Bronchoscopy and Esophagoscopy.

by Chevalier Jackson.

CHAPTER I--INSTRUMENTARIUM

Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy are procedures in which the lower air and food pa.s.sages are inspected and treated by the aid of electrically lighted tubes which serve as specula to manipulate obstructing tissues out of the way and to bring others into the line of direct vision.

Illumination is supplied by a small tungsten-filamented, electric, "cold" lamp situated at the distal extremity of the instrument in a special groove which protects it from any possible injury during the introduction of instruments through the tube. The bronchi and the esophagus will not allow dilatation beyond their normal caliber; therefore, it is necessary to have tubes of the sizes to fit these pa.s.sages at various developmental ages. Rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal. The armamentarium of the endoscopist must be complete, for it is rarely possible to subst.i.tute, or to improvise makeshifts, while the bronchoscope is in situ. Furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them.

_Laryngoscopes_.--The regular type of laryngoscope shown in Fig. I (A, B, C) is made in adult's, child's, and infant's sizes. The instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. The infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. For operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. With this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (Fig. 1, D). The tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be pa.s.sed through the adult glottis for work in the subglottic region. This instrument may also be used as an esophageal speculum and as a pleuroscope. A side-slide laryngoscope, used with or without the slide, is occasionally useful.

_Bronchoscopes_.--The regular bronchoscope is a hollow bra.s.s tube slanted at its distal end, and having a handle at its proximal or ocular extremity. An auxiliary ca.n.a.l on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. Numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. The accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).

For certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful The drainage ca.n.a.l may be on top, or on the under surface next to the light-carrier ca.n.a.l. For ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (Q.V.) which at the same time cleans the lamp. The drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome.

As before mentioned, the lower air pa.s.sages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the pa.s.sages to be examined. Four sizes are sufficient for any possible case, from a newborn infant to the largest adult.

For infants under one year, the proper tube is the 4 mm. by 30 cm.; the child's size, 5 mm. by 30 cm., is used for children aged from one to five years. For children six years or over, the 7 mm. by 40 cm.

bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. The adult bronchoscope measures 9 mm.

by 40 cm.

The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35 cm., 8 mm. x 40 cm.

_Esophagoscopes_.-The esophagoscope, like the bronchoscope, is a hollow bra.s.s 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 ca.n.a.l on its upper surface, or next to the light-carrier ca.n.a.l which opens within the distal end of the tube. The exact size, position, and shape of the drainage outlets is important on bronchoscopes, and to an even greater degree on esophagoscopes. If the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube, the mucosa will be drawn into the outlet, not only obstructing it, but, most important, traumatizing the mucosa. If, for instance, the esophagoscope were to be pushed upon with a fold thus anch.o.r.ed in the distal end, the esophageal wall could easily be torn. To admit the largest sizes of esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are made with both light ca.n.a.l and drainage ca.n.a.l outside the lumen of the tube, leaving the full area of luminal cross-section unencroached upon. They can, of course, be used for all purposes, but the slightly greater circ.u.mference is at times a disadvantage. The esophageal and stomach secretions are much thinner than bronchial secretions, and, if free from food, are readily aspirated through a comparatively small ca.n.a.l. If the ca.n.a.l becomes obstructed during esophagoscopy, the positive pressure tube of the aspirator is used to blow out the obstruction. Two sizes of esophagoscopes are all that are required--7 mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A and B); but various other sizes and lengths are used by the author for special purposes.* Large esophagoscopes cause dangerous dyspnea in children. If, it is desired to balloon the esophagus with air, the window plug shown in Fig. 6, is inserted into the proximal end of the esophagoscope, and air insufflated by means of the hand aspirator or with a hand bulb. The window can be replaced by a rubber diaphragm with a perforation for forceps if desired. It will be noted that none of the endoscopic tubes are fitted with mandrins. They are to be introduced under the direct guidance of the eye only. Mandrins are obtainable, but their use is objectionable for a number of reasons, chief of which is the danger of overriding a foreign body or a lesion, or of perforating a lesion, or even the normal esophageal wall. The slanted end on the esophagoscope obviates the necessity of a mandrin for introduction. The longer the slant, with consequent acuting of the angle, the more the introduction is facilitated; but too acute an angle increases the risk of perforating the esophageal wall, and necessitates the utmost caution. In some foreign-body cases an acute angle giving a long slant is useful, in others a short slant is better, and in a few cases the squarely cut-off distal end is best. To have all of these different slants on hand would require too many tubes. Therefore the author has settled upon a moderate angle for the end of both esophagoscopes and bronchoscopes that is easy to insert, and serves all purposes in the version and other manipulations required by the various mechanical problems of foreign-body extraction. He has, however, retained all the experimental models, for occasional use in such cases as he falls heir to because of a problem of extraordinary difficulty.

* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all adults and is somewhat easier to introduce than the 10 mm. X 53 cm., which may be omitted from the set if economy must be practiced.

[FIG. I.--Author's laryngoscopes. These are the standard sizes and fulfill all requirements. Many other forms have been devised by the author, but have been omitted from the list as unnecessary. The infant diagnostic laryngoscope (C) is not for introducing bronchoscopes, and is not absolutely necessary, as the larynx of any infant can be inspected with the child's size laryngoscope (B).

A Adult's size; B, child's size; C, infant's diagnostic size; D, anterior commissure laryngoscope; E, with drainage ca.n.a.l; 17, intubating laryngoscope, large lumen. All the laryngoscopes are preferred without drainage ca.n.a.ls.]

[FIG. 2.--The author's bronchoscopes of the sizes regularly used.

Various other lengths and diameters are on hand for occasional use for special purposes. With the exception of a 6 mm. X 35 cm. size for older children, these special bronchoscopes are very rarely used and none of them can be regarded as necessary. For special purposes, however, special shapes of tube-mouth are useful, as, for instance, the oval end to facilitate the getting of both points of a staple into the tube-mouth The ill.u.s.trated instruments are as follows:

A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.; C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.; E, aspirating bronchoscope made in all the foregoing sizes, and in a special size, 5 mm. X 45 cm.]

[FIG. 3.--The author's esophagoscopes of the sizes he has standardized for all ordinary requirements. He uses various other lengths and sizes for special purposes, but none of them are really necessary. A gastroscope, 10 mm. X 70 cm., is useful for adults, especially in cases of gastroptosis. Drainage ca.n.a.ls are placed at the top or at the side of the tube, next to the light-carrier ca.n.a.l.

A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C and D, full lumen, with both light ca.n.a.l and drainage ca.n.a.l outside the wall of the tube, to be used for pa.s.sing very large bougies. This instrument is made in adult, child, and adolescent (8 mm. by 45 cm.) sizes. Gastroscopes and esophagoscopes of the sizes given above (A) and (B), can be used also as gastroscopes. A small form of C, 5 mm. X 30 cm. is used in infants, and also as a retrograde esophagoscope in patients of any age. E, window plug for ballooning gastroscope, F.]

[FIG. 4.--Author's short esophagoscopes and esophageal specula A, Esophageal speculum and hypopharyngoscope, adult's size; B, esophageal speculum and hypopharyngoscope, child's size; C, heavy handled short esophagoscope; D, heavy handled short esophagoscope with drainage.]

[FIG. 5.--Cross section of full-lumen esophagoscope for the use of largest bourgies. The ca.n.a.ls for the light carrier and for drainage are so constructed that they do not encroach upon the lumen of the tube.]

[25] The special sized esophagoscopes most often useful are the 8 mm.

X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made with the drainage ca.n.a.l in various positions.

For operations on the upper end of the esophagus, and particularly for foreign body work, the esophageal speculum shown at A and B, in Fig.

4, is of the greatest service. With it, the anterior wall of the post-cricoidal pharynx is lifted forward, and the upper esophageal orifice exposed. It can then be inserted deeper, and the upper third of the esophagus can be explored. Two sizes are made, the adult's and the child's size. These instruments serve, very efficiently as pleuroscopes. They are made with and without drainage ca.n.a.ls, the latter being the more useful form.

[FIG. 6.--Window-plug with gla.s.s cap interchangeable with a cap having a rubber diaphragm with a perforation so that forceps may be used without allowing air to escape. Valves on the ca.n.a.ls (E, F, Fig. 3) are preferable.]

_Gastroscopes_.--The gastroscope is of the same construction as the esophagoscope, with the exception that it is made longer, in order to reach all parts of the stomach. In ordinary cases, the regular esophagoscopes for adults and children respectively will afford a good view of the stomach, but there are cases which require longer tubes, and for these a gastroscope 10 mm. X 70 cm. is made, and also one 10 mm. X 80 cm., though the latter has never been needed but once.

[26] _Pleuroscopes_.--As mentioned above the anterior commissure laryngoscope and the esophageal specula make very efficient pleuroscopes; but three different forms of pleuroscopes have been devised by the author for pleuroscopy. The retrograde esophagoscope serves very well for work through small fistulae.

_Measuring Rule_ (Fig. 7).--It is customary to locate esophageal lesions by denoting their distance from the incisor teeth. This is readily done by measuring the distance from the proximal end of the esophagoscope to the upper incisor teeth, or in their absence, to the upper alveolar process, and subtracting this measurement from the known length of the tube. Thus, if an esophagoscope 45 cm. long be introduced and we find that the distance from the incisor teeth to the ocular end of the esophagoscope as measured by the rule is 20 cm., we subtract this 20 cm. from the total length of the esophagoscope (45 cm.) and then know that the distal end of the tube is 25 cm. from the incisor teeth. Graduation marks on the tube have been used, but are objectionable.

[FIG. 7.--Measuring rule for gauging in centimeters the depth of any location by subtraction of the length of the uninserted portion of the esophagoscope or bronchoscope. This is preferable to graduations marked on the tubes, though the tubes can be marked with a scale if desired.]

_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 two additional cords, to be kept in reserve for use in case a cord becomes defective.* The commercial current reduced through a rheostat should never be used, because there is always the possibility of "grounding"

the circuit through the patient; a highly dangerous accident when we consider that the tube makes a long moist contact in tissues close to the course of both the vagi and the heart. The endoscopist should never depend upon a pocket battery as a source of illumination, for it is almost certain to fail during the endoscopy. The wires connecting the battery and endoscopic instrument are covered with rubber, so that they may be cleansed and superficially sterilized with alcohol. They may be totally immersed in alcohol for any length of time without injury.

* When this is done care is necessary to avoid attempting to use simultaneously the two cords from one pair of posts.

[FIG 8.--The author's endoscopic battery, heavily built for reliability.

It contains 6 dry cells, series-connected in 3 groups of 2 cells each.

Each group has its own rheostat and pair of binding posts.]

_Aspirating Tubes_.--Independent aspirating tubes involve delay in their use as compared to aspirating ca.n.a.ls 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" cannot traumatize the mucosa (Fig. 9). To hold a foreign body by suction, a squarely cut off end is necessary. For use through the tracheotomic wound without a bronchoscope a malleable tube (Fig. 10) is better.

[FIG. 9.--The author's protected-aperture endoscopic aspirating tube for aspiration of pharyngeal secretions during direct laryngoscopy and endotracheobronchial secretions at bronchoscopy, also for draining retropharyngeal abscesses. The laryngoscopes are obtainable with drainage ca.n.a.ls, but for most purposes the independent aspirating tube shown above is more satisfactory. The tubes are made in 20 30, 40, and 60 cm. lengths. An aperture on both sides prevents drawing in the mucosa. It can be used for insufflation of ether if desired. An aspirating tube of the same design, but having a squarely cut off end, is sometimes useful for removing secretions lying close to a foreign body; for removing papillomata; and even for withdrawing foreign bodies of a soft surface consistency. It is not often that the foreign bodies can be thus withdrawn through the glottis, but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps s.p.a.ces will permit application of forceps. Such aspirating tubes, however, are not so safe to use as the protected, double aperture tubes.]

[FIG. 10.--The author's malleable tracheotomic aspirating tube for removal of secretions, exudates, crusts, etc., from the tracheobronchial tree through the tracheotomic wound without a bronchoscope. The tube is made of copper so that it can be bent to any curve, and the copper wire stylet prevents kinking. The stylet is removed before using the tube for aspiration.]

[28] _Aspirators_.--The various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage ca.n.a.ls. They, however, have the disadvantages of not being easily transported, and of occasionally being out of order. The hand aspirator shown in Fig. 11 is, therefore, a necessary part of the instrumental equipment. It never fails to work, is portable, and affords both positive and negative pressures.

The positive pressure is sometimes useful in clearing the drainage ca.n.a.l of any particles of food, tissue, clots, or secretion which may obstruct it; and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used. The mechanical aspirator (Fig. 12) is highly efficient and is the one used in the Bronchoscopic Clinic. The positive pressure will quickly clear obstructed drainage ca.n.a.ls, and may be used while the esophagoscope is in situ, by simply detaching the minus pressure tube and attaching the plus pressure. In the lungs, however, high plus pressures are so dangerous that the pressure valve must be lowered.

[Fig. 11--Portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage ca.n.a.l. This aspirator has the advantage of great power with portability. Where portability is not required the electrically operated aspirator is better.]

[FIG. 12.--Robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author. The positive pressure is used for clearing obstructed drainage ca.n.a.ls and tubes.]

[FIG. 13.--Apparatus for insufflation of ether or chloroform during bronchoscopy, for those who may desire to use general anesthesia. The mechanical methods of intratracheal insufflation anesthesia subsequently developed by Meltzer and Auer, Elsberg, Geo. P. Muller and others have rightly superseded this apparatus for all general surgical purposes.]

_Sponge-pumping_.--While the usually thin, watery esophageal and gastric secretions, if free from food, are readily aspirated through a drainage ca.n.a.l, the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty. Further-more, bronchial secretions as a rule are not collected in pools, but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough. The aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is un.o.bjectionable. In most cases, however, the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier (Fig. 14), so that the sponge extends beyond the distal end of the bronchoscope, causing cough. Then withdrawal of the sponge carrier will remove all of the secretion in the tube just as the plunger in a pump will lift all of the water above it. By this maneuver the walls of the bronchus are wiped free from secretions, and the lamp itself is cleansed.

[FIG. 14.--Sponge carrier with long collar for carrying the small sponges shown in Fig. 15. The collar screws down as in the Coolidge cotton carrier. About a dozen of these are needed and they should all be small enough to go through the 4 mm. (diameter) bronchoscope and long enough to reach through the 53 cm. (length) esophagoscope, so that one set will do for all tubes. The schema shows method of sponging. The carrier C, armed with the sponge, S, when rotated as shown by the dart, D, wipes the field, P, at the same time wiping the lamp, L. The lamp does not need ever to be withdrawn for cleaning during bronchoscopy. It is protected in a recess so that it does not catch in the sponges.]

[FIG 15.--Exact size to which the bandage-gauze is cut to make endoscopic sponges. Each rectangle is the size for the tubal diameter given. The dimensions of the respective rectangles are not given because it is easier for the nurse or any one to cut a cardboard pattern of each size directly from this drawing. The gauze rectangles are folded up endwise as shown at A, then once in the middle as at B, then strung one dozen on a safety pin. In America gauze bandages run about 16 threads to the centimeter. Different material might require a slightly different size and the pattern could be made to suit.]

[32] The gauze sponges are made by the instrument nurse as directed in Fig. 15, and are strung on safety pins, wrapped in paper, the size indicated by a figure on the wrapper, and then sterilized in an autoclave. The sterile packages are opened only as needed. These "bronchoscopic sponges" are also made by Johnston and Johnston, of New Brunswick, N. J. and are sold in the shops.

_Mouth-gag_.--Wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone. The mouth should be gently opened and a bite block (Fig. 16) inserted between the teeth on the left side of the patient's mouth, to prevent closing of the jaws on the delicate bronchoscope or esophagoscope.

[FIG. 16.--Bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube. This is the McKee-McCready modification of the Boyce thimble with the omission of the etherizing tube, which is no longer needed. The block has been improved by Dr. W. F. Moore of the Bronchoscopic Clinic.]

_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 benign laryngeal growths, the alligator forceps with roughened jaws shown in Fig. 17 serve every purpose.

[FIG. 17.--Laryngeal grasping forceps designed by Mosher. For my own use I have taken off the ratchet-locking device for all general work, to be reapplied on the rare occasions when it is required.]