A Manual Of Peroral Endoscopy An
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Plate Iv
A, Gastroscopic view of a gastrojejunostomy opening drawn patulous by the tube mouth. (Gastrojejunostomy done by Dr. George L. Hays.) B, Carcinoma of the lesser curvature. (Patient afterward surgically explored and diagnosis verified by Dr. John J. ... Preparation Of The Patient For Peroral Endoscopy
The suggestions of the author in the earlier volumes in regard to preparation of the patient, as for any operation, by a bath, laxative, etc., and especially by special cleansing of the mouth with 25 per cent alcohol, have received general endorseme... Abscess Of The Lung
If of foreign-body origin, pulmonary abscess almost invariably heals after the removal of the object and a regime of fresh air and rest, without local measures of any kind. Acute pulmonary abscess from other causes may require bronchoscopic drainage... Acquiring Skill
Endoscopic ability cannot be bought with the instruments. As with all mechanical procedures, facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers. As with learning to play a musi... Actinomycosis Of The Esophagus
Esophageal actinomycosis has been autoptically discovered. Its diagnosis, and differentiation from tuberculosis, would probably rest upon the microscopic study of tissue removed esophagoscopically, though as yet no such case has been reported. ... Acute Esophagitis
This is usually of traumatic or cauterant origin. If severe or extensive, all the symptoms described under Rupture of the Esophagus may be present. The endoscopic appearances are unmistakable to anyone familiar with the appearance of mucosal inflamm... Acute Stenosis Of The Larynx
Etiology.--Causes of a relatively sudden narrowing of the lumen of the larynx and subjacent trachea are included in the following list. Two or more may be combined. 1. Foreign body. 2. Accumulation of secretions or exudate in the lumen. 3. D... Anatomy Of Larynx Trachea Bronchi And Esophagus Endoscopically Considered
The larynx is a cartilaginous box, triangular in cross-section, with the apex of the triangle directed anteriorly. It is readily felt in the neck and is a landmark for the operation of tracheotomy. We are concerned endoscopically with four of its ca... Anchoring The Foreign Body Against The Tube Mouth
If withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip ... Anesthesia
No dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. When this action is stopped by beginning unco... Anesthesia For Peroral Endoscopy
A dyspneic patient should never be given a general anesthetic. Cocaine should not be used on children under ten years of age because of its extreme toxicity. To these two postulates always in mind, a third one, applicable to both general and local a... Angioneurotic Edema
Angioneurotic edema involving the esophagus, may produce intermittent and transient dysphagia. The lesions are rarely limited to the esophagus alone; they may occur in any portion of the gastrointestinal, genitourinary, or respiratory tracts, and c... Angioneurotic Edema
Angioneurotic edema manifests itself by a pale or red swollen mucosa producing stenosis of the lumen. The temporary character of the lesion and its appearance in other regions confirm the diagnosis. Scleroma of the trachea is characterized by inf... Ankylosis
Fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. This, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endos... Anomalies Of The Esophagus
Congenital esophagotracheal fistulae are the most frequent of the embryonic developmental errors of this organ. Septic pneumonia from the entrance of fluids into the lungs usually causes death within a few weeks. Imperforate esophagus usually sho... Anomalies Of The Tracheobronchial Tree
Tracheobronchial anomalies are relatively rare. Congenital esophagotracheal and esophagobronchial fistulae are occasionally seen, and cases of cervicotracheal fistulae have been reported. Congenital webs and diverticula of the trachea are cited inf... Aphorisms
Educate your eye and your fingers. Be sure you are right, but not too sure. Follow your judgment, never your impulse. Cry over spilled milk enough to memorize how you spilled it. Let your mistakes worry you enough to prevent repetition. ... Asepsis
Strict aseptic technic must be observed in all endoscopic procedures. The operator, first assistant, and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation. The o... Aspirating Tubes
Independent aspirating tubes involve delay in their use as compared to aspirating canals in the wall of the endoscopic tube; but there are special cases in which an independent tube is invaluable. Three forms are used by the author. The velvet eye ... Autodrownage
Autodrownage is the name given by the author to the drowning of the patient in his own secretions. Tracheobronchial secretions in excess of the amount required to moisten the inspired air, become, in certain cases, a mechanical menace to life, unles... Ballooning Esophagoscopy
By inserting the window plug shown in Fig. 6 the esophagus may be inflated and studied in the distended state. The folds are thus smoothed out and constrictions rendered more marked. Ether anesthesia is advocated by Mosher. The danger of respirator... Batteries
The simplest, best, and safest source of current is a double dry battery arranged in three groups of two cells each, connected in series (Fig. 8). Each set should have two binding posts and a rheostat. The binding posts should have double holes for ... Benign Growths In The Larynx
Benign growths in the larynx are easily and accurately removable by direct laryngoscopy; but perhaps no method has been more often misused and followed by most unfortunate results. It should always be remembered that benign growths are benign, and t... Benign Growths Primary In The Tracheobronchial Tree
Extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. True primary growths of the tracheobronchial tree, though not frequent, are by no means rare. These prima... Benign Neoplasms Of The Esophagus
As a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen, but true benign tumors of the esophagus are rare affections. Keloidal changes in scar tissue may occur. Cases of retention, epithelial and dermoid cyst... Bronchial Aspiration
As mentioned above, bronchial aspiration is often necessary. When the patient is unable to get up secretions, he will, as demonstrated by the author many years ago, drown in his own secretions. In some cases bronchoscopic aspiration is required (Pe... Bronchial Dilators
It is not uncommon to find a stricture of the bronchus superjacent to a foreign body that has been in situ for a period of months. In order to remove the foreign body, this stricture must be dilated, and for this the bronchial dilator shown in Fig. ... Bronchial Stenosis
Stenosis of one or more bronchi results at times from cicatricial contraction following secondary infection of leutic, tuberculous or traumatic lesions. The narrowing resulting from foreign body traumatism rarely requires secondary dilatation after ... Bronchiectasis
In most cases of bronchiectasis there are strong indications for a bronchoscopic diagnosis, to eliminate such conditions as foreign body, cicatricial bronchial stenosis, or endobronchial neoplasm as etiologic factors. In the idiopathic types consid... Bronchoscopes
The regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. An auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a reces... Bronchoscopic And Esophagoscopic Grasping Forceps
are of the tubular type, that is, a stylet carrying the jaws works in a slender tube so that traction on the stylet draws the V of the open jaws into the lumen of the tube, thus causing the blades to approximate. They are very delicate and light, y... Bronchoscopic Appearances In Disease
The first look should note the color of the bronchial mucosa, due allowance being made for the pressure of tubal contact, secretions, and the engorgement incident to continued cough. The carina trachealis normally moves slowly forward as well as do... Bronchoscopic Oxygen Insufflation
Bronchoscopic oxygen insufflation is a life-saving measure equalled by no other method known to the science of medicine, in all cases of asphyxia, or apnea, present or impending. Its especial sphere of usefulness is in severe cases of electric shock... Bronchoscopy In Diseases Of The Trachea And Bronchi
The indications for bronchoscopy in disease are becoming increasingly numerous. Among the more important may be mentioned: 1. Bronchiectasis. 2. Chronic pulmonary abscess. 3. Unexplained dyspnea. 4. Dyspnea unrelieved by tracheotomy calls ... Bronchoscopy In Malignant Growths Of The Trachea
The trachea is often secondarily invaded by malignancy of the esophagus, thyroid gland, peritracheal or peribronchial glands. Primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy. Peritrach... Cadaver Practice
The fundamental principles of peroral endoscopy are best taught on the cadaver. It is necessary that a specially prepared subject be had, in order to obtain the required degree of flexibility. Injecting fluid of the following formula worked out by ... Care Of Instruments
The endoscopist must either personally care for his instruments, or have an instrument nurse in his own employ, for if they are intrusted to the general operating room routine he will find that small parts will be lost; blades of forceps bent, brok... Choice Of Time To Do Bronchoscopy For Foreign Body
The difficulties of removal usually increase from the time of aspiration of the object. It tends to work downward and outward, while the mucosa becomes edematous, partly closing over the foreign body, and even completely obliterating the lumen of sm... Chronic Esophagitis
This is usually a result of stagnation of food or secretion, and will be considered under spasmodic stenosis and diffuse dilatation of the esophagus. A very marked case with local distress and pain extending through to the back was seen by the au... Chronic Stenosis Of The Larynx And Trachea
The various forms of laryngeal stenosis for which tracheotomy or intubation has been performed, and the difficulties encountered in restoring the natural breathing, may be classified into the following types: 1. Panic 2. Spasmodic 3. Paraly... Cicatricial Stenosis Of The Esophagus
Etiology.--The accidental swallowing of caustic alkali in solutions of lye or proprietary washing and cleansing powders, is the most frequent cause of cicatricial stenosis. Commercial lye preparations are about 95 per cent sodium hydroxide. The clea... Complications And After-effects Of Bronchoscopy
All foreign body cases should be watched day and night by special nurses until all danger of complications is passed. Complications are rare after careful work, but if they do occur, they may require immediate attention. This applies especially to t... Complications Following Esophagoscopy
These are to be avoided in large measure by the exercise of gentleness, care, and skill that are acquired by practice. If the instructions herein given are followed, esophagoscopy is absolutely without mortality apart from the conditions for which ... Compression Stenosis Of The Esophagus
The esophagus may be narrowed by the pressure of any periesophageal disease or anomaly. The lesions most frequently found are: 1. Goiter, cervical or thoracic. 2. Malignancy of any of the intrathoracic viscera. 3. Aneurysm. 4. Cardiac and ... Compression Stenosis Of The Trachea
Decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. Glandular disease may be of the Hodgkins' type. Thymic compression yields readily to radium and the roe... Compression Stenosis Of The Trachea And Bronchi
Compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. Less frequently, enlarged mediastinal tuberculous, leukemic, leutic or Hodgkin's glands compress the ai... Contraindications
There is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies, even in the presence of aneurism, serious cardiovascular disease, hypertension or the like, although these conditions would render the procedure inadvi... Contraindications To Direct Laryngoscopy
There are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment. In extremely dyspneic patients, if the operator is not confident in his ability for a prompt and sure ... Contraindications To Esophagoscopy
In the presence of aneurysm, advanced organic disease, extensive esophageal varicosities, acute necrotic or corrosive esophagitis, esophagoscopy should not be done except for urgent reasons, such as the lodgment of a foreign body; and in this case ... Decannulation
When the tracheal incision is placed below the first ring, no difficulty in decannulation should result from the operation per se. When by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained suffi... Decannulation After Cure Of Laryngeal Stenosis
In order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. This is best done by inserting a rubber cork in the inner cannula. At first it may be necessary to make a slot in the cork so as to permit some... Deviation Of The Esophagus
Deviation of the esophagus may be marked in the presence of a deformed vertebral column, though dysphagia is a very uncommon symptom. The lack of esophageal symptoms in deviation of spinal production is probably explained by the longitudinal shorten... Diagnosis
The swallowing function can be studied only with the fluoroscope; esophagoscopy for diagnosis, should therefore always be preceded by a fluoroscopic study of deglutition with a barium or other opaque mixture and examination of the thoracic organs to... Diagnosis
It has been estimated that 70 per cent of stenoses of the esophagus in adults are malignant in nature. This should stimulate the early and careful investigation of every case of dysphagia. When all cases of persistent dysphagia, however slight, are ... Diagnosis Of Foreign Body In The Air Or Food Passages
The questions arising are: I. Is a foreign body present? 2. Where is it located? 3. Is a peroral endoscopic procedure indicated? 4. Are there any contraindications to endoscopy? In order to answer these questions the definite routine giv... Differential Diagnosis Of Laryngeal Growths In The Larynx Of Adults
Determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities, namely, 1. Lues. 2. Tuberculosis, including lupus. 3. Scleroma. 4. Malignant neoplasm. In the Bronchoscopic C... Differential Diagnosis Of Ulcer Of The Esophagus
Simple ulcer requires the exclusion of lues, tuberculosis, epithelioma, endothelioma, sarcoma, and actinomycosis. Simple ulcer of the esophagus is usually associated with stenosis, spastic or organic. Luetic ulcers commonly show a surrounding infl... Difficulties In The Introduction Of The Bronchoscope
The beginner may enter the esophagus instead of the trachea: this might be a dangerous accident in a dyspneic case, for the tube could, by pressure on the trachea, cause respiratory arrest. A bronchoscope thus misplaced should be resterilized befor... Difficulties Of Direct Laryngoscopy
The larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. Failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. The s... Difficulties Of Esophagoscopy
The beginner may find the esophagoscope seemingly rigidly fixed, so that it can be neither introduced nor withdrawn. This usually results from a wedging of the tube in the dental angle, and is overcome by a wider opening of the jaws, or perhaps by ... Diffuse Dilatation Of The Esophagus
This is practically always due to stagnation ectasia, which is invariably associated with either organic or spasmodic stricture, existing at the time of observation or at some time prior thereto. The dilating effect of the repeatedly accumulated foo... Dimensions Of The Trachea And Bronchi
It will be noted that the bronchi divide monopodially, not dichotomously. While the lumina of the individual bronchi diminish as the bronchi divide, the sum of the areas shows a progressive increase in total tubular area of cross-section. Thus, the... Diphtheria
Chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. Only too frequently the stenosis should be called posttracheotomic rather than p... Direct Laryngoscopy Adult Patient
Before starting, every detail in regard to instrumental equipment and operating room assistants, (including an assistant to hold the arms and legs of the patient) must be complete. Preparation of the patient and the technic of local anesthesia have... Direct Laryngoscopy In Children
The epiglottis in children is usually strongly curled, often omega shaped, and is very elusive and slippery. The larynx of a child is very freely movable in the neck during respiration and deglutition, and has a strong tendency to retreat downward ... Direct Laryngoscopy In Diseases Of The Larynx
The diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. No anesthetic, local or general, should be used, for the practised endoscopist can complete t... Direction Of The Esophagus
The esophagus enters the chest in a decidedly backward as well as downward direction, parallel to that of the trachea, following the curves of the cervical and upper dorsal spine. Below the left bronchus the esophagus turns forward, passing through... Diseases Of The Esophagus
The more frequent causes of the one common symptom of esophageal disease, dysphagia, are included in the list given below. To avoid elaboration and to obtain maximum usefulness as a reminder, overlapping has not been eliminated. 1. Anomalies. ... Diverticulum Of The Esophagus
Diverticula may, and usually do, consist in a pouching by herniation, of the whole thickness of the esophageal wall; or they may be herniations of the mucosa between the muscular layers. They are classified according to their etiology, as traction a... Early Symptoms Of Irritating Foreign Body Such As A Peanut Kernel In The Bronchus
1. Initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. 2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24 hours in children under 2 years. ... Edematous Tracheobronchitis
This is chiefly observed in children. The most frequently encountered form is the epidemic disease to which the name Influenza has been given (q.v. supra). The only noticeable difference between the epidemic and the sporadic cases is in the more ge... Emergency Tracheotomy
Stabbing of the cricothyroid membrane, or an attempted stabbing of the trachea, so long taught as an emergency tracheotomy, is a mistake. The author's two stage, finger guided method is safer, quicker, more efficient, and not likely to be followed ... Endogastric Version
A very useful and comparatively safe method is illustrated in Figs. 94 and 95. In the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus passed along with the esophagoscope into the stomach where it is rotat... Endoscopic Operations For Laryngeal Stenosis
Web formations may be excised with sliding punch forceps, or if the web is due to contraction only, incision of the true band may allow its retraction. In some instances liberation of adhesions will favor the formation of adventitious vocal cords. ... Endoscopy In Malignant Disease Of The Larynx
The general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. The facility, accuracy and thoroughness... Endoscopy On The Human Being
Dog work offers but little practice in laryngoscopy. Because of the slight angle at which the dog's head joins his spine, the larynx is in a direct line with the open mouth; hence little displacement of the anterior cervical tissues is necessary. M... Entering The Bronchi
The lip of the bronchoscope should be turned in the direction of the bronchus to be explored, and the axis of the bronchoscope should be made to correspond as nearly as possible to the axis of this bronchus. The position of the lip is designated by ... Errors To Avoid In Suspected Foreign Body Cases
1. Do not reach for the foreign body with the fingers, lest the foreign body be thereby pushed into the larynx, or the larynx be thus traumatized. 2. Do not hold up the patient by the heels, lest a tracheally lodged foreign body be dislodged an... Esophageal Dilators
The dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods. Blind esophageal bouginage is highly dangerous, for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate ... Esophageal Foreign Body
After initial choking and gagging, or without these, there may be a subjective sense of a foreign body, constant or, more often, on swallowing. Odynphagia and dysphagia or aphagia may or may not be present. Pain, sub-sternal or extending to the bac... Esophageal Foreign Body Symptoms
1. There are no absolutely diagnostic symptoms. 2. Dysphagia, however, is the most constant complaint, varying with the size of the foreign body, and the degree of inflammatory or spasmodic reaction produced. 3. Pain may be caused by penetrat... Esophagoscopes
The esophagoscope, like the bronchoscope, is a hollow brass tube with beveled distal end containing a small electric light. It differs from the bronchoscope in that it has no perforations, and has a drainage canal on its upper surface, or next to ... Esophagoscopic Extraction Of Foreign Bodies
It is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look. Everything likely to be needed for extraction of the intruder should be sterile and ready at hand. Furthermore, all required instruments for la... Esophagoscopy For Foreign Body
... Etiology
The lodgement of foreign bodies in the esophagus is influenced by: 1. The shape of the foreign body (disc-shaped, pointed, irregular). 2. Resiliency of the object (safety pins). 3. The size of the foreign body. 4. Narrowing of the esophagu... Examination Of The Trachea And Bronchi
All bronchial orifices must be identified seriatim; because this is the only way by which the bronchoscopist can know what part of the tree he is examining. Appearances alone are not enough. It is the order in which they are exposed that enables th... Extraction Of Foreign Bodies From The Strictured Esophagus
Foreign bodies of relatively small size will lodge in a strictured esophagus. Removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body passing the first one lodges at the s... Extraction Of Open Safety-pins From The Esophagus
An open safety pin with the point down offers no particular mechanical difficulty in removal. Great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pi... Extraction Of Soft Friable Foreign Bodies From The Tracheobronchial Tree
The difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps space. There is usually... Extraction Of Tacks Nails And Large Headed Foreign Bodies From The Tracheobronchial Tree
In cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. The author's inward-rotation method when executed with the Tucker forceps is id... First Stage
The spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. It was the German method to introduce the laryngoscope over the dorsum of the tongue but in o... Forceps
Delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality; therefore, heavily built and spring-opposed forceps are dangerous as well as useless. For foreign-body work in the larynx, and for the removal of ... Foreign Bodies In The Air And Food Passages
The air and food passages may be invaded by any foreign substance of solid, liquid or gaseous nature, from the animal, vegetable, or mineral kingdoms. Its origin may be from within the body (blood, pus, secretion, broncholiths, sequestra, worms); in... Foreign Bodies In The Bronchi For Prolonged Periods
The sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis, pulmonary abscess, and fibrous changes. The symptoms of tuberculosis may all be presented, but tubercle bacilli have never ... Foreign Bodies In The Insane
Foreign bodies may be introduced voluntarily and in great numbers by the insane. Hysterical individuals may assert the presence of a foreign body, or may even volitionally swallow or aspirate objects. It is a mistake to do a bronchoscopy in order t... Foreign Bodies In The Larynx
Laryngeally lodged foreign bodies produce a wheezing respiration, the quality of which is peculiar to the larynx and is readily localized to this organ. If swelling or the size of the foreign body be sufficient to produce dyspnea, inspiratory indraw... Foreign Bodies In The Larynx And Tracheobronchial Tree
The protective reflexes preventing the entrance of foreign bodies into the lower air passages are: (1) The laryngeal closing reflex and (2) the bechic reflex. Laryngeal closing for normal swallowing consists chiefly in the tilting and the closure of... Foreign Bodies In The Stomach
Gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two. Foreign bodies in very large numbers in the stomach, as in the insane, may be removed by gastrostomy. The symptomatology of foreign bodies may be epito... Functional Hiatal Stenosis Hiatal Esophagismus Phrenospasm Diaphragmatic Pinchcock Stenosis
There is no sphincteric muscular arrangement at the cardiac orifice of the esophagus, so that spasmodic stenosis at this level is not possible and the term cardiospasm is, therefore, a misnomer. It was first demonstrated by the author that in so-cal... Gangrene Of The Lung
Pulmonary gangrene has been followed by recovery after the endobronchial injection of oily solutions of gomenol and guaiacol (Guisez). The injections are readily made through the laryngoscope without the insertion of a bronchoscope. A silk woven ca...