there is no dyspnoea, a general anesthetic 
 should be used, as the relaxation and absence of tetanic reflexes renders the 
 examination very nnich easier. It is not painful, though a spectator would 
 not believe this, as in many instances the patient looks as if he were chok- 
 ing to death. Cocain must he used cautiouslv in children.
 
 40 
 
 TECHNIC 
 
 If a general anesthetic be used, chloroform is preferable; being con- 
 tinued, after the examination starts, by a gauze sponge held with a hem- 
 ostat and saturated with chloroform. This is held over the mouth and 
 nostrils, or, if the jiatient has been tracheotomized, over the tracheotomy 
 wound. 
 
 Direct laryiii/oscol^y. Patient sittiiu/. For ordinary routine direct lar- 
 yngoscopy in the consulting ro(^m, the patient sits upon a low stool, the 
 assistant sits on a higher stool or stands behind the patient and holds the 
 gag and the head an<l keeps the lip out of the way, so that it will not hs 
 pinched betweeri the instrument and the upper teeth. It is possible to hold 
 even an unrulv child bv using- the followins; method : The nurse holds the 
 
 Fli;. .'I.'i. — IHrrct Un-yiiuescoiiy. I'aticiil ^iliiii^. 
 
 child's knees between her own, crossing her arms in front of the child and 
 catching opposite hands with the child. The head on her shoulder is held 
 by an assistant. Another way is to wrap the child in a sheet. The author 
 does not advise working thus. Dorsal decubitus is better with unruly 
 children, and the author ]irefers it under almost all conditions. 
 
 In the operating room the posture of the patient and tke positions of 
 the second assistant and the nurse are as shown in Figs. 35 and 36. The 
 operator in the position shown in Fig. ;^j. I^'orceps and other instruments 
 are handed as called for. 
 
 The duties of the first assistant are to hand all in.struments to the ope- 
 rator in the piosition for insertion with their axes corresponding to that of
 
 DVTir.S OF .LSSfSTANTS. 
 
 41 
 
 tlio tulie. }\e shoulil do this with his ri5:jht hand while in his left he holds 
 a half dozen or more sponge-holders, which are handed as needed to the 
 patient sits on a low stool, the second assistant sits on a higlier stool back 
 of the patient. Tlie first assistant and the nurse are to the right of the 
 o|)erator with the instrument table between them. (These are removed in 
 in the cut so as not to hide the positions, etc. ) The battery is on a low 
 strong table to tlie left. It is covered with sterile towels on which the cord 
 may be laid when not in use. The knob of the riieostat can be felt through 
 the towel and moved as needed. 
 
 The duties of tlie nurse are to stand back of the table (the first assist- 
 ant being in front) to refill the sponge-holders as they are laid down on the 
 table, soiled, by the first assistant. As refilled she lavs them in position 
 
 an aspirator 
 
 so that the first assistant can pick them tip conveniently. If a 
 
 OPERATOR 
 
 ^ 
 
 
 !>' ASSISTANT 
 
 
 ^ 
 
 
 INSTRUMENl 
 
 TABLE 
 
 l-'io. .^0. — Direct lar.vngo.s(:oi).v. I'atient sitting. iJiasrain of posilions of jktsous 
 and liiiiigs. Table slionld be a little nearer the operator. 
 
 is used she may work this, or it may be done by the second nurse. If but 
 one nurse is to be had, a good supply of sponge-holders is needed. 
 
 In looking at Fig. 37 the table would be the foreground, with the 
 nurse to the right, and the first assistant to the left, as seen in the diagram 
 Fig. 36. 
 
 The duties of the second assistant are extremely important. He must 
 liold the patient's head bent backward, with the trunk, and especially the 
 neck pushed forward, the bend being as much as possible in the region of 
 the axis and adjacent cervical vertebrae. At the same time he holds the 
 mouth widely open with the gag, and in a case of a sitting patient, with 
 the forefinger he keeps the patient's upper lip away from the upper teeth.
 
 42 
 
 USE OF LARYNGEAL SPECULUM. 
 
 He should realize the importance of his duties, and that a cut upper liji 
 means the most reprehensible carelessness upon his part. 
 
 All of the details as here given are not absolutely necessary for the 
 brief examination in the consulting room ; but for more prolonged exami- 
 nations, removal of foreign bodies, and certainly for all operative proced- 
 ures attention to all the details given is absolutely essential, as already 
 mentioned, for good work. 
 
 Using the laryngeal speenhiui. The light on head lani]) or light car- 
 rier having been adjusted to the proper brilliancy, and the field being an- 
 esthetized, the tubular speculum is inserted until the epiglottis appears in 
 view. The flat end of the tube is passed behind the epiglottis about a 
 
 I'll;. '.1. Liiwur traclit'o-broiicliosciipy. I'atirut siltiiij;. 
 
 centimeter, and now comes the only point where difficulty in the manipula- 
 tion is encountered. Once this knack is acquired, no difificult}- will be met 
 with. The epiglottis must be pushed forward tightly against the base of 
 the tongue, which, with the tissues attached to the hyoid bone, must be 
 forcibly pushed forward out of the line of vision. This pushing is done 
 with the spatular extremity, the directioii of motion being shown schemat- 
 ically in Fig. 38. The instrument is given a forward motion of the tip by 
 an upward and backward motion of the handle, the pivotal point bemg at 
 the junction of handle and tube. By this it is not meant that the tube 
 rests on the upper teeth. This is the first and most serious error made bv
 
 Tf.CHNIC. 
 
 43 
 
 the iiu'xp.Ticnccl. li is mtcrly impossible to get a good. view, of the 
 laryii.x if the upp-''- t^^'th are used as a fulcrum to pry the mouth open and 
 the hyoid tissues forward, and the strength required is painfully great for 
 both patient and operator. 
 
 Another error frequently ronnnitted by the inexperienced is the inser- 
 tion of the speculum too deeply, so that it gets behind the cricoid cartilage. 
 This is evidenced h\ interference with the patient's breathing, by the open- 
 ing up of the upper end of the csojihagus to view and resistance to the for- 
 ward pressure of the tip of the mstrument. Under these circumstances, 
 when the specuUnn is withdrawn slightly the "brassy" tubular respiratory 
 sound denotes the right place. One soon learns to tell by the sound when 
 tubes are at the laryngeal orifice. 
 
 Upper tmcheo-bronchoscopy. Silting posture. If desired, as in se- 
 vere dvspnoea. the bronchoscope may be passed with the patient seated. 
 
 j.'iQ 38.— Diagrammatic represeutation of direct laryngoscopy and scliema. sbow- 
 iug dh-ection of force applied in usiug llie tubular speculum and separable spatula. 
 
 The split tubular speculum is used and the bronchoscope passed as shown 
 in Fig. 39, which, however, shows the first assistant in the wrong position, 
 the correct one being as in Figs. 36 and 37. Hie technic is the same as 
 described for the recumbent posture. The author prefers the latter post- 
 ure for bronchoscopy and he would tracheotomize patients too dyspnoeic 
 to lie down without it Should tracheotomy be demanded, it is an advan- 
 tage for the patient to be already recumbent upon the tal)le. \Mien a gen- 
 eral anesthetic is used recumbency is imperative. Fig. 39 .shows left upper 
 bronchoscopy, the split tubular spatula in the right buccal angle, the bron- 
 choscope passed througli the tubular spatula which has not yet been re- 
 moved. The second assistant holds the gag in the right side of the pa- 
 tient's mouth, while with his left forefinger he elevates tb.e patient's upper 
 lip at the left side (removed when the photograph was taken so as not to 
 hide the instruments).
 
 44 
 
 TRACHEO-BROXCHOSCOPy. 
 
 Fii;. '.i'J. — \jnit u\)\)vv iracliHu-brimsfUoscopy. Patient >ittiLig. First assistant's 
 position should be as shown in Figs. 30 and 37. 
 
 Fid. 40. — Left upper tracheo-bronchoscopy, showing the introduction of broncho- 
 scope through the separable speculum.
 
 TRACHF.O-BRONCHOSCOPY. 45 
 
 Urwcv tyachco-bronchoscofx. Stttuui tosturc. ( Fis,'. 37- I This also 
 is not advisable for prolonged work, hut it is perfectly feasible. It is a 
 ..reat convenience and should always he used in one class of cases : namely, 
 walking cases wearing tracheal eanuUe. A close watch should be kept on 
 these cases, for tjranulations, ulcers, et cetera, in the trachea. I lus is 
 easily and quicklv done with a short tracheoscope, which is nu.ch better 
 than anv form of dilator tor even the deeper parts of the wound, wlule for 
 the trachea itself it is the only wav that ulcers, granulations, etc.. may be 
 treated and cicatrices and stenotic webs prevented. Shenild dyspnoea 
 supervene when the tracheal caiuila is removed, a quick inserti..n ot the 
 tracheoscope will give instant relief. 
 
 If previously tracheotomized the bn.nchi may be examined in this 
 
 wav 
 
 Of course in patients just tracheotomized. the recumbent posture is 
 used and the author prefers recumbency in all cases, 
 
 Direct laryu^oscotx. dorsal decubitus. The chief differences between 
 direct larvngosccipN- with the patient in the sitting and dorsally decumbent 
 positions.' are in the arrangement of nurses, assistants and operating room 
 detail and in the manner of grasping the tubular speculum. The operating 
 room arrangement is the same as described in the following pages under 
 "Upper tracheo-bronchoscopy." 
 
 The manner of making pressure with the tube does not differ so far as 
 the relation of tube to the patient's anatomy is concerned. The tubular 
 spatula is grasped f^rmlv in the operator's left hand, as shown in Fig. 40, 
 and the motion .shown in the schema ( Fig. 38) is imparte.l to it, as if to 
 lift the patient off the table with the tip of the speculum, or as if to force 
 the epiglottis out between the hyoid bone and the thyroid cartilage with 
 the tip of the speculum. Care must be taken to avoid mistaking the infe- 
 rior constrictor, or a glosso-epiglottic fold for the epiglottis. 
 
 UPPER TR.VCHF.O-BRONCHOSCOPV, DORSAL DKCIJBITUS. 
 
 Posture and oilier detaUs. The patient lies upon an operating table, 
 the foot of which is 15 inches lower than the head. The table shown in 
 the figure 40 was designed by the author for this and other throat work. 
 It is pivoted horizontally in the center so that it balances and no matter 
 how heavv the patient, it is easily raised or lowered. The headlioard is 
 only dropped after the second assistant is ready to support the head. Most 
 tables have a dropping headboard of this kind, but if not the patient must 
 be moved until his shoulders slightly overhang the edge of the table. 
 \\''hen everything is ready, lights regulated, tubes greased, sponge-holders 
 armed, assistants in position, the headboard is dropped and the patient's 
 head is in the air free to move in every direction (Fig. 40) under the con-
 
 46 
 
 TRACHEO-BRONCHOSCOPY. 
 
 trol of the second assistant, who (in left upper bronchoscopy) sits upon a 
 high stool on the right side of the patient, his right arm back of the pa- 
 tient's neck, holding the gag in the left side of the patient's mouth, while 
 his left hand supports and controls the patient's head from underneath, the 
 hand resting upon his (the assistant's) knee, which is elevated to the 
 proper height by a footstool or by crossing one knee over the other, de- 
 pending upon the height of the table. In this position the second assistant 
 can do his duty without undue fatigue during a prolonged search or opera- 
 tion. As before stated, the second assistant is the most important factor 
 in the work. His work is fatiguing and he should be made as comfort- 
 able as possible. The holding of the gag is a thing that few men ever do 
 correctly. The best gag is Ferguson's, and it must be placed on the canine 
 or lateral incisor teeth, not back on the molars, where it is sure to slip. It 
 
 NURSE 
 
 STRUMENT 
 TABLE 
 
 
 I'.' ASSISTANT 
 
 
 
 OPERMOR 
 
 :V ASSISTANT j 
 
 ^ 
 
 OPERATING 
 TABLE 
 
 ane:sthetist 
 
 Fi(i. 41. — Direct laryugoscopy. tiMrlii'ij-ljnmi-hoscuii.v. esopliagoscopy. gastro.'iooiiy. 
 Patiei.l itoi'mbent. 
 
 is placed on the side of the mouth opposite to that through which the tube 
 is passed. 
 
 In order to take the jihotograph tlie operating room arrangement was 
 disturbed. It is shown diagrammatically in Fig. 41, and it is very essential 
 that this arrangement be strictly follov\'ed, otherwise all will b^chaos with 
 the long instruments needed in upper tracheo-bronchoscopy. The duty of 
 the first assistant is to pass instruments, always in position for insertion. 
 The nurse works the aspirator, refills sponge -holders, and cleans the in- 
 struments.
 
 ANESTHESIA. 47 
 
 The anesthetist stands upon the left side of the patient and wlicther 
 giving the anesthetic or not. must keep the hp of the patient away from the 
 edge of the teeth with the loft forefinger. This duty cannot he performed 
 hv the second assistant with a recumbent patient. 
 
 Anesthesia. The examination of the bronchi is perfectly feasible un- 
 der cocain anesthesia. especiall\- if a large dose of morphin be given: 
 the morphin adding courage, rather than anestliesia : but except in dysp- 
 noeic cases the author prefers chloroform, and in any case he considers 
 morphin, with its prolonged alx>lition of the cough reflex unsafe. The 
 cough reflex is the watch-guard of the lungs, by which infective or dele- 
 terious materials are removed. 
 
 Cocain is first applied as described when writing of direct laryn- 
 goscopv. 
 
 After the glottis is passed, the tracheal antl bronchial mucosa are 
 anesthetized a portion at a time in stages as the tulx^ is advanced, using 
 cotton, or as the author prefers, gauze, sponges. 
 
 Chloroform is given in the usual way on an Esmarch i'.ihaler until the 
 patient is fullv under its influence. Then the split spatu'.a is inserted and 
 the lar>nx is mopped with 20 per cent cocain solution. It is often pos- 
 sible to anesthetize the trachea also thus through the tube spatula with a 
 long applicator. After the bronchoscope is passed the cocain solution is 
 apiilied to the tracheal and bronchial mucosje from time to time. In this 
 way a minimum amount of chloroform is needed and the cardiac stimu- 
 lant effect of the cocain is a safeguard of value. 
 
 After the bronchoscope is passed the chloroform is dropped upon a 
 gauze sponge held intermittently in front of the tube, for but little air is 
 taken in past the tube which is clamped in the glottis by the reflex spasm 
 of the adductors. 
 
 The preliminary use of atropine to lessen secretion as suggested by 
 Ingals is a good, safe procedure. It has the additional advantage of pro- 
 tecting the circulation from shock. Adrenalin assists in this and also m 
 lessening the mucosal swelling. 
 
 Passhi^ the broiicliosrope. The author's first work was done by 
 passing the bronchoscope witli the left forefinger as a guide and fulcrum 
 upon which the tube was ti;rncd into and through the glottis by a rocking 
 motion. Tlie pilot was in situ and was removed as soon as the glottis was 
 passed. When Killian devised his ingenious split tubular spatula, the sim- 
 pler method was followed. At present the author uses the split speculum 
 shown in Fig. 7, one battery cord being attached to it and one to the bron- 
 choscope. 
 
 The method is briefly as follows : The separable speculum is passed 
 in precisely the same way as is the tubular speculum, as described under
 
 48 FASS/XG THR BRONCHOSCOPE. 
 
 direct laryngoscopy. After the glottic aperture is brought fully into view, 
 the patient, if under local anesthesia, is told to take a deep breath and when 
 the cords separate the well greased bronchoscope without a mandrin, with 
 tubing unattached, is pushed in. .\fter passing the glottis the aspirating 
 tubing is attached if necessary, which it rarely is. 
 
 The patient does not always take the deep inspiration at command 
 because the glottis is closed by a spasm of the adductors, due to a reflex 
 from the presence of the instrument. He may be making violent efforts 
 to draw in a deep breath, but cannot do so. Slightly withdrawing the in- 
 strument and a quiet reassurance of the patient by the operator usually 
 relaxes the spasm. It is less likely to occur if the laryn.x is well cocainized. 
 
 If a general anesthetic be used, of course the patient cannot be told to 
 take a deep breath ; but anyway it is needless, as the rythmic respiratory 
 movements of the cords are watched and the bronchoscope inserted just as 
 they are on their inspiratory abductive excursion. The tube mouth should 
 not touch the cords until it is thrust through. 
 
 The split tulnilar spatula is used in its illuminated form, but the light 
 of the bronchoscope may be used by simply holding it in place within the 
 tubular speculum with the right hand to show when the glottis is exposed 
 to view by the energetic lifting of the split tubular spatula held in the 
 left hand. The operator's eye is held at the bronchoscope, which is then 
 passed by sight. 
 
 The latter plan is necessary when a double battery is not used. The 
 mandrin is not used, and the battery cord is attached to the bronchoscope 
 from the beginning. In the first described plan one battery cord is used 
 on the separable speculum, and another cord on the bronchoscope. In 
 either method, after the bronchoscope mouth has passed the larynx, the 
 spatula is separated and removed. (See schema, page 53.) 
 
 Once past the glottis, the entire bronchial tree is easily explored. 
 
 The left bronchus, which deviates more obtusely from the trachea 
 than the right, is no more difficult to enter with the tube than is the right. 
 The right upper lobe bronchus is perhaps the most difficult. 
 
 To explore the right bronchus the tulie is moved to the left angle of 
 the moutli, and the head and neck of the patient are moved slightly to the 
 left. The amount of elasticity of the bronchial tree is astonishing. 
 
 Care must be taken to see that there is always a free passage for air. 
 As shown by Killian if the bronchus examined is occluded by a foreign 
 body, the other bronchus being shut off by the passage of the tube, will 
 leave the patient without air. 
 
 In passing Killian's tubes the Kirstein headlight should be first care- 
 fully focused and then adjusted before the eye. Then the tube should be 
 warmed, as, if cold, the polish of the interior of the tulic will be dimmed
 
 TR.ICllliU-BKUXCIIUSCUry 
 
 4SI 
 
 by the condensation of moisture from the patient's i)reath, wliich will se- 
 riously interfere with the amount of liijht that will reach the nhject at the 
 distal'end of the tube. Much of the li,i;ln that reaches ihe hntmm ni the 
 tube is not tlie direct rays but the rays ret1ecte<l from wall t.> wall one or 
 more times in the length of the tube. I'or this reason, also, the interior of 
 the tubes must be kept cleaned of secretion and blocd as thonni-hly as pos- 
 sible during the examination. 
 
 .\11 tubes, of whatever kind, should he lubricateil with vaseline. A 
 jelh- lubricant soluble in water is not satisfactory. In the use of the unil- 
 iuniinated tubes particular care should be taken that none is allowed to get 
 upon the interior walls, as this will diminish the illumination of the object. 
 Particular care is necessary to see that a Mirplus does not get upon the far 
 end of the tube where the wididrawal of the swabs will carry it into the 
 
 tulie. 
 
 Another method of jiassing the unillummated bronchoscope is witn 
 the aid of a catheter-like mandrin which is longer than the tube and pro- 
 jects bevond the tube, acting as a pilot. As soon as the catheter passes the 
 glottis, the tube is pushetl on past, also, and then the catheter is (piickly 
 withdrawn. Sufficient air passes through the catheter to prevent inter- 
 ruption of respiration. 
 
 It may be in some cases advisable to have the tongue drawn forward 
 out of the mouth during the introduction of a tube. The author has not 
 found this necessary except m a few instances, even before the use of the 
 separable spatula. A rocking motion of the tube, throwing the distal end 
 of the tube forward and the proximal end backward, using the end of the 
 left index finger as a fulcrum has always served the author better than 
 drawing out the tongue or pulling it forward with the Kirstein spatula. 
 Much depends upon the operator's training. Those accustomed to intuba- 
 tion will find their index finger the best guide. The separable tube spatula 
 has. however, rendered all other methods difficult by comparison. Thor- 
 ough masterv of direct laryngoscopy renders bronchoscopy easy. 
 
 An absolute essential in the use of unilluminated tubes is the skillful 
 technical management of the headlamp or handlamp. Many of the utter 
 failures to get results with these tubes is due to faulty management of the 
 Kirstein headlamp. 
 
 Adjustiiii^ the Kirstein headlamp. I'irst the hood (L l-'ig. i ) should 
 be removed, the mirror (S) and lens cleaned and polished, and then the 
 rheostat run up to the point where full illumination is secured, yet not so 
 high as to burn out the lam]i or materially to shorten its life. This point 
 should be learned bv demonstration if possible. It may be described as 
 the point where the filament seems to thicken and grow white, bcuinning 
 to lose the vellowness of its earlier and weaker stage of illumination.
 
 50 TRACHEO-BRONCHOSCOPY. 
 
 The next step is to focus the rays. The ho<jd (L) should be moved 
 upward and downward until the proper focus is found, which is when the 
 rays are parallel as shown by the disk of light thrown upon the hand held 
 up in front of the light and moved backward and forward. The disk 
 should grow neither larger nor smaller as the hand is moved. Pushing 
 the hood upward diverges the rays, and pulling it downward converges 
 them. If pulled too far downward the rays cross over, which is a disad- 
 vantage. Most lamps will not permit of pulling down this far ; in fact, 
 many lamps upon the market are made so short that the hood will come 
 clear off before parallel rays are obtained. 
 
 Having obtained a good strong light and parallel rays, the headband 
 is adjusted to the head and the hole in the lens is brought directly in front 
 of the pupil of the right eye. Closing the left eye, the operator looking 
 through the hole witii the right eye adjusts the mirror until the image of 
 the light can be seen upon the palm of the hand. This assures parallelity 
 of the illuminating and the visual axes. This is absolutely essential, for 
 while the walls of the tube, if highly polished and undimmed, will reflect 
 the rays obliquely backward and forward until they reach the object, yet 
 the walls in use are always more or less dimmed by condensation and se- 
 cretions resulting in loss of light. Further, with tubes of small diameter, 
 relatively so few rays enter the tube that if there is even a little loss the 
 object is verv feeblv illuminated. If in addition, more light is cut otf by 
 the introduction of instruments total darkness results. 
 
 No second person can put the headlamp on one's head like one"s self. 
 Therefore it should be put on and all adjustments should be made before 
 the hands are sterilized. [Minor adjustments constantly necessary in work, 
 and the turning oft' and on of the switch (A. E. Fig. i) if the cords be 
 fitted with one, can be made with a bit of sterile gauze or a towel, held in 
 the fingers. 
 
 Lozver trachco-broiiclioscopy. Dorsal dcciihitits. This ditters from 
 upper tracheo-bronchoscopy chiefly in operating room detail, and in the 
 much greater ease of its performance, especially in the hands of the inex- 
 perienced. 
 
 If the wound be made expressly for tracheo-bronchoscopy, all bleed- 
 ing is stopped. If a previously tracheotomized case is to be examined, the 
 wound is cleaned. In either case a Trousseau dilator is intro- 
 duced and the trachea swabbed with a 20 per cent solution of cocain. 
 After waiting a few moments for anesthesia to take place, the patient's 
 head is turned slightly to the opposite side and the bronchoscope is intro- 
 duced from the right side for the exploration of the left bronchus and vice 
 versa. The bronchoscope is passed carefully by sight until the bifurcation 
 is reached. As soon as the desired main bronchial opening is entered,
 
 SELECT I OS OE TUBES. 51 
 
 cougli su])crvcnes because the anesthetic has only been api)lie(l to tlie tra- 
 chea. A swab nn)istene(I with lo per cent cocain solution is passed dcjwn 
 and the nuictxsa swabbed. At the secondary and tertairy bifurcations the 
 cocain application will have to be made, probably in other places. This 
 has to be done whether a f;eneral anesthetic is used or not, as ether is con- 
 tra-indicated and chloroform anesthesia alone cannot safely be maintained 
 at the depth necessary totally to abolish the cough reflex for anv length of 
 time. Cocain or morjihin may be given hypodermatically. 
 
 Selection of tubes for the particular ease. In regard to the sizes of 
 tubes required for a given case, it may be stated that for lower trache- 
 oscopy a tube 8 mm. x 20 cm. will be required for adults, and 5 mm x 14 
 cm. for children. For upper .tracheo-bronchoscopy a tube 7 mm. x 45 cm. 
 will be needed for adults and 3 mm. x 20 cm. for infants. In older chil- 
 dren a 7 mm. x 20 cm. tube may be used. It is, of course, a great desid- 
 eratum to use the largest possible tube. Fortunately the trachea and 
 bronchi are dilatable so that the tube need not be nuich smaller than their 
 diameter. But. of course, it nnist be remembered the size diminishes with 
 each bifurcation. When a bronclius of such small caliber is reached that 
 It is not wise to push the tube further, a smaller one should be introduced 
 
 C = t f-. 
 
 Fio 42. — Inner bronchoscopic tube, for insertion throusb a larser tube wlicn tlie 
 la Iter has reached as far as its size -will permit. 
 
 through the first. This inner tube (Fig. 42) may be pushed 4 or 5 centi- 
 meters further, which will serve to reach the periphery of the lung. 
 
 For instrinnentalion it is always of great advantage to use the largest 
 possible tube. 
 
 Tracheotomy. For lower bronchoscopy the tracheotomy should be a 
 low line; the lower the better. Xot so much for the shortness of the tube 
 thus rendered possible, but because the chin is so much less in the wa\'. 
 When necessary, however, it is feasible to tracheoscopize through the high- 
 est of tracheotomy woinids. The author has moie than nnce tracheoscopi- 
 cally examined the trachea through a thyrotomy woiintl that did not ex- 
 tend into the cricoid cartilage. 
 
 The dangers of tracheotomy may be minimized by attention to the 
 following details : 
 
 The technic of both the tracbtotimi}- and the bronchoscopy must be as 
 near absolute asepsis as it is possible to make it. 
 
 The patient, diuMn^' the operation and for 12 hours afterward, nuist
 
 52 TRACHEOTOMY. 
 
 be kept in a semi-Trendelenburg position. That is there must be no pillow 
 and the foot of the table, and later the foot of the bed, must be raised. 
 
 The tracheotomy wound must not be stitched except perhaps one 
 stitch at the extreme upper and lower angles. T'he tracheal canula should, 
 if possible, be abandoned before the patient leaves the warm, moist air of 
 the operating room. The wound should be packed with gauze w rung out 
 of mercuric bichloride solution i :50oo, and it should be repacked every 3 
 hours. Healing should be allowed to take place from the bottom, making 
 sure of the binding together of the li]is of the tracheal wound by fibrous 
 tissue before the more superficial portions of the wound are allowed to 
 close. If this be not done fungating granulations from uncovered cartilage 
 will intrude into the trachea for a long time (see Fig. 12, Plate 11).
 
 Mt»a»»t( iwc'ji.^ M-o.(0 Lt«"-. ■B;wowot « wjiiTCN 
 SCHEIE LLUSTHAnNO UPPER TliACHEO- BRONCHOSCOTV.
 
 CHAPTER V. 
 Direct Laryngoscopy for Diagnosis and Treatment. 
 
 By laryngoscopy ordinarily is meant the examination of the image of 
 the larynx as seen in the laryngoscopic mirror, by whose aid the interior of 
 the larynx is illnmhiated. 
 
 By direct laryngoscopy is meant the direct inspection of the interior 
 of the larynx without reflection of the image. 
 
 In order to do this, the base of the tongue and various structures 
 above the larynx must be held out of the way, and the head must be 
 thrown backward, in the manner described in the preceding chapter. 
 
 In general it may be stated that direct laryngoscopy for diagnosis and 
 treatment is justifiable in all cases: 
 
 hirst, where these ends are not satisfactorily attained with the lar- 
 yngeal mirror ; and 
 
 Second, where the gravity of the disease renders it our duty to use 
 every means to aid our patient. 
 
 This is a conservative statement based upon the present state of prac- 
 tice. The author believes the near fututre will see the tubular speculum in 
 use for the routine examination of the larynx and upper end of the esoph- 
 agus. 
 
 Dangers and Contr.v-indicatuixs 
 
 It may be stated that the danger of direct laryngoscopy, per sc, under 
 local anesthesia in the normal larynx is nil ; and that absolute contra-indi- 
 cations are few. In cases with extreme dyspnoea from laryngeal stenosis 
 there may exist indications for tracheotomy without the laryngoscopy, and 
 it is in the hope, well founded, of obviating this operation that laryngos- 
 copy is attempted, as in a number of cases in the author's practice, some of 
 which are herein reported. It may, therefore, be stated that the danger 
 arises from the condition calling for the proceedure and not from the pro- 
 ceedure itself. This is predicated upon skillful manipulation, the judg- 
 ment as to when to stop in case laryngeal spasm is excited by the presence
 
 DIFFICULTIES IX DIRF.CT LARYNGOSCOPY. 55 
 
 of the tube, and upon the abilit\ to stab the traclica instantly in case the 
 attempt to avoid the tracheotomy proves unsuccessful. If no one is pres- 
 ent who can do this, severe dyspnoea is a contra-indication. The gagging 
 and atteni]3ted vomiting excited in those who have sensitive throats if not 
 controllable by cocain, might be a contra-indication in such conditions as 
 aneurysm and those with hard arteries and apoplectic tendencies. 
 
 The author has never yet seen a case in which he deemed it unsafe 
 directly to inspect under local anesthesia or without anesthesia, the larynx, 
 save those that demanded an immediate tracheotomy any way without a 
 direct laryngoscopy. Of course, a general anesthesia introduces a risk of 
 its own in any case, and it is an enormous one in case of dyspnoea. Should 
 respiration fail, it will never be started again, unless the trachea be opened 
 instantly. Delaying a tracheotomy, all the world over, at the present day, 
 is a common, but unjustifiable and unnecessary risk in all kinds of obstruct- 
 ive dyspnoea. 
 
 DlFFICULTIICS. 
 
 Rigidity of the neck, in elderly subjects, or in those suffering from 
 various vertebral diseases, tubercular, rheumatic, traumatic or congenital 
 spinal deformities, is at times a serious impediment by interference with a 
 sufficient degree of extension of the head. 
 
 Spastic iiiiisciilar cniitracfipus in young vigorous subjects with short 
 thick necks, and a good full set of teeth are hindrances, though in most 
 instances the difficulties disappear under general anesthesia. 
 
 Abiiudant secretions are a difficulty with ordinary plain tubes, but 
 with the author's improved drainage system, the nurse pumps away the se- 
 cretion as fast as it reaches the end of the tube. In the absence of this, it 
 is necessary to interrupt the work frequently to insert the drainage tube of 
 the aspirator, and armed sponge holders. The desire to expectorate or 
 swallow, both of which are practically impossible with the mouth gagged 
 open, is the cause of much discomfort to the patient locally anesthetized. 
 
 Cough would be one of the greatest difficulties to contend with, were 
 it not for the fortunate fact that it is usually controllable bv local and gen- 
 eral anesthesia. 
 
 Respiratory difheultics. In wi irking with a local anesthetic patients 
 often struggle so violently to get up that the examination is interrupted. 
 This is due in some instances to excitability or "nervousness," but usually 
 it is due to a sense of suffocation. .\ great deal of trouble and difiicultv will 
 be avoided, if the patient is told beforehand that he will feel as if smother- 
 ing, but that there is absolutely no danger, and that he must have confi- 
 dence in the operator, and take matters quietly and easily. The sense of 
 suffocation in direct larxngoscopy may come from spasm of the larvnx 
 from the presence of the tubular speculum, or from covering the laryngeal
 
 56 DIFFICULTIES IX DIRECT LARVXGOSCOPY. 
 
 orifice with the spatula which is pushed in too far, going behind the cri- 
 coid cartilage. In either case withdrawing the speculum slightly relieves 
 the difficulty. In spasmodic conditions, cocain should be reapplied. If 
 bronchoscopy is to be done, the bronchoscope may be pushed through the 
 cords gently without injury even if they are in a state of spasm, though 
 it is better, usualh', to recocainize and wait. 
 
 In bronchoscopy the respiratory difficulty usually comes from failure 
 to bring one of the breathing orifices of the tube opposite the orifice of the 
 lateral branch which is shut oft' by the tube 
 
 In patients wearing a tracheal canula the absence of glottic breathing 
 sometimes renders the glottis less easy to find. Patients who have had 
 previous laryngeal or tracheal disease involving the cartilages, or who 
 have had operations performed upon the structures are less easy to exam- 
 ine on account of the cicatricial inflexibility. 
 
 Abrasion of the upper Up will frequently cause interruption of the pro- 
 cedure by the patient struggling in frantic efforts to indicate to the opera- 
 tor the cause of the needless pain. 
 
 The foregoing and all other difficulties are readily overcome bv the 
 skill that comes from practice and by quiet, orderly procedure. 
 
 It is always wise to have tracheotomy instruments prepared for everv 
 direct laryngoscopy as well as every tracheo-bronchoscopy or esophagos- 
 copy. Not that they are likely to be needed except in the dyspnoeic cases, 
 and only rarely in these, but it is a good safe routine to drill the nurses 
 into, so that when needed no time will be lost. If this be not done, it is 
 quite certain that when needed they will not be on hand. It is only in gen- 
 eral narcosis that they are likely to be required. It is certain that in serious 
 respiratory arrest occurring in any sort of case, it is often impossible to 
 start respiration without tracheotomy. Indeed, it should be the routine of 
 every operating room to have tracheotomy instruments sterile and readv 
 for every case of any kind in which a general anesthetic is used. 
 
 It is also advisable in all cases of direct laryngoscopy and esophagos- 
 copy to have at hand a small bronchoscope that can be pushed into the 
 larynx in case of respiratory arrest and thus save the necessity for trach- 
 eotomy. If the operator is not facile at jiassing a tube through the glottis, 
 the tracheotomy should be done at once. 
 
 These matters are mentioned as wise precautions that any operator of 
 experience in laryngeal and tracheal diseases will understand and aopre- 
 ciate. As a matter of fact, ordinarily, direct laryngoscopy and tracheo- 
 bronchial or esophageal endoscopy involve no risk of respiratory arrest, 
 and it is hoped that the mention of respiratory arrest will not induce the 
 inexperienced to regard them as serious procedures. 
 
 "It is the unexpected that happens." might be parodied: "It is the 
 unprepared for that happens," though logically unprovable.
 
 DIRECT ]..4Ry\c:oscory for foriugx bodies. --.7 
 
 Direct Laio ncoscoi-v fow I-okkicn IVidiks. 
 Foroio-n bodies in the larynx are in all cases n..rc promptly, more 
 safelv an.lless painfuUv removed by direct than by indn-ect laryngosop) . 
 vh h atter .s now ob;olete for this purpose. Not one n, a dozen cases 
 : a sufficiently tolerant larynx to render feasible the removal o a fore.gn 
 bodv with perfect safetv to his vocal apparatus. In ahno.t all ms ance. 
 foreign bocHes can be removed fron, the larynx without pan. or danger 
 with the aid of the tubular speculum. Tbe exceptions are the cases m 
 which the foreign bodv is sharp or impacted, or in those havmg a danger- 
 ous stenosis from acute edema or the presence of the fore.gn body ,tsel . 
 In' these cases, tracheotomy will occasionally be necessary though much 
 less frequentlv than bv any other method. It should, of course, always be 
 prepared for as a matter of routine, so that when necde.l. everythmg will 
 be at hand for c|uiet. orderlv procedure. 
 
 The technic in general has been considered in a previous cliapter 
 Cocain anesthesia is sufficient in most cases, and general anesthesia should 
 be especially avoided in cases where there is the slightest dyspnoea or 
 
 ''"''porceps of various forms and a hook will be neede.l for the best re- 
 sults in .leahng with every case encountered, though m most cases the for- 
 c;. shown in Fig. .. will be sufficient. In cases such as o coii.s^ 
 similar Hat objects lying crosswise with an edge in each ven rid . a gM 
 angled forceps such as shown in Fig. 25. but with thm and flat, nsteaa 
 of punch shaped jaws, will be best. In a case referred to the author by 
 Dr Crawford, a button was lying not in the ventricles, but cross.i.e be- 
 low the cords, fixed bv the swollen mucosa (Fig. 7. plate I). The dii d. 
 a bov of 14 vears. had been playing with a hard rubber button through the 
 holes of which a loop of string had been tied. While jerking thus against 
 his teeth the center of the button pulled out and the button was aspirated. 
 Violent coughing and deep cyanosis followed immediately but cleared up 
 and recurred e^'erv few minutes for several hours. After one of these 
 paroxvsms. loud whistling breathing was noticed and continued until the 
 patient was seen bv the author the following day. There was shght cyano- 
 sis increased bv exertion. Upon attempting an examination with tlie la- 
 rvn-o«copic mirror the child became so cyanotic that it was feared that im- 
 mediate tracheotomv would have to be done. Upon direct laryngoscopy 
 under cocain anesthesia, the button was seen in the position shown. It 
 was evident that the button had been fixed by the swollen mucosa and that 
 the whistling came from the passage of air through the hole m the center. 
 A hook was slipiied down flatwise in the interarytenoid space until below 
 the button, then turned sidewise and brought up until the point entered the 
 rao-o-ed h-ilc in the center. The button was then pulled against the end of
 
 58 DIRECT LARYXGOSCOPY FOR DISEASED CONDITIONS. 
 
 tlie tulie. turning edgewise as it came upward. Then tube, hook and but- 
 ton were pulled out as one piece. The child made a good recovery with- 
 out impairment of the voice. 
 
 As illustrating the advantages of direct laryngoscopy in a very 
 dyspnoeic case of impacted foreign body in the larynx, the following case 
 may be cited : 
 
 Infant G., aged 9 months, a croupy cough, with, slight elevation of 
 temperature. A diagnosis of membranous croup was made by an expert 
 diagnostician, and antitoxin given. The temperature fell to normal but 
 the croup\- cough persisted for a month and other advice was sought by 
 the parents who suspected that a piece of egg shell with which the child 
 had been playing had lodged in the throat. Dr. ^loyer and Dr. \\'echsler. 
 who each saw the case independently, made a probable diagnosis of foreign 
 body in the larynx, in spite of a negative radiograph by an expert Roent- 
 genologist, and referred the case to the author for exploration. On ad- 
 mission cyanosis and dyspnoea forbade a mirror examination, and even 
 cocainization was not attempted. Upon passing the tubular speculum a 
 fragnnent of egg shell was seen on edge lying between two edematous 
 masses as shown in Fig. 6, Plate I. It was quickly removed with forceps, 
 and the child watched all night in anticipation of the need of a trache- 
 otomy, which, however, was not required. In a few days the perichron- 
 ditis and mucosal ulceration set up by the month's sojourn of the egg shell 
 in the infant larynx had subsided. This case points several valuable les- 
 sons. It is unwise for any practitioner persistently to reassure patients 
 or their relatives with the statement that there is no foreign body present 
 and that if present it could do no harm. Strange as it may seem, it is the 
 custom with many practitioners to oppose not onl\- a search for a foreign 
 body but its removal, when found. TTiis course is a relic of the days 
 when attempts at removal were crudely and blindly made. The other 
 lesson tatight by this case is that when symptoms point to a foreign body, 
 it is better to explore even if the radiograph by an expert Roentgenologist 
 be negative. More will be said in a future chapter on this subject. 
 
 Direct Laryngoscopy for Diseased Conditions. 
 
 In inalignaiit diseases of the larynx, direct laryngoscopy is of the 
 greatest utilitv for diagnosis. The naked eye diagnosis is greatly aided, 
 and the taking of a specimen instead of being a difficult uncertain groping 
 procedure, is done with a precision and a nicety that makes direct laryn- 
 goscopv a necessary procedure with the laryngologist. The cup-shaped 
 or punch-like jaws should be used in the forceps for this purpose, and 
 where possible the piece bitten out should include both pathologic and ap-
 
 DIRECT LARYXCOSCOPy I'OR DISEASED COXDI'I lOXS. •')» 
 
 parently normal tissue; in oUkt words, it should be taken from the b irder 
 of the growth. 
 
 The diagnosis of paralyses is better made with the old indirect meth- 
 od of laryngoscopy, for the pressure of a laryngeal speculum interferes 
 somewhat with motility in certain individuals. \\'ith this exceptiim. how- 
 ever, the diagnosis of all laryngeal diseases is greatly facilitated by direct 
 laryngoscopy. In children, indirect laryngoscopy is often difificult, and at 
 times it is impossible to see beyond the epiglottis. ( )f course, when anes- 
 thetized, indirect laryngoscopy is easily carried out in children, it the 
 tongue is drawn out with a piece of silk worm gut passed througli it. The 
 great disadvantage is that most diseases of the larynx in children are ab- 
 solute contra-indications to anesthesia. Local anesthesia is usually suffi- 
 cient for direct laryngoscopy. \'ery unruh^ children \vill have to be held 
 firmly, as the procedure may terrify, though it is not painful in the )ciung. 
 whose tissues are always yielding. The reflex C(iughing and gagging 
 make it seem to the onlooker a desperate procedure, and relatives should 
 always be excluded from the room. 
 
 For the treatment of malignant disease, endolaryngeal methods are, 
 in the author's opinion, absolutely contra-indicated in the present state of 
 our knowledge. Some day a therapeutic cure will he discovered, and 
 should that c'u-e be by topical application direct laryngoscopy will 1:)e the 
 method of applying it. tint at present, direct laryngoscopy is of aid cinly 
 in the diagnosis. 
 
 Benign iicoplasins oiler a wide field for not only the diagnosis bat for 
 treatment with the aid of direct laryngoscopy. 
 
 Papillomata in adults may be removed with good chances of com- 
 plete cure, at a single operation. The serrated jaw forceps (Fig. 22) 
 should be used for pedunculated growths, following with the cup-shaped 
 jaws (Fig. 24) with which the entire base should be bitten out along with 
 some normal tissue. In some cases the lar\-ngeal speculum is not suffi- 
 cient and the tracheoscope will have to be passed, as the growth, though 
 presenting above the cords, has a long pedicule springing from a sub- 
 glottic portion of the larynx. The best procedure in subglottic cases 
 often is to push the tracheoscope on past the growth and then tci withdraw 
 it until the growth drops in front of the tube. 
 
 When springing from the anterior angle of the lar\nx at or above the 
 cords, the most skillful technic is necessary to extiq^ate the growth by di- 
 rect laryngoscopy under local anesthesia in an adult. In a young, vigor- 
 ous, muscular adult, all the anterior cervical muscles are thrown into a 
 state of tetany by the reflexes, and the liyoid bone and attached tissues do 
 not yield readily to pressure unless relaxed by general anesthesia. The 
 curved jaws, (Fig. 23) turned to point upw'ard, are very convenient for
 
 60 DIRECT LARYNGOSCOPY FOR DISEASED CONDITIONS. 
 
 removing- growths from the anterior angle, or hetter still the punch jaws 
 ( Fig. 25 ) . For other locations, intrinsic and extrinsic, the instruments 
 of Moslier. (Fig. 5) designed for the upper end of the esophagus, are 
 convenient for use through the laryngeal speculum. 
 
 Papillomata in children may be very readily removed from any por- 
 tion of the larvnx. and usually under local anesthesia. They are almost 
 certain to recur, so that many sittings are necessary. In one case a girl 
 of four years, the author removed recurrent multiple papillomata twenty 
 times anil the end is not yet near. Tracheotomy is not necessary, if the 
 growths are small, but should always be prepared for. The wearing of a 
 trachc(itiim\- canula is supposed to inhibit growth and retard recurrence. 
 Thyrotoniy is absolutely contra-indicated for pajMllomata in children, and 
 the best method known to-day is repeated endoscopic removal with or 
 with( )Ut tracheotomy. 
 
 ( )ther benign laryngeal neoplasms as fibromata, angiomata, edema- 
 tous pohpi. lipomata, chondromata, cysts, etc., are- very satisfactorily 
 treated tliror.gh the direct laryngeal speculum. 
 
 Singers nodes are also amenable to local direct treatment. 
 
 Larviii;cal tuberculosis occurring as a complication of pulmonary or 
 general tuberculosis, or in the form of a local lesion as lupus, or as a chronic 
 tubercular abscess of a crico-arytenoid joint, may be treated medically and 
 surgically by direct laryngoscopy, and with a precision possible in no 
 other wav save by thyrotomy, which will not often be required by the pa- 
 tient of the facile direct laryngoscopist. 
 
 Iiiflauiiuatory diseases, especially in their edematous phases, have 
 never been handled with the facility now possible. At the Eye and Ear 
 Hospital, in a number of very severe cases which ordinarily would have 
 been tracheotomized at once, the author made a dozen punctures in the 
 edematous tissues in less than a minute with the knife (Fig. 29) evacuat- 
 ing the serum and curing the cases promptly and safely. A bronchoscope 
 was kept at hand so that should asphyxia threaten, it could be pushed 
 through the glottis and thus relieve the dyspnoea ; but the necessity did 
 not arise. Alan\- less urgent cases have been quite as satisfactorily dealt 
 with. 
 
 /;/ abscess of tlie larynx , following edematous laryngitis or other 
 ■ acute or chronic cause may be evacuated with precision and without risk 
 to local structures or to life. 
 
 Cicatricial Stenoses of the larynx consisting of fibrous webs, adhe- 
 sions, and cordal synechise when not complicated by defomiity from car- 
 tilaginous necrosis, are best treated by endoscopic incision of the cicatrices, 
 followed by prolonged intubation. The author has successfully treated a 
 number of such cases following typhoid fever, erosions from prolonged
 
 LARYSGIIAL PARALYSES. <il 
 
 sojourn of fiircii;n l)i)clics and intubation tubes, etc. \\ iu-n iiniluui^fil in- 
 tubation is to be used after tbe incisiiMi of cicatrices, the tul)e should be 
 removed everv 5 or 6 days lest concretions on the tulx-s lead to ulceration 
 and fresh cicatrices. This is less likely to happen with hard rubber in- 
 tubation tubes. 
 
 Laryngctil Paralyses. For the galvanic and Faradic treatment of 
 laryngeal paralyses the author has devised a monopolar electrode (Fig. 43) 
 with which applications may be made with nicety to the various muscular 
 groups and it is a beautiful sight to see the muscles work thus at the ope- 
 rator's will. This, of course, is onlv possible in recent conditions prior 
 to atrophic change, and must be done with cautinn in untracheotomized 
 cases. In a case of bilateral abductor paralysis sent to me by Dr. F. D. 
 Johnston, the muscle play was beautiful, but the muscles eventually lost 
 their electro-excitability after going through an increased excitability, 
 followed by a period in wliich they showed a reaction of degeneration. 
 This case had been previous!}- tracheotomized bv the author for dyspnoea. 
 In a case not tracheotomized due caution must be exercised. 
 
 The rules and indications for the application of galvanism and Far- 
 adism, strenglh of current and nther matters are not within the scope of 
 
 E^ 
 
 Fi(i. 4.". — .Mnii.niular l.ii-yuiifal elf (-•trade for (iah aiii.-iii and Fai-ailism. 
 
 this work. Fndoscopic applications, of course, follow the satne rules as 
 apply to applications by the difficult, uncertain, indirect method with 
 curved electrode and laryngeal mirror. 
 
 The technic is simple. The one pole (positive or negative, as de- 
 sired) is apjilied with a "sponge" electrode held Iiv a luirse to the neck 
 externally, while the operator touches the desired piiiiit with the monopolar 
 endo-laryngeal electrode under direct inspection through the tubular 
 speculum. A hi-polar instrument has also been used bv the author, en- 
 abling the use nf both poles within the larynx. Its application is not 
 much more difficult, but it has not \ielded any better results than follow 
 rnono-polar endolaryiigeal ap])lications. In all forms of recurrent paral- 
 yses, the external electrode should be aiijilied on the course of the recur- 
 rent as low in the neck as possible. 
 
 In sensory laryn(;cal neuroses as anesthesia. Iiyperesthesia, and pares- 
 thesia the local application of the Faradic and the cnnstant currents are of 
 great thera])eutic value. Tliey can be applied to the pyriform fosss in 
 close proximity to the course of the superior laryngeal nerve with the elec-
 
 fi2 RETROGRADE LARYXGOSCOPY. 
 
 trode (Fig. 43) passed through llic laryngeal speculum. In paresthesia 
 the same application is useful. 
 
 For the a['pUcation of the cautery, electric or cheniicai. the tubular 
 speculum lends itself as a most necessary aid. Personally, the writer's 
 experience is not very favorable with these agents, however applied, but if 
 used at all. it should be by the direct method. P.e the apparatus ever so 
 ingeniouslv devised and the operator incomparably facile, the indirect 
 method is at best uncertain, and the apjilication is apt to be made where 
 not wanted. 
 
 Congenial! icebs of the larynx, while not strictly diseased conditions, 
 mav be considered here. They are quickly and accurately dealt with 
 endoscopically, using the straight laryngeal knife ( Fig. 29) and making 
 such incisions as ma}- be planned for the particular case. In some in- 
 stances, it may be necessary practically to carve out and form a cord or a 
 pair of cords. 
 
 r'ld. 44. — GahaiiO-eaiitory electrode for use lliroiigU the tiiliiilar siieeuliim. 
 RliTROGRADE L.\RYXGOSCOPV. 
 
 In mam- instances valuable information can be obtained by looking 
 upward at the larvnx from below. It should be a matter of routine thus 
 to examine everv case requiring tracheotomy for laryngeal obstruction. 
 The cords mav be seen to move beautifully where there is no paralysis or 
 fixation. The lesions of inflammation, syphilis, tuberculosis, typhoid 
 fever, diphtheria, etc.. are revealed. \\'hile these are not so often infra- 
 glottic as supra-glottic, yet they occur and should be sought for. In two 
 instances the author has discovered a malignant infiltration that had es- 
 caped indirect laryngoscopic observation from above by the good laryn- 
 gologist attending the cases. Obviously it is only called for when the 
 tracheotomy wound is low, not extending to the thyroid cartilage. 
 
 The method is simple. A short tracheoscope ( 5 mm. x 14 cm. for a 
 child. 8 mm. X 20 cm. for an adult), is inserted in an upward direction, 
 after cocainizing; the mucosa.
 
 CHAPTER VI. 
 
 Anatomy of the Tracheo-Bronchial Tree, Topo- 
 graphically, Radiographicaliy and Lndos- 
 copically Considered. 
 
 An absolute essential to the best work in a difficult case is a knowl- 
 edge of the anatomy of the tracheo-bronchial tree as seen from the inside 
 in the living. 
 
 For this purpose the anatomical works afford little help. To begin 
 with the illustrations are upside down for the tracheo-bronchoscopist work- 
 ing on the recumbent patient ; and, further, the older works are in some 
 instances absolutely erroneous. 
 
 A brief synopsis is all that comes within the scope of the present 
 work. For further anatomical details the student is referred to the ca- 
 daver. Tlie bri mchoscope has opened up a large field for original work 
 in practical broncho-pulmonary anatomy, normal as well as pathologic. 
 
 The trachea just below its entrance into the thora.K deviates slightly 
 to the right, to allow room for the aorta. At about the level of the second 
 costal cartilage in adults, the third in children, the trachea bifurcates into 
 the right and left main bronchi. This corresponds to about the fourth or 
 fifth thoracic vertebra, the trachea being elastic and displaced by various 
 mo\'emcnts. These landmarks are of ^/aluc in tlie interpretation of radio- 
 graphs. 
 
 The non-bran(-hcd part of the right main brnnchiis is steeper and 
 shorter and wider than its follow of the opposite side, and is praclicalh- 
 the continuation of the trachea, while the left might be considered as a 
 branch. This is seen in Figure 45. The right bronchus gives ofif first 
 the superior lobe bronchus, (SL), then the middle lobe bronchus, (ML), 
 the continuation downward being the inferior lobe bronchus (IL), Tlie 
 superior lobe bronchus is the only bronchus classed as eparterial : that is 
 given off above the crossing of the pulmonary arteries. .Ml the others 
 come off below the crossing and are classed as hvparterial.
 
 64 
 
 TRACHEO-BROSCHIAL TREE. 
 
 TIk- k-ft main hn melius gives off first the superior Inhe lironehus 
 (SL). the eontinuation being the inferior lobe bronchus (IL). 
 
 The bronchial branches are classed into dorsal and ventral groups, 
 four in each group. This is by no means constant. An occasional anoni- 
 oly is a fifth right lironehus sometimes called a cardiac bronchus. The 
 ventral branches are usually the longer. 
 
 As just mentioned, the bifurcation of the trachea is at the level of the 
 intervertebral disc between the fourth and fifth dorsal vertebne : and the 
 anterior landmark is. in adults, the second right chondro-sternal articu- 
 lation. In a child of 2 vears. on account of the more nearly horizi.mtal 
 direction of the ribs, the level is that of the tliird chondrosternal articu- 
 lation. \Mien the patient is between two years and adult life, the point 
 must be estimated pro rata. 
 
 Fig. 4.J. — Traclii'u-liroiiiliinl (n^e. 
 LM. Lffl main bronchus: S L. SupciMdi' \i<W lu-oiieluis 
 bronclui.s : 1 L, Infenor lobe bronchus. 
 
 M L. Midillf Iobc> 
 
 The bifurcation is usually a little to the right of the medium line : 
 about half way between the vertical center line of the sternum and its right 
 border. This varies, of course, though slightly, with the position of the 
 body and with the respiratory movements. 
 
 Tlie deviation of the right bronchus is usually about ly . and its 
 length unbranched. measured from the bifurcation, is about j.5 cm. The 
 deviation of the left bronchus is about 75°, and its length is about 5 cm. 
 These angles and distances laid off, upon a radiograph, from the bifurca- 
 tion as indicated by the landmarks just referred to, will give the location
 
 TRACH EO-BKOX C H I AL TRUE. fi5 
 
 of the first branch of the respective main bronclii. These are the land- 
 marks most important radiographically, and for the lateral plane, they are 
 fairly constant and very satisfactory, both for the location of foreign bodies 
 and diseased areas at or above these points. For localization below, they 
 are accurate enough, so far as the lateral plane is concerned, but beginning 
 with the first branch of the bronchi below the bifurcation, the anteropos- 
 terior plane has to be studied, and here the radiograph is not of much aid 
 on account of the distance the rays must pass through the body before 
 reaching the plate, in attempting to take a lateral view of the thorax. 
 However, having localized a foreign body or diseased area in reference to 
 the tracheal bifurcation and the first branch of the main bronchus, we will 
 have accomplished all that is needed in the majority of cases, and in in- 
 stances of involvement of even the deepest bronchi, we will have reduced 
 the area to be explored to very narrow limits. Much remains to be ac- 
 complished in the topographic, radiographic, and endoscopic study of the 
 finer subdivisions of the bronchi and their relation to peripheral lung 
 areas. 
 
 Dimensions of the traeliea and bronelii. While the lumen of the in- 
 dividual bronchi diminishes as they bifurcate the sum of all the areas 
 shows an increase of total tubular area of cross section. Thus, the sum 
 of the areas of cross section of tiie two main bronchi, right and left, is 
 greater than the area of cross section of the trachea. The same is true 
 of each bronchial branching. TTiis follows the well known dynamic law. 
 The relative increase in surface as the tubes diminish in size increases the 
 friction of the passing air, so that an actual increase in area of cross sec- 
 tion is necessary. This is a fortunate thing for the tracheo-bronchoscop- 
 ist. If the area of cross section were cut in half at every bifurcation he 
 would not get as near the periphery as he now does. 
 
 The dimensions of the tracheo-bronchial tree may be epitomized ap- 
 proximately thus: 
 
 Ailult Male. Female. Chilil. Infant. 
 
 Diameter, Trachea 14x20 mm. 12x16 mm. SxlO 6x7. 
 
 Length Trachea 12. cm. Ic . cm. 6. cm. 4. cm. 
 
 Right Bronchus 2.5 " 2.5 " 2. " 1.5 " 
 
 Left " 5. " 5. " 3. " 2.5 " 
 
 Upper Teeth to Trachea 15. " 13. 10. 9. 
 
 Total to Secondary Broiichus..32. 28. 19. 15. 
 
 These dimensions, especially those given in the last line, are subject to 
 wide variations, and are only approximate. Tliey were taken from the 
 cadaver. The diameters do not take into account the dilatability of the 
 trachea and the amount of yielding of the membranous posterior wall. 
 
 When the foregoing table is used as a basis for the selection of tubes, 
 several things must be taken into consideration. The full diameter of the 
 trachea is not available for upper tracheo-bronchoscopy, on account of the
 
 66 TRACHEO-BRONChllAL TREE. 
 
 glottic ajxM'ture which in the atUilt is an cciuilatcral triangle measuring ap- 
 proximately 12x22x22 millimeters, and permitting of the passage of a 
 tube not over ten millimeters in diameter without risk of injury. 
 
 As to length, a number of additional centimeters will have to be al- 
 lowed. The tube must project above the upper teeth for convenience in 
 working. 
 
 As to the length of tube required to reach below the first branch of the 
 bronchi, tubes of 45 cm. and even 50 cm. will occasionally be recjuired, 
 though these very long and necessarily slender tubes are usually introduced 
 inside of shorter and wider ones. In many instances, a view is had, and 
 probes and applicators are passed, beyond the tube so that a full length is 
 not always required. 
 
 The endoscopic appearances of the trachea and bronchi are interest- 
 ing and their study is easily accomplished. The appearance of the inte- 
 rior of the trachea is familiar to all who have used the laryngeal mirror. 
 The interior of the bronchi in the living was never studied until the 
 advent of the bronchoscope. 
 
 As seen in the bronchoscope the trachea is a tube slightly flattened 
 on the posterior wall. It assumes in some instances a greater or lesser 
 tendency to an elliptical outline, the longer axis being variously placed. 
 This is noted more particularly in twV) locations. The upper flattening is 
 in the cervical portion and is due to pressure of the thyroid gland. The 
 lower one is intra-thoracic, just above the bifurcation, and is due to the 
 pressure of the aorta. This flattening is rythmically increased with each 
 pulsation. In children a flattening is occasionally noticed due to pressure 
 of the thyroid gland. In mentioning these flattenings reference is had 
 only to conditions strictly within the limits of health. All these changes 
 of outline may be enormously exaggerated, even to entire obliteration of 
 the tracheal lumen, in diseased states. 
 
 The entire trachea is often seen to deviate slightly, usually toward the 
 left, and occasionally it is seen to deviate first in one direction, then in 
 another, making a slight tendency to an S curve. 
 
 The mucosa of the trachea is moist and glistening, whitish in circular 
 ridges corresponding to the cartilaginous rings, the intervening grooves 
 being reddish. 
 
 At the bottom of the trachea a white shining ridge is seen to divide 
 the trachea antero-posteriorly into two unequal parts. The ridge shades 
 ofif anteriorlv and posteriorly into two reddish triangles. On the left of 
 the ridge is the slanting orifice of the left main bronchus, and on the right, 
 its larger fellow. 
 
 Passing the tube down the right bronchus, a view is presented that 
 differs considerably in different instances. The view shown in Figure 11,
 
 TRACHEO-BROXCHIAL TREE. (57 
 
 Plate II, is from a water color drawing of the right hrcjiicluis of a man 
 25 years of age. In Figure 47 the same view is shown without color. 
 At the right (SL) is seen the orifice of the fi.rst branch, the upper lobe 
 bronchus. Farther down anteriorly is seen tlie orifice of the middle lobe 
 bronchus (M). At the left (1) we look into the depth of the inferior lobe 
 bronchus in which the orifices of ventral and dorsal branches arc seen. 
 
 In Figure 46 is shown a bronchoscopic view of the left bronchus of 
 this same man (see also colored Plate II, Fig. 10). At S is seen the 
 opening of the superior lobe bronchus while th.e entire right of the view 
 shows the inferior lobe bronchus, (really the continuation of the main 
 bronchus) with the 0[)enings of the dorsal and ventral Ijranchcs in more 
 or less perspective. It will be noted that the dorsal and ventral branches 
 are not given ofl:' opposite each other. 
 
 Tlie reference letters are duplicated in the dlustration of the traclieo- 
 
 FiG. 40. Fig. 47. 
 
 Bronchoscopic views. 
 Left bronchus. Right bronchus. 
 
 S. Superior lolic bruiHii.w. 
 S L, Superior lobe bronchus. 
 I, Inferior lobe bronchus. 
 .M. iliddle lobe broiu'hu>-. 
 
 bronchial tree, Figure 45, and it will be found useful to study these to- 
 gether. Not that they are to be taken as accurate representations of con- 
 stant anatomical types, but, rather, as a suggestion as to how the tracheo- 
 bronchial tree is to be studied endoscopically. The illustrations are semi- 
 diagrammatic. 
 
 The mucosa of the bronchi is siniilar to that of the trachea, showing, 
 however, difil'erenccs meriting the closest scrutiny. 
 
 The movements of the trachea and bronchi as observed endoscopically 
 in health and disease are worthy of study, of -which thcv have as yet re- 
 ceived but little. The normal movements may be classified as respiratory, 
 pulsatory, and deglutitory. The two former being rythmic the latter be- 
 ing noticed occasionally, and only in lower tracheoscopy. Various spas- 
 modic and transmitted movements, the true nature of which has not yet 
 been demonstrated, have been noted.
 
 CHAPTER VII. 
 
 Tracheo-Bronchoscopy in Diseases of the Trachea 
 
 and Bronchi. 
 
 The brilliant work in the removal of foreign bodies has led to the im- 
 pression that tracheo-bronchoscopy is useful for this only. The near fu- 
 ture, however, will see the bronchoscope, and even more the tracheoscope 
 and tubular speculum, in frequent use for the diagnosis and treatment of 
 diseased conditions. 
 
 The diseases of the trachea and bronchi in which tracheo-broncho- 
 scopy is useful may be divided into non-stenotic and stenotic. All cases 
 of stenosis of the trachea or bronchi justify tracheoscopy, upper or lower, 
 as may be indicated. Of the non-stenotic tracheal diseases it is chiefly 
 those in which no satisfactory view is obtainable by indirect or direct lar- 
 yngoscopy that will demand tracheoscopy. Of non-stenotic bronchial dis- 
 eases, many that cannot be said at the present day to demand broncho- 
 scopy, certainly should be investigated from a scientific point of view, as 
 thus our knowledge of n:aii}- bronchial and pulmonic conditions will be in- 
 creased. 
 
 Nou-stcnolic morbid conditions of the trachea and bronchi may be 
 tabulated the same as the stenotic diseases, the difference being chiefly 
 of degree. 
 
 In addition, however, there are a number of diseases rarely associated 
 with stenosis. Acu.te and chronic inflammatory conditions of a mild 
 type usually called "catarrhal," objectionable as this word may be, will 
 occasionally demand tracheoscopy when they cannot be examined by in- 
 direct or direct laryngoscopy. Many of the chronic inflammatory condi- 
 tions will require tracheo-bronchoscopy, not only for diagnosis but for 
 treatment of the diseased conditions revealed. Many a case labelled ner- 
 vous cough, and allowed to annoy the patient and relatives for months will 
 be found, when tracheo-bronchoscopized, not only to be due to visible 
 lesions, but to lesions that can be cured.
 
 TRACHEO-BRONCHOSCOPY . 69 
 
 In a case of this kind referred lo mc by Dr. L. W. Swopc, an annoy- 
 ing cough of several months' duration, which had been disturbing rest and 
 producing emaciation, was promptly cured by six direct swabbing appli- 
 cations of argentic nitrate to a non-specific ulcer discovered, at the bifur- 
 cation of the trachea, by tracheoscopy. Ulcerations more deeply seated, 
 as in -inother case of the author's at the bifurcation of a bronchu';, may 
 be discovered and treated. 
 
 Qironic tracheal inflammation, that does not yield to treatment based 
 upon indirect laryngoscopy, justifies direct laryngoscopy or tracheoscopy 
 for diagnosis and treatment. The same may be said of ozena, if necessary 
 for diagnosis, but the results of treatment are so far too discouraging to 
 render it advisable. 
 
 Pus foci near the periphery of the lung may be endoscopically evac- 
 uated or may be localized for the general surgeon to attack externally. 
 Necessarily the cases of this kind of tracheoscopic possibilities will be 
 those in which communications have been established with the bronchi of 
 not too small lumen. Knowing the anatomy and the normal endoscopic 
 appearances, the bronchoscopist starts his tube downward from the trach- 
 eal bifurcation, noting the orifices of the lateral branches as they are 
 passed until a bronchus is reached in which disease products are found, 
 or the walls of which give ocular evidence of disease, as inflammation, 
 perforation, granulation. Specimens may be taken with a mop or aspi- 
 rated into the accessory drainage tube. As orientation is not easy, a 
 radiograph ma}' be taken after blowing in bismuth oxide through a dry 
 extra drainage tube. Abscesses of the lung due to the presence of a for- 
 eign body may be thus localized ; and if the foreign body cannot be re- 
 moved endoscopically, a probe passed through the bronchoscope into the 
 pus focus can be felt through the lung and pleura after the thoracic wall 
 is opened. 
 
 Stenoses of the tracliea may be classified as to their pathologic mech- 
 anism into peri-tracheal, muro-tracheal and endo-tracheal conditions. 
 Bronchial stenoses may be likewise classified. 
 
 In considering peri-tracheal conditions causing stenosis we nnist re- 
 member that the trachea, though not soft as compared with the esophagus, 
 is not a rigid tube. It is very readily compressible, and is subject to the 
 encroachment of cervical and intra-thoracic tumors. Peri-tracheal con- 
 ditions producing stenosis include glandular hypertrophies, glandular 
 (lymphatic) infiltrations, aneurysm, benign and malignant tumors of ad- 
 jacent tissues. 
 
 The great frequency of stenosis from these peri-tracheal and peri- 
 bronchial conditions was not known until the development of- tracheo- 
 bronchoscopy, as in many instances they do not show at autopsy.
 
 70 1 RACHEAL STENOSES. 
 
 Of glandular livpcrtropliics the most frequent is the thyroid. Struma 
 intrudes upon the tracheal lumen much more frequently than was sus- 
 pected until tracheoscopy was extensively practiced. The outline of the 
 cross section of the tracheal lumen may be compressed from before back- 
 ward and to one side as in Figure 2, Plate I, drawn from a case 
 of goitre in a man 36 years of age. Or it may be compressed in addition 
 from behind forward by the retro-tracheal portion of the goitre producing 
 a narrow oval slit, the so-called "scabbard" trachea. 
 
 The long axis of the ellipse is more apt to be at an angle than exactly 
 in the transverse plane owing to the relative frequency of asymmetric 
 Aruma. 
 
 For many years it has been a disputed question as to whether the 
 thymus gland can compress the trachea. It has been the author's privi- 
 lege to demonstrate tracheoscopicallv the error of Friedleben's dictum, 
 "Es gicbt kein asthma thyuiiciun:' 
 
 This case, already reported, is here briefly abstracted : 
 
 Case XXI, Earl L., aged 4, was admitted for dyspnoea and stridi^rous 
 breathing, increasing since the sudden onset of a croupy attack six weeks 
 before. Immediate tracheotomy by the author failed to relieve the dysp- 
 noea, but the passage of a tracheoscope relieved it completely. Tlie walls 
 of the trachea were collapsed from before backward (Fig. 5, Plate I) and 
 they opened up ahead of the tracheoscope like the cervical esophagus, and 
 like those of the esophagus they tended to close on expiration. One of 
 the author's long tracheal canulae was inserted which relieved the dysp- 
 noea, and later held the trachea open while the little finger was passed be- 
 hind the sternum into the anterior mediastinum, and while the thymus 
 gland was thus brought up and removed. The d\spnoea never recurred 
 and a complete cure resulted, without ill eiTect from the absence of the 
 gland. (Fig. 48.) A radiograph by Dr. Russell H. Boggs shows th; 
 hypertrophied gland before operation. (Fig. 49.) 
 
 This case demonstrates the diagnostic value of tracheoscopy in com- 
 pression tracheo-stenoses. In the absence of his long tracheal canulx the 
 author has more than once used a tracheoscope as a temporary canula 
 until one of the latter of proper length could be procured. 
 
 Infiltrated lymph nodes frequently produce stenosis of the trachea 
 and bronchi. Fig. 15, Plate II, shows compression stenosis of the right 
 bronchus thus produced, in a woman of 26 years. 
 
 Benign and malignant tumors of the peri-tracheal tissues produce 
 compression stenoses. Such a case is illustrated in Fig. 9, Plate I, wdiich is 
 drawn from the case of a man, aged 60, in whom an epithelioma of the 
 thoracic esophagus produced a compression stenosis of the trachea. Later 
 the tracheal wall became secondarily involved by extension of the infiltra-
 
 THYMIC TRACHEOSTENOSIS. 
 
 71 
 
 Fig. 4S. — From photograpli of patieut 4 months 
 thymic Iracheo-stei.osis diagnosticaterl tracheoscopically 
 
 after th.vmi'ctom.v. Case of
 
 TRACHEAL STENOSES. 
 
 Fli;. V.) — Tliymic traflieo-stenosis. ItacHograpb sUovviiig gland before operatiou.
 
 TRACHEAL STENOSES. 73 
 
 tion. AFediastinal tumors are frequently the cause of tracheal compres- 
 sion. 
 
 Aneurysm is a not infre(|uent invader of the trachea and bronchi, as 
 shown in Fig. 3. Plate I, drawn from the case of a man aged 50, a physi- 
 cian. The excursion of each pulsation is shown by the dotted line. This 
 pulsatory excursion inward of one portion of the tracheal wall must not 
 be confused with the transmitted cardiac or aortic impulse in which the 
 entire trachea is pushed or tugged aside. A radiograph of this case is 
 repro<luced in Fig. 50. 
 
 In Graves" disease the transmitted pulsations may simulate aneurysm. 
 
 Some observers have seen an aneurysm on the eve of bursting into 
 the trachea. 
 
 \'arious peri-tracheal and peri-bronchial inflammatory conditions, as 
 Ludwig's angina, abscess, etc., and also other states such as emphysema 
 from wounds or disease of the upper and lower air passages also compress 
 the bronchial and tracheal walls, as do also mediastinal diseases occa- 
 sionally. 
 
 ^luro-trachcal and muro-bronchial conditions producing stenosis may 
 be enumerated as : 
 
 1. jNlalignant neoplasms. 
 
 2. Benign neoplasms. 
 
 3. Specific inflammations, 
 
 a. Syphilis, 
 
 b. Tuberculosis, 
 
 c. Glanders, 
 
 d. Typhoid fever, 
 
 e. Diphtheria. 
 
 4. Inflanmiations, 
 
 a. "Catarrhal," 
 
 b. Irritative, 
 
 c. Traumatic, 
 
 d. Operative, 
 
 e. Post operative. 
 
 5.. Ulcerations associated with the foregoing conditions. 
 
 6. Post inflammatory conditions as cicatrices, hyperplasia and ad- 
 hesions. 
 
 7. Vaso-motor disturbances, angio-neurotic edema. 
 
 Benign neoplasms, while not frequent, are seen occasionally by the 
 tracheoscopist and are especially adapted to endoscopic treatment. 
 
 Fig. I, Plate I, shows a papilloma of the trachea in a child of 4 years, 
 under the author's care at the Eye and Ear Hospital. 
 
 Of the specific inflammations, syphilis is by far the most frequent
 
 \ 
 
 TRACHEAL STENOSES 
 
 Fig. 50. — Itadiuyraph showiug location of aneuryrsiu tliat liroiluced tracheal com- 
 pression and recurrent paralysis.
 
 TRACHEAL S'illXOSES. 75 
 
 cause of stenosis, in, first, its edematous and later in its cicatricial stage. 
 Fig. 8, Plate I, is a tracheoscopic view of post syphilitic tracheal stenosis 
 in a man aged 24, referred to me by Dr. Frank Trester Smith. 
 
 In tvi)hrii(l fever as in -lil of the conditions enumerated, the tracheo- 
 scope rnav render valuable M-rvices. By this it is not meant that we should 
 go through the wards of a hospital and pass the tracheoscope on every 
 case of typhoid fever. Bui. to illustrate, a number of the cases of typhoid 
 fever in the Western IViinsylvania Hospital that required tracheotomy 
 were examined by the author tracheoscopically after the tracheotomy. Le- 
 sions were discovered that would be invisible by any method other than 
 tracheoscopv. 
 
 The detailed consideration of diseases of tlie trachea is without ths 
 scope of this work and the subject is briefly alluded to as showing the 
 enormous field of usefulness open to tracheo-bronchoscopy. 
 
 The reader who is interested is referred to the bibliography appended, 
 and in particular to the papers of Rodgers, Simpson and Chiari, on trach- 
 eal stenoses, Theisen uii tumors of the trachea, and Newcomb on diseases 
 of the trachea, and to I lie work of von Schrotter on all of these subjects. 
 
 Cicatricial tracheal stenoses offer a wide field of usefulness for the 
 tracheoscope. These cases formerly were nften very difficult of diag- 
 nosis bv the old indirect mirror method. A tracheotomy occasionally aid- 
 ed, but ver\- often it did not. Now any case of tracheal stenosis may be 
 positively diagnosticated by direct laryngoscopy or tracheoscopy. 
 
 Cicatricial tracheal strictures may be of traumatic, post-operative, 
 post-nlcerative, luetic, tubercular or other origin. 
 
 As examples the following cases may be reported : 
 
 Case \T]I. Pcnn\ in esophagus 2 months. Erosion through into 
 triichca. Cicatricial tracheal stenosis. Cure. Seen in consultation with 
 Dr. Sandels and Dr. Ryal. Raymond B., aged 2 years, had a penny in the 
 esophagus for two months. (Fig. 51.) For two weeks after the acci- 
 dent he had some dysphagia which became better, as increasing cough and 
 dyspnoea developed. Cyanosis was so great on admission that immediate 
 tracheotomy was necessary. The penny was removed from its ulcerated 
 bed by the esophagoscopic method, and the child allowed to go home. 
 Three weeks later he was brought in. quite cyanotic again, and upon pass- 
 ing the tracheoscope the cicatricial web shown in Fig. 4, Plate I, was 
 seen. A complete cure resulted from prolonged intubation and forci])le 
 dilatation. There was no stenosis of the esophagus. 
 
 Remarks: This case illustrates the danger of a swallowed foreign 
 body. The ease with which intubation tubes pass through the alimentary 
 canal is apt to lead us intn the error of supposing that anything swal- 
 lowed is harmless, especial])- if withnut sharp points or edges, as in this
 
 76 
 
 TRACHEAL STENOSES. 
 
 Fio. 51.— Radiograph of a penny in esopliagus, producing traclieal 
 two months, by ulceration through the tracheo-esophageal wall. 
 
 steno.sis after
 
 TRACHEAL SrnXOSES. 77 
 
 case. This cliild, if iinrelicvi-d, would liavc been dead oi septic ])neu- 
 monia in a few days, from tlie pus which was being' aspirated down the 
 trachea into the lungs. 
 
 Fig-. 8, Plate I, shows a cicatricial web [jroducing partial occlusion of 
 the tracheal lumen in a man aged ;^2, sent to me by Dr. Frank Trester 
 Smith, of Chattanooga. Tliis stricture was incised and dilated, with 
 satisfactory results, though a laryngeal stenosis in the same case could uot 
 be relieved. 
 
 Cicatricial strictures of the bronchi from causes similar to those pro- 
 ducing tracheal stricture are occasionally encountered. Fig. 14, Plate II, 
 is a good example of this condition, in a man of 33. 
 
 Deviations of the trachea without stenosis are frequent. They may 
 occur as anomalies or as a displacement by peri-tracheal tissues. One 
 very interesting case of this kind in a woman of 23 years was referred 
 to me by Dr. Ewing W. Day. There was a sharp deflection forward to 
 the left, then backward to the right. The axis of the lumen of the larynx 
 was from above downward and backward, the downward-forward-left de- 
 viation starting abruptly below the cricoid cartilage. There was marked 
 ptosis of the larynx, the lower border of the thyroid cartilage being back 
 of the sternum, and all of the trachea being subglottic. The esophagus 
 followed the same deviations as the trachea, which would seem to indi- 
 cate that the anomaly was not congenital. Two cervical ribs were pres- 
 ent. (Fig. 52.) 
 
 Treatment. In many instances the diagnostic results of tracheo- 
 bronchoscopy will point the way to successful general therapy. This is 
 occasionally true of tuberculosis, but more often of syphilis. 
 
 The local treatment of stublxjrn chronic tracheitis, especially if ulcer- 
 ative, which is rare, is notably successful. 
 
 The endoscopic application of dilute solutions of argyrol, argentic 
 nitrate, balsam of Peru, ichthyol, and iodine gives excellent results. In 
 many instances these applications can be made with the tubular specidum 
 under local anesthesia. 
 
 Benign growths of the trachea can be readily removed through the 
 tracheoscope. 
 
 It is quite feasible to remove malignant growths originating in the 
 tracheal mucosa, though it is seldom advisable to do so, on account of the 
 rapid repullulation afterward. Adequate removal of a malignant growth 
 is seldom possible. 
 
 The tracheal stenosis due to fungating granulations in the trachea 
 at the site of a tracheotomy wound that has been allowed to heal at the 
 skin before the trachea has healed, may be very promptly cured bv the 
 endo-tracheal application of a saturated solution of resorcin. Fig. 12,
 
 78 
 
 STRICTURILS OF THll TRACHEA. 
 
 Plate II, represents such a case. Of course, a better plan is not to allow 
 such a condition to occur, but unless carefully watched, internes are very 
 prone to permit it to happen. 
 
 Strictures of the larynx and upper trachea are best treated by thy- 
 rotomy, thyro-tracheotomy, or by dilation with tupelo tents followed by 
 prolonged intubation. In one case, (Fig. 4, Plate I,) a high tracheal 
 stricture, due to the erosion of a foreign body through from the esoph- 
 agus, was dilated with an extubator, and treated by prolonged intuba- 
 tion, with a result of perfect cure. 
 
 Strictures of the cervical portion of the trachea associated with loss 
 of cartilage, are probably best treated by tracheoplastic surgery, which 
 
 Fig. 52. — Cervical ribs in-csent iu a case of deviaUU trachea and larynsoptosis. 
 
 substitutes some rigid material for the lost cartilage. Such methods are, 
 however, strictly limited to the cervical trachea. P)elow the sternal notch 
 only endoscopic methods are available. Some excellent results have been 
 recorded. 
 
 The tracheal cases recjuiring treatment are those in which the strict- 
 ure is so small as to interfere with respiration. In the bronchi the cases 
 requiring treatment are those in which there is interference with the pass- 
 age in and out of the respiratory current, and with the escape of secre- 
 tions. This condition is recognized by bronchoscopy and by auscultation 
 and percussion.
 
 DIL.IT.ITJOX OP BROXCfU.lL STRICTURE. 
 
 79 
 
 For dilation of a bronchial stricture the most practical method is von 
 Schrotter's. Obviously it is not adapted to the trachea. \Mth forceps, 
 through the bronchoscope, a laminaria tent (1.5 cm. to 2.5 cm. in length, 
 4 to 7 mm. in diameter) is inserted in the stricture and allowed to remain 
 for 25 minutes, during which time the thread attached to the tent is al- 
 lowed to hang out the mouth. The tent is then removed and a metallic 
 tube, like Fig. 53, is inserted. The tubes used by von Schrotter were of 
 aluminum, though he also used German silver and iron, because, being 
 more dense, they cast denser shadows, enabling a better radiographic 
 
 Fin. 53. 
 
 Fir.. .i6. 
 
 Fig. 54. 
 
 FiCi. 5:1. — von Schriittoi's bronchial iiilubatiou Uil)e. 
 Fig. 54. — voii SchriUter's brouchial iulubatiou tiilie aud mauilriu. 
 Fir,. 5.5. — von Schriittef'.s iracheo-bronohial clilating tnbe and end of special bron- 
 cbo.-^cope for introduction. 
 
 watch to be kept on the position ol the tube. The sizes used were from 
 3 to 10 mm. in diameter, and 10 to 25 mm. in length, and the weight in some 
 instances was as much as 4 grams. The shape and the encircling ridges pre- 
 vent expulsion of the tube by coughing. In dilation of strictures of the 
 trachea, a tube with a bail to which a thread was attached was used, tlie 
 thread being long enough to come out of the mouth or tracheotomy 
 wound. The dilating tubes were inserted without the mandrin used in 
 earlier cases (Fig. 54), using instead a bronchoscojje with a dilated end 
 into which the end of the dilating tube telescoped, being held in place bv 
 the thread held taut. (Fig. 55.) 
 
 The author has devised an attachment for the forceps bv which tents 
 may be placed. (Fig. 25.)
 
 CHAPTER VIII. 
 
 Tracheo-Bronchoscopy, Upper and Lower, for the 
 Diagnosis and Lxtraction of Foreign Bodies. 
 
 General Considerations. Since Killian startled the medical and sur- 
 gical world with the announcement of his removal of a foreign body from 
 a bronchus by means of forceps passed through a straight tube introduced 
 through natural passages, the crude and dangerous blind groping in the 
 trachea and bronchi for foreign bodies with forceps introduced through a 
 tracheotomy wound has in enlightened circles, gradually given way to 
 exact methods associated with little risk. It is not meant that the trach- 
 eotomy wound has been altogether dispensed with, but instead of groping 
 in the dark, the foreign body is now found and seized under the guidance 
 of the eye. 
 
 The relative adz'isabilify of upper and lozcer broncJwscopy. Save 
 where the breathing is bad, it is rarely necessary to open the trachea for 
 tracheoscopy. For bronchoscopy, however, the mechanical manipula- 
 tions of entering the tertiary and even the secondary bronchi are slightly 
 more difficult through the natural passages. So far as seeing is con- 
 cerned, if unilluiiiinated tubes are used, it will be found that the length of 
 tube required makes it much more difficult sufficiently to illuminate the 
 object. Ingals states that upper bronchoscopy is rarely satisfactory in 
 children under 3 years of age. If a bronchoscopist of his experience 
 finds it unsatisfactory, the inexperienced will find it useless. 
 
 \Mth the light carrier instruments, however, a foor more or less of 
 tube makes no difiference, if the observer's eye be normal. The object, 
 whether one foot or two feet away, is always illuminated with the same 
 brilliancy, while, with unilluminated tubes, the intensity of the light dimin- 
 ishes as the distance, ^^'ith a properly adjusted headlamp and a high 
 polish on the interior of the tubes, the loss is not as the square of the dis- 
 tance, for the rays are nearly parallel.
 
 TRACHEO-BRONCHOSCOPY FOR FOREIGN BODY. 81 
 
 After a prolonged upper bronchoscopic examination, tiie larynx will 
 show some irritation, and hoarseness will usually persist for some hours 
 or days, but if no actual traumatism of the cords has occurred, the voice 
 is perfectly regained at the end of a week. Even if some traumatism 
 has occurred the voice ultimately recovers. In one case reported by 
 Nehrkorn, tracheotomy was required for post-bronchoscopic edema, pro- 
 duced by a two-hour examination. Von Schrottcr also reports a case of 
 severe laryngeal edema. In general, therefore, it may be stated that it is 
 unwise to persist too long in an ujiper bronchoscopy. The added risk of 
 a tracheotomy is less than the risks of prolonging the anesthesia, prolong- 
 ing the shock, and prolonging the abolition of the cough reflex. The 
 possibility of being ultimately compelled to resort to a tracheotomy any 
 way, either from unsuccess, or because of edema of the larynx, should be 
 borne in mind. Edema is unlikely if a small tube be used. 
 
 In each particular case, the operator will weigh the personal equation 
 of himself and his patient in arriving at a decision. 
 
 Indications. 
 
 Tracheo-bronchoscopy is indicated in any case in which the presence 
 of a foreign body in the trachea, bronchi, or lungs is suspected. It is not 
 wise to hesitate because of a lack of certainty of its presence. 
 
 Professional opposition to this view will be rarely encountered in these 
 days of safe and easy tracheo-bronchoscopy. Occasionally a relic of the 
 old days of dangerous, and usually fruitless, fishing with hooks and for- 
 ceps introduced into the trachea and bronchi through a tracheotomy 
 wound, will crop out in the form of an opinion that an expectant plan of 
 treatment is indicated, at least for a time, if not indefinitely. This op- 
 position will arise, in three classes of cases : 
 
 1. Those cases in which tlic history is corroborated by the Roentgen 
 ray. 
 
 2. Those in which it is corroborated by the symptoms or the physi- 
 cal signs. 
 
 3. Those in which it is not corroborated at all. 
 
 It is the author's opinion that in ail three of these classes of case 
 tracheo-bronchoscopy is indicated. 
 
 It has seemed more convenient to consider the prognosis of the ex- 
 pectant plan under the head of "Dangers." 
 
 Results. 
 
 Of 94 cases of tracheo-bronchoscopy, upper and lower for foreign 
 bodies, collected statistically for the author, the corpus delicti was found 
 and extracted in 78 or 85.1 per cent.
 
 82 DANGERS OF TRACHEO-BRONCHOSCOPY. 
 
 The cases of failure were those in which : 
 
 I. Inorganic substances as pieces of kernels of nuts or gram, beans 
 and the like had swollen and become impacted and buried in a minute 
 bronchus ; or, 2. In which there was a stricture above the site of lodg- 
 ment ; or, 3. In which there were such grave symptoms (present before 
 operation) that the procedure had to be abandoned. 
 
 CONTRA-INDICATIONS. 
 
 Tlie author's views are rather radical on the subject, but he does not 
 consider anything an absolute contra-indication to tracheo-bronchoscopy 
 in a patient known to have a foreign body in the trachea or bronchi, as 
 the patient is very much safer without the foreign body than with it, no 
 matter what the condition may be. Of course, should there be doubt as 
 to the presence of the foreign body, it may become a question as to wheth- 
 er the procedure would be justifiable in case of serious diseases such as 
 mentioned under the general subject of contra-indications. 
 
 D.VNGERS. 
 
 The dangers of tracheo-bronchoscopy in general have been consid- 
 ered in a previous chapter, and they are but little more than those of 
 anesthesia. 
 
 Before the days of tracheo-bronchoscopy the physician was confront- 
 ed with the problem of comparing the dangers of removal with those of 
 leaving the foreign body to nature. To-day when endoscopy has reached 
 such a high degree of perfection, the dangers of removal are exceedingly 
 slight, while the dangers of doing nothing are great. This subject is 
 gone into more fully on a subsequent page. 
 
 Pneumonia and bronchitis when tliey occur are far more likely the 
 result of the condition calling for the tracheo-bronchoscopy than of the 
 procedure itself. 
 
 Ingals reports two deaths of obscure pathologic mechanism. One 
 occurred 3, the other 6, hours after the successful removal of the foreign 
 body. He is unable to explain it but suggests the possibility of its being 
 due to the application of adrenalin and cocain. so close to the vagus 
 nerve : or possiblv to the chloroform, though this' seems doubtful as the 
 anesthesia was of short duration. He also suggests the possibility of 
 secondary surgical shock. 
 
 Xchrkorn and von Shrotter each report a serious laryngeal edema, 
 requiring tracheotomy after upper bronchoscopy. This edema is an ele- 
 ment of danger if the patient is discharged immediately after extraction. 
 Kept in the hospital there is no danger other than that of tracheotomy, 
 should this become necessarv.
 
 DANGERS OF TRACHliO-BROSCHOSCOPY. 88 
 
 The risk of lower bronchoscopy indc])endcnt of that of the trache- 
 otomy is exceedingly slight if done gently and at once after the trache- 
 otomy. If delayed until the tracheal wound becomes infected, the danger 
 of carrying in septic materia! increases the risk materially. In lower 
 tracheo-bronchoscopy, the risk of tracheotomy, independent of the condi- 
 tion calling for it, is not over 2 per cent. Tracheotomy here must not be con- 
 sidered in the same light as when done for diseased conditions. TTie 
 latter have an extra risk in the primary disease and in the usual postpone- 
 ment of tracheotomy until the respiratory and cardiac centers are poisoned 
 with carbonic acid, and the resisting power of respiratory and other or- 
 gans is dangerously weakened. 
 
 One danger that can be avoidctl is putting tracheotomy off, until the 
 patient has ceased to breathe. Then a moment's delay in the opening of 
 the trachea may be fatal through cardiac arrest. Respiratory arrest is not 
 dangerous after the trachea is opened, but cardiac arrest is usually fatal. 
 Respiration often cannot be started unless the trachea be opened. All of 
 these dangers are avoided by preliminary tracheotomy and lower bron- 
 choscopy. The operator's ability to stab the trachea in a moment when 
 necessary will govern the risk. In a few of the author's earlier cases of 
 tracheoscopy, tracheotomy had to be done to start respiration which had 
 stopped apparently from respiratory inhibition. 
 
 The hints given under tracheotomy if followed will minimize the risks 
 of opening the trachea. 
 
 Tracheal varicosities might be an element of danger did they exist 
 in a foreign body case. The author has seen several instances of these 
 lesions unassociated, however, with a foreign body. Should they exist 
 they are readily seen and injury to them readily avoided by careful manip- 
 ulation of the tube. 
 
 The dangers of leaving the foreign body alone, in these days of per- 
 fected endoscopic technic do not merit lengthy consideration. But as the 
 relative gravity of prognosis will arise in nearly every case, and occasion- 
 ally a relic of the days of blind groping in the dark, will be encountered 
 in opposition to tracheo-bronchoscopy, the dangers of the "let alone" plan 
 require mention. They are, briefly, bronchitis, bronchiectasis, pneumonia, 
 abscess, gangrene, cirrhosis, pneumothorax, and possibly tuberculosis. 
 The dangers are, therefore, immediate or more or less remote. 
 
 The degree of danger, of course, varies with the nature, shape and 
 size of the foreign body, its position and the condition of the patient. 
 
 The shape and size will determine the depth of penetration and the 
 probability of excluding air from the pyramid of lung tissue supplied by 
 the occluded tube. Rounded objects are particularly prone tighth- to fit 
 a bronchial tube, excluding air and producing gangrene and abscess.
 
 84 FOREIGN BODIES IN THE BRONCHI. 
 
 Rough or pointed objects are prone to cause trauma either by being 
 coughed back and forth or by erosion from a prolonged sojourn in one 
 position. Either of these conditions is ant to be associated with infection, 
 and prolonged irritation ending in fatal exhaustion. Occasionally, an 
 abscess may discharge spontaneously into a bronchus, the foreign body 
 being also expelled in some instances, in others, not. 
 
 Inorganic substances are prone to swell, macerate and decay, usually 
 causing sepsis. The cooked kernels of nuts, especially peanuts, may, as 
 shown by Claytor, macerate in about a month sufficiently for the pulp to 
 be coughed up. During this time, the risks of bronchitis, pneumonia, and 
 gangrene and sepsis are run. Kernels of nuts and grain, if uncooked, do 
 not macerate sufficiently to be coughed up and their swelling fixes them, 
 so that they are not dislodged by coughing unless they slough out. 
 
 In regard to sepsis, there are two factors to be considered. The in- 
 fection carried down with the foreign bod\-. as for instance, a decayed 
 tooth ; and infection by organisms occasionally present in the trachea and 
 larger bronchi. The latter are the least to be feared. Several instances of 
 the former variety of infection have fallen under the author's observation. 
 One was that of a girl, 12 years of age^ who had aspirated into her right 
 lung part of a carious incisor broken off in a fall. The author's urgent 
 advice of immediate bronchoscopy was opposed by the family physician, 
 who had many years before seen a death from blind fishing through a 
 tracheotomy wound ; and subsequently, a recovery from the "let alone" 
 method. The child who had aspirated the tooth died of septic pneumonia 
 about a week after the accident. 
 
 In the prognosis of aspirated bodies we must consider the possibility 
 of asphyxia from loosening of the foreign body and its being cast, by 
 coughing, violently up against the subglottic portion of the larynx and 
 thus causing asphyxia from spasm ; and also the possibility of its causing 
 asphyxia by being fixed in the upper portion of the air tract. 
 
 It is exceedingly rare for a foreign body larger than a millimeter or 
 two in size to become encysted. 
 
 The first 24 hours is the period during which expulsion is most likely 
 to occur, if at all. By the end of that time it is so buried in the swollen 
 mucosa that it is seldom expelled until after sloughing has occurred. 
 
 Statistics are against the "let alone" method. Roe collected 1417 
 cases of foreign body in the air passages, in which no extraction was at- 
 tempted. There was a mortality of 27 per cent. It may be argued that 
 these statistics do not include many cases in which a small object was in- 
 haled and shortly thereafter coughed up again. In the author's opinion, 
 this is fully counterbalanced by the numerous cases where a small child, 
 unable to talk, or forgetting to tell of it, has aspirated a small foreign
 
 svMrroMS of porrign body. 85 
 
 body and died of pneumonia or other complication, the true cause of 
 which never was suspected. 
 
 Of 94 cases of bronchoscopy, upper and lower together, collected for 
 the author, 9 died, making a mortality of 9.6 per cent. Eliminating six 
 that were in bad condition and jjrobably would have died without opera- 
 tion, the mortality may be placed at 3.2 per cent. Tlie author would feel 
 inclined to place it at less than this were it not for two mysterious deaths 
 reported bv Ingals, where in 3 and 6 hours respectively, after removal of 
 a foreign body the patient unexplainably sank and died. 
 
 Summing up, the prognosis of tracheo-bronchoscopy is good if the 
 operation be not postponed until the patient's condition has become serious. 
 In cases where the general condition is serious the prognosis is not so 
 good as in cases in better condition, yet the ultimate prognosis is better 
 with the operation than without. 
 
 Other things being equal, the prognosis is the better the sooner the 
 foreign body is extracted. 
 
 In conclusion the author's opinion is that we do full justice to our 
 patients when we tell them that while the foreign body may be coughed 
 up, the chances of this are remote and it is very dangerous to wait; and 
 further, that the difficulty of removal increases with each hour the body is 
 allowed to remain. 
 
 Symptoms. 
 
 Cough. This is the most constant symptom of foreign body in the 
 air passages. It appears as an immediate symptom in the effort to pre- 
 vent the entrance of the body at the laryngeal orifice, and later, in more or 
 less paroxysmal efforts to rid the air passages. Later still cough is pres- 
 ent from the inflammatory reaction to the irritating presence of the in- 
 vader. This later cough is more apt to be constant than that which 
 occurs earlier. The early coughing is usually paroxysmal some minutes 
 or hours elapsing between the seizures. These intervals may be entirely 
 quiet, but are often attended with an occasional cough which interrupts 
 the sleep of exhaustion. 
 
 Dyspnoea is a very frequent symptom. It is usually inspiratory in 
 character, but may be expiratory or both. It may be due to actual ob- 
 struction to the passage of air by the presence of the foreign substance 
 itself, or by the bulk of the body plus the resultant swelling and secre- 
 tions ; or it may be due to the air hunger from the diminished mucosal 
 surface reachable by air. Tlie dyspnoea is always worse during the par- 
 oxysms of coughing, at which times it may reach unconsciousness from 
 carbonic acid narcosis. 
 
 It is worth while bearing in nn'nd that dyspnoea may be present in a 
 case where the foreign body is in the esophagus, but is eroding through.
 
 86 DIAGNOSIS OF FORllIGN BODY. 
 
 as in a case of the author's, elsewhere reported in tliis book, or by dis- 
 placement of the trachea due to its bulk. 
 
 The temperature is usually elevated which is often misleading, and 
 in cases of doubtful diagnosis will be erroneously advanced as negative 
 evidence, and urged against a diagnosis of foreign body. It may be, in 
 the earl)- stages, irritative. Later it is toxemic due to septic absorption 
 from a localized inflammatory area. It may be due to the complications 
 as pneumonia, bronchitis, etcetera. 
 
 Chills are often present. They are due to the same causes as the 
 elevation of temperature, together with which, especially in abscess cases, 
 they may closely simulate pulmonary tuberculosis. 
 
 Hciiioplysis is not very constantly present, but when it occurs, it is a 
 valuable symptom. Blood most frequently occurs as streaks or clots 
 in the expectoration : only in case of very sharp bodies is it in any amount, 
 and is then dependent on the accident of cutting a small vessel. 
 
 Pain is often noted but it is apt to be vaguely localized and may be 
 due to tissue soreness due to violent coughing. 
 
 Dl.-VGNOSIS. 
 
 The Roentgen Ray. In all cases even in those where there is little 
 hope of the foreign body showing opacity to the ray, a radiograph should 
 be taken if the conditions are not urgent. If there is very urgent dysp- 
 noea, there should be no delay, not only on account of the urgency, but 
 because the dyspnoea itself is an indication that the foreign body is in the 
 larvnx or trachea, or at any rate not lower than a main bronchus. 
 
 The fluoroscope is not reliable as, unless quite dense, the corpus 
 delicti will not be seen. A radiograph should be made in all instances 
 and should be interpreted b\' the Roentgenologist, as few others see a 
 sufficient number of radiographs, normal or abnormal, reliably to interpret 
 the plate. Even then mistakes, both negatively and positively, are apt to 
 occur occasionally. 
 
 The production of the radiographic shadow by a foreign body is a 
 matter of the density of the foreign substance. 
 
 This shciuld be remembered when deciding whether the substance of 
 which there is a history in the particular case would show radiographi- 
 callv or not. ^Metallic substances with the exception of aluminum usually 
 show clearly. Aluminum will only show when of some little bulk, and on 
 a radiograph, not upon a fluoroscopic screen. Pewter and lead usually 
 throw dense shadows. Fig. 57 illustrates how clearly a cast pewter shirt 
 button in the trachea was demonstrated radiographically, in an infant 
 referred to me h\' Dr. Day. The child was turned partly sidewise to en- 
 deavor to prcyent the shadow of the foreign body overla}'ing that of the
 
 FOR max BODY. 
 
 87 
 
 Fl(.. ."id. — I5oiir ill hrunclms of iiiaidi'u of IS 
 
 year.s.
 
 88 
 
 FOREIGN BODY. 
 
 FiG- oT. — Pewter shirt bulluu in the trachea of au iiifaul
 
 DIAGNOSIS OF FOREIGN BODY. 
 
 89 
 
 vertebr.^-an unnecessary precaution in this case on account of the very 
 
 dense shadow cast by the alloy of lead. 
 
 Inorganic substances other than metal, such as pebbles, toy marbles, 
 
 elass, and the like, usually show well. 
 
 Or-anic substances, such as bones, containing considerable quantities 
 
 of earthy salts, usually show well if not overlying the bones of the patient, 
 
 especialiv the vertebrae. _ 
 
 The particular bone in question has nnich tn dn with the decision. 
 The hard dense bones .show best, the semi-cartilaginous bones least, bulk 
 for Inilk If it is a question of fish bone, the determination of whether it 
 is a vertebral or rib bone is of value. Rib bones of the fish, ca,st almost 
 no shadow and even the vertebral bones as a rule will not show unless of 
 crood size and not overlving the patient's denser bones. Fig. 56 is from 
 a radiograph which shows clearly a small fragment of bone in a secondary 
 bronchus Had the bone been less dense, or had its position overlaid the 
 vertebral colunm or even a rib. or had the radiograph been poor tins bone 
 would not have shown, and the author would not have had permission to 
 
 remove it. . 
 
 Vegetable substances as a rule do not show well, unless quite dense, 
 
 as some kinds of woody fibre. 
 
 Various nut kernels within the thorax are not easy to demonstrate 
 radiographicallv. Some of them are not very important as they are apt 
 to macerate and be coughed out. This is more especially true of the 
 cooked kernels, such as peanuts and chestnuts. The shells or hulls of 
 hard-shelled nuts usually throw radiographic shadows. 
 
 In all this work, it is important to have the very best possible radio- 
 graphic technic. With a history of a metallic body, and in an unruly, 
 terrified child, it is usual to make too short an exposure, and to fail^ to 
 hold the child still. Tliis usually suffices, but is of little value if negative. 
 In rare instances, it may. as pointed out by ^losher apropos of one of the 
 author's cases, be dangerously deficient in not showing other conditions 
 such as a hypertrophic thymus gland, that might he the cause of the symp- 
 toms wrongly attributed to the supposed foreign body. 
 
 In few cases is it wise to decline endoscopically to examine a patient 
 because the radiograph shows nothing. Only in the case of a metallic or 
 other dense substance failing to show upon a technically good radiograph 
 should we reassure ourselves and patient that nothing is present. Even in 
 such cases, if there are any symptoms to corroborate the history, it is 
 safer to tracheo-bronchoscopize, and, usually, either the cause of the symp- 
 toms, be it foreign body, traumatism, lesion or neurosis, will be discov- 
 ered ; or the absence of such cause will be positively demonstrated. 
 
 An otherwise unexplainablc dyspnoea, especially if intermittent and
 
 90 PHYSICAL SIGNS OF FORHIGX BODY. 
 
 unassociatcd with fever, is almost diagnostic of foreign body in the air 
 passages. 
 
 As a matter of fact, however, fever is nearly always present, except 
 in the early stages. So much so that with the chills, cough, and expecto- 
 ration, there is no doubt that many a case of abscess from a foreign body 
 has gone to the grave labelled erroneously with the diagnosis of tubercu- 
 losis. Usually the persistent absence of bacilli in the sputum will decide. 
 But it must not be forgotten that a foreign body abscess may be or become 
 tubercular. The author has seen one such case. In addition it must not 
 be forgotten that a tuberculous subject may, as well as anyone, inhale a 
 foreign body. Of this also the author has seen one case, a girl of i8 years 
 who, in taking a deep inspiration after a sudden coughing paroxysm at 
 table, aspirated a small piece of beef bone. The radiograph was doubt- 
 ful (by some the shadow being thought to be the shadow of a vertebral 
 process. Fig. 56), and it was some time before the author was permited 
 to remove the bone from a secondarv bronchus. 
 
 Physical signs are of value diagnostically if done, not by a laryngolo- 
 gist, but one who is accustomed to auscultatory and percussive work. In 
 other words, one who has educated his ear. Perhaps, the most value will 
 attach to the physical signs as indicating which side the foreign body is on, 
 especially in a case of a negative radiograph. This is an important part 
 of the diagnosis, often saving time by indicating which side to search first ; 
 though in no case should this lessen the necessity of examining the other 
 side in case of failure to find the corpus delicti, which may have in the 
 meantime been coughed up and re-aspirated into the other side. 
 
 The following notes prepared at the request of the author by Dr. John 
 \V. Boyce, will be found exceedingly valuable. 
 
 The physical signs are as a rule illy reported in published cases, and seem 
 to have been studied with but scant interest. They are apparently insufficient 
 for diagnosis. Frequent cases of serious lung trouble are explained and ter- 
 minated by the coughing up of an unsuspected foreign body, but I can find 
 no instance in which the diagnosis was made in the absence of history. Yet 
 the findings in physical examination are occasionally quite distinctive, and 
 very frequently of use in localization. It is to be hoped that wider use of the 
 X-raj' and of modern methods of exploration will not overshadow ausculta- 
 tion whose full value has certainly not been exploited as yet. 
 
 In the examination a distinction must be made between those signs due 
 simply to the presence of the foreign body and those due to the inflammatory 
 accidents which rapidly follow. 
 
 In the classic period of auscultation, two pathognomonic signs were de- 
 scribed; a laryngeal click due to body fixed in the larynx, "the bruit of the 
 standard" (resembling the flapping of a flag in the wind) caused by a body 
 loose in the trachea. It has not been my fortune to observe either of these 
 nor are they mentioned in recent literature, possibly because bodies ui these
 
 PHYSICAL SIGXS OP POKPIGN BODY. 5)1 
 
 localities .irc so easy of diagnosis or tlic operative indication is so plain and 
 urgent as to forestall careful examination. 
 
 A body obstructing the bronchus may lead to atelectasis of the lung with 
 the ordinary signs of this condition. This occurrence is not so frequent, how- 
 ever, as is generally supposed. The most common finding is a marked local 
 diminution of the respiratory murmur together with preservation or accentua- 
 tion of the normal resonance and this may be rated as the typical condition 
 in foreign body cases. When a body partially obstructs the bronchus it may 
 give rise to a peculiar dry rale, easily distinguished in quality from tliat of 
 inflammatory or tubercular thickenings of the mucous membrane. Even vv'ere 
 this distinctive quality lacking it is scarcely possible for inflammatory condi- 
 tions to produce dry rales, limited always to a particular area and remaining 
 unchanged for hours at a time. Such a condition would seem to justify ex- 
 ploration. The case of Infant J., which I have reported, furnished an example 
 of a whistling rale heard over one cone of lung in which the respiratory mur- 
 mur was first diminished and later replaced by moist rales due to the consecu- 
 tive bronchitis. 
 
 Of consecutive inflammatory conditions, the most common and earliest is 
 a moist localized bronchitis. Unfortunately the secretions of the diseased area 
 are apt to be inspired into normal bronchial tubes and so when the case first 
 comes under observation we may find the signs of diffuse bronchitis. Even so 
 it is to be remembered that diffuse bronchitis, with very bloody expectoration, 
 coming on suddenly, is a most unusual condition and would produce shock or 
 septic phenomena with less prominence of dysptioea and cyanosis. Expectora- 
 tion in foreign body cases, is usually bloody and has a great tendency to be- 
 come free, purulent, and fetid. The diagnosis usually made in these cases is 
 that of tuberculosis; but systematic examination of the sputum should guard 
 against error. If localized abscess, gangrene or pneumonia of lobular type re- 
 sults, it is indistinguishable by physical signs from similar conditions due to 
 the more ordinary causes. Lobar pneumonia sometimes occurs. One most 
 interesting case, reported by Ingals, gave a typical picture of pleural effusion 
 and two attempts at tapping had been made before the case was referred for 
 bronchoscophy. 
 
 It is very evidtnt that auscultation for localization may be useful as a pre- 
 liminary to bronchoscopy. It is perhaps too much to hope that the presence 
 of foreign bodies will ever be diagnosticated by this means alone, but should 
 often lead to suspicion. "Tuberculosis" without bacilli in the sputum, particu- 
 larly if located towards the base of the right lung; unilateral or unilobular 
 bronchitis; more paiticularly if hemorrhagic or fetid in character; atelectasis 
 abscess or gangrene not otherwise explainable — these conditions should sug- 
 gest the possibility of the presence of foreign body in the bronchi. 
 
 The most likely point of lodgment of a foreign body depends some- 
 what upon its form ,md surface. Smooth round bodies usually lodge in 
 the smallest bronchus that will admit them, stopping at a bifurcation or, 
 rather, the giving ofl if a lateral branch. Pins, tacks, and nails are likely 
 to drop head downward into a small bronchus. Safety pins, imless closed, 
 rarely get into the air lassagcs. 
 
 The radiographic localization as to the ])articular air passage invaded
 
 92 TRACHEO-BRONCHOSCOPY FOR FOREIGN BODIES. 
 
 has been touched upon wlien writing of the anatomy of the tracheo-bron- 
 chial tree. 
 
 Tech NIC. 
 
 There is httle to add to what has been said previously on the general 
 subject of technic, save in regard to the use of the forceps, hooks, et cetera. 
 
 The chief difficulties other than those previously enumerated arise in 
 the case of very small bodies very deeply located in small bronchi^ es- 
 pecially if macerated and embedded in the swollen mucosa. 
 
 In working- near the periphery, with unilluminated tubes, it may be- 
 come impossible to work by sight, as the forceps shut off what little light 
 enters. The forceps have to be passed blindly, reliance being placed upon 
 memory of the previously observed position of the foreign body. A mark 
 must have been previously placed upon the forceps canula to show when 
 the point of the forceps has reached the distal end of the tube. The sense 
 of touch is not of much aid even in case of metallic foreign bodies for con- 
 tact of the forceps with the tube gives a confusing sensation of metallic 
 contact. In case of a soft foreign body, the sensation would be no differ- 
 ent from touching the mucosa. Ingals, who has done some of the most 
 brilliant work, always inserts and uses the forceps without light. 
 
 In the trachea and larger bronchi of adults, there are no difficulties 
 other than those previously mentioned. The use of forceps through the 
 large tubes is not difficult, especially if illuminated tubes are used. In 
 children under 3 years of age the small tubes used render the procedure 
 more difficult, though the shorter length of tube required is some com- 
 pensation. 
 
 \'ariously shaped hooks are often of use in turning over foreign 
 bodies into a position where they can be seized with the forceps, and occa- 
 sionally they may afford sufficient hold entirely to remove the foreign sub- 
 stance. They are passed flat until below the intruder, then rotated so as 
 to come up below it, when they are withdrawn until they come in contact 
 with it. Fully curved hooks must be used cautiously lest they get caught 
 in a bronchia! orifice. 
 
 In case of hollow foreign bodies the expanding forceps (Fig. 21) will 
 be found of service if it can be inserted into the hole in the intruder, which 
 is then held by expansion of the forceps in somewhat the same manner as 
 is an intubation tube in the extubator. It is not intended to be screwed 
 into the foreign substance as might be inferred from its appearance. It is 
 roughened to lessen the likelihood of its slipping. 
 
 Usually outcoming exudate or secretion will indicate the bionchus 
 invaded; or if the foreign body has been in for sometime, inflammatory 
 signs will indicate. In one of the author's cases the orifice was swollen 
 shut, but the intruder was felt beyond with the probe and removed.
 
 FOREIGN BODIES. 
 
 !)3 
 
 Fig. 58. — Foreign bodies from the air passages. 
 (From the author's collection.) 
 
 A, Shirf button from trachea of 19 year-old boy. Cocain. Upper tracheoscopy. 
 I, IVbblc from left bronchus of man of 28 years of age. Ether. Upper bron- 
 choscopy 
 
 B, Penny, which in 2 nioi.ths ulcei'ated through into trachea from esophagus. 
 2 year-old child. Chloroform. 
 
 C, Shoe button in bronchus 2 years. Maid of IS years. Upper tracheoscopy. 
 L), Bono from bronchus, maid of IS years. Upper bronchoscopy. Chloroform. 
 G, I'in from trachea of woman aged 20. Upper tracheoscopy. Chloroform. 
 
 E, Fragments of egg shell from larynx. Symptoms simulated croup ; antitoxiu 
 given. Infant months old. Direct laryngoscopy. No anesthesia. 
 
 H, Fron right secondary bronchus, man aged 24 years. Upper bronchoscopy. 
 Chloroform. 
 
 F, From trachea. Boy 14 years of age. Cocain.
 
 Part 11. 
 
 ESOPHAGOSCOPY.
 
 CHAPTER IX. 
 
 Lsophagoscopy. 
 
 Introduction. 
 
 By esophagoscopy is understood, at the present day, the examination 
 of the esophagus with tlie aid of tubes introduced through the mouth. By 
 retrograde esophagoscopy is meant the examination of the lower end 
 of the esophagus, with the aid of tubes introduced upward from below 
 through a celiotomic wound. 
 
 In dealing with this subject, to avoid iteration, the difficulties, dan- 
 gers, contraindication and much of the technic will be deferred for subse- 
 quent consideration along with the same topics under "Gastroscopy." 
 
 The use of the flexible esophageal bougie has no place in this book, 
 and, in the author's opinion, it has no place in the advanced surgery of 
 the esophagus. In remote localities, where no other instnmient is avail- 
 able, it may, as a makeshift, yield information otherwise unobtainable, 
 and may serve slightly to open a stricture, but its use is attended with 
 great risk, because the end is beyond control. Instruments passed by 
 sight with the aid of the esophagoscope are alone permissable. 
 
 It is not possible within the limits of this manual to attempt the con- 
 sideration of diseases of the esophagus. Only a few of the more frequent 
 conditions will be considered, and these but briefly.
 
 CHAPTER X. 
 Anatomical Notes on the Esophagus. 
 
 It is not intended to go into the anatomical details, but there are a 
 few points in the gross anatomy of the eso])hagus that must be borne in 
 mind in the passage of rigid straight instruments down its lumen. 
 
 Dimi;nsions. 
 
 Length. The wide and bewildering differences in the length of the 
 esophagus as given by different authorities are due to : 
 
 1. Different anatomical points from and to which measurements 
 are taken. 
 
 2. Observations in some instances upon the cadaver, in others upon 
 the living, yielding differences due to: 
 
 3. The elasticity of the esophagus, which is greater in the living 
 than in the dead subject, and which permits of extension and displace- 
 ment. 
 
 4. The movements and displacements of the esophagus. 
 
 5. Anatomical variations which are, with few exceptions, wider 
 than in any other organ in the body. Besides anomalous variations, there 
 are those more or less regular, corresponding to age, sex, height and body 
 weight. 
 
 To go at length into tliese variations in dimensions would be out of 
 place in a practical manual. The practical working lengths are those 
 taken from the upper teeth as a starting point. The following table com- 
 piled from Stark by iMosher is convenient: 
 
 IjENGTH OF THE ESOPHAGUS 
 
 4T Different Ages. 
 
 
 Teeth to Cricoid. 
 
 To 
 Bifurcation. 
 
 To Cardia. 
 
 I^ength of Whole 
 Esophagus. 
 
 Birth, 7 cm. (2^ in.) 
 
 12 cm. ( i% in.) 
 
 14 cm. ( by, in.) 
 
 15 cm. (6 in.) 
 
 17 cm. ( 6'4 in.l 
 
 18 cm. ( 7 in.) 
 23 cm. ( 9 in.) 
 26 cm. (lOM'n.) 
 
 18 cm. ( 634 in.) 
 
 22 cm. ( S'i in.) 
 
 23 cm. ( 9 in.) 
 26 cm. (10'4 in) 
 28 cm. (11 in.) 
 33 cm. (13 in.) 
 40 cm. (I.V4 in.) 
 
 10 cm. (4 in ) 
 
 
 12 cm ( 4^4 in I 
 
 2 years 10 cm (4 in ) 
 
 13 cm ( 5^rt in ) 
 
 
 
 10 years 10 cm (4 in.) 
 
 18 cm (7 in ) 
 
 
 
 Adult. l.'j cm. (6 in.) 
 
 25 cm. (10 in.)
 
 98 
 
 ANATOMICAL NOTES. 
 
 The diameter of the esophageal Uinien is subject to relativel}' greater 
 variations than its length. It is not at any point a definite dimension 
 owing to the elasticity of the esophageal wall. For practical purposes, 
 however, it is only necessary to consider its diameter at the four points of 
 constriction. 
 
 Mosher's compilation from Stark is practical. 
 
 Diameters of the Ksophagus at the Four Constrictions. 
 
 Constriction, 
 
 Diameter. 
 
 Vertebra. 
 
 
 
 
 
 
 
 
 Transverse 24 mm (1 in ) 
 
 
 
 
 
 
 
 
 
 
 
 Diaphragm 
 
 Transverse 23 mm. {1 in. +) 
 
 Antero-posterior 23 mm (1 in — ) 
 
 Tenth thoracic 
 
 
 
 
 For esophagoscopic purposes the most important constriction is at the 
 introitus. This has already been described. 
 
 The next constriction in point of importance is at the hiatus 
 esophageus. The opening in the diaphragm, which goes by this 
 name, (Fig. 59), is subject to wide variations dependent upon the state 
 
 Fig. .59. — Under surface of the diaphragm. 
 E, Hiatus e.sophageus. Note the direction of its axis. 
 A, Aortic opening. 
 VC, Opening for vena cava. Note direction of tendons and muscular fibers. 
 
 of the diaphragmatic muscular fibres, whether these be in a state of relax- 
 ation, normal contraction, or spastic rigidity. Tliese are important points 
 to bear in mind. The axis of the lumen at this point, (I"ig. 59) should be 
 memorized, as it is exceedingly useful to know in passing the esophago- 
 scope and gastroscope.
 
 POSITION OF THE ESOPHAGUS. 99 
 
 Between the two constrictions just mentioned are two others of lesser 
 importance. They are often not noticed, unless watched for closely. The 
 upper of these being the second constriction from above downwards, cor- 
 responds to the arch of the aorta, opposite the fourtii thoracic vertebra, 
 back of the manubrium sterni. This is often exaggerated in esophago- 
 scopy by the active pulsation of the aorta, due to excitement or to mor- 
 phin or ether stimulation. 
 
 The other constriction, being the tliird from above downward, cor- 
 responds to the crossing of the left bronchus in front of the esophagus, at 
 the level of the fifth thoracic vertebra. 
 
 All of these constrictions are distensible, the upper one, at the introi- 
 tus, less so than the others. The extreme elasticity of the esophageal 
 walls penuits of stretching the normal adult esophagus to over two centi- 
 meters without rupture, though this is not available for esophagoscopy. 
 For practical purposes it is onlv necessary to remember that in a normal 
 esophagus the following sized rigid tubes should pass freely: 
 
 Infants 7 '■"'"• 
 
 Adults TO mm. 
 
 Considerably larger tubes may be used in many cases, but in all cases 
 where these cannot be passed, stricture, spasmodic or anatomic, exists. 
 Flexible bougies of 8 mm. diameter, should pass in infants and children 
 up to ten years of age, and in adults 14 mm. should pass. Though for 
 reasons given elsewhere the author disapproves of the use of the bougie 
 
 Position. Beginning at the level of the bifurcation of the trachea, 
 the gullet curves around the aorta decendens, to the left of which it passes 
 through the hiatus close to the vertebrae. 
 
 The subphrenic portion of the esophagus which deviates to the left 
 has a certain range of mobility, amounting to, apparently, 10 or 15 centi- 
 meters in relaxed persons of spare build. It is apparently attached to the 
 surrounding tissues by loose cellular tissues. It is this mobility which 
 renders it possible to introduce a straight and rigid gastroscope which 
 straightens out the cur\'e and the deviation of this subphrenic portion of 
 the esophagus. 
 
 In studying the gross anatomy of the esophagus, the first essential 
 point to remember is that the esophagus is never twice alike, not only in 
 dififerent individuals, but in the same individual at different moments. The 
 only really fixed point is at its junction with the posterior pharyngeal wall. 
 All other portions are subject to various movements, intrinsic and those 
 imparted by contiguous structures. The intrinsic movements are those of 
 deglutition and its reverse regurgitation. The extrinsic or transmitted 
 movements are respiratory and pulsatory. The respiratory movements
 
 100 MOVEMENTS OF THE ESOPHAGUS. 
 
 are noticed chiefly in the thoracic esophagus, and consist in a dilatation, or 
 opening up. of the esophageal lumen due to the negative intra-thoracic 
 pressure. 
 
 The normal pulsatory movements are aortic and cardiac, due to the 
 pulsatile pressure of the aorta at the level of the fourth thoracic vertebra, 
 (24 cm. from the upper teeth in the adult), and of the heart itself noticed 
 most markedly at about the level of the seventh and eighth thoracic ver- 
 tebrae (about 30 cm. from the upper teeth in the adult). These move- 
 ments vary greatly within the limits of health. 
 
 The intrinsic movements of the esophagus are involuntary muscular 
 contractions, as in deglutition, and regurgitation ; and spasmodic, the lat- 
 ter usually having some pathologic relation. 
 
 The presence of a sphincter at the cardia has been much discussed. 
 Anyone who has carefull}- observed cardio-spasm must admit that it indi- 
 cates the presence of the two layers of muscular fibres surrounding the 
 cardia as described by Hyrtl. Yet the author feels inclined to the belief 
 that the prevention of regurgitation of food up the esophagus is due large- 
 ly to a kinking of the esophagus upon itself at the hiatus diaphragmatis 
 increased by expansion of the stomach when dilated with food. Whether 
 this be true or not remains to be proven. But in examinations the author 
 has frequently noticed this kinking, even when the stomach was empty.
 
 tract. 
 
 CHAPTER XI. 
 
 Normal Lsophagoscopic Appearances. 
 
 The form of the esophageal picture changes hi various portions of the 
 
 The introitus esophagi is closed by the constriction produced mainly 
 by the inferior constrictor of the pharynx, producing a backward pressure 
 of the cricoid cartilage, which, at all times except during the act of swal- 
 lowing, lies in contact with the posterior pharyngeal wall. 
 
 The form of the cervical portion of the esophagus is a transverse slit 
 due to the collapse of the walls from before backward, it opens up ahead 
 of the tube in a way that shows a more or less flat anterior and posterior 
 wall, meeting at the sides. Tliis opens and closes, often audibly, with the 
 respiratory movements. Upon entering the thoracic esophagus, the esoph- 
 agoscope reveals a more or less oval or quadrangular opening into the 
 depths of which the observer looks. (Fig. 2. Plate III, and Fig. i. Plate 
 IV.) This opening is very much smaller than the entire esophageal lu- 
 men, and it increases very much with each inspiration, lessening but not 
 completely closing with expiration. The position of this opening changes 
 as the esophagoscope, during insertion, is deviated to one side or the other, 
 and in case of great deviation it may disappear altogether, the flat wall 
 only being in view. 
 
 At the hiatus diaphragmatis the form of the lumen again becomes a 
 slit, the axis being placed obliquely from the right posterioriy to the left 
 anterioriy. (See Fig. 3, Pate III, and also Fig. 59 in the text.) 
 
 The subphrenic portion of the esophagus is usually opened but slight- 
 ly by respiratory movements, and is at times collapsed by movements of 
 the diaphragm and the abdominal viscera. The observer is prone to con- 
 sider it collapsed when really the fault is in the gastroscope not following 
 the axis of the esophageal lumen. 
 
 Folds probably do not exist in the quiescent state of the esophagus. 
 When muscular contractions occur, folds probably exist. Of these thmgs 
 there is no absolute certainty. When a tube is introduced, however, the
 
 102 NORMAL ESOPHAGOSCOPIC APPEARANCES. 
 
 wall may be thrown into folds, either transverse or longitudinal. There 
 has been much useless discussion upon this point, one observer seeing 
 one kind of folds and another observer another kind. In most instances, 
 in the author's opinion, the folds were produced by the manipulation of 
 the esophagoscope. 
 
 The color of the normal esophageal lumen varies greatly in different 
 individuals, in the same person at different times, and still more greatly 
 does the apparent color vary with the form of illumination. With the 
 bright white light of the self-illuminated tubes, the mucosa is almost 
 white, shading to pale grayish pink. With reflected sunlight which the 
 author used experimentally to determine the color, the mucosa seemed to 
 be of about the same tint. With the unilluminated tubes the color varies 
 with the amount of light that reaches the mucosa. If well illuminated, 
 the color is the same as with the illuminated tubes. If poorly lighted up, 
 the mucosa seems dark red or brown. The colors as given here refer to 
 the perfectly cleansed mucosa. Overlying secretions vary the tint greatly ; 
 so also may drugs, as chloroform, ether, cocain, etc. The surface of the 
 mucosa is moist and glistening. In the cervical and the abdominal por- 
 tions minute vascular twigs are at times seen. They are less often noted 
 in the thoracic portion in health. A fair idea of the appearance of the 
 normal esophageal mucosa may be conveyed by comparing it to the mu- 
 cosa of the inside of the cheek.
 
 CHAPTER XII. 
 Technic of Lsophagoscopy. 
 
 Examination of the Upper End of the Esophagus. 
 
 The examination of the upper end of the esophagus is a very easy 
 matter. Technically it is the same as direct laryngoscopy, (q. v.) but it 
 is much easier of accomplishment by the inexperienced. It may, and 
 should, be a routine procedure in the consulting room. A full operating 
 room detail is not necessary. The patient is told to arrive with an empty 
 stomach and a clean mouth. The positions of patient, assistant and nurse 
 and apparatus are exactly the same as described for direct laryngoscopy. 
 
 The pharynx and introitus esophagi are cocainized with the aid of a 
 Sajous, curved, laryngeal sponge forceps. The tubular speculum is then 
 passed down back of the tongue until the epiglottis comes into view. It 
 is wise, usually, at this point to take a straight applicator dripping with a 
 ID per cent cocain solution and cocainize the epiglottis and then, passing 
 on, to cocainize the laryngeal orifice and tlie introitus esophageus, waiting 
 a few minutes for anesthesia to supervene. 
 
 Tlae tubular speculum is passed down back of the epiglottis which is 
 lifted forward against the base of the tongue. This brings into view the 
 arytenoids which are seen to lie in contact with the posterior pharyngeal 
 wall. (Fig. I, Plate III, shows this as seen in the dorsally decumbent 
 patient. To get the view as seen in the erect patient, invert the plate.) 
 There is no slit; only a depression is seen. The spatular end of the tubu- 
 lar speculum is inserted in this slit, far enough to reach below the aryte- 
 noids and engage posteriorly to the cricoid cartilage, which is lifted for- 
 ward, thus exposing the pyriform fossje. (Fig. 60.) The lifting forward 
 of the cricoid cartilage exposes the upper esophageal lumen as seen in Fig. 
 6, Plate III. 
 
 Passing the Esophagoscope. 
 
 Preliminary to the passing of the esophagoscope for any cause what- 
 soever, the tubular speculum should be used ; not as a guide through which
 
 104 
 
 TECHNIC OF ESOPHAGOSCOPY. 
 
 to pass the longer tube, as in tracheo-bronchoscopy, but to gain a knowl- 
 edge of the conditions, nomial or pathologic, of the upper end of the esoph- 
 agus. This will prevent the danger of pushing the longer tube into a 
 lesion, or prevent the unnecessary deeper search for a highly located for- 
 eign body. Furthermore, examinations should be thorough and thor- 
 oughness is only accomplished by a routine examination of all the struct- 
 ures seriatim from above downward. Thus, not only is all chance of 
 
 Fic. 00. — Basr of llie tongue anil iipijci- border of the uoruiiil larynx, viewed from 
 behind. 1. Median gIo?so-epiglottic fold. 2. Right glosso-epiglottic fossa. .3, Lateral 
 glosso-epiglottic fold. 4. I'haryugo-cpiglottic fold. 5. Aryepiglottic fold. 6, Right 
 pyriforni sinus, by way o£ which esophagoscope should lie passed. 
 
 missing anything avoided, but we reduce the dangers of esophagoscopy 
 almost to naught, bv seeing and avoiding penetration or even abrasion of 
 all weak places in the esophageal wall. 
 
 The manipulations of passing the esophagoscope arc exactly the same 
 as those of passing the gastroscope and to save repetition they will be 
 given in the cha]5ter devoted to that subject.
 
 CHAPTER XIII. 
 Diseases and Anomalies of the Lsophagus. 
 
 Anomalies. 
 
 A'arious congenital anomalies of the esophagus occur, but their ex- 
 tended consideration would be out of place here. The esophagus may be 
 bifid, or the esophagus may end in a blind imperforate pouch. In either 
 case the child seldom lives any length of time. Esophago-tracheal fistula 
 is a form that occurs, and some such cases have been known to live. In 
 one such case, a valve-like fold of mucosa seemed to close the fistula so 
 that no food escaped into the trachea. 
 
 Diseases of the Esophagus. 
 
 Diseases of the esophagus may be divided into stenotic and non- 
 stenotic classes. Stenotic diseases may be classified into acute inflamma- 
 tory, neoplastic, sjjastic and compression .stenoses. 
 
 The non-stenotic diseases include diverticula, dilTuse dilations, 
 paralyses and pareses, and inflammations and ulcerations. 
 
 In all of these diseases the esophagoscope stands ready to lend inval- 
 uable aid for the purposes uf diagnosis and treatment. But, separately to 
 consider all these diseases would far exceed the scope of this manual. 
 Only a few of the many subjects in this interesting field will be considered 
 and onlv briefly.
 
 CHAPTER XIV. 
 Stenotic Diseases of the Lsophagus. 
 
 Acute Inflammatory Stenoses. 
 
 Acute inflammatory stenoses must be approached with great caution. 
 As a rule, when they are due to a corrosive, as lye, or carbolic acid, it is 
 better not to pass an esophagoscope, but to wait for the inflammatory re- 
 action to subside. So, too, in traumatic cases, when the implement of 
 traumatism has been removed, it is better not to intrude any instrument. 
 Better results will be obtained by waiting a week or more for the acute 
 inflammation to subside. An esophagoscopic examination then will en- 
 able the determination of a plan of treatment to prevent the formation of a 
 cicatricial stenosis. If, however, when first seen, the foreign body, mis- 
 sile, or implement of traumatism is still present, immediate esophagoscopy 
 is imperatively demanded. After removal the trauma is best let alone for 
 a few days until the granulation tissue has made esophagoscopy safe and 
 associated remedial measures effective. 
 
 Cicatricial Stenoses. 
 
 Cicatricial stenoses are commonly due to post-operative, traumatic, 
 escharotic, luetic, or ulcerative scars. 
 
 The diagnosis of the presence of the stricture is readily made esoph- 
 agoscopically, though the history must be relied upon to determine the 
 etiology. 
 
 Post-operative cicatricial stenoses are usually in the cervical portion, 
 as intrathoracic surgery of the esophagus is as yet rarely attempted. The 
 author has seen a number of cases of post -operative esophageal stenosis of 
 the cervical esophagus follow total laryngectomy. It has been known to 
 follow thyrotomy for malignant disease, though it would seem that the 
 proper limits of thyrotomy had been exceeded in such cases. In excision 
 of malignant disease of the glands of the neck, the esophagus has been 
 resected for involvement, with resultant stricture.
 
 STENOSES OF THE ESOPHAGUS. 107 
 
 Of traumatic stenoses, the most frequent forms result from penetrat- 
 ing gunshot wounds, and from swallowing sharp foreign bodies, as glass, 
 knives, dentures, etc. 
 
 Escharotic cicatricial stenoses are perhaps the most frequent. In the 
 days of home made soap, swallowing of caustic soda and potash in the 
 form of lye was not an infrequent accident to children. 
 
 Syphilitic ulceration of the esophagus is much more frequent than 
 generally supposed, and the author has seen a number of cicatricial sten- 
 oses from this cause. 
 
 Of the ulcerations, other than luetic, that may be followed by cicatri- 
 cial contraction, those of typhoid fever may be cited. One such case was 
 seen by the writer, though it occurred in a case with an escharotic history. 
 
 Mr. H., aged l8 years, was referred to me by Dr. A. M. Stevenson for a 
 diagnosis of the esophageal condition. During the fourth week of typhoid 
 fever it was found that there was increasing difficulty in swallowing the liquid 
 food. Finally a stage was reached where nothing but ice cream would pass 
 down, and fully two-thirds of it were regurgitated. Upon passing the esopha- 
 goscope, an old hard cicatrical stenosis was found. Upon its edge there was 
 an ulcer of linear form, long a.xis longitudinal. The old cicatrices (Fig. 4, 
 Plate III.) were also longitudinal giving a radiating arrangement, when viewed 
 through the esophagoscope. Applications of argentic nitrate were made at in- 
 tervals and resulted in a complete cure of the ulcer, though the difficulty in 
 swallowing persisted for a long time, eventually, however, recovering. Upon 
 close questioning, Dr. Stevenson elicited a vague history of swallowing lye in 
 childhood, followed by some swallowing difficulty which soon disappeared. 
 For 14 years there had been no trouble in swallowing any and every kind of 
 solid or liquid food, until the attack of typhoid fever. 
 
 The treatment of cicatricial stenosis with the aid of the esophagoscope 
 has yielded very satisfactory results in many cases of a class formerly con- 
 demned to gastrostomy. The passing of bougies blindly, which formerly 
 was the chief method of treatment, is now only used for the maintenance 
 of a dilation accomplished esophagoscopically. Bouginage was a danger- 
 ous procedure in the absence of any definite information as to the endo- 
 esophageal conditions present in a given case. In the absence of an esoph- 
 agoscopic examination, when a bougie is blindly introduced and meets 
 with an obstruction, there is no means of knowing whether it has encoun- 
 tered a stricture or the bottom of a diverticulum. Obviously, to force the 
 bougie under such circumstances is to court disaster. Cases of stricture 
 requiring treatment are always severe cases, so that they require a very 
 small bougie. Strictures are rarely concentric with a funnel shaped up- 
 per portion which might guide the bougie to the stricture. On the con- 
 trary, there are folds, bands, pockets, and diverticula that render the 
 chances very much against a bougie finding the lumen of the strictured
 
 108 BOUGINAGE PER TUB AM. 
 
 passage. It is utterly unjustifiable under these circumstances to force a 
 small bougie. There are many cases of death from this unsurgical, blind, 
 rarely justifiable procedure. Anyone who has done, or seen done, the pre- 
 cise operation of passing an esophagoscope, locating the stricture, insert- 
 ing an instrument therein, dilating the stricture and restoring the patient's 
 power of swallowing will never endorse the reckless making of false pas- 
 sages in the mediastinum, pleura, pericardium, bronchi or lungs, by blind 
 stabbing with a bougie. 
 
 If the stricture case gives a history of great difficulty in getting down 
 soft solids, even though fluids pass without difficulty, it will be found, upon 
 esophagoscopy. that the lumen of the stricture is exceedingly small and 
 difficult to find. One wonders how even fluids could leak through in 
 sufficient quantity to sustain life. In such cases the most brilliant results 
 can be safely obtained with the aid of the esophagoscope. 
 
 The best form of bougie for these cases is Bunt's (Fig. 6i). They 
 are made with two olivary bulbs ; one covering the point and one a size 
 (French scale) larger, situated 3 cm. from the end. Tliis has two ad- 
 vantages : 
 
 I. It permits following up a sized olive that passes readily and safe- 
 ly with one of a size that may safely do some dilating. 
 
 Fig. 61. — Biiut's (loul)le olive bougie. 
 
 2. The distance between the olives permits the passage of the inter- 
 vening 3 cm. of stem before the second bulb engages in the stricture. This 
 acts as a guide and assures safety in using some force on the second bulb. 
 
 Bunt used these bougies with the aid of the sense of touch, without 
 the esophagoscope, and obtained excellent results. They are, however, 
 more accurately and advantageously used with the aid of the esophago- 
 scope. 
 
 The esophagoscope is passed, the esophageal wall closely inspected, 
 scars, diverticula and other abnormalities examined. When the tube 
 mouth reaches the constriction that is loo narrow to admit it, if not too 
 small, a smaller tube may be passed through the first, or, better, the first 
 may be withdrawn and a smaller one introduced. In many cases it will 
 be found that this first stricture is but the vestibule to a second, smaller 
 stricture. Tiiere may be several strictures and in one instance, the author 
 saw six. As a rule, they do not all require treatment other than to ensure 
 their getting no smaller. Having arrived at a stricture which will not 
 permit a 7 mm. esophagoscope to pass, the esophageal wall ahead is
 
 STENOSES OF THE ESOFII.ICUS. 109 
 
 sponged clean and a search is made for the lumen nf the '>tricturc. Very 
 often this will be of almost a pin-hole size seen in tlie ll:it wall against 
 which the tube moutl! is gently pressed. Often prolonged exploration of 
 a diverticulum or a number of diverticula will he necessary before the 
 strictural opening is discoveretl. When found, the smallest Hmit bougie 
 is inserted. If it pass readil}', the next size is inserted, and so on up until 
 a size is reached whose distal olive passes readily, but the second olive en- 
 gages. Tliis is pushed through and the next larger size is used. At the 
 next treatment, three or four days later, these same sizes are used again, 
 followed bv one size larger. This is continued until a sufficientl)' large 
 lumen is secured to permit the patient to swallow solids normally. 
 
 The ordinar\- flexible silk-and-wax bougie is then gently tried with- 
 out the esophagoscope, the patient being instructed to make continual-swal- 
 lowing efforts wdiile the bougie is being passed. If the flexible bougie 
 pass readily, the patient is taught to pass it himself, and instructed to pass 
 it regularlv once a week or oftener, if any signs of strictural closure super- 
 vene. After a time, once a month will be enough. This may be called a 
 symptomatic cure and is brilliant compared to gastrostomy, either with or 
 without retrograde chlatation. 
 
 Of the other methods, dilatation with a laminaria tent placed with the 
 aid of the esophagoscope, deserves mention. It is carried on the end of a 
 stylet fitted to the tube forceps (Fig. 22). The disadvantage to tent dila- 
 tations is that the tent expands more below the stricture than at it. This 
 lower expansion in extraction has tc be pulled through th.e stricture. This 
 is not often difficult to do, but may be attended with slight risk, though 
 no cases of untoward results have come to the author's knowledge. The 
 axial tugging on the esophagus, rather than the stretching of the circum- 
 ference constitutes the danger ; for as demonstrated sphygmomanometri- 
 cally by Boyce on some of the author's cases of laryngectomy, tugging on 
 the esophagus produces a great fall in blood pressure. 
 
 Instrumental dilatation with steel expanding forceps is a feasible pro- 
 cedure and is advisable in a few instances. There is always some risk of 
 rupture of the esophageal wall, which is a very serious complication. 
 There are many other plans of treatment, instrumental, electrolvtic, etc., 
 but that given is the most practical. 
 
 Medicinal treatment is of no use so far as cure is concerned, but it 
 may be well to know that cocain. adrenalin and morphin have a decided 
 effect in temporarily opening a stricture sufficiently to permit liquids to 
 pass. This is of use at times in tiding over a few davs, when the patient 
 is not seen until he is in a serious state of inanition. Under these circum- 
 stances it is also well to know that ice cream will go down when nothing 
 else will. The action of the cold probably is to contract the chronically
 
 110 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 inflamed mucosa, so as temporarily to increase the available lumen. Of 
 course most of the ice cream is regurgitated, but enough leaks through to 
 prevent starvation. 
 
 Malignant Disease of the Esophagus. 
 
 As in malignant disease elsewhere in the body, the crime of the day 
 is in the failure to recognize malignancy and pre-malignant conditions 
 early. It is not until emaciation, cachexia, regurgitation and absolute ina- 
 bility to swallow solids supervene that the profession, even the laryngolog- 
 ical member of the profession, thinks of serious disease of the esophagus. 
 All earlier stages are dismissed thoughtlessly with the label "globus hys- 
 tericus." Illustrative of this the following case may be cited : 
 
 Miss L., aged 41, was under the author's care for chronic maxillary 
 sinuitis. She mentioned incidentally that she felt a lump in her throat at times 
 upon swallowing. When asked if she felt the lump rise in her throat when she 
 was not attempting to swallow, she answered that at times she did. There had 
 been no difficulty in getting even solid food down, and there was no regurgi- 
 tation. She was undoubtly a neurasthenic, yet the author has made it a rule 
 to consider that a neurasthenic may have a lesion as well as a person without 
 neuropathy, and that a person with abnormal esophageal sensations should be 
 examined as well as one with abnormal laryngeal sensations. In this instance, 
 it was two months before the attending physician grudingly gave his consent 
 to an esophageal examination. Under ether, preliminary to a secondary sinus 
 operation, the esophagoscope was passed and an epithelioma (Fig. 8, Plate 
 III.) discovered. 
 
 The foregoing case dlustrates : 
 
 1. The latency of esophageal symptoms. 
 
 2. TTie necessity for the examination of the esophagus in all cases 
 where any chronic throat symptoms, other than laryngeal, are complained 
 
 3. The fallacy of labelling (it would not be accurate to say diagnos- 
 ticating) a case of "globus hystericus," because the patient complains of 
 "a lump rising in the throat," whether she be a neurasthenic or a hysteric 
 subject or not. 
 
 Malignant diseases of the esophagus for esophagoscopic purposes 
 may be divided into endo-esophageal, muro-esophageal and peri-esopha- 
 geal diseases. Naturally this only applies to the early stages. Late in the 
 disease all three forms are usually combined. 
 
 Peri-esophageal disease in its earlier stages will present a hard resist- 
 ing sensation to the end of the esophagoscope, though the overlying muco- 
 sa is normal. This is well shown in Fig. 7, Plate III, where the mass is to 
 the left, the lumen to the right. This deviation of the lumen must be dis- 
 tinguished from the simple neglect of making the tube follow the direction
 
 MALIGNANT DISEASE OF THE ESOPHAGUS. 1 1 1 
 
 of the axis of the normal hinien. The figure is drawn from a case of 
 epithelioma in a man 6o years of age, referred lo me by Dr. Sanes. Tlie 
 esophagoscope could not be introduced past the hard mass, though the 
 mucosa was normal. Later the wall and still later the mucosa, became 
 involved. 
 
 The esophagoscopic appearances of nuiroand endo-esophageal ma- 
 lignancy varies in different cases and in different stages. In the early 
 stage Von Acker regards distinctive, slight narrowing of the lumen with 
 islands of infiltration raising the mucosa in spots, the mucosa being red- 
 dish with purplish hemorrhagic dots, and with here and there enlarged 
 vessels visible. This is an early condition prior to ulceration. 
 
 Gottstein, whose experience is large, describes five forms of esoph- 
 agoscopic appearances in esophageal cancer. 
 
 1. Segmentary mural infiltration in thickened whitish patches alter- 
 nating with bright red. 
 
 2. Annular form, seen as a more or less extended ring of infiltration 
 which narrows the lumen below a fungating ulceration occupying m.ore or 
 less of the ring. Above this ulcerated area there is more or less dilatation 
 dependent upon the duration of the narrowing. The mucosa of this dilated 
 area is more or less altered. 
 
 3. Carcinomatous infiltration not only annular but funnel-shaped. 
 
 4. Bleeding cauliflower fungating masses. 
 
 5. Papillomatous vegetations. 
 
 The most common in form is the second. 
 
 Stoerk urges the diagnostic importance of the absence of the respira- 
 tory enlargement and the diminution of the esophageal lumen, due to infil- 
 tration of the esophageal walls. He also attaches weight to flat infiltra- 
 tion, bleeding after wiping, and superficial ulceration of the tumor. 
 
 It must not be forgotten that all of these appearances may be simu- 
 lated by syphilis, but the therapeutic test will soon distinguish. 
 
 The taking of a specimen is in all cases advisable, and is quite harm- 
 less. If bleeding follow, which is rare, it can be stopped by swallowing 
 ice cream, iced water, or pieces of ice. Epithelioma and endothelioma 
 may be distinguished microscopically with some degree of certainty, if an 
 adequate specimen be removed. But, obviously, the pathologist can only 
 report on the specimen submitted, so that a good, ample specimen must 
 be obtained, preferably one at the edge of the neoplasm and including both 
 normal and neoplastic tissue. In cases of deep-seated growth covered 
 with normal mucosa, it is useless to take a specimen unless the forceps be 
 plunged deeply into the mass, which is seldom justifiable. In fibro-sar- 
 comata, of which the author has seen one case, the microscopic appear- 
 ances are characteristic, as they are also in sarcomata of other than the
 
 112 BEXIGN NEOPLASMS OF THE ESOPHAGUS. 
 
 small round-celled variety. The latter form is not with certainty dis- 
 tino-uishable from tuberculoma, syphiloma, and inflammatory round-celled 
 infiltration ; at least such has been the author's experience from small in- 
 adequate specimens submitted to various pathologists. If the entire mass 
 or a portion extending from the surface of the growth clear down into 
 healthv tissue be obtained, the pathologist would have a fair opportunity 
 and could give a dependable opinion in all cases. 
 
 Tlie treatment of malignant disease of the upper portion of the esoph- 
 agus when associated with similar disease in the larynx may be extirpated 
 by resection of the esophagus at the laryngectomy. For extensive opera- 
 tive work upon the upper end of the esophagus, Mosher's ingenious spec- 
 ulum (Fig. 5) is well adapted. If the patient be not tracheotomized it is 
 necessary to watch the breathing carefully while using this, as the broad 
 flat surface is apt to close the laryngeal orifice. The author has had a 
 large oval opening made in the spatular part of iMosher's instrument which 
 obviates this to a great extent. It is better in most cases to do a trache- 
 otomy as the chloroform may be administered through the tracheal canula 
 bv means of a simple piece of rubber tubing one end of which is fitted into 
 the tracheal canula, while the other end has tied over its extremity a tuft 
 of gauze upon which the chloroform is poured. Used with a tracheotomy, 
 the Mosher instrument has the advantage of closing the laryngeal orifice 
 so that tamponade of the larynx is unnecessary, or if tamponade be needed 
 the instrument serves to hold the previously placed tampon in place. 
 
 In deeper portions of the esophagus palliative treatment will greatly 
 prolong life and relieve pain. When stenosis threatens to interfere with 
 nutrition the esophagoscope is introduced and the narrowed lumen dilated, 
 as described in reference to cicatricial stricture. Tlie ordinary flexible 
 bougie should never be used except after the esophagoscope has deter- 
 mined the absence of ulceration or weakening of the esophageal wall. 
 
 Benign Neopt^asms of the Esophagus. 
 
 Benign neoplasms, when large enough, produce esophageal stenosis. 
 In many instances, however, they will be discovered quite accidentally. 
 In this connection, however, it must be remembered that, at the present 
 dav, slight difficulty or inconvenience in swallowing is either absolutely 
 ignored or labelled "neurasthenia" or "globus hystericus," and dismissed. 
 Such a thing as examining the case with an esophagoscope does not seem 
 to occur to the clinician's mind. When the neglected subject of esopha- 
 geal disease receives its merited study, benign tumors will be found to be 
 less infrequent than is at present supposed. 
 
 Edematous polypus has been observed but is rare. The most fre- 
 quent benign tumors are. papillomata, fibromata, myomata, fibromyomata, 
 mixomata, angiomata, lipomata, adenomata and cystomata.
 
 BHXIGX MiOrL.ISMS OJ- THE IlSUI'U .IGUS. 11.'? 
 
 The base of a benign ,u;n>\vth is never indurated : though we must be 
 on our guard against diagnostic error in case of its occurring at the site 
 of a scar. 
 
 The naked eve diagnosis of benign tumors is only possible when they 
 are observed to have long, distinct pedunculi. Malignant ncoplasmata 
 rarely, if ever, occur ni this form. All sessile growths, whether ulcerated, 
 fungating or smooth, can only be diagnosticated with certainty by the aid 
 of the microscope. The removal of a specimen is always justifiable. No 
 hemorrhage need be feared, if one condition be excluded, namely, vari- 
 cosities of the esophageal vessels. Even in such a case it is doubtful if 
 any hemorrhage will occur that will not yield to the eating of ice cream, or 
 the swallowing of pieces of ice. 
 
 Treatment. All benign tumors of the esophagus demand removal. 
 Tlie possibility of their undergoing malignant degeneration is disputed, 
 but, while it is true that cells never change their type, the benign neoplastic 
 tissue is more liable than normal tissue to become the site of a malignant 
 neoplasm. 
 
 For removal, strong forceps are necessary, especially in case of pe- 
 dunculated tumors. Necessarily the pedunculi are tough and strongly 
 attached, else the growth would be detached and swept downward by the 
 swallowed food. It is necessary as a rule to bite out the mucosa where 
 the peduncle is attached, not only because it is safer than the severe trac- 
 tion necessary to tear away the growth, but to prevent repullulation. This 
 is illustrated in the following case : 
 
 Mr. P., aged 36 years, was referred to the aiitlmr by Dr. Heard for vague 
 and indefinite throat symptoms, which would certainly not have aroused any 
 suspicion of esophageal disease in a mind not particularly bent toward the 
 subject. He said his throat "bothered" him, he had some "throat trouble" and 
 like indefinite expressions of his unlocated sensations. There was some cough, 
 also occasional hoarseness. Examination with the laryngoscope revealed a 
 chronic laryngitis, nothing more. Examination of the upper end of the esopha- 
 gus with the laryngeal speculum revealed whitish granular tumor attached by a 
 pedicle three centimeters in length. (Eig. 12, Plate III.) The pedicle was at- 
 tached about two centimeters below the level of the inlerarytenoid space. Upon 
 a subsequent e-xamination with the laryngeal mirror the growth was seen lying 
 in the inlerarytenoid space (Fig. 9, Plate III.). The growth was certainly not 
 there at the first examination with the laryngeal mirror. The mystery was ex- 
 plained, however, when the patient was told to swallow, and upon re-examina- 
 tion the tumor was nowhere to be seen. The long pedicle permitted the tumor 
 to rise above the introitus like a floating buoy above its anchorage, but in 
 swallowing the growth was carried below the inferior constrictor. With the 
 assistance of Dr. Heard, the neoplasm was removed under local anesthesia by 
 direct inspection through the tubular speculum (Fig. 6). The peduncle was 
 found of such a tough fibrous nature that the esophageal wall was pulled into 
 the mouth of the speculum, without tearing away. The cup-shaped forceps
 
 114 SPASTIC STENOSES OF THE ESOPHAGUS. 
 
 (Fig. 24) were then used to bite out the esophageal wall to which the peduncle 
 was attached. The wound healed promptly and si.x months later there was no 
 sign of recurrence. The growth was examined by Dr. Jonathan Wright, who 
 pronounced it fibroma papillare. 
 
 This case is interesting as showing: 
 
 1. The absence of symptoms associated with small esophageal neo- 
 plasms. 
 
 2. The likelihood of overlooking such conditions. 
 
 3. The necessity of examination of the esophagus in all doubtful 
 throat cases. 
 
 4. The ease with which the upper end of tlie esophagus can be ex- 
 amined, and the ease of removal of neoplasms therefroni, with the aid of 
 the tubular speculum. 
 
 5. Tlie advisability of excision of benign growths with the cupped 
 forceps, as compared to evulsion with serrated forceps. 
 
 Many benign growths have a strong tendency to recur. They do not 
 infiltrate, hence are not malignant, but they repullulate in a most stubborn 
 manner if any portion is left. 
 
 Spastic Stenoses of the Esophagus. 
 
 Cardiospasm, as its name implies, is applied to a condition of spas- 
 modic closure of the cardiac orifice of the stomach. It is applied, how- 
 ever, to spasmodic closure of the esophageal lumen without limitation 
 strictly to the cardia. The cardia is not a genuine sphincter, though Hyrtl 
 has demonstrated circular fibres. The prevention of regurgitation is prob- 
 ably as mucli a ki'.iking of the esophagus due to expansion and upward 
 movement of the fundus ventriculi as to any sphincter-like action at the 
 cardiac orifice. There is, however, a distinct sphincter-like action at the 
 hiatus esophageus. Wherever future study may demonstrate the seat of the 
 spasm to be, there can be no doubt of its occurrence. Many observers 
 have seen it. In all three of the author's cases it occurred in the abdom- 
 inal esophagus between the cardia (as indicated by the mucosa) and the 
 hiatus. In two of these cases it was associated with peptic ulcer of the 
 abdominal esophagus. It disappeared completely while the patient was 
 under deep general anesthesia. It was associated with slight dilatation of 
 the superjacent esophagus. A number of competent observers have noted 
 this dilatation of a very marked degree. 
 
 Phrenospasm is a name given by the author to a closure of the esoph- 
 agus at the hiatus esophageus by a tonic spasm of the neighboring portion 
 of the diaphragm. It is frequently seen in passing the long esophagoscope 
 or gastroscope without anesthesia or in withdrawal of the instrument after 
 the tube mouth has retreated from the hiatal portion of the esophagus. 
 Frequently in the absence of anesthesia, the instrument is clamped so
 
 COMPRESSION STENOSES OP THE ESOPHAGUS. 115 
 
 tightly in this plircnospasni that the niovoments of the tube are hindered. 
 It disappears completely during the relaxation of deep general anesthesia. 
 This complete disappearance of the obstruction, along with a normal yield- 
 ing wall and a normal mucosa establishes the diagnosis absolutely. It is 
 almost invariably associated with dilatation of the portion of the eophagus 
 immediately above it, just as organic stricture is. 
 
 Esophagospasni or esophagismus is usually the condition found m 
 globus hystericus. It is associated with great difficulty in introducing an 
 esophagoscope under local anesthesia, but it disappears promptly under 
 deep anesthesia, when the esophagoscope may be passed freely up and 
 down the esophagus, revealing a wall of normal resiliency, which wall 
 shows the normal respiratory excursion, and which is covered with normal 
 mucosa. Occasionally esophagisnuis will be found to be secondary to a 
 lesion, the most frequent lesion being a simple ulcer. 
 
 The treatment of spastic conditions of the esophagus may be pallia- 
 tive or curative. Palliative treatment consists in the use of iced liquid 
 food in some instances, of hot liquids in others. Drugs as morphin and 
 cocain have an effect, but their use should be avoided. Curative treat- 
 ment consists in the cure of ulcers if present, in the application of gal- 
 vanism with the olive-pointed electrode, and in bouginage. After the 
 esophagoscope has demonstrated the normality of the esophageal wall, the 
 daily passage of the flexible esophageal bougie by the patient will establisii 
 a cure after extreme tolerance to the bougie is developed. Retrograde in- 
 strumental dilatation is used in extreme cases, but the esophagoscopic di- 
 latation is the most useful in abolishing the hypersensibility of the esoph- 
 agus, which is the chief factor in many cases. 
 
 Compression Stenoses of the Esophagus. 
 
 Compression stenoses of the esophagus are produced by many differ- 
 ent conditions. Hypertrophic, inflammatory, neoplastic and exudative 
 diseases of adjacent tissues may compress the esophagus. The most fre- 
 quent conditions are: struma, glandular infiltrations, mediastinal or cer- 
 vical tumors, aneurysms, pleural and pericardial effusions, abscesses, spinal 
 deformities, etcetera. 
 
 The differential diagnosis of these conditions depends less upon end- 
 oscopic examination than upon general clinical diagnostic methods. Tlie 
 location of the stenosis as measured esophagoscopically is often an aid. 
 In aneurysm the pulsations are diagnostic, if the observer is familiar with 
 the normal pulsatory movements as observed in the esophagoscope. The 
 radiograph is a very important aid in diagnosticating aneurysm and some 
 forms of mediastinal tumors. (Figs. 50 and 62.) In aneurysm the pul- 
 sations may be seen fluoroscopically.
 
 Fill. 62. — Radiogram showing location of a malignant mciliastmal tumor produc- 
 ing ctanpression stenosis of the esophagus.
 
 CHAPTER XV. 
 Non-5tenotic Diseases of the Esophagus. 
 
 Diverticula. 
 
 A divcrticulniii is a circumscribed ectasi?. of the esophageal wall, in 
 centra-distinction to a dilatation which is a diffuse ectasia. Though a di- 
 verticulum of the esophagus is not in itself a stenotic disease, it is usually 
 associated with a subjacent stenosis, which is the chief factor in its pro- 
 duction, lliis form is called a pressure diverticulum, because of the 
 probable etiologic influence of the pressure of the esophageal contents, 
 which the musculature is endeavoring to propel. The other form is called 
 a traction diverticulum, being due tc traction, as by an adhesion, externally 
 on a circumscribed portion of the esophageal wall. 
 
 The esophagoscopic picture is not as clear as might be at first sup- 
 posed, though the diagnosis can be made in every case bv careful explora- 
 tion. The possibility of the presence of a diverticulum must be borne in 
 mind in every case of esophagoscop}-. ^^'hen the esophagoscope enters 
 the diverticulum the orifice of the sub-diverticular esophagus is usually not 
 noticed. The tube mouth comes against a flat surface which is usually 
 mistaken for a strictural or neoplastic stenosis. The tube is withdrawn 
 and yet no orifice is seen. Often it cannot be found until regurgitation 
 forces some fluid through, or forms one or more bubbles. The orifice is 
 usually very small, often slit like, and hidden by a fold or band. To 
 favor regurgitation, the patient, if under general anesthesia, should be 
 allowed to come out partially. The bottom of the diverticulum is usually 
 chronically inflamed as shown in Fig. 5, Plate III, drawn from one of the 
 author's ca.ses. This chronic inflammation is probably due to the pres- 
 ence of food, which is not well tolerated by the esophagus. The normal 
 esophagus endeavors to rid itself of everything, even its own secretions, 
 by upward or downward expulsion. Frequently the diverticulum will be 
 found full of secretions, but, with the aspirator attached to the esophago- 
 scope, (Figs. 17 and 18,) the latter is slowlv inserted and the secretions
 
 118 DILATATION OF THE ESOPHAGUS. 
 
 removed ahead of the tuhe in a manner that eliminates all trouble from 
 this source during the examination. Large masses of food, sometimes 
 present, may be removed with the forceps. 
 
 The treatment of diverticula is mainly surgical. Dilatation of the 
 sub-diverticular stricture will produce a symptomatic cure and occasion- 
 ally some recession of the size of the diverticulum may thus be brought 
 about, if the strictured passage be kept open. If so located that external 
 surgery is of aid, a radical cure may be brought about. Such cases have 
 been reported by Depage, Kocher, Bilroth, Goris, and others. 
 
 DlL.^TATlOX OF THE EsOPHAGUS. 
 
 Dilatation is a diffuse ectasia of the esophageal wall, in coiitra-dis- 
 tinction to a diverticulum which is a circumscribed ectasia. 
 
 The most common form is the spindle shaped esophagus. 
 
 It is very rare in tiie upper portion of the esophagus. It occurs in 
 three classes of cases : 
 
 1. Those in vvhich there is below the dilatation an anatomic stricture 
 which is evidently its cause. 
 
 2. Those in which there is a spasmodic stricture, usually a phreno- 
 spasm or cardiospasm below the dilatation. 
 
 3. Those in which there is no stricture anatomic or spastic demon- 
 strable, and which are supposed to be due to atony of the esophageal wall. 
 There is every likelihood that there has existed at some previous time a 
 cardiospasm or a phrenospasm. 
 
 Various clinical and chemical methods of differential diagnosis be- 
 tween diffuse dilatation and diverticulum have been advocated from time 
 to time, but none of them compare in accuracy with the simple procedure 
 of esopliagoscopy, by which we put a tube down and actually see the con- 
 ditions present. 
 
 The esophagoscopic picture in dilatation is unmistakable. In the 
 normal esophagus, the walls are visible at all times ; the lumen enlarging 
 upon inspiration, but never to such an extent that the walls are not visible. 
 In dilatation, on the contrary, during inspiration the entire wall disappears 
 and the tube end is seen to be in a large cavity, the walls of which are 
 ballooned out. The upper wall, if the patient be in dorsal decubitus, may 
 sag downward, and it will be noticed that to bring the lower (posterior) 
 wall into view the tube mouth must be lowered quite a distance. Later- 
 ally the enlargement of the lumen is equally apparent upon a lateral move- 
 ment of the tube mouth. Of course, this description applies to extreme 
 degrees of dilatation. All sizes and stages of dilatations are met with 
 and the lesser degrees may raise the question of the border line between 
 normalitv and disease.
 
 DILATATION OF THE P.SOPHAGUS. 119 
 
 The dilatation is not always concentric and it is not always possible 
 to determine whether it is concentric or not. The possible extent of lat- 
 eral drag in all directions is some criterion, but this varies within the 
 limits of health, and considerable experience in esophagoscopy is neces- 
 sary to determine the degree of eccentricity of the dilatation, and, indeed, 
 the presence of a dilatation, if the dilatation be of very slight degree. 
 
 Dilatations, if of any size, usually contain food particles, and also 
 more secretion than the normal esophagus, due to the chronic turgescence 
 and inflammation of the mucosa. TTie accumulation is due rather to the 
 obstruction below, and to the motor insufficienc}- than to the mere dilata- 
 tion per se. The mucosa often shows dilated capillaries and occasionally 
 erosions. In cases associated with cicatricial stenosis, cicatrices may be 
 seen. In pushing the tube on downward the presence of the subjacent 
 stenosis and its character, whether anatomic, cardiospastic, or phrenos- 
 pastic will be determined as before described when speaking of stenotic 
 diseases. 
 
 A tumor more frequently malignant than benign may exist in the 
 dilatation. Ulceration, benign or malignant, occurs. In cardiospastic 
 and phrenospastic dilatations, the mucosa is very much reddened, especially 
 in the upper two-thirds of the dilatation. In the lower third, it is usually 
 paler and the dilated branching capillaries are particularly noticeable at 
 the site of the spastic stricture. Below this the mucosa is sometimes 
 noticed to fold in over the end of the tube in transverse folds. 
 
 The differential diagnosis between spasmogenic dilatations and those 
 resulting from anatomic stricture is easily made by the determination of 
 the presence or absence of an anatomic stenosis. TTie differential 
 diagnosis between spasmogenic and atonic dilatations, if, indeed the 
 latter kind ever exists alone, is difficult. As previously stated, tlie 
 author's belief is that the so-called atonic dilatation is a result of pre-ex- 
 istant spasmogenic conditions. The differential diagnosis between dilata- 
 tion and a deeply situated diverticulum, impossible by other methods, is 
 easily made esophagoscopically. If a diverticulum exists, no hiatal slit 
 or cardia will be found, instead, the tube mouth will stop against a lightly 
 stretched wall, the bottom of the diverticulum. The orifice of the sub- 
 diverticular esophagus can be found by careful search as the esophago- 
 scope is very slowly withdrawn. 
 
 The treatment of dilatations is based upon eradication of the cause. 
 The subjacent stenosis, anatomic or spastic must be dealt with. If ana- 
 tomic it is treated as previously outlined, by dilatation, forcible or prefer- 
 ably gradual. The wearing of a short tube or sound for an hour or more 
 is beneficial, but the size must be exactly determined so as to cause some 
 dilatation and yet not too much. The size should be gradually increased,
 
 120 INFLAMMATIOX .IXD ULCERATION. 
 
 and a strong heavy braided silk cord must be attached for removal. 
 Electrol\tic dilatation of the stricture might be tried. The inflammation 
 and ulceration of the mucosa can be treated by topical applications, if 
 necessary, after the relief of the dilatogenic stenosis. Often it will not be 
 necessary. 
 
 Inflammation and Ulceration of thic Esophagus. 
 
 Acute csophagitis arising from any cause save traumatism is a posi- 
 tive contra-indication to esophagoscopy. Where due to traumatism, 
 esophagoscopv is also contraindicated save where the traumatic agent, as 
 a foreign body, is still in the esophagus. In this case it should be re- 
 moved at once. 
 
 The esophagoscopic appearances are those of an acute mucosal in- 
 flammation elsewhere. Intense congestion of the mucosal capillaries pro- 
 duces as intense reddening, which may be diffuse or circumscribed ac- 
 cording to origin. If the inflammation is more intense in some point than 
 others, a flecked or patchy appearance may be observed. After the in- 
 cipient stage is passed, if serous effusion takes place, the mucosa assumes 
 the edematous semitranslucent appearance often seen in the larynx. 
 Vessels are not, as a rule, visible in acute inflammation. 
 
 Acute inflammation is easily diagnosticated, but care must be taken 
 that we do not overlook associated lesions. For instance, a nniral esopha- 
 geal carcinoma may be intruding the overlying mucosa into the lumen, 
 wherewith the irritation thus resulting, the mucosa may give the ap- 
 pearance of acute inflammation. 
 
 Chronic csopliagitis may follow acute csophagitis, or, more fre- 
 quentlv. it mav be the result of long-continued irritation of food particles, 
 mucus, ])us, etcetera, which are entrapped in the esophagus by spastic or 
 anatomic stenoses, dilatations or diverticula, which prevent the esophagus 
 from immediately emptying itself, which it always does promptly under 
 normal conditions. 
 
 Uncomplicated simple catarrhal inflammation of the esophagus 
 exists, commonly in alcoholics, due to general engorgement and vaso- 
 motor relaxation from the systemic action of the alcohol, and also from 
 the local irritant eft'ect of the insufficiently diluted alcohol upon the 
 esophageal mucosa. Catarrhal inflammations also result from other 
 causes local and systemic, the latter usually diathetic. 
 
 The esophagoscopic appearances are usually a dirty gray, or grayish 
 white, or pale red, sometimes mottled, mucosa streaked with vessels, and 
 covered with a tenacious mucus which is sponged away with difficulty. 
 (Fig. 5, Plate III.)
 
 ULCliRATlOX or rill-. JiSUI'JLlGUS. 1-il 
 
 Ulceration is often seen. I'lcers may be divided into two general 
 classes : 
 
 Those above and those lielow the hiatus. 'I be npjier class may be 
 due to the same causes as tlie innammation. abrasions and the like, or they 
 may be due to the intensity of the inflammation itself, resulting in a 
 localized tissue necrosis. They may be due to a local thrombosis of em- 
 bolic or other origin. Those occurring in tyjihoid fever are usually of 
 thrombotic pathology. Epithelial erosions frequently occur in profound 
 toxemic states in the course of the general infections. 
 
 Deep ulcerations occur in syphilis more often than is realized, as 
 unless the resultant cicatrix is sufficient to interfere seriously with de- 
 glutition the lesion is overlooked, as it is usually painless. Deep ulcera- 
 tive lesions occur in tuberculosis, and is very frequently overlooked. As 
 much as four-fifths of the esophagus has been known to be involved 
 without an esophageal disease having been suspected. The author has 
 seen a great many cases where the dysphagia and odynphagia present 
 were attributed to the concomitant laryngeal tubercular lesion. Tuber- 
 culosis of the esophagus, like that of the larynx, is usually secondary to 
 a pulmnnarv lesion, the infection being conveyed by the sputum: or it 
 mav occur by continuative extension from a tubercular bronchial gland 
 or vertebra. It may occur by contiguous extension, as for instance on 
 the posterior wall from contact of the tubercular larynx. (Fig. 6, 
 Plate III.) 
 
 Peptic ulcer. Ulcers occurring below the hiatus esophageus are usual- 
 ly classed as peptic ulcers and often bear a strong resemblance to peptic 
 ulcer of the stomach. They are often attributed to functional insuf- 
 ficiency of the cardia. but the author's opinion elsewhere stated is that the 
 functional closure of the upper end of the stomach is due to a kinking of 
 the esophagus at the hiatus, due to pressttre of the gastric fundus and the 
 peri-hiatal structures. This permits the stomachal contents frequently to 
 invade the lower end of the esophagus. Whatever may be the ]:)athology 
 of peptic ulceration of the esophagus, it has a pathology essentially dif- 
 ferent from that of other mucosal ulcerations. In whatever they may 
 consist these differences are participated in to some extent by duodenal 
 and lower esphageal ulcerations. It is, therefore, logical to suppose that 
 the stomach contents are a factor in the production of these ulcerations. 
 
 Ulcerations of [jathology other than that of those enumerated occur 
 rarelv. When an unexplainable ulcer is found, especially if fungating a 
 buried foreign body should be thought of. 
 
 The treatment of inflammation and ulceration, consists in removal of 
 the cause, be it local or general. Then topical applications of argentic 
 nitrate, arg^rol, glvcerole of iodin or of tannin will be beneficial. If
 
 1-22 NEUROSES OF THE ESOPHAGUS. 
 
 the lesion be circumscribed, the apphcations should be made with a dossil 
 of cotton on a sponge holder. In the treatment of peptic ulcer the gen- 
 eral methods advocated for gastric ulcer are useful, but they are of only 
 secondary importance to the direct application of silver nitrate, argyrol, 
 etcetera, to the ulcer under direct inspection of the eye, looking through 
 the esophagoscope. Bismuth powder may be blown directly upon the 
 ulcer by means of the extra drainage tube. The ulcerated surface should 
 first be cleaned off with a dossil of cotton dipped in hydrogen perqxid 
 solution. There is no danger of either perforation or of hemorrhage from 
 these procedures if the manipulations be gentle, and guided by the eye 
 through the esophagoscope. There is great danger from blind poking 
 with a bougie, especially in these lowly situated ulcers, as reflex spasm 
 from the presence of the tube is apt to close up the lumen ahead. 
 
 Neuroses of the Esophagus. 
 
 Spastic neuroses have already been touched upon. 
 
 Sensory neuroses, including hyperesthesia, anesthesia, and para- 
 esthesia exist, but careful esophagoscopic search often reveals an anatomic 
 basis, such as an ulcer, a scar, or an inflammatory area, in cases in which 
 theretofore a diagnosis of neurosis had been made on the anamnesis and 
 sounding. The symptoms complained of are usually of a vague char- 
 acter as of contraction, itching, sticking, pricking, uneasiness or irritation, 
 or of a foreign body or crawling insect. 
 
 Exclusive of hysteria, sensory neurosis of the esophagus will be found 
 exceedingly rare. In almost all cases of anamnestic similarity will be 
 found to be anatomic, not purely neurotic in origin. 
 
 The treatment is by very mild galvanism locally, using the inter- 
 rupted current, and general treatment and regime as deemed best by the 
 internist or neurologist. 
 
 Paralysis and Pareses oe the Esophagus. 
 
 Tlie symptoms of defective inervation of the esophagus point very 
 markedly to esophageal trouble. All solid food is swallowed with diffi- 
 culty ; fluids are usually swallowed freely. In some cases even fluids re- 
 fuse to go down except in very small quantities. There are pain back of 
 the sternum after eating, regurgitation of food and mucus. 
 
 With a history of trouble of this magnitude one is apt to expect 
 the esophagoscope to meet with obstruction to its passage. Exactly the 
 reverse is the case. It readily enters the introitus and passes on down 
 into the stomach without the slightest resistance, going as readily without 
 an anesthetic as it would in the normal esophagus with the deepest general
 
 PARALYSIS OF THE ESOPHAGUS. 123 
 
 anesthesia. Tlius the (Hagnosis is estaWished. In spastic stenoses we 
 find the spasm if no anesthetic be used, while in anatomic stenoses we 
 find a stricture uninfluenced by anesthesia. The paralysis may be ocularly 
 demonstrated by Stark's pill experiment. With the aid of an csophago- 
 scope and forceps a pill or capsule is deposited in the esophagus at a dis- 
 tance of 27 cm. from the upper teeth. If the peristalsis be normal the pill 
 will be carried downward into the stomach ; if the pill remains where 
 placed it demonstrates a paralysis or at least an abnormal feebleness or 
 atony of the esophageal musculature. 
 
 The causes of paralytic conditions of the esophagus include central 
 and peripheral nerve lesions, most common being bulbar paralysis and 
 neuritis, including diptheritic, alcoholic and lead palsies. 
 
 TTie treatment of these conditions is usually not esophagoscopic, but 
 general. Local electrical applications are beneficial adjuncts. 
 
 It must be confessed that we know but little of esophageal neuroses 
 and much remains to be studied esophagoscopically. For this purpose 
 all clinical material should be availed of, and experimentally the dog may 
 be used, double vagotomy, being done under chloretone and morphia 
 anesthesia.
 
 CHAPTER XVI. 
 Foreign Bodies in the Lsophagus, 
 
 Considering the brilliant achievements of esophagoscopy in the re- 
 moval of foreign bodies from the esophagus, it is time to pronounce the 
 prevalent use of the sound, the vertebrated forceps, the coin catcher, the 
 bristle and the sponge probangs obsolete, dangerous, unsurgical and ut- 
 terly unjustifiable. There are numerous cases on record of fatal results 
 from their use, and there are many times as many cases that have never 
 been reported. The author has seen in consultation two fatal cases from 
 attempted extraction, both unsuccessful. In one case a sound (with 
 stilet) had been pushed through the thoracic esophageal wall in an efifort 
 to push a peach stone downward, and in the other, the esophagus had 
 been ripped open by a coin catcher. A number of instances of shock 
 from esophageal wounds have been observed by the author, and many 
 cases of minor wounds. (Fig. lo, Plate III.) Even the sound may make 
 dangerous wounds by forcing a sharp or pointed body through the eso- 
 phageal wall. Equally erroneous and dangerous is the practice of making 
 light of the patient's fears, and the telling him that if he has swallowed 
 anything, it will go on downward without doing any harm. Some things 
 will, and others will not. Pointed and sharp objects, as a rule, lodge, 
 perforate and often prove fatal. Smooth round objects, such as intuba- 
 tion tubes, usually pass without difficulty. Coins are very prone to lodge, 
 though usually in a vertical position, so that they allow food to pass. In 
 one case of the author's a penny remained in the esophagus of an i8- 
 months-old child for two months and eroded through into the trachea. 
 
 The anamnesis is unreliable and misleading. The patient often does 
 not know that he has a foreign body, but comes for difficulty in swallow- 
 ing. In infants the swallowing of the foreign body may not have been 
 observed. Tlie little patient is taken to the physician for regurgitation of 
 food, or as in one case of the author's for respiratory difficulty, which 
 arose from perforation of the foreign body from the esophagus forward 
 into the trachea. Often patients will sav thcv no longer feel it when the
 
 ESorii.nnTis. i-5 
 
 foreign body is still in situ. Still nmrc mislca.ling is the patient's localiza- 
 tion. The corpus delicti is very rarcl> located where the patient assures 
 
 us it is. 
 
 The Roentgen ray is much more reliable and its aid should be avaded 
 of in every case. What has been said in a previous chapter in regard to 
 the rav in the diagnosis of foreign bodies in the air passages, applies 
 equallv well in relation to the esophagus. It may be well here to em- 
 phasize a statement there made. In no case should a negative radiograph 
 deter one from making an esophagoscopic examination, if the anamnesis 
 or the symptoms justify a suspicion of the presence- of a foreign sub- 
 stance. 
 
 In a number of instances the author has been rewarded l)>- success in 
 the face of a negative radiograph. In other instances he has found lesions 
 of the esophagus due to long standing disease attributed to a supposed 
 swallowing of a foreign bodv. In ,Mie instance the patient complained of 
 the lodgement of a chicken boiu- which she located back of the sternum, 
 where she could feel it every time she swallowed. fpon gastroscopic 
 examination an old ulcer was found just above the cardia, and another on 
 the posterior wall of the stomacli. As suggested bv Dr. Clement Jones, 
 who assisted at the gastroscopy, a large l.iolus of food in passing the ulcer 
 had produced a sensation of pain which had since persisted, and which had 
 been wrongly attributed to a supposed bone. 
 
 The matter of anesthesia is governed by rules elsewhere given. 
 Local anesthesia is sufficient, though as a rule, a general anesthetic is 
 better in all cases free from respiratory difficulty, which complication is 
 more frequent than might at first be supposed. In ad.lition to edema of 
 the larvnx from previous blind groping attempts at removal, there may be 
 mechanical obstruction of the trachea from pressure of a large body or 
 from inflammatory exudates in the tracheo-esophageal wall, or possibly 
 feebleness of the respiratory movements from pressure of the foreign sub- 
 stance or inflammatory exudates upon the vagi. 
 
 When a case suspected of a foreign body comes to the author, a 
 regular routine is followed. After taking the history, the nasopharynx, 
 fauces, pillars, tonsils, the back of the tongue, gloss-epiglottic fossae, 
 larvnx. and all parts of the upi)er air passages accessible are ex- 
 amined with the mirror and brushed with a cotton moii. If nothing is 
 found the case is sent to a Roentgenologist and a plate is made (the 
 fluoroscope is not used). If no foreign substance is seen and the symp- 
 toms and anamnesis warrant the case is esophagoscopized ; and, if noth- 
 ing is found, the trachea and larger bronchi are examined in some cases, 
 if'"'the foreign bodv supposed to be present is small enough to pass the 
 glottis. If the radiograph shows the foreign bodv to be in the thoracic
 
 116 ESOPHAGOSCOPY FOR FOREIGN BODY. 
 
 esophagus, there is a great temptation to put the esophagoscope down at 
 once to the point located. This would be a mistake. The tubular specu- 
 lum should first be used to examine the pyriform sinuses and all the 
 neighborhood of the introitus. The necessity of this is shown by a case 
 referred to the author by Dr. Pool. While we were esophagoscopically 
 searching the thoracic esophagus at the level of the fourth dorsal vertebra, 
 where the pin was when the radiograph was made by Dr. Boggs, the as- 
 sistant picked the pin out of the mouth with the fingers. Possibly it had 
 been regurgitated by the retching incidental to the application of the 
 local anesthetic. Be this as it may, it emphasizes the rule to examine 
 seriatim all the surfaces from above downward. This pin might have 
 escaped into the air passages. Another reason for the rule is that lesions 
 weakening the walls or exposing vessels may exist coincidentally or as a 
 cause of the symptoms of a foreign body when none exists. The only 
 safe and certain way is by careful, orderly procedure to examine all 
 tissues. 
 
 The technic of the passing of the esophagoscope is given under 
 "Gastroscopy." As a rule, the finding of a foreign body in the esophagus 
 is a very easy matter. It is possible, however, for it to get so buried in 
 the swollen mucosa as not to be visible. In one case referred to the 
 author by Dr. Day a double-pointed pin (D Fig. 63) was buried out of 
 sight, having penetrated beneath the mucosa and having wandered from 
 the point of entrance. Even in such a case patient search is usually suc- 
 cessful. The same may be said of foreign bodies lodged in diverticula. 
 When found, the foreign substance may be so large that it cannot be ex- 
 tracted through the esophagoscope. In such a case the tube, forceps and 
 the intruder are all withdrawn together. The foreign body may be so 
 sharp or so angular or pointed that to remove it involves serious risk 
 of wounding the esophageal wall. If the points cannot be covered by 
 withdrawal into the esophagoscope, the substance in some instances may 
 be divided and removed in sections. 
 
 In the case of an open safety pin with point downward, a hook or 
 forceps may be used to draw it into the esophagoscope. If the point is 
 upward (Fig. 64), it may be possible to draw the point into the tube 
 mouth with the forceps, to turn the pin with a hook inserted in the ring of 
 the spring end. This, however, involves some risk of forcing the point 
 through the esophageal wall. A safer plan is to close the pin. The 
 credit of having first done this belongs to Mosher. The ring of the 
 instrument (Fig. 27) is inserted and insinuated into position below the 
 pin which is then pushed into the ring with the pronged instrument. 
 
 The author has modified this instrument to facilitate its introduction. 
 The ring lies in the same plane as the stem during introduction, and is
 
 FOREIGN BODIES. 
 
 127 
 
 Fig. C3. — Foreign bodies removed by esophagoscopy aud gastroscopy. 
 
 (From the author's collection.) 
 
 C, I'in lemoved from esophagus of pregnant woman aged 23 years. Cocain. 
 
 F, Safety pin from esophagus of 9 mouths' old infant. Chloroform. 
 
 E, Forceps jaw removed from the stomach of man aged 32 years. Ether. 
 A, Cufl" bntlon removed from esophagus of 4 months' old infant. Cocain. 
 
 G. Joint of carpenter's rule removed from esophagus of boy of 7 years. Cocain.
 
 128 
 
 FOREIGN BODY IN THE ESOPHAGUS. 
 
 turned to a ris^ht anisic after ii has reached a [xiiiit below tlie pin. If the 
 ring of the needed size for tlie narticiihir ])in is too large for introduction 
 through the esophagoscope. the closer may be started in first, and the 
 esophagoscope "threaded" over it, or the esophagoscope may be started 
 alongside the stem of the closer. Tn tlie latter case care must be taken 
 that the combined diameters of the closer and the esophagoscope do not 
 exceed the safe dilatability of the esophageal lumen. 
 
 Fig. G4. — Open .safety piu in osopliagiis
 
 Part III. 
 
 GASTROSCOPY.
 
 CHAPTER XVII. 
 History of Gastroscopy. 
 
 \Mien the author first obtained gooil endoscopic views of the stomach 
 he thought it had never been attemjotcd before. But a search of the hter- 
 ature brouglit to hght several previous attempts. 
 
 Nitsc and Letter. The first recorded attem]5t to construct a gastro- 
 scope was by Mr. Leiter and Dr. Nitze, whose names are inseparably con- 
 nected with the cystoscope. Both before and after this time attempts to 
 construct flexible and jointed instruments containing optical apparatus 
 failed in the mechanical stage. 
 
 Tvouvc. in 1873. perfected a "])olyscope" (Fig. 65) with which Col- 
 lin, of France, demonstrated endoscopically the functions of the stomach 
 
 Fig. (!•■>. — The "Polyscope" of Trouve.
 
 HISTORY 01' G.ISTKOSCOI'V. 
 
 181 
 
 of a bull, and with whicli Ledcntn and Raynaud diaiincisticatod a cicatri- 
 cial stricture of the esophagus near the cardia. 
 
 Mikiilic::. in 1881, started on the l)asis that a gastroscope must be 
 ris^id. but after rejjcated trials he came to the conclusion that a straight 
 rigid instrument could not be passed into the stomach on account of the 
 physiologic curve of the vertebral column, to accommodate his instrument 
 to which, he gave the instrument an angle of 150° at the junction of the 
 ventral and middle thirds. (Fig. 66. ]•".) This angle prevented a rotation 
 
 Fig. iii> — .MiUulicz's gastroscopo. 
 
 of more than 180° within the stomach, so that two complete instruments 
 were necessary with windows o]iening in opposite directions as shown m 
 Fig. 67. T'o touch the gastric walls means to fog the window and dim 
 the image. The Mikulicz gastroscope was ^.5 cm. long and 14 mm. thick. 
 The light was furnished bv a platinum loop at the ventral end which shone 
 through a window in the side (Fig. 66, B). The loop was sup])lied with 
 current b\- wires entering at C. and was kept cool by water circulating 
 through two canals in the wall of the tube, the entrance and exit being 
 shown at D. .\ third canal in the wall of the tube, with an exit at L' was 
 for inflation of the stomach with air pumped in at L. ( )ne did not look 
 directlv at the tissues, but an image was projected outward through a ter-
 
 132 
 
 HISTORY OF GASTROSCOPY. 
 
 restrial telescopic optic apparatus with the aid of two prisms, one at E 
 and one at F. To prevent soihng the window during introduction, a sHde 
 is attached at H, operated by a hand-piece J, b)' which the window is un- 
 covered after the stomach walls are distended. 
 
 Mikulicz arrived at the conclusion that a straight instrument was 
 absolutely impracticable ; that it could be passed as far as the cardia, 
 which he believed to be located at the eighth or ninth vertebra, where it 
 encountered an insurpassable obstruction in the subjacent vertebra. His 
 straight experimental staff never really reached the cardia at all. What 
 he encountered was the constriction, anatomic and spasmodic, at the hiatus 
 diaphragmatis and the subjacent esophageal curve. Later Mikulicz tried 
 to adapt to gastroscopy his method of passing the esophagoscope, by 
 which, instead of a mandrin he introduced a flexible bougie, the distal 
 
 Fin. 67. — Mikulicz's gastroscope in stomach. Dotted lines show the necessity for 
 right and left instruments. Center instrument does not show its bend. 
 
 end of which protruding lo cm. beyond the esophagoscope, piloted tlie lat- 
 ter in. He did not succeed in thus piloting the gastroscope. 
 
 Mikulicz used morphin anesthesia and placed the patient on a table 
 in lateral horizontal position, first one side then the other, according as 
 the right or left gastroscope was being used. In quite a proportion of 
 cases Mikulicz was unable to pass his gastroscope into the stomach. He 
 tried chloroform, but states that under partial anesthesia the reflex irrita- 
 bility seemed to be so much increased that he could not get his instrument 
 even into the esophagus ; while under deep anesthesia he was afraid ta 
 pass it lest it might prove dangerous from pressure on the trachea, 
 larynx or other parts. Mikulicz's examinations were mostly on healthy 
 persons, as he thought the normal was to be studied first, and he seemed 
 to doubt the safety of examining the stomach in serious disease of this 
 organ. W ith one exception he did not record the appearance of any
 
 MIKVLICZ'S GASTROSCOPE. 
 
 133 
 
 lesion within the stomach, and his description of the normal is very 
 
 meagre and unilhistrated. 
 
 After 1883 no account of the use of gastroscopy appears in literature 
 
 for 12 years, and the procedure was evidently abandoned by its originator. 
 
 Rosenheim, in 1896, reported experiments with a gastroscope 12 mm. 
 
 Fig. 68. — Mikulicz's gastroscope iu situ, 
 bility of passing a straight instrument. 
 
 Drawing by Mikulicz to show impossi- 
 
 in diameter, 68 cm. in length. It was made up of three concentric tubes, 
 the inner (i, Fig. 69) being a terrestrial telescope of 60°, with the addition 
 of a prism below the objective, a different prism to be substituted to inspect 
 different areas as shown in Fig. 70. the optic tube being withdrawn for 
 the purpose. External to the optic tube is the intermediate or illuminat-
 
 134 
 
 ROSENHEI.]rS .GJSTROSCOPE. 
 
 ing tube, containing a window, F, behind which is the electric lamp, S. 
 Above this window is an opening closed b}- the prism of the optic tube. 
 Four canals run in the walls of this intermediate tube (2, Fig. 69) ; two 
 for water (CD.) circulation to cool the lamp, (water at 40° C to prevent 
 condensation on the glass surfaces being required) ; a third canal for con- 
 
 3. t 
 
 Fig. 00. — Itoscnheim's gastroscope. 
 1, Optical apparatus. 2, Cooling water jacket. 3, Casing to keep wimlow clean 
 during ii.trodiiction. S, Lamp. G, Itubber tip. G. Rigid exploratory staff, hard rubber. 
 
 ducting wires : and a fourth canal beginning at L and ending below F, 
 for the purpose of inflating the stomach with air. Tlie external tube (3) 
 serves two purposes ; a measure of depth by its scale markings, and a 
 protector to prevent soiling of the window and the prism during introduc- 
 tion, the external tube being turned after introduction so that its windows
 
 IflsrORV OF G.lSTROSCOPy 
 
 135 
 
 mav correspond to those of llic i)]itic ami intcrmcclialo tul)i.s. all three be- 
 ing- known to be in line when the knobs on the external llans'es of all three 
 are in line. The stativ ( l-'ii;'. 71 ) holds the snpply and escape vessels for 
 cirenlating- water and the l)attery. Rosenheim tried to (Hs]iense with the 
 water eircnlation, bnt the .^reat heat nf the platinnm filament lamj) con- 
 fined in a closed instrnnient threateneil canterization of the nnieosa if 
 lighted for longer than ten seconds. 
 
 In addition to the straight gastroscope, Rosenheim stales that in Si)nie 
 cases the spiral twist of the lower esophagns required an instrument bent 
 at an angle of i()0° at a point 7 cm. from its distal extremity (6, Fig. 69). 
 He also used a straight rigid stai? of the size of the gastroscope to ascer- 
 tain if it were possible to pass his gastroscope in the particular ease, and 
 if possible to nieasnic the dist?nce that the gastroscope will have to be 
 introduced. He also used a straight sound to overcome the reflex excita- 
 liilitv in ditficult cases. This straight sound could be intrdduced in only 
 
 Fid 70. — Itusinilu'im".s ga^troricope iu stomach, showing need for prisui.s of dif- 
 fei-eut degrees. 
 
 about 70 per cent of his eases. He found that various bends and curves 
 were necessarv and in some instances lie used a corkscrew-like twist, 
 throwing the longitudinal axes of parts of the instrument above and be- 
 low the bend out of the same plane. A very significant' fact is that after 
 the beak of the instrument entered the stomach the straight part followed 
 readily. His whole trouble in introduction was that his instrument was 
 not designed to be passed by sight. He used cocain anesthesia applied 
 with an esophageal syringe. 
 
 As to results, Rosenheim states that gastroscopy is impossible in 
 tumor of the stomach, and that it is contra-indicated in ulcer. 
 
 Rcividcof, in 1889, reported results with a modified Rosenlicini gas- 
 troscope which he passed through a previousl)- introduced flexible rubber 
 tube.
 
 136 
 
 HISTORY OF GASTROSCOPy. 
 
 None of these early workers has left us any drawing of what he saw, 
 and the written descriptions are hopelessly meagre. The procedure has 
 been entirely abandoned. The cause for the failure and abandonment of 
 gastroscopy may be summed up in two words : Impractical instruments. 
 
 At the door of the Nitze cystoscopc must be laid the blame of the 
 
 practical failure of gastroscopy up until the present 
 
 The attempt to 
 
 adapt the cystoscopic principles to the totally different conditions in the 
 
 QESORVOIP 
 
 J\ 
 
 BATTERY ^1 \ WATER 
 TUBES 
 
 Fic. 71. — Stativ for Rosenheim's gastroscope. 
 
 stomach resulted in the misdirection of the earnest, able, scientific efforts 
 of Mikulicz, Rosenheim and Rewidzof. 
 
 T'he instruments were difficult of introduction. The optic apparatus 
 absorbed light and yielded a feeble image, which soon disappeared alto- 
 gether from soiling of the window every time it touched the mucosa. For 
 the same reason the apparatus could not be greased for introduction. 
 
 The optic apparatus, furthermore, prevented the passage of the in- 
 struments by sight, it prevented the wiping away of secretions and the
 
 HISTORY OF GASTKOSCOPY. 137 
 
 probing of suspected areas, without wliich little or nothing can bo learned. 
 The stomach had to be empty, which it never is. All failed to recognize 
 the mistake of trying to see a large field in a dilated stomach. The field 
 must be traversed in the collapsed state of the stomach, fold by fold. 
 These things are not said in criticism, for, while the work of these pio- 
 neers was of no help to the author, as his work was done before he learned 
 of their lalxirs, yet they have rendered great aid, as we now know by their 
 lack of success, tliat cystoscopic methods are not adapted to gastroscopic 
 work. This would certainly have been tried by others, and nuich time and 
 thought consumed by some one. ]\Iikidicz himself recognized the com- 
 plexity of his apparatus. He said : "There remains no doubt but that 
 the instruments, as well as the method, furnish ample room for improve- 
 ment and simplification." The simplification, I think, has now been 
 reached, though of course, there is still ample room for improvement. 
 The steps in the development of gastroscopy are these : 
 ^Mikulicz determined one point, namely : that a gastroscope must be 
 rigid, but he gave it a bend. 
 
 Rosenheim went a step further and said it must not only be rigid but 
 should be straight, though he failed at times to introduce it without a 
 bend. Now, I think, we are ready to add four more dicta: 
 
 1. Optic apparatus must be abandoned. 
 
 2. The tube must be passed by sight. 
 
 3. Tlie stomach must be examined in a collapsed state, to permit of 
 mopping, palpation with the instrument, probing, and combined endo- 
 scopy and external palpation. 
 
 4. General anesthesia is indispensable to prevent retching, during 
 ■which the diaphragm clamps the tube, rendering exploration impossible.
 
 CHAPTER XVIII. 
 The Usefulness of Gastroscopy. 
 
 (jastroscopy is not simply a feat. It has a field of usefulness that 
 will increase as our skill and knowledge increase. Naturally, the ten- 
 dency of everyone is to say that only in the obscure cases will gastroscopy 
 be needed. Yet this opens a gap for the loss of the opportunity for an 
 early diagnosis of malignancy, and pre-cancerons conditions. 
 
 ^^'hen the gastroscope shall have reached its deserved recognition, 
 patients will be examined gastroscopically sufficiently early to give the 
 abdominal surgeon a fair chance. Better still, a positive diagnosis of 
 pre-cancerous conditions vviill be made sufficiently early to enable him to 
 save lives now being lost through reluctance of the patient to submit to an 
 exploratory operation. Gastroscopy is not a substitute for exploratory 
 celiotomy in every case. 
 
 Every surgeon knows the number of cases of malignant disease of 
 the stomach that are fatal because the patients have refused an explora- 
 tory operation in the early curable stages. A large proportion of all cases 
 of merely suspected malignancy will refuse to be (as they express it) 
 "cut open to see what the matter is." They start out to find a man who 
 can make a diagnosis without "cutting them open," and they soon find one 
 who will give them the comforting assurance that they have no cancer 
 and only need a little treatment. Thus their last opportunity is lost. If, 
 however, it is proposed to pass an instrument through the mouth, consent 
 will rarely be refused, especially when the patient realizes that one is 
 going actually to sec the conditions present. Indeed, the author has been 
 begged in two instances by hopeless cases of cancer to examine them. He 
 deemed examination inadvisable, lest their impending death might be 
 attributed to the gastroscope, which at this stage should not be subjected 
 to more than its share of criticism. 
 
 That the diagnosis of malignant disease of the stomach by symptom- 
 atic and chemical data is not always easy, even in the later stages, is 
 shown by the following quotation from Riegel :
 
 THE USEFULXESS OF GASTKOSCOFY. 
 
 i;!9 
 
 "There is another class of cancer cases in which the symptoms that are 
 ordinarily considered characteristic for carcinoma are absent, but ,n wh>ch 
 dyspeptic disturbances, loss of appetite, belchin;, and general weakness appear. 
 
 1„ view of this, it wotild seem diffictilt by the common methods abso- 
 hitelv to excltide carcinoma in a patient past thirty years of age. All 
 such cases tlien would seem to justify gastroscopy, rather than to be con- 
 fronted with the neeessit^■ of revising the diagnosis later after treatment 
 on the basis of a benign condition has failed to cure. By that time the 
 patient will have become hopelessly inoperable, and his death will be due 
 to the lack of an early diagnosis. 
 
 And this from Satmdby : 
 
 ••Since the era of stomach surgery we havejearned how latent in certain 
 •cases the characteristic signs of cancer may be." 
 
 ^\■hen the diagnosis is made from a palpable tumor, cachexia an<l the 
 vomitus. it is useless, usually, except for in-ognosis. ■ 
 
 In carcinoma of adjacent viscera, as of the spleen, where the healtliy 
 stomach wall is displaced, but not infiltrated, the normal stomach folds 
 visible in the ^astroscope will demonstrate the uninvolved condition of the 
 stomach and thus aid, for instance, in the differential diagnosis between 
 tumor of the spleen and tumor of the stomach. 
 
 I„ considering the possibilities of gastroscopy, the occurrence of 
 tumors other than carcinomata and sarcomata must not be forgotten. 
 The gastroscope renders it possible to take a specimen in cases of fibro- 
 mata mvomata, Ivmphadenomata, etcetera. 
 
 One of the limitations of gastroscop> at present is the limited value 
 to be placed ttpon negative results. Any lesion, if it exist in the explor- 
 able area can be seen and. if advisable, felt, with the probe, and its nature 
 determined ; but if no lesion be found we cannot be certain that none 
 exists in the unexplorable area. However, with improvements m technic 
 this unexplorable area will be diminished. 
 
 When the gastro-enterologist shall have put the instrument into fre- 
 quent use. it is reasonable to expect that our knowledge of the physiology 
 and clinical pathology of the stomach will be greatly enlarged. 
 
 In peptic ulcer the gastroscope is of great service both for diagnosis 
 
 and treatment. 
 
 Forcii^n Bodies. The feasibility of removing foreign bodies from 
 the stomach has been demonstrated by the author. Any foreign body, 
 the sharp points or edges of which can be guarded by the forceps or by 
 the end of the tube, so as not to lacerate the esophagus, can be removed 
 from the stomach with the aid of the gastroscope.
 
 CHAPTER XIX. 
 Instruments for Gastroscopy. 
 
 The Gastroscope. To examine the stomach requires frequently an 
 80 cm. tube, though for many cases a 70 cm. length is sufficient. It is 
 impossible to illuminate a field of view at this distance by any form of 
 light projected in through the proximal end, for while the loss of light is 
 not, with parallel rays and a polisVied interior, as the square of the dis- 
 tance, there is too great a loss for practical work. Kirstein's light, though 
 excellent for other purposes, is useless for this great length. In addition 
 to the loss by distance, there is the loss from slight springing of the tube 
 and from bubbles in its lumen. These, while not interfering greatly with 
 vision, do cut off much of the light projected in. 
 
 With the gastroscope shown (Fig. 17), the length of tube is immate- 
 rial. Tile view is as good at the end of an 80 cm. tube as that of a 45 cm. 
 esophagoscope of the same diameter. 
 
 The construction of the instrument is the same as the bronchoscopes 
 and esophagoscopes devised by the author. 
 
 In the wall of the gastroscope, as in the esophagoscope, there are 
 made two small auxiliary tubes or canals. Both of these canals open into 
 the main tube close to the distal end. One canal ends near the handle in a 
 tip for the attachment of rubber tubing connected with the aspirating 
 apparatus. This keeps the field clear of all fluids, and prevents smearing 
 of the lamp. Large quantities of fluids have to be pumped out of the 
 stomach in some cases. 
 
 The other canal is for the light carrier, which is a small removable 
 double conductor carrying the lamp to the distal end of the instrument 
 where it sheds its light at close range at the point where needed, leaving 
 every object between it and the observer's eye in darkness. 
 
 The diameter of the lumen of the adult gastroscope is 10 mm. Many 
 cases will permit a larger tube than this and die author uses frequentlv a 
 tube whose outside dimensions are 11 mm. in one diameter bv 14 in the 
 other.
 
 IXSTRUMEXTS FOR GASTROSCOPY. 141 
 
 The distal end of the instruniciiL is funned uf a thickened ring to 
 prevent injury to the tissues. 
 
 The exterior of the tube is not graduated. The depth is measured 
 with a steriHzed steel rule by noting the distance between the proximal 
 end and the upper teeth. 
 
 Thus, 80 — 20=60 centimeters. 
 
 An obturator or mandrin witli a projecting conical end is fitted to 
 
 
 Fig. 72. — The Clement Jones bougie for facilitating the introduction of the 
 gastroseope. 
 
 facilitate the passing of the inferior pharyngeal constrictor, especially for 
 those unfamiliar with esophageal work. 
 
 At the suggestion of Dr. Clement Jones, the Kny-Scheerer Co. have 
 made a sound of 90 cm. in length (Fig. yz) to facilitate the introduction 
 of the gastroseope at the hands of those accustomed to passing the stom- 
 ach tube, but who are unfamiliar with the passing of rigid instruments.
 
 CHAPTER XX. 
 Technic of Gastroscopy. 
 
 Anesthesia. Cocain in a courageous patient is sufficient so far as 
 the pain of examination is concerned, but it does not stop the retching like 
 deep general anesthesia. A large dose of morphin given hypodermati- 
 callv assists. The stomach itself was altogether insensitive in the only 
 case examined under local anesthesia by the author. Qiloroform the 
 author considers dangerous for esophagoscopic. and especially for gastro- 
 scopic, though not for bronchoscopic work. Deep anesthesia is absolutely 
 necessarv to prevent retching, which is to be avoided while the tube is in 
 the stomach, both because it might be fraught with danger, and because it 
 stops the examination by the diaphragm clamping the tube at the hiatus. 
 Prolonged deep anesthesia is not safely maintainable with chloroform. 
 Ether, then, is the choice, preferably started with nitrous oxide. A little 
 chloroform mav be given from time to time as relaxation is needed, espe- 
 ciallv in bad ether subjects. Dr. Boyce has demonstrated for the author, 
 that chloroform is much preferable technicall}' to ether, but this does not 
 outweigh against the increased risk. 
 
 Once the patient is anesthetized, ether and the occasional few drops 
 of cliloroform are administered on several layers of folded gauze laid over 
 the mouth, nose, gag and instrument. 
 
 Incidentally it may be said that considerable quantities of the anes- 
 thetic reach the stomach ; whether it be swallowed or be excreted by the 
 gastric mucosa, remains to be demonstrated ; but certain it is that a strpng 
 vapor is ejected from the tube into the observer's eye during examination, 
 and this seems to be the case regardless of the n.iethod of administration. 
 
 The preparation of the poticnt. is, in a general wa}-, the same as for 
 tracheo-bronchoscopy. 
 
 The essentials are an empty gastro-intestinal canal and a clean mouth. 
 No food is allowed for twelve hours, black coffee and water may be taken 
 within seven hours unless there have been symptoms of pyloric stenosis, 
 in which case eighteen hours with nothing at all per os is essential. 
 
 ^^^ashing out the stomach is not a satisfactory substitute for fasting. 
 When necessarv, as in motor inadequacy, it should be done three or four
 
 TECH.XIC OF G.ISTROSCOPy. 
 
 148 
 
 hours before the gastroscopic examination, so that the remains of food or 
 fluid will have had time to be absorbed or to pass on. The author has 
 discovered in p^astroscopic investigations that after washing out the stom- 
 ach there are from four to six ounces of fluid retained, pocketed off in the 
 folds. The autlior has never seen an absolutely empty human stomach. 
 There is always some fluid to he drained or pumped from pockets and 
 valleys here and there. 
 
 Postiirr. The author's earlier work was dune in a ])osture half way 
 between the Trendelenburg and the horizontal, so that fluids drained away 
 through the tube by gravity. But at the suggestion of Dr. E. S. Mont- 
 gomery he has been using in some instances the reverse of this: that is, 
 
 Fi(i To. — I'osiiioi: uf a>.sUiaiit.s, nurses, operator and patk'ut during the iulroduc- 
 tion of the ga.stroscope. 
 
 with the f(X)t of the table lowered about fifteen inches. To do this, the 
 aspirating apparatus has been improved so that every ])ocket is pumped 
 out as soon as entered. This permits of a comfortable seat on a stool for 
 the operator. 
 
 After the gastroscope is passed with the table horizontal, the plane of 
 the whole table top is changed so that the head of the table is about 30 cm. 
 higher than the foot. This would be too high for starting. 
 
 The jxisition of the patient, operating table, operator, assistants, anes- 
 thetist, nurses and apparatus during the starting of the gastroscope is- 
 shown in Fig. j^. The diagram (Fig. 41 ) shows the positions more
 
 144 PASSING THE GASTROSCOPE. 
 
 accuratelv. These positions are absolutely essential, because of the length 
 of the instruments. Otherwise everything will be in chaos. 
 
 Passing the Esophagoscope or the Gastroscope. The first essential 
 is gentleness. If the tube does not pass readily it is either not in the right 
 place or not rightly directed. The tube should be well lubricated with 
 vaseline. The proximal end should be held lightly between the fingers of 
 the right hand, the handle directed horizontally to the right as in Fig. 74, 
 which shows the position as seen by the operator looking down upon it. 
 
 The forefinger of the left hand passes into the right glosso-epiglottic 
 fossa, posteriorly to the lateral glosso-epiglottic fold, posteriorly to the 
 tense pharvngo-epiglottic fold, and if possible into the right pyriform 
 sinus. 
 
 The tube then is made to follow this same route, while the finger 
 
 Fig 74. — Position ol the riglit liand during tlie introduction o£ tlie gastroscope. 
 viewed from above by tlie operator loolcing downward. 
 
 slides toward the median line and lifts the tongue and anterior pharyngeal 
 tissues upward (dorsal decubitus). When the cricoid cartilage can be 
 reached, which is possible usually only in children, it is better to lift upon 
 it directly (Fig. 75). When impossible, as it is usually in adults, the 
 cartilage must be lifted indirectly by traction upon the tissues at the ex- 
 treme point reachable, often the right glasso-epiglottic fossa. 
 
 The introduction of the gastroscope is easy to one accustomed to the 
 esophagoscope, and is readily learned by any one. Personally the author 
 prefers itsing one index finger as a guide. Some may prefer starting the 
 instrument by sight, without the obturator as in bronchoscopy ; others may 
 prefer threading the instrument over an esophageal bougie as suggested 
 by Dr. Clement R. Jones. Whichever of these methods be used, as soon 
 as the introitus is passed the instrument must be guided by sight to make 
 a safe procedure. v
 
 DUTIES OP THE SE.COND ASSISTANT. 
 
 14.-) 
 
 The neck of the patient is bent backward to straighten tiic cervical 
 curvature, or rather to cause the axis of llie oral cavity to approach paral- 
 lelism with that of the esophagus. This also moves the upper teeth as 
 nuich as possible out of the wav of the tube. 
 
 In bending tlie neck the angle should be as much as possible at the 
 upper cervical vertebrae so as to straighten the oro-pharyngeal angle as 
 much as feasible, while keeping the pharyngeal axis as straight as it can 
 be kept. After the tube is started the head may have to be raised (supine 
 patient) slightly to prevent tracheal compression. 
 
 Dr. Bovce has develo|)ed the details of holding the head to a degree 
 
 Fig. To. — Diagramalio positiou of the left band in starting the esophagoscope or 
 gasti'oscope. 
 
 of perfection that makes all endoscopy per os easy. It is more difficult to 
 teach an assistant how to hold the head than to teach him endoscopy. Tlie 
 following is a description of the correct position. 
 
 DUTIES OF THE SECOND ASSISTANT IN ENDOSCOPY 
 
 PER OS. 
 
 By Dr. John W. Boyce. 
 
 In all this work safety demands that the mouth, pharynx, and esophagus 
 be brought into a straight line, not by a crowbar like action of the tube, but 
 by holding the head steadily in extreme extension with the mouth widely open. 
 Not only does lateral pressure add to the operator's diflSculty, but it also en- 
 tirely prevents any sense of what the point of the tube is touching. Trial with 
 an unanesthetized patient will show that if the head is simply allowed to hang 
 over the edge of the table, not only is an unnecessary strain thrown upon the 
 ligaments of the neck, but full extension is not as well secured as by proper 
 support of the head. It is further to be remembered that no mouth gag is 
 absolutely self-retaining and a slight slip while the tube is in position may 
 have serious consequences. For this reason it is best to detail a second as- 
 sistant to hold the head and steady the mouth-gag, impressing him with the 
 importance of the matter and his entire responsibility therein. To carry him 
 out of the operator's way it is necessary that he shall hold the head at arm's
 
 146 
 
 DUTIES OF THE SECOXD ASSIST AXT. 
 
 length and to hold it in this position steadilj' for fifteen or twenty minntes a 
 support is necessary. The weight of the head is so little that the matter seems 
 easy, but if the assistant's arms are unsupported, about the time the most 
 critical point of the examination or operation is reached his muscles will be 
 trembling. Nor is it possible to rest him by any shift of position after the 
 tube is started, .\fter many unsuccessful trials, it has been found that the 
 best position is as shown in Fig. 76. The patient is drawn forward until the 
 tops of his shoulders clear the table by from four to six inches, and the mouth- 
 
 ^•V^ 
 
 Fig. 70. — Position of sucond assistant and patient for endoscopy per os. 
 caps and cover.* arc omitted better to show the positions. 
 
 Gowns. 
 
 gag is inserted on the left side. The assistant is placed on the right side of 
 the patient's head on a stool of appropriate height, as though on a side saddle; 
 his right leg beneath him in the kneeling position, his left foot supported on a 
 stool 26 inches lower than the top of the table; his right forearm is passed 
 beneath the patient's neck, supporting it; his right hand grasps the mouth-gag 
 drawing it strongly backward. His left hand rests on the left knee, grasps the 
 head strongly at or in front of the bregma, bending it backward and exerting 
 a certain degree of upward pressure. The exact proportion of backward and 
 upward pressure cannot be described, but is readily appreciated on trial, es-
 
 i'assim; the cisTROscorn. i it 
 
 pecially it" the assistant lias actually oxperienccd the difference in sensation 
 when the head hangs free and when it is properly supported in extreme ex- 
 
 After the introitus is passed, the obturator is rcmovcrl, the cord is 
 attached to the light carrier by the bayonet fitting, which by rotation is 
 used as a switch to turn on and oft" the current, the rheostat on the battery 
 having been previously reguhited to full illumination when the instruments 
 were ])repared. Turning the ba\-onet fitting now lights up the instrument 
 and the passing is under the guidance of the eye. the sense of touch onl_\- 
 being used to note resistance, which if felt, means something to be over- 
 come bv skill, not force. Once started, the passage of the instrument 
 down the esophagus is easy if three important points are watched: 
 
 1. The instrument must have been well greased before starting. 
 
 2. The tube must be guided by the eye so as to follow the esophgeal 
 lumen by sight. 
 
 3. The pinching of the tube by the teeth must be avoided so that 
 the tube will be free to move as needed to follow the axis of the esophageal 
 lumen as it is seen to open up ahead. 
 
 Ik;. 77. — Diagram showing occlusion of the trachci hy faulty dirnlion of the 
 gastroscope (or esopbagoscope). 
 
 4. The holding of tlie head must be exactly as just described by Dr. 
 Boyce. 
 
 After passing the introitiis care must be taken to raise the head of the 
 patient slightly to prevent the tube pressing on the trachea (Fig. yj). 
 This is readily noticed if the passing is done by sight. 
 
 In finding the lumen the normal respiratory movements are of great 
 assistance. The way often seems to be completely blocked ahead by what 
 seems to be the esophageal wall, but with the next inspiration a lumen ap- 
 pears in one or other quadrant of the tube, a few bubbles are seen, and the 
 tube is readily glided along. 
 
 The introitus passed, onlv two points will give any trouble. The first 
 is at the hiatus diaphragmatis. the second the bend of the abdominal 
 esophagus to the left. The hiatus is passed by placing the long axis of 
 the elliptic cross section of the tube from the right posteriorly forw-ard 
 toward the left anteriorly. This is easily done by placing the handle of 
 the gastroscope in the direction of the visual axis of the ]3atient, if he were
 
 148 
 
 PASSING THE GASTROSCOPE. 
 
 looking forward (if erect) to the left. The axis of the hiatus is shown in 
 Figure 59. 
 
 Full relaxation assists passing both the hiatal narrowing and the 
 abdominal esophageal bend. 
 
 The abdominal esophagus is readily passed if the head and neck of 
 the patient are moved to the right (Fig. 78) and the lumen is carefully 
 watched and followed. The difficulty met here is very nutch like the fold- 
 ing over of the trousers when the foot is not inserted in the right direction. 
 
 If any serious difficulty is experienced in passing the hiatus, it will 
 be found, usually, that the patient has come partially out. Upon deepen- 
 
 FlG. 78. — Schema. Head and neck moved to right to reach left limit of the ex- 
 plorable area ; also, during introduction, to pass through the hiatus and abdominal 
 esophagus. 
 
 ing the anesthesia the gastroscope will glide easily through the hiatal 
 esophagus into the subphrenic portion if the lumen be watched for 
 through the tube and follow^ed. This involves a lateral drag. After the 
 distal end of the tube is in the stomach, the exploration is easily accom- 
 plished if a systematic plan be followed. From one to six square centi- 
 meters are visible at one time, so that a systematic plan of tube travel has 
 to be followed to be reasonably certain of examining all portions of the 
 ventricular mucosa.
 
 TECHXIC OF G.ISTKUSCOI'Y. 
 
 14!) 
 
 There are two plans of exploration, both of which should be carried 
 out. First the tjastroscope should be jiassed down carefully and gently to 
 the greater curvature, inspecting the anterior and j)ostcrior walls. At 
 times these walls do not seem to be fully collapsed ahead of the tube and 
 one will have to be examined first, then the other. Then the tul)e is with- 
 drawn, inclined slightly laterally in the same iilane. then pushed gently 
 downward again in a new series of folds. This is repeated until the ex- 
 treme pyloric limit is reached. To reach this limit the head and neck of 
 the patient are moved to the left (Fig. 79) with the tube below the cardia. 
 
 After the whole possible range has been covered in this way. we pro- 
 
 FiG. 79. — Schema. IK-aJ uuJ ueck moved to left to reach right limit of the ex- 
 plorable area. 
 
 ceed to the second plan. The tube is passed down until the extremity 
 touches the wall of the greater curvature in the extreme left of the pos- 
 sible field. Then the tube is moved slowly along the greater curvature, 
 but not in too close contact tiierewith. until the extreme right is reached. 
 Withdrawing the tube a centimeter or two. the field is slowly swept again 
 in the same plane, but at a higher level, and so on upward to the cardia. 
 Next the deft fingers of one skilled in abdominal palpitation are called 
 upon to manipulate the unexplored portions over in front of the tube. 
 This is sometimes better accomplished by turning the patient on his side,
 
 150 TECHXIC OF GJSTKOSCOPY. 
 
 first on line then on the otlier. DurinL;- all these manipulations the tube 
 must be \\ itlvlrawn witiiin the esophas^us. When the stomaeh is in its 
 new position the gastroscope is again pushed downward and the newly 
 available surfaces are explored. Should retelling supervene while the 
 gfastroscope is in the esophagus, no harm will result. Init when the tulie is in 
 the stomach, retching is the signal for immediate withdrawal of the gas- 
 troscope until the distal end of the tube is above the diaphragm. No 
 harm has been done in a number of the author's cases where retching has 
 occurred with the tubal extremity in the stomach, vet it is to be regarded 
 as dangerous in diseased conditions at least, and to be avoided in all cases. 
 
 The vertical diameter of the stomach is easilv determined by meas- 
 iirement. The depth from the teeth to the cardia is taken, then the gas- 
 troscope is pushed on down until the greater curvature is encountered and 
 the distance from the teeth again is taken. The diiTerence between this 
 and the first measurement gives the vertical diameter of the stomach at 
 this point. Care must be used that the measurements are not rendered 
 inaccurate by pushing the greater curvature downward, which is exceed- 
 ingly easy to do without knowing it, if the sense of touch is relied upon 
 to determine when the lower wall is reached. If the downward progress 
 of the gastroscope is watched through the upjier orifice, it is easy to see 
 when the wall at the greater curvature is touched. Having taken our 
 measurements, we then place the obturator externally parallel to the tube 
 within and indicate to the abdominal manipulator the exact position of the 
 lower end of the tube which he can then mark on the skin, giving thus 
 with absolute certainty the exact location of the greater curvature of the 
 empt}- stomach at that point. Care must be taken of course to re-steril- 
 ize the obturator should it touch anything unclean. 
 
 The smallest vertical diameter found by the author in any adult was 
 4 cm. (I'j inches) and the greatest 36 cm. (14 inches). 
 
 There is a tendency for the gastric walls to be dragged along with 
 the tube when the tube is moved, so that we shall not get a full new area 
 unless care be taken. Withdrawal for a few cm., followed by re-insertion, 
 allows the walls to regain their average place. 
 
 The time required to examine the entire explorable area is about 
 thirty minutes, if there are no interruptions.
 
 CHAPTER XXI. 
 Area of the Stomach Lxplorable by Gastroscopy. 
 
 Tt ,.av be acccpte.l as an axio.n tbat the more horizontal the stomachal 
 posit':S;e less J,l he the e.plorable area. Thus ^-roptotu. v.n,c^ 
 Ld infantile-form stomachs afford the greatest range. The reason tor 
 2t ;: atonce apparent when we consider that the lateral range ot mot.on 
 is that of the hiatus esophageus. 
 
 The lateral distance to which this hiatus can be slutted ^'"'^;- 
 the individual being greatest in feeble, elderly, emacated patents, and 
 vM h^S h of an^s^esia, being greatest in profound chloroform a,je. 
 esia The antero-posterior mobility of the hiatus ,s of h tie use ( ex ep^ 
 arS;ili^ng the pLing of the tube at this point) for the surroun.hng 
 "scera crowd the stomach walls in ahead of the tube, and usuallv both 
 anterior and posterior walls are visible at one tmie. 
 
 The pivotal point of rocking of the gastroscope .s ---\'-- ; ^ 
 thorax, not, as might be supposed, either at the upper thoracK ap.rtu.e 
 or at the hiatus esophageus. ( Schema, b ig. 80. ) 
 
 The full range of the upper thoracic aperture ,s --1^"^ 5;^'*^\' ; 
 the whole head and neck laterally, as well as, n. some cases, shghtu ante 
 
 ^°"^r':;dio4if"(S^tj'bl Dr. .oggs. taken in the li.ng under 
 ethe7 how^^ rang! ofmotion of the gastroscope in th,s particular ^ase 
 of gastroptosis. which was not a very good one for den.onstrat.on as re- 
 laxation was not complete and the diaphragm hampered movement. 
 '^ol^Lrilv there is no diffictdtym making the ^^^^^^ -- 
 toward the ri-ht and the left anterior superior spnie ol the il um. He 
 
 no force was used, and it was not a case of ecta.-,ii.. 
 
 rFicr 8^) shows the position of the pylons m this case. 
 
 ^ 'if ;i e iaphragn' were rigid, gastroscopy would be very much ban. 
 
 pered I'ut ,t has. when the patient is fully relaxed under anesthesia, a
 
 152 
 
 EXPLORABLE AREA. 
 
 range of flexibility that may be averaged roughly at a 5x15 centimeter 
 ellipse, the long axis being laterally, and a very slight antero-posterior 
 rocking will bring either the anterior or posterior wall into view alone. 
 
 In one gastroptotic stomach the author succeeded in exploring about 
 the entire mucosal area. In one instance, a horizontal stomach, not more 
 than one-third of the stomach could be explored. 
 
 Fig. so. — Schema. Showing extreme right aud left positions. 
 
 In the foregoing remarks reference is had only to cases in which the 
 esophagus is normal. Anomaly or organic disease of the esophagus may 
 render esophagoscopy and gastroscopy difficult or impossible.
 
 GASTKOSCOPy. 
 
 l.>i 
 
 Fig. si. — Radiograph of gostro-scope in two ditFerent positions, in a case of gas- 
 ti'optosis, the patient under etiier. Sbadow of coin locates tlie umbilicus. ( Radi- 
 graph by Dr. Russell H. Boggs. )
 
 G.-^STROSCOPY. 
 
 n 
 
 rv <^^y:^.-'iyfe*yv^' >■>'->> ■ 
 
 V'. .aavVaC 
 
 Flo. S2. — Kadiograph of gasl roscope in position in tin' living patient. Tiilje 
 mouth iu tlifi pyloris (gastroptosis). .Shadow of coin louatos the umbilicus. (Radio- 
 graph by Dr. Russel! H. Boggs.)
 
 CHAPTER XXII. 
 Difficulties, Dangers and Contra-Indications. 
 
 Difficulties. When it is said that gastroscopy is easy, it is not meant 
 tlnat no training is necessary. One does not learn ophtiialmoscopy in a 
 day. Yet so far as seeing the tissnes is concerned, gastroscopy is the 
 easier. 
 
 There are two classes of dil^ficulties. They are toth slight and easily 
 surmounted. One class concerns manipulation, including introduction 
 and exploration, and the other class concerns the eye, which consists in 
 comprehending the picture. 
 
 Those physicians who have looke.l through the instrument at tUe 
 stomach mucosa without any previous training at tube work, or at oph- 
 thalmoscopv or microscopy, have been able to see clearly. Some of these 
 same men have said that they cannot tell, on looking into an ear. what is 
 drum membrane and what is canal. 
 
 Naturally, those accustomed, like the laryngo-rhinologist. to viewing 
 
 deep-seated mucoss with one eye, while relaxing the accommodation of 
 
 the other eye, and ignoring its image will be enabled to see at a glance. 
 
 His experience in intubation and in esophageal work will also make 
 
 him facile at passing the instrument. 
 
 By this It is not meant that gastroscopy should be done by the laryn- 
 gologist. On the contrary, it is the province of the gastro-enterologist, 
 The physician and the surgeon. None of these will have the slightest 
 difficulty in acquiring the necessary technic, and manual dexterity. 
 
 Lordosis, Potts disease and other morbid conditions of the vertebra: 
 mav make gastroscopy- impossible. 
 
 ' Daiii;a-s. In careful hands there is no danger other than that of 
 ether anesthesia. 
 
 In general, it mav be stated that the stomach is a very much less sensi- 
 tive organ than the esophagus ; not .mly less sensitive in the strict meaning 
 of the Sensation, but in the matter of efferent impulses for the production
 
 loG DANGERS OF GASTROSCOPY. 
 
 of reflexes, and of congestion and inflaniinatory reactions to local irrita- 
 tions. 
 
 As the real question of importance is as to shock incident to the 
 passing of a rigid instrument through the entire length of the esophagus, 
 (which, a priori, would seem the only question of importance as the stom- 
 ach is quite insensitive) a number of sphygmomanometric observations 
 upon the author's cases were made by Drs. Boyce, Barach and Upham. 
 Tbe analysis of these observations was published in the jMedical Record, 
 from which the following is quoted : 
 
 "Gastroscopy is apt to be done under very shallow anesthesia, and the pres- 
 sure curve is particularly likely to be distorted by accidental circumstances, 
 but in the four cases observed, the readings were fairly imiform, and it seemed 
 safe to say that there is ordinarily no appreciable disturbance of the circula- 
 tion, but that in an occasional case the characteristic esophageal fall will occur 
 from the passage of a rigid instrument of this length. In these cases, how- 
 ever, the pressure does not remain at the low point, but starts to rise at once 
 and reaches the original level while gastroscopic search is in progress." 
 
 Gastroscopy certainly is not as dangerous as passing a sound or tube, 
 for all diseased spots are seen and pressure upon them avoided. Thus in 
 malignant disease of the cervical esophagus, the natural constriction at the 
 introitus is increased, and carelessness might force a stomach tube 
 through, but with the rigid gastroscope passed by sight the growth at once 
 is discovered. As stated, the tube is started with the finger, and a pre- 
 vious laryngoscopic examination is relied upon to exclude disease of the 
 introitus. Dysphagia without regurgitation is usual in disease of the 
 upper esophagus ; so that in dysphagia with regurgitation we may safely 
 conclude that the disease is far enough within the esophagus to allow the 
 tube to be started by the sense of touch without reaching the diseased 
 tissue. 
 
 Mikulicz doubted the safet}' of examining cases of suspected malig- 
 nancy, and doubtless he was correct, with his instrument with its bend 
 which had to be swung with necessarily imperfect control, and most im- 
 portant of all without seeing what the end was doing. With a perfectly 
 controllable straight instrument unobscured and unweighted with a tele- 
 scopic optic apparatus, the touch is gentle, certain and under full control. 
 
 Suspicious spots can be seen and pressure upon them avoided. Dis- 
 v-'ase of the abdominal esophagus, which makes a more or less sharp turn, 
 (relative to the advancing tube) would be particularly dangerous with an 
 instrument passed blindlv. 
 
 As to the danger of taknig a specimen, the author has done so in a 
 number of cases without any ill result. They were all cases associated 
 with fungation. It is wise, probably, not to remove a specimen from the
 
 coNTR.i-i\Dic.rno.\'s to GASTROSCOI'V. 1">7 
 
 edge of a.:y flat ulceration, as there nni;-ht lie some risk of perforation, or 
 possiblv of hemorrhage. 
 
 The foregoing statement of dangers is based upon the utmost gentle- 
 ness of manipulation under the relaxation of deep anesthesia; the passage 
 of the gastroscope bv sight : the withdrawal of it within the esophagus, 
 should retching supervene: and upon the strict ,.bservance of all the mmor 
 details already alluded to. 
 
 Confra-indicahoiis. \Miile. as stated, there is practically no danger, 
 there are certain cases where gastroscopy is not advisable. In the pro- 
 found cachexia of the last stages of malignancy : in the profound anemia 
 of inanition from known or unknown cause; cardiac, pericardiac or major 
 vascular lesions ; general or local, acute or chronic conditions associated 
 with either dyspnoea or dropsical effusions ; the late stages of organic dis- 
 eases, as cirrhosis of the liver, nephritis, etc. 
 
 It will be noted that all foregoing conditions are really contra-mdi- 
 
 cations to anesthesia. 
 
 While it is bv no means certain that even in these cases there is any 
 
 danger other than that of anesthesia, it is prudent to be particularly care- 
 . iul.'m the earlv development of gastroscopy, not to risk a death that, 
 " rightlv or wrongly, would be attributed to the procedure and not to the 
 
 anesthetic or the concomitant aneurysm or other lesion, thus attaching a 
 
 stigma of danger to a safe and useful procedure.
 
 CHAPTER XXIII. 
 Gastroscopic Appearances. 
 
 In describing and illustrating; what he has seen, the author wishes to 
 ])oint out that these may not be usual or averag-e appearances. They are 
 only descriptive and illustrative of these particular cases. Not until at 
 least a thousand cases have been examined can any ono say what is the 
 average or usual appearance of normal and pathologic conditions. Nor, 
 until then, can any one properly classify the latter. This opens up an 
 enormous field for research. 
 
 There are many difficulties in the wav of reproducing the gastro- 
 scopic views. These difficulties have been surmounted so far as possible 
 in the accompanying color drawings which were made by the author from 
 memory after the examinations. They are only a few of thousands of 
 pictures. 
 
 Normal. The folds of the stomach form an endless variety of pic- 
 tures in front of the gastroscope. A hundred or more difTerent views are 
 presented at a single examination. Not that the folds themselves vary so 
 much, but the manner in which they are presented to the tube varies. 
 
 T'here is one horseshoe-shaped form (Figs. 4, 16 and 18, Plates IV 
 and V) that is often seen, especially near the cardia. It seems to come 
 most often from the lesser curvature, and to be formed by the tube mouth 
 encountering a fold at nearly a right angle to the side of the fold. In 
 some instances it may be formed at the branching of a fold. 
 
 When the tube mouth enters the cardia the folds seem to extend down- 
 ward away from the tube and parallel with its axis, and the tube enters 
 upon a half-open tunnel, the walls of which are formed by longitudinally 
 arranged ridges separated by narrow and deep valleys. The sense of 
 depth of the tunnel is difiicult to portray. Proceeding on down this tun- 
 nel the ridges show a lateral trend and we suddenly end with a blank, 
 sometiines mottled surface, rather flat, sometimes slightly ridged. It flat- 
 tens and blanches as we proceed downward, for although we have en- 
 countered the wall of the greater curvature of the stomach, we do not
 
 ^forF.^[l:^'Ts or the stomach. i')'.t 
 
 realize it at once by the touch as we pu^li it on (lnwnw.'ird fur len or more 
 centimeters before resistance is felt, if the patient he fully anesthetized. 
 If the jiatient comes out partially and bevjins retchins;' resistance is at once 
 felt, but less than misiht be expected. 
 
 \\'hen the tul)e i.s withdrawn the di^k of tlattened stomach wall fol- 
 lows the tube mouth in close contact to a position sometimes higher than 
 where it was encountered. 
 
 Landmarks, among' these folds, in size or direction, will be discciv- 
 ered, probably, but as yet orientation is difficult except by the general 
 sense of direction and distance from the cardia. This is difficult to esti- 
 mate because of the dragging along of the walls by the tube. 
 
 In addition to the change iri form of the folds by the pressure of the 
 tube, variations are caused by the various movements. 
 
 The iiwvciiiciits of the stomach are constant. The\' may be classified 
 into respiratory, pulsatory, anti-peristaltic and peristaltic. llie latter 
 class possibly includes different motions which further work will analyze. 
 Of the anti-]ieristaltic movements there are two kinds, the duodenal vari- 
 ety Ijeing limited to the pyloric end and the vomitory to the fundal half. 
 Other movements of the stomach resulting from, apparently, the activity 
 of its own muscular fibres, are frequently seen, and may be classed as 
 peristaltic, but may be due to the communicated movements of adjacent 
 intestines. 
 
 Tlie respiratory movements in the strmiach are not so marked as 
 those in the esophagus. They seem to produce alternately negative and 
 positive pressures. They are sufficient to cause an in-and-out flow of air, 
 the outflow being strongly saturated with the vapor of the anesthetic which 
 is present in considerable quantity in the gastric secretions. 
 
 The pulsatory movements are transmitted from the heart and to a 
 great extent from the descending aorta. The impulses are not so strong 
 as those in the esophagus where the aorta is crossed. 
 
 The p^■lcric third is the most unstable portion of the stomach. In 
 one instance the pylorus was surrounded by a rosette of annular folds. 
 In another case the folds were seen to be larger as the pylorus was ap- 
 proached. These folds would cur\-e in ahead of the tube, tlien be pushed 
 aside by the advancing tube mouth. Finally cue large fold was moved 
 aside and a slit something like Fig. 25 came into view. Almost imme- 
 diately it resolved itself into a rounded opening which receded into a cup- 
 like depression followed by the wrmkling into the tube of numerous small 
 folds as shown in Fig. 26, accompanied by the ocuding of a dram or two 
 of dark cloudy olive-colored fluid. This evidently was an anti-peristaltic 
 movement, and it immediately preceded retching. 
 
 This was at the apex of the interior of a hollow cone, the walls of
 
 IHO GASTROSCOPIC APPEARANCES. 
 
 which the tube had followed. The question arose in the author's niinu 
 whether this was the pylorus, or the constriction of an hour-glass con- 
 traction, or the kink of a gastroptotic stomach. Either of the latter might 
 show a narrowed opening lying at the apex of the interior of a hollow 
 cone, with a reverse flow of fluid exuding, and an hour-glass contraction 
 might show the depth beyond ; but the question was decided when the 
 small, annular duodenal folds beyond were seen, and no doubt remained 
 when these folds wrinkled up, came toward the tube and filled the opening. 
 
 There seemed to be a degree of rh\1;hm in the movements of the py- 
 loric end of the stomach in one case, but the author could not be certain. 
 It was a much slower rhythm than that of the heart, the movements being 
 a minute or two apart. Whether the presence of the tube was a factor in 
 their production or not, could not be determined. 
 
 The line of demarcation between the esophageal and the gastric mu- 
 cosa is sometimes one of strongly constrasting color. The gastric mucosa 
 varies more in tint than does the esophagus, probably on account of its 
 greater vascularity. It is at times a deep crimson and then the contrast 
 with the pale pink mucosa of the esophagus is marked. The contrast is 
 represented by writers on esophagoscopy as much greater than it really is, 
 because the writers have never seen it except by endoscopic tubes that use 
 reflected light projected down into the tube from without. This brings 
 out the esophageal margin in pale pink, while the insufficiently illuminated 
 depths of the stomach are all in dark shadow if indeed they can be seen at 
 all, and thus the true color of the gastric mucosa has never been seen 
 properly illuminated. 
 
 While in some cases it is a very dark, deep crimson, it is quite often 
 verv pale pink. In one case, the color of the stomach about an hour after 
 taking a glass of milk was crimson (Fig. i6, Plate III), due to the en- 
 gorge;nent of active function from the presence of food. Half hour after 
 vomiting the milk the mucosa was very i^ale. 
 
 In another case, the mucosa was this same color four hours after tak- 
 ing chicken soup, but as whiskey had been taken about one hour before 
 this may have uifluenced the vascularity and consequently the color. 
 There was carcinomatous pyloric stenosis, also, in this case, with conse- 
 quent feeble motility. 
 
 In many cases of foreign body in the esophagus the author has used 
 a gastroscope instead of an esophagoscope, and after removing the foreign 
 body has taken a look at the gastric mucosa by passing the cardia. These 
 were presumably healthy stomachs, and from these experiences, as well as 
 the views obtained in cases where only cardiospasm and csophagismus 
 were found, he has come to the conclusion that \\hen the stomach is empty 
 its nnicosa varies from pale red to pale pink, llie co'or seems deeper in
 
 GJSTROSCOPIC APPEARANCES. 161 
 
 ether anesthesias than wlun chloroform is used, prohably due to the 
 greater engorgement of tlie stomach vessels. Possibly it may be the ether 
 present in the stomach. It was much less deeply colored than in the two 
 cases examined after eating food. 
 
 The gastric mucosa as seen through the gastroscope presents a moist 
 appearance, but it has a more velvety, less glistening, and less transparent 
 look, than the upper mucosre. 
 
 The visibilitv of the minute arterial twigs is a matter which affords 
 great opportunities for investigation. 
 
 Vessels are not usually visible through the gastroscope in the normal 
 gastric mucosa when the stomach is empty, as it usually is when examined 
 gastroscopicallv. In the instance where the author has seen vessels, there 
 was reason to believe that recent taking of food or presence of ether itself 
 or of ether intoxication has engorged the vessels. Yet in some cases no 
 vessels were visible. 
 
 In one case where the gastroscope was passed under cocain and 
 morphin anesthesia for a foreign body in the esophagus, after removing 
 the foreign body, the tube was passed on down a few centimeters distance 
 into the stomach and arterial twigs were noted in a number of locations. 
 There were no stomach symptoms in this case, and no secretion that lead 
 one to think that a lesion might have existed. 
 
 Gastritis. In one case the mucosa was covered everywhere with 
 thick pasty secretions that looked like an exudate and was very difficult to 
 wipe away. In another case the secretion was in patches. Swallowed 
 muco-pus was seen in several cases without gastritis lying free, not adher- 
 ing : so that tliere is no danger of confusing swallowed mucus with that 
 of the stomach. 
 
 The color of the mucosa was a darker red in one case than seemed 
 normal, and the mucosa seemed thickene<l. In only one of these 
 cases were there dilated capillaries such as are seen in chronic intlamma- 
 tion'of th; esoi^hagus. 
 
 Many more cases will have to be examined before definite diagnostic 
 appearances can be classified. This will be but a matter for repeated ex- 
 aminations, for the view is as clear as we get of other mucosae, chronic 
 inflammations of wliieh are apparer.t at a glance. 
 
 Peptic Ulcer. The gastroscopic appearance of benign ulcer was dif- 
 ferent in each case. The nrst one seen (Fig. ii. Plate IV) was a dirty 
 grayish }'ellow, (color in the figure is too bright) not apparently iiunched 
 out and not infiltrated. But at the time, the author hesitated to touch an 
 ulcer, and did not mop the surface. 
 
 In the second case (Fig. 28. Plate \') there was very little secretion, 
 and after wiijint; the surface it was dark in color, did not bleed, and was
 
 1(;2 GASTROSCOPIC APPEARANCES. 
 
 sharpiv punched out in appearance, the edges being- sliglitly infiltrated. 
 In another case (Fig. 27, Plate \"), there was a dark longitudinal slit on 
 the crest of a ridge which looked like an ulcer, but as it was necessary to 
 terminate the examination, it was not possible to determine for certain. 
 There was a cancer in the stomach, but this slit was not part of the growth 
 and was in an otherwise normal fold. 
 
 In another case( Fig. 15, Palate III) the ulcer bed was dark, some- 
 what rough and without any secretion or debris in its cavity, and it re- 
 quired no mopping. 
 
 Malignancy. The gastroscopic appearance of malignant neoplasms 
 varies widely, not only in different cases but in- different portions of the 
 same lesion. In all that have been observed, however, there is marked 
 contrast with the normal mucosa that is very striking. Not only the nor- 
 mal folds are gone, but the surface of the lesion is irregular and granular 
 or nodular. In most instances it was covered with secretion varying in 
 color from white through gray and yellow to pink, red, crimson, purple 
 and brown. 
 
 The secretion is sometimes mottled with brown flakes. 
 
 In the first two cases examined (Figures 14 and 15, Plate IV), the 
 author hesitated to remove this secretion lest hemorrhage be started. In 
 the later cases, however, it was found that wiping away the secretion 
 gently did not produce hemorrhage, and a better view of the colors of the 
 lesions themselves was thus obtained. 
 
 These colors vary widely not only in different lesions but in different 
 parts of the same lesion. In one case the color varied in ditferent parts 
 from pale grayish yellow to pink, deep red, crimson, and brown, with a 
 number of patches of small brown and crimson points apparently where 
 hemorrhages had occurred. One portion of this mass after wiping looked 
 like an over-ripe mulberr\-. This was beautifully shown at one point 
 where a nodule of this mass came out in contrast with the normal pale red 
 mucosa beyond (Fig. 18, Plate III). * 
 
 In one case a portion of the growth external to the stomach wall could 
 be felt, with gastroscope and probe, as a densely hard mass, yet the over- 
 lying mucosa was normal as to folds and color (Fig. 20, Plate V). In 
 another portion the color was normal but the folds were absent. In this 
 portion the muscular wall was evidently involved but the mucosa was not. 
 (Fig. 48, Plate V.) These points, I think, promise to be of great value 
 '.n differential diagnosis between lesions of the gastric wall and lesions of 
 neighboring tissues displacing the uninvolved gastric wall inward. 
 
 \'essels were seen in a number of locations in two cases of malig- 
 nancy, one of these showing a well marked zone. (Fig. 17, Plate III.) 
 
 T'he sense of touch as transmitted through the tube is a remarkablv
 
 GASTROPTOSIS AND GASTRECTASl.l. 163 
 
 efficient aid in the diagnosis of malignancy. Tn one case (Fig. 34, Plate 
 \j the hardness of the mass shown to the right in the plate was diagnos- 
 tic, as was also the mass shown to the right in Fig. 13, I'late I\'. 
 
 G astro l^tosis and Gastrcctasia. The position of the greater cun'atnre 
 is always easily determined, as is also the vertical diameter of the stomach. 
 
 These data are, of course, insufficient to differentiate hetwcen an 
 ectatic and a gastroptotic stomach. If we can reach the pylorus, the diag- 
 nosis is clear. The position of the lesser curvature which is the diag- 
 nostic point and which is difficult to determine clinically, is very readify 
 determined gastroscopically in gastroptotic or infantile stomachs. If the 
 lesser curvatmx is far from vertical its position cannot be accurately de- 
 termined, as in this case it can be inspected by external abdominal manip- 
 ulation, which, of course, gives no idea as to its usual position. 
 
 The recent developments in Roentgenograph}' lessen the value of gas- 
 troscopy in the diagnosis of anomalies or abnormalities of position. 
 Authorities state that the lesser curvatare is difficult to show, bv the 
 bismuth method, and the air, gas or water methods cause displacements ; 
 and, further, ihat the Roentgen process is difficult in the vers- stout. If 
 these things be, gastroscopy can supplement Roentgenograph}' in many 
 instances.
 
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 neren Medizin. Allg. med. Zentr.-Zeitschr. 1896, Nr. 98, S. 
 1 177. Nr. 99, S. 1 189. 
 
 (315) Roscniiciiii. Th., Beitrage zur Oesophagoskopie. I. Oesopha- 
 
 goskopische Bilder beim Speiserohrenkrebs. Deutsche med. 
 Wochenschr. 1895, Nr. 50. S. 836. 
 
 (316) Rosenheim, Ih.. Ueber Oesophagoskopie. Berlin, klin. \\'nchen- 
 
 schr. 1895, Nr. 12, S. 247. (\'ortrag mit Demonstration) ge- 
 hal. in der Berliner med. Gesellschaft 13. Marz. 1895.) 
 
 (317) Rosenheim, Th., Ueber die Besichtigung der Kardia nebst 
 
 Bemerkungen uber Gastroskopie. Deutsche med. Wochenschr. 
 1895, Nr. 45, S. 740. 
 
 (318) Rosenheim, Th., Ueber die Neurosen des Oesophagus. Allg. 
 
 med. Zentral-Zeitung 1895, Nr. 98, S. 1173, Nr. 99, S. 1189. 
 
 (319) Rosenheim, Th., Pathologic und Therapie der Krankheiten der 
 
 \'erdauungsorgane. Teil L Krankheiten der Speiserohre und 
 des ]\Iagens einschliesslich der Gastroskopie und Oesophagos- 
 kopie. Wien (Urban und Schwarzenberg) 1896. 
 
 (320) Rosenheim, Th., Ueber Oesophagoskopie und Gastroskopie. 
 
 Deutsche med. Wochenschr. 1896, Nr. 43, S. 688. 
 
 (321) Rosenlieiin, Th., Uber Gastroskopie (mit Demonstration). Berl. 
 
 klin. Wochenschr. 1896, Nr. 13, S. 239 u. s. 275. (Vortrag 
 gehalten in d. Berl. med. Gesellsch. 4. Marz 1896.)
 
 BIBLIOGRAPHY OF ESOPHAGOSCOPY. 185 
 
 (322) Rosenheim. Th., Uber Fremdkorperextraktion aus dcm Oesopha- 
 
 gus. Berl. klin. Wochenschr. 1896. Nr. 48. S. 1072. \\^rtrag 
 d. Berl. nied. Gesellsch. 11. Nov. 1896. 
 
 (323) Rosenheim. Th., Ueber Sondierung- Speiserdhrc iin ( Jcsopha- 
 
 goskop. r>erl. med. Gesellsch. 12. Mai 1897. Berliner incd. Wo- 
 chenschr. 1897. Nr. 22. 
 
 (324) Rosenheim. Th.. Ueber Hcilung eines Falles von Oesophagus- 
 
 striktur nach Diphtheric. Vortrag gehahen in d. Berl. mcd. 
 Gesellschaft 11. Mai 1898. Berliner klin. Wochenschr. 1898, 
 Nr. 22, S. 496. 
 
 (325) Rosenheim. Th.. Ueber einige Behandlungsniethoden bei Speise- 
 
 rohrenerkranknngen. Therapie d. Gegenw. 1899, H. 2, S. 56. 
 (326! Rosenheim. Th.. P.eitrage zur Oesophagoskopie. ( Ueber einige 
 seltenere Oesophagealerkrankungen und ihre diagnostische 
 Abgrenzung vom Krebs.) Deutsche med. Wochenschr. 1899, 
 Nr. 4 u. 5. .S. 53 u. 75. 
 
 (327) Rosenheim. Th., Ueber Spasmus und Atonie der Speiscrohre. 
 
 Verein f. innerc ]\Iedizin Berlin. Sitzung vom 5. Juni 1899. 
 
 (328) Rosenheim. Th., Beitrage zur Kenntnis der Divcrtikel und Ek- 
 
 tasieen der Speiserohre. Zeitschr. f. klin. Medizin. Bd. 41, H. 
 
 ■ 1-4. S- 177- 
 
 (329) Rosenheiiii. Th., I'ber Oesophagusstenose. Deutsche Klinik 
 
 1901. 
 
 (330) Rezvidcoff, P. 
 
 1. Noch einige W'orte iiber mein Gumme-Gastrostrop. Ach. 
 f. \'erdauungskr. Berl. 1899. vol. 5 p. 484. 
 
 2. Zur Teknik der Gastroskopie (Modification des Rosen- 
 heimschen Gastroskopie (Cong. Internal ]\[ed. Cong. Mosc. 
 
 1899, III. Sect. 5, p. 214. 
 
 (331) Sehilling. F.. Erkankungen der Speiserohre und Oesophagos- 
 
 kopie. Wien. med. Blatter. 1901, Nr. 36. 
 
 (332) Schilling. Die Krankheiten der Speiserohre. Leipzig 1903. 
 
 (333) Schniillinsky. Demonstration eines Falles von Oesophaguskarzi- 
 
 nom. A'ortrag gehalten im arztl. Verein Hamberg. Sitzung 
 
 vom 2. Mai 1899. Miinch. med. Wochenschr. 1899, Nr. 20, 
 S. 680. 
 
 (334) Sehinilinslcy. Zur Diagnose der pharyngo-osophagealen Pvil- 
 
 sionsdivertikel. Deutsche med. W'ochenschr. 1901, Xr. 33, S. 
 
 ■ 556. 
 
 (335) Schreiber. J., Ein Oesophagoskop. Arch. f. \'erd. -Krankheiten. 
 
 1902. Ylll. S. 243. 
 
 (336) v. Sehrotter. H.. Beitrag zur Oesophagoskopie bei Fremdkor- 
 
 pern. ^^'ien. mecl. \\'()chenschr. 1904, Nr. 45 u. ^f).
 
 186 BIBLIOGRAPHY OF ESOPHAGOSCOPY. 
 
 (337) ^'^ Schrottcr. H., W citerliin Beitrag ziir Oesophagoskopie bei 
 
 Fremdkorpern. Monatsschr. f. Ohrenheilkunde 1904, Nr. 11. 
 
 (338) Schworcr, R.. Ein Fall von spindelforniigcr Erweiterung der 
 
 Speiserohre. Munch nied. \\'(ichesclir. 1899. Nr. 25, S. 825. 
 
 (339) Segahis, Revue medicale francaise et etrangere. 1827, I. S. 157. 
 
 (340) Scmclcdcr. Wien Medizinalhalle. 1862, Nr. 34, S. 319 (zit. n. 
 
 Killian). 
 
 (341) Starck. H.. Die diffuse Erweitung der Speiserohre. Deutsche 
 
 I'raxis. Zeitschr. f. prakt. Arzte. 1903. Nr. 7 n. 8. 
 
 (342) Starck. Die osophagoskopische Diagnose divertikelartiger Er- 
 
 weiterungen der Speiserohre. Arch, fiir \ erdauungskrank- 
 heiten. Ikl. XI. 
 
 (343) Starck. H., Bericht iiber osophagoskopische Diagiiostik. Miinch. 
 
 med. Wochenschr. 1904. Nr. 6. 
 
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 im naturhist. med. \'erein Heidelberg 8. XI. 04, s. Aliinch. 
 med. Wochenschr. 1905, Nr. 8. 
 (345 ) Starck. H.. Die Oesophagoskopie und ihr diagnostischer Wert. 
 \'ortr. XIV. internal, med. Kongr. Madrid April 1903, s. 
 Petersburgher med. \\'ochensciir. 1903, Nr. 26. 
 
 (346) Stein, Ih., Das Photo-Endoskop. Berliner klin. \\'ochenschr. 
 
 1874, Nr. 3, S. 31. 
 
 (347) Stocrk, Ein neues Oesophagoskop. \\'ien. med. \\'ochenschr. 
 
 1887. Nr. 34. S. 1 1 17. 
 
 (348) Stocrk, Die L'ntersuchung des Oesophagus mit dem Kehlkopf- 
 
 spiegel. Wien. med. Wochenschr. 1881, Nr. 8. S. 210, Nr. 25, 
 S. 706, Nr. 30, S. Sfio. 
 
 (349) Stocrk. Ueber Oesophagoskopie. Naturforscher-\'ersammlung in 
 
 Wien 1894. 
 
 (350} Stocrk, Die L'ntersuchnng der Speiserdhre (Oesophagoskopie). 
 \\'ien und Leipzig, ^^'ilhelm Braummuller. 1S96 (s. auch Die 
 Oesophagoskopie. Wiener klin. Wochenschr. 1896. Nr. 28, S. 
 625, s. auch Wien. laryngol. Gesellsch. 1896. Wien klin. Wo- 
 chenschr. 1896. Nr. 26, S. 590). 
 
 (351) Strauss. H., Klinische Beitrage zur Pathologic und Therapie der 
 sogenannten idiopatliischen Oesophagus-Erweiterung ( '"sack- 
 formige Oesophsgus-Erweitctung ohne anat. Stenose"). Zeit- 
 schr. f. klin. Medizin 1901. Bd. 44. H. 3 u. 4. 
 
 (332) Stiibeiirauch. Mehrfache luetische Strikturen des Oesophagus. 
 Gastrostomie. Retrograde Sondierung ohne Ende. Rasche 
 Besserung. \'ortrag gehalten im arzt. Verein. Miinchen Sit-
 
 BIBLIOGRAPHY OF ESOPHAGOSCOPY . 187 
 
 zuni;- voiii ii. Xov. 1900. Miincli. nied. W'ochenschrift I'joi, 
 
 Nr. 6. S. 240. 
 [^,S^,^ Starck. H., Esophagoscopy, A. Stuber. Wurzlnirg-, 1905. 
 (354) Trcitcl. Demmistration eines Oesopliagoskopcs. ISerlincr nic(l. 
 
 Gest'llsch. 6. ]\[arz 1895. (Dan Oesophagoskop ciitsiM-icIit 
 
 einem der altesteii ]\Iodelle. niittelst welchem man die W'anduiig 
 
 des obersten Speiserohrenabschnittes iibersieht) s. auch lar\n- 
 
 golog. Gesellsch. Berlin 7. Dez, 1904. 
 '355) VoUoUni, Sitziing der Gesellschaft fiir wissenschattliclie Medi- 
 
 zin in Berlin vom 2. Juli i860. Deutscbe Klinik i860, S. 393. 
 
 (356) Wahlcnbtiig, L., Oesophagoskopie. Eine neue Untersuchungs- 
 
 methode. Berl. klin. \\'ochenschr. 1870, Nr. 48, S. 578. 
 
 (357) JVintcniitc. A., Frenidkorperextraktion aus dem Osophagus im 
 
 Oesophagoskop. Vortrag im Bndapester kon. Arzteverein 19. 
 Okt. 1901. Wien. med. Wochenschr. 1902, S. 378. 
 '^358) ''• Zander, Ein grosser Fremdkorper in der Speiserohre. Char- 
 ite-Annalen 1898, Bd. 23, S. 501.
 
 DESCRIPTION OF PLATES. 
 
 Plate I. 
 
 1. Tracheal papilloma. Girl of 4 years. Removed through trache- 
 oscope. Referred by Dr. Brush. 
 
 2. Tracheal compression by struma. Feeble pulsatory excursion. 
 Man of ^^ years. Referred by Dr. Heard. 
 
 3. Tracheal compression by aneurysm. Violent pulsatory excur- 
 sion. Dotted line shows limit of recession of bulging. Man of 60 years 
 referred by Dr. Price. 
 
 4. Cicatrical stenotic web in trachea resulting from ulceration caused 
 by a foreign body in the esophagus. Child 2 years of age. Referred by 
 Dr. Ryall." 
 
 5. Scabbard trachea. Thymic tracheo-stenosis. Cured by thymec- 
 tomy. Child of 4 years. Referred by Dr. Boyce. 
 
 6. Egg shell in edematous larynx. In situ 4 weeks. Removed by 
 direct laryngoscopy. Infant 9 months of age. Referred by Dr. Moyer 
 and Dr. Wechsler. 
 
 7. Button fixed in the trachea by the swollen mucosa. Whistling 
 respiration. Boy of 14 years. Referred by Dr. Crawford. 
 
 8. Luetic tracheal stenosis. Man 24 years of age. Referred by Dr. 
 F. T. Smith. 
 
 9. Compression stenosis of the trachea by an esophageal carcinoma. 
 Man aged 60. Referred by Dr. Sanes. 
 
 Plate II. 
 
 10. View looking down left bronchus. To the left above is the 
 opening of the superior lobe bronclius. To' the right the inferior lobe 
 bronchus. 
 
 11. Normal \'iew looking down right bronchus. Above is the mid- 
 dle lobe bronchus : below to the left the inferior lobe bronchus ; to the 
 right the superior lobe bronchus, appearing larger because nearer. 
 
 12. Fungating granulations from healing cartilage, after trache- 
 otomy. Skin allowed to unite per priiuam.
 
 DiLSCRirriox or plates. i89 
 
 13. ]^-in,ary Irechcal ozena, (iirl aged ih years. Referred by Dr. 
 
 Wallace. ^^^^^^^^^ ^^^^^^ ^^^^^^,^ cicatrices. Right bronchus of man aged 
 
 23 years. Referred by Dr. F. T. Smith. „ , , , . , 
 
 IS Compression stenosis of trachea. Posterior wall bulged forward 
 
 by tubercular lymph nodes. Woman aged 25 years. Referred by Dr. 
 
 Schildecker. 
 
 Pi,.\TE HI. 
 
 1. Introitus esophagi. Normal. Dark lino must not be understood 
 as a gaping. Collapsed shut. Man of 36. 
 
 2. Intra-thoracic esophagus. Unusual view, but normal. More 
 usual appearance shown in Fig. I.. Plate I\ . ... 
 
 3. Esophagus at hiatus diaphragmatis normal. Note axis of lumen. 
 
 ^""T" Gcatricial esophageal stenosis. Pin-hole lumen. White scars. 
 Recurrence of stenosis following ulceration during typhoid fever. Prim- 
 ary lesion, burned bv swallowing lye in childhood 14 years previously. 
 I\l'r H. aged 21 years. Referred by Dr. Stevenson. _ 
 
 5 Ibid Bottom of diverticulum. ?>Iucosa chronically inflamed. 
 
 6 Tubercular ulceration posterior esophageal wall, simulating 
 decubitus ulcer often seen in typhoid fever. Tubercular lesion m this 
 location is somewhat rare, though still more rarely is it diagnosticated 
 Incidentally this figure shows the introitus esophagi when the cricoid 
 cartilage is lifted bv the laryngeal speculum. Compare Fig. I., above. 
 
 7 Carcinoma of the thoracic esophageal wall (left) covered with 
 normal mucosa. Lumen pushed to the right and almost obliterated. Man 
 aged 60 years, referred by Dr. Sanes. 
 
 8 Carcinoma, endo-esophageal. Woman of 41 vears, referred for 
 chronic nasal sinus disease. Esophageal symptoms slight and attributed 
 to globus hystericus. 
 
 9 and 12. Fibroma papillare, attached by long slender fibrous ped- 
 uncle Disappeared into the esophagus at times after swallowing. Fig. 
 12 shows the attachment within the esophagus when the cricoid cartilage 
 is moved forward (instrument not shown). Removed through tubular 
 speculum. ]Man aged 36 years, referred by Dr. Heard. 
 
 10. View in thoracic esophagus showing wounds (above) made by 
 blind groping with a coin extractor which did not extract. Boy of 14 
 
 years. 
 
 II. Wound in esophageal wall made by a pin which was afterward 
 found higher up. Woman of 23 years, referred by Dr. Pool. 
 
 13. Normal. "Kink" of the esophagus at the hiatus, probably more 
 a preventive of regurgitation than the cardia.
 
 190 DESCRIPTION OF PLATES. 
 
 14. Peri-esophageal carcinoma overlaid with normal mucosa, lumen 
 deviated so far to right as to be out of view. Diagnosis upon hardness 
 of mass, and age of the patient. jNIan of 60 years, referred by Dr. Swope. 
 
 15. Stomach ulcer (on left side of right fold in the view), bed 
 showing dark after secretions had been wiped away. ( )ther folds normal. 
 Woman aged 26 years, sent by Dr. Moss. 
 
 16. Stomach. Normal. Branched fold. Dark crimson color. Ex- 
 amined one horn- after drinking milk. Man of 32 years. 
 
 17. Stomach. Carcinoma. Zone of hyperemia. ]dan of 46 years, 
 referred by Dr. Walton. 
 
 18. Stomach. Same patient. Mulbcrry-likc nudule at another por- 
 tion of growth. 
 
 Pl.vte IV. 
 
 1. Thoracic esophagus. Expiration. Xote lumen not entirely 
 closed. Man aged 40. 
 
 2, 3, 4, 5 and 6. Normal stomach. I'olds in various positions as 
 seen separating and collapsing ahead of the tube as it is inserted and 
 withdrawn. In Fig. 4 is shown a horseshoe-shaped position of a fold 
 often seen near the cardia, usually to the right. At times seen elsewhere. 
 Compare Figs. 16 and 18, Plate V. 
 
 7 and 8. Stomach. Normal wall of inferior curvature flattened by 
 pressure of the tube mouth. 
 
 9. Gastritis. F'old in lower right hand corner is cajiped by secretion 
 sitnulating ulcer, before wiped away. 
 
 10. Gastritis. All folds sponged but one. which shows thick tena- 
 cious secretion. 
 
 11. Gastric nicer seen on edge. Not sponged. Man aged 32. Pa- 
 tient of Dr. Finkelpearl. 
 
 12. Same patient. Scar after healing of the ulcer. Scar shows 
 yellow bv engraver's error ; it should be grayish, nearly white. 
 
 13. Carcinoma of cardia. Infiltrated but not ulcerated hard mass 
 to right of view. Man 38 years. Referred by Dr. Haworth. 
 
 14. Same patient. Farther to right than Fig. 13, on lesser curva- 
 ture. Fungating portion of mass. 
 
 15. Carcinoma of pylorus. Left bolder of the tumor. Man of 44 
 years. Referred by Dr. Haworth. 
 
 16. Normal stomach. Three cm. below the cardia. Note horseshoe- 
 shaped fold to the right. Maid of 19 years. Patient of Dr. Lichty. 
 
 17. Normal stomach, farther down, same patient. (\'iews are never 
 twice alike, no form is meant as t\pical of local it w) 
 
 18. Normal .'■-tomacH. Four cm. from cardia. Woman of ^t, years.
 
 DIISCRH'TIOX or f'L.ITF.S. 191 
 
 19. Normal stdiiiacli. W niiian ui 19 years. Showing diversifie<l 
 forms of folds. 
 
 20. Xormal stomach. T'-ans verse trend of folds as greater curva- 
 ture is approached. Folds are rarely seen as straight as the central one in 
 this view. 
 
 21. Approaching the pyloris. Gastroptotic stomach. (View proh- 
 ably not abnormal.) Woman of :ii years. Referred by Dr. Dranga. 
 
 22. Gastroptotic stomach (same patient). Pyloris hidden by folds. 
 
 23. Folds at fundus (not typical). 
 
 24. Approaching the pyloris. Folds disturheil b>- tube-mouth. Same 
 patient as Fig. 21. 
 
 23. Same patient, same location, about one minute later. 
 
 26. Ditto, about one minute later. Amiular folds of pyloris sur- 
 rounding prolapsed duodenal folds. Brownish fluid was regurgitated into 
 stomach. 
 
 2/. Cancerous ( ?) infiltration near pyloris. Fluid exuded from 
 triangular slit. Woman aged 26 years. Referred by Dr. Montgomery. 
 
 28. Gastric ulcer, filled with secretion, and seen on edge. Man 
 aged 59 years. Referred by Dr. Goldsmith. 
 
 29. Same ulcer wiped clean. Looking into bed of ulcer. 
 
 30. Cicatrix ( ?) of stomach, in a man 59 years of age who had a 
 specific history. 
 
 31. Carcinoma of esophagus. Man of 60 years, referred by Dr. 
 Sanes. 
 
 32. Carcinoma ( ?) of pyloris. View not at, but near the pyloris 
 on greaer curvature. Color should be much darker. Woman aged 26 
 years. Referred by Dr. Montgomery. 
 
 33. Carcinoma of pyloris. \'iew at left border. Other portions of 
 growth were spotted with dark brown. Man 46 years of age. Referred 
 by Dr. Walton. Afterward operated upon by Dr. MacClelland and diag- 
 nosis as to size, shape, position and nature verified. 
 
 34. Another ])ortion of same growth. Mucosa normal but foldless 
 and hard. (Right in view.) 
 
 35. Cardiospasm. Abdominal esophagismus. Man aged 59 years. 
 Referred by Dr. Goldsmith.
 
 PLATE !.
 
 PLATE II.
 
 PLATE III.
 
 PLATE IV.
 
 PLATE V.
 
 APPENDIX,
 
 l'.)4 
 
 APPENDIX. 
 
 (X, 
 
 h. 
 
 A'on Kicktni's ForL*eps iiiid Hriininiis' Broiichosi opes. 
 
 A. B, Forcci)s, large aii<l small, ailjiistalilo iu li'ii^tli. 
 
 ('. A.spi ni 1 or. 
 
 1>. 10. F. i;. II. Tubes of iliffereut size.s. 
 
 I. Handle for use ou tubes when iisiui; (lie Kjrsleiii lieaillainii. 
 
 J, IIaii(llaiH|] r<ir jlliiniinaticiu of tiihe,
 
 Appnxnix. liT) 
 
 W'iiik' this honk was in press. Professor (lustav Killian. upon a visit 
 to this country, exliihited the l)ninch;isco]iic ttihes of llriinini^'s. These 
 consist essentially of a long tnlie-spatula in which an inner tnhe tele- 
 scopes ( D, E, F, G, H). The itiner tuhe has at one side a long ^lenller 
 piece of coiled steel, like a watch spring, which, when the inner tube is 
 piislted in until flush with tlie outer tube, serves to ])ush the inner tube as 
 much farther as desired. 
 
 The illumination is by a hand lamp (J ) attached to the outer end of 
 the outer tube, the light mirror being thrown out of the wa\' when it is 
 desired to introduce an aspirator, cotton carriers or other instruments. In 
 the event of the giving out of the hand lamp, the Kirstein headlamp is 
 used, and may be preferred by some operators, though the hand lamp 
 will be found best for use during introduction of the instruments. The 
 handle (I) may be used instead of the hand lamp, when a headlamp is 
 used for illumination. 
 
 In use. the outer tube of tubc-spatular form is inserted over the dor- 
 sum of the tongue, posterior to the epiglottis, and into anil through the 
 glottis into the upper end of the trachea. Then the inner telescopic tube 
 is inserted into the tube-spatula and pushed downward as far as desired. 
 
 A forceps (.\, P.), which also telescopes so as to |iermit of shorten- 
 ing and lengthening, was designed by \'on Eicken. 
 
 At C is shown an aspirator, the tube of which is inserted into the 
 bronchoscope as often as needed.
 
 INDEX. 
 
 Page 
 
 Anomalies of the esophagus 105 
 
 Appearances, normal esophago- 
 
 scopic lOi 
 
 Bronchi, anatomy of 63 
 
 Diaphragm, esophageal opening in. gS 
 Dimensions of the trachea and 
 
 bronchi 65 
 
 Endoscopic appearances of the 
 
 trachea and bronchi 66 
 
 Esophagus, anatomy of 97 
 
 Esophagus, anomalies of 105 
 
 Esophagus, dimensions of 97 
 
 Esophagus, position of 99 
 
 Stomach, size, shape and position 
 
 of 150 
 
 Tracheo-bronchial tree, anatnniv 
 
 of 63 
 
 Direct Laryngoscopy. 
 
 Abscess of the laryn.\ 60 
 
 Benign neoplasms 59 
 
 Contra-indications and dangers in 
 
 direct laryngoscopy 54 
 
 Cicatricial stenoses of the larynx. 60 
 
 Dangers and contra-indications.. 54 
 
 Difficulties in direct laryngoscopy. 55 
 
 Diseased conditions 58 
 
 Direct laryngoscopy for diagnosis 
 
 and treatment 54 
 
 Foreign bodies in the larynx.... 57 
 
 Galvano-cauitery use of in larynx. 62 
 Inflammatory diseases of the 
 
 larynx 60 
 
 Laryngeal paralyses 61 
 
 Malignant disease of ithe larynx. 58 
 
 Retrograde laryngoscopy 6j 
 
 Position of the patient for di- 
 rect laryngoscopy 146 
 
 Preparation of the patient 3S 
 
 Second assistant, duties of, in en- 
 doscopy /><»)• OS 145 
 
 Sensory laryngeal neuroses 61 
 
 Tcchnic 39, 42 
 
 Tuberculosis, laryngeal 60 
 
 Webs of the larynx, congenital.. 62 
 
 LsopH.\r.us. 
 
 Acute esophagitis 120 
 
 Anomalies of the esophagus 105 
 
 Page 
 
 Anatomy of the esophagus 97 
 
 Appearances, normal csophago- 
 
 scopic loi 
 
 Benign neoplasms of the esopha- 
 gus, treatment of 113 
 
 Benign neoplasms of the esopha- 
 gus 112 
 
 Bibliography, esophagoscopy and 
 
 gastroscopy 176 
 
 Bouginage per tubam in the treat- 
 ment of esophageal stenosis.... 108 
 
 Cardiospasm 114 
 
 Cicatricial stenoses of the esopha- 
 gus, treatment of 107 
 
 Cicatricial stenoses of the esopha- 
 gus 106 
 
 Compression stenoses of the 
 
 esophagus 115 
 
 Contra-indications, esophagoscopy 155 
 
 Chronic esophagitis 120 
 
 Dangers of esophagoscopy 155 
 
 Diaphragmatis, hiatus esophagcus. 96 
 
 Diseases of the esophagus 105 
 
 Difficulties in esophagoscopy .. 147, 15s 
 
 Dilatations of the esophagus 118 
 
 Dilatation of esophageal stricture 
 
 with the laminaria tent 109 
 
 Dilatation of esophageal stricture 
 
 with the laminaria tent 109 
 
 Dimensions of the esophagus 97 
 
 Diverticula, esophageal 117 
 
 Esophagitis, acute 120 
 
 Esophagitis, chronic 120 
 
 Esophagitis, treatment of 121 
 
 Esophagoscope, passing the 144 
 
 Esophagoscopy 96 
 
 Esophagospasm 115 
 
 Examination of the upper end of 
 
 the esophagus 103 
 
 Foreign bodies in the esophagus.. 124 
 
 Hiatus esophageus 98 
 
 Inflammation of the esophagus... 120 
 Inflammatory diseases of the 
 
 esophagus 106 
 
 Malignant disease of the esopha- 
 gus no 
 
 Malignant disease of the esopha- 
 gus, treatment of 1 12 
 
 Movements of the esophagus.... gg
 
 INDEX. 
 
 107 
 
 PaKe 
 
 XcitroECS of the esophagus 122 
 
 Non-stcnotic diseases of the 
 
 esophagus 117 
 
 Paralyses of the esophagus 122 
 
 Pareses of the esophagus 122 
 
 Passing the esophagoscopc 103 
 
 Passing the esophagoscope 144 
 
 Phrenospasni 114 
 
 Position of the esophagus 99 
 
 Position of the patient 146 
 
 Safety pin in the esophagus, clos- 
 ing a 126 
 
 Second assistant, duties of in 
 
 endoscopy f'cr os 145 
 
 Shock, question of, in esophgo- 
 
 scopy 156 
 
 Spastic stenoses of the esopha- 
 gus, treatment of 115 
 
 Stenoses of the esophagus due to 
 
 compression it? 
 
 Stenoses of the esophagus, spastic. 114 
 Stenotic diseases of the esopha- 
 gus 106 
 
 Teclinic of csophagoscopy 103 
 
 Treatment of cicatricial stenoses 
 
 of the esophagus 107 
 
 Treatment of malignant disease 
 
 of the esophagus 112 
 
 Ulceration of the esophagus T2i 
 
 Ulceration of the esophagus, sten- 
 osis following 107 
 
 Gastroscopv. 
 
 Anesthesia in gastroscopy 142 
 
 Appearances, gastroscopic 158 
 
 Area of stomach explorahle by 
 
 gastroscopy 151 
 
 Bibliography of csophagoscopy 
 
 and gastroscopy 176 
 
 Contra-indications to gastroscopy. 155 
 
 Dangers of gastroscopy 155 
 
 Dicta, fundamental, in gastroscopy 137 
 
 Difificulties in gastroscopy 47, 153 
 
 Explorahle area of the stomacli.. 151 
 Foreign bodies in the stomach, re- 
 moval of by gastroscopy 139 
 
 Gastroptosis and gastreotasia. . . . 163 
 
 Gastritis 161 
 
 History of gastroscopy 130 
 
 Instruments for gastroscopy 140 
 
 Jones, Clement R., method of in- 
 troducing the gastroscope 144 
 
 Alalignant disease of the stomach. 162 
 Mikulicz's work in gastroscopy.. 132 
 
 Passing the gastroscope 144 
 
 Peptic ulcer 161 
 
 Position of the patient in gastro- 
 scopy 146 
 
 Position of the patient .. 143, 145, 146 
 
 Preparation of the patient 142 
 
 Rosenheim, work in gastroscopy.. 133 
 Second assistant, duties of in 
 endoscopy per os 145 
 
 Pak'c 
 Shock, question of, in gastro- 
 scopy 1 56 
 
 Stomach, area of explorahle l)y 
 
 gastroscopy 151 
 
 Stomach, determination of its size 
 
 and position 150, 163 
 
 Stomach, movements of, as seen 
 
 gastroscopically 159 
 
 Technic of gastroscopy 142 
 
 Usefulness of gastroscopy 13S 
 
 IIlSTORIC.XL \OTF.S. 
 
 Bozini, Vol'talini, Waldenberg, 
 Stocrck, Kussmaul, Trouve, 
 Mikulicz, Gottstein, Von .\cker, 
 Kirstein, Killian, Coolidge, Von 
 
 Schroetter, Piniazek 13 
 
 Einhorn, Guisez, Ingals, Jackson. 14 
 
 Gastroscopy, history of 130 
 
 Mikulicz's, work in gastroscopy.. 132 
 Xitze, attempt to construct a gas- 
 troscope 130 
 
 Rcwidzof, work in gastroscopy.. 135 
 
 Rosenheim's work in gastroscopy. 133 
 
 Instruments. 
 
 Aspirator, Killian 192 
 
 Aspirator, Jackson 25 
 
 Battery, bronchoscopic, Jackson.. 30 
 
 Bougie, Bunt, esophageal 108 
 
 Bronchoscope, Briinings 192 
 
 Bronchoscopes', sizes of 31 
 
 Bronchoscopes, selection of sizes 
 
 for particular case 51 
 
 Bronchoscope, Jackson 24 
 
 Bronchoscope, Ingals 24 
 
 Bronchoscope, Von Schroetter... 23 
 
 Bronchoscope, Killian 22 
 
 Bunt, esophageal bougie 108 
 
 Briinings, bronchoscope 192 
 
 Casper, electroscope 16 
 
 Coolidge, cotton carrier 28 
 
 Coolidge, forceps 25 
 
 Cotton carrier, Coolidge 28 
 
 Cotton carriers, Mikulicz 28 
 
 Von Eicken, forceps 192 
 
 Einhorn, Esophagoscope 23 
 
 Electrode, laryngeal 61 
 
 Electrode, galvano-cautery 62 
 
 Electroscope, Casper 16 
 
 Esopliagoscope, Jackson 24 
 
 Esophagoscope, Einhorn 23 
 
 Esophagoscope, fenestrated, Kir- 
 stein 22 
 
 Esophagoscope, Starck 21 
 
 Esophagoscope, Von Hacker 21 
 
 Esophagoscope, Rosenheim 20 
 
 Esophagoscope, Mikulicz 20 
 
 Ferguson, mouth ga.g 29 
 
 Forceps, cotton holding laryngeal, 
 
 Sajous .'. .' 39 
 
 Forceps, Coolidge '2^ 
 
 Forceps, Von Eicken 192
 
 198 
 
 INDEX. 
 
 Page 
 
 Forceps, Jackson 27 
 
 Forceps, Killian 27 
 
 Gag, Ferguson 29 
 
 Gastroscopy, instruments for.... 140 
 
 Gastroscope. Jackson 24, 140 
 
 Gastroscope, Mikulicz 131 
 
 Gostroscope, Rewidzof 135 
 
 Gastroscope, Rosenheim 133 
 
 Gastroscope. Trouve 130 
 
 Guisez, headlamp 15 
 
 Von Hacker, esophagoscope 21 
 
 Headlamp, Guisez 15 
 
 Headlamp, Kirstein 15 
 
 Hooks 28 
 
 Ingals, Bronchoscope 24 
 
 Instruments, list of 31 
 
 Jackson, bronchoscope 24 
 
 Jackson, esophagoscope 24 
 
 Jackson, forceps 27 
 
 Jackson, gastroscope 24, 140 
 
 Jackson, laryngeal knife 2g 
 
 Jackson, safety pin closer 28 
 
 Jackson, secretion aspirator 25 
 
 Jackson separable speculum 19 
 
 Jackson, tent carrier 28 
 
 Jackson tubular speculum ig 
 
 Jones, Clement, sound for the in- 
 troduction of the gastroscope.. 141 
 
 Killian. aspirator 192 
 
 Killian, bronchoscope 22 
 
 Killian, forceps 27 
 
 Killian, split tubular spaitula.... 17 
 
 Killian, tubular spatula 17 
 
 Kirstein, esophagoscope, fenes- 
 trated 22 
 
 Kirstein, headlamp 15 
 
 Knife, laryngeal, Jackson 29 
 
 Manikin, Killian 35 
 
 Mikulicz, cotton carrier 2-! 
 
 ^Mikulicz, esophagoscope 20 
 
 Mikulicz, gastroscope 13' 
 
 Mosher, esophageal instrument... 18 
 
 Mosher, esophageal speculum.... 18 
 
 Mosher, safety pin closer 2-! 
 
 Mouth gag. Ferguson 29 
 
 Rewidzof, gastroscope 135 
 
 Rosenheim, esophagoscope 20 
 
 Rosenheim, gastroscope 133 
 
 Safety pin closer, Jackson 28 
 
 Safety pin closer, Mosher 28 
 
 Sojous_, cotton-holding forceps... 39 
 Von Schroetter, bronchoscope... 22, 
 Sound, Clement Jones, for intro- 
 ducing the gastroscope 141 
 
 Starck. esophagoscope 21 
 
 Speculum. Jackson's, separable 
 
 tubular 19 
 
 Speculum. Mosher's esophageal.. 18 
 
 Spatula, split, tubular. Killian's.. 17 
 
 Spectdum. tubular. Jackson's 19 
 
 Spatula, tubular. Killian's 17 
 
 Tent carrier. Jackson 28 
 
 Trouve. polyscope 130 
 
 Paire 
 
 Tfchnic. 
 
 Acquiring skill 33 
 
 Adjusting the Kirstein headlamp. 43 
 
 Anesthesia in bronchoscopy 47 
 
 Anesthesia in direct laryngoscopy. 39 
 
 ■Anesthesia in gastroscopy 142 
 
 Asepsis 37 
 
 Bronchoscopy, anesthesia in 47 
 
 Bronchoscopy, lower, dorsal decu- 
 bitus 50 
 
 Bronchoscopy, lower, patient sit- 
 ting 45 
 
 Bronchoscope, passing the 47 
 
 Bronchoscope, passing the 53 
 
 Bouginage per tubam in esopha- 
 geal stenosis 109 
 
 Bronchoscopy, upper 43 
 
 Bronchoscopy, upper 45 
 
 Cauterization laryngeal 62 
 
 Dilatation of esophageal stenosis. 
 
 instrumental 109 
 
 Diltation of esophageal stricture. 
 
 instrumental 109 
 
 Direct laryngoscopy, anesthesia in. 39 
 Direct laryngoscopy, diagram of 
 
 position in operating-room 41 
 
 Direct laryngoscopy, dorsal decu- 
 bitus 45 
 
 Direct laryngoscopy, patient sit- 
 ting 40 
 
 Dog, as an animal subject 35 
 
 Esophagoscopy, technic of 103 
 
 Foreign body, tracheo-bronchos- 
 
 copy for 92 
 
 Gastroscope, Clement R. Jones 
 
 method of introduction of the.. 144 
 
 Gastroscope, introduction of the. 144 
 
 Gastroscopy. anesthesia in 142 
 
 Gastroscopy. technic of 142 
 
 Jones. Clement R., method of in- 
 troducing the gastroscope 144 
 
 Killian. manikin 35 
 
 Kirstein headlamp, adjusting the. 49 
 
 Laryngeal speculum, use of 42 
 
 Laryngoscopy, direct, dorsal de- 
 cubitus 45 
 
 Laryngoscopy, retrograde 62 
 
 Lower tracheobronchoscopy 45 
 
 Operating" room arrangement.... 41 
 
 Operating room arrangement.... 46 
 
 Passing the bronchoscope 47 
 
 Passing the bronchoscope -. . . S3 
 
 Patient, preparation of 38 
 
 Position of patient in direct laryn- 
 goscopy, tracheo-bronclioscopy 
 
 esophagoscopy and gastroscopy. 146 
 
 Preparation of patient 38 
 
 Preparation of the patient for gas- 
 troscopy 142 
 
 Safety pin closer, use of 126 
 
 Second assistant, duties of. in en- 
 doscopy per OS 145 
 
 Sterilization },'/
 
 lADJzX. 
 
 I'.iit 
 
 Page 
 
 Tracheo-broiichoscopy for for- 
 eign liody 9- 
 
 Traciieo-bronchoscopy, lower, dor- 
 sal deculMtus 50 
 
 Tracheo-bronchoscopy. lower, pa- 
 tient sitting 45 
 
 Tracheo-bronchoscopy, upper 4,? 
 
 Tracheo-bronchoscopy, upper 45 
 
 Tracheotomy 5t 
 
 Upper tracheo-bronchoscopy 4,1 
 
 Trachea and Bronchi. 
 
 Anatomy of the trachea and 
 bronchi 64 
 
 Aneurysm as a cause of traclieal 
 stenosis 7,? 
 
 Asthma thymicuin 70 
 
 Benign neoplasms nuiro-tracbcal. 73 
 
 Bibliography of tracheo-broncho- 
 scopy 164 
 
 Boyce, physical signs of foreign 
 body in the air passages 90 
 
 Bronchoscopy, upper and lower, 
 rehuive advisability of 80 
 
 Cicatricial stenosis of the trachea 
 from foreign body "5 
 
 Contra-indications to traclieo- 
 bronchoscopy in foreign body 
 cases 8j 
 
 Dangers of tracheo-bronchoscopy 
 in foreign body cases 82 
 
 Deviation of the trachea 77 
 
 Diagnosis of foreign body in the 
 trachea and bronchi 86 
 
 Dimensions of the trachea and 
 bronchi 65 
 
 Diseas'es of the trachea and bron- 
 chi, non-stenotic 63 
 
 Diseases of the trachea and bron- 
 chi, tracheo-bronchoscopy in... 68 
 
 Endoscopic appearances of the 
 trachea and bronchi 66 
 
 Extraction of foreign bodies 92 
 
 Foreign body cases, dangers of 
 traceo-bronchoscopy in 82 
 
 Foreign body, dangers of not re- 
 moving 8,^ 
 
 Foreign body, diagnosis of 86 
 
 Foreign bodies in the trachea 
 and bronchi 80 
 
 Foreign Ijodies in the trachea and 
 bronchi, indications for tracheo- 
 bronchoscopy , 81 
 
 Page 
 
 Foreign bodies, results of tracheo- 
 bronchoscopy in the extraction 
 
 of 81 
 
 Foreign body, symptoms of 85 
 
 Glanders of the tracliea and 
 
 bronchi 7.? 
 
 Indications for tracheo-broncho- 
 scopy in foreign body cases.... 81 
 Inflammations of the trachea and 
 
 bronchi 7,? 
 
 Malignant neoplasms, muro- 
 
 tracheal 73 
 
 Non-stenotic diseases of the 
 
 trachea and bronchi 68 
 
 Physical signs in diagnosis of for- 
 eign body 93 
 
 Position of the patient 146 
 
 Stenoses of the tracliea 75 
 
 Stricture of the trachea 75 
 
 Retrograde laryngoscopy 62 
 
 Roentgen ray, in the diagnosis of 
 
 foreign l>ody 86 
 
 Second assistant, duties of, in en- 
 doscopy per OS 145 
 
 Specific inflammations of the 
 
 trachea and bronchi 7.3 
 
 Stenoses of the trachea 69 
 
 Stenosis of the trachea from 
 
 muro-tracheal conditions 7,; 
 
 Symptoius of foreign body in the 
 
 trachea and bronchi 86 
 
 Svphilis of the trachea and liron 
 
 'chi 7.? 
 
 Technic of extraction of foreign 
 
 liodies 92 
 
 Thymic asthma 70 
 
 Thymic tracheo-stenosis 70 
 
 Tracheo-bronchoscopy, contra-in- 
 dications in foreign body cases. 82 
 Tracheo-bronchoscopy in diseases 
 of the trachea and Ijronchi .... 68 
 
 Trachea, stenoses of 69 
 
 Tracheal stenoses, treatment of.. 77 
 
 Tracheotomy 51 
 
 Treatment of tracheal stenoses.. 77 
 
 Tumors, mediastinal 70 
 
 Tumors, peritracheal 70 
 
 Tuberculosis of the trachea and 
 
 bronchi 7,? 
 
 Typhoid fever, inflammation of 
 
 the trachea in 75 
 
 Ulcerations of the trachea and 
 bronchi 7,5
 
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