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

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

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

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

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

_Extraction of Foreign Bodies from the Strictured Esophagus_.--Foreign bodies of relatively small size will lodge in a strictured esophagus.

Removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body pa.s.sing the first one lodges at the second. Still more difficult is the case when the second stricture is considerably below the first, and not concentric. Under these circ.u.mstances it is best to divulse the upper stricture mechanically, when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body.

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

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

[197] Complications and Dangers of Esophagoscopy for Foreign Bodies.

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

_Treatment_.--Acute esophagitis calls for rest in bed, sterile liquid food, and the administration of bis.m.u.th powder mentioned in the paragraph on contraindications. An ice bag applied to the neck may afford some relief. The mouth should be hourly cleansed with the following solution: Dakin's solution 1 part Cinnamon water 5 parts.

Emphysema unaccompanied by pyogenic processes usually requires no treatment, though an occasional case may require punctures of the skin to liberate the air. Gaseous emphysema and pus formation urgently demand early external drainage, preferably behind the sternomastoid.

Should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable. Prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected. Foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae. In the serious degrees of esophageal trauma, particularly if the pleura be perforated, gastrostomy is indicated to afford rest of the esophagus, and for alimentation. A duodenal feeding tube may be placed through an esophagoscope pa.s.sed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly pa.s.sed stomach tube would be very likely to enter, with probably dangerous results.

[199] CHAPTER XX--PLEUROSCOPY

_Foreign bodies in the pleural cavity_ should be immediately removed.

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

The aspirating ca.n.a.l keeps a clear field while searching for the drain.

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

[201] CHAPTER XXI--BENIGN GROWTHS IN THE LARYNX

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

_Granulomata in the larynx_, while not true neoplasms, require extirpation in some instances.

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

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

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

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

_Lymphoma, enchondroma and osteoma_, if not too extensively involving the laryngeal walls, may be excised with basket punch forceps, but lymphoma is probably better treated by radium.* _True myxomata and lipomata_ are very rare. _Amyloid tumors_ are occasionally met with, and are very resistant to treatment. _Aberrant thyroid tumors_ do not require very radical excision of normal base, but should be removed as completely as possible.

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

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

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

PAPILLOMATA OF THE LARYNX IN CHILDREN

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

Papillomata are of inflammatory origin and are not true neoplasms in the strictest sense.

_Methods of Treatment_.--Irritating applications probably provoke recurrences, because the growths are of inflammatory origin. Formerly laryngostomy was recommended as a last resort when all other means had failed. The excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. Thyrotomy for papillomata is mentioned only to be condemned. Fulguration has been satisfactory in the hands of some, disappointing to others. It is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. Radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. In my experience, however, I have never seen a cure of papillomata which could be attributed to the radiation.

I have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. In other most unfortunate cases I have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. Possibly the disastrous results were due to overdosage; but I feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. Multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. In cancer we have an infiltrating process that has no limits short of life itself.

_Endolaryngeal extirpation_ of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility.

If, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway.

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

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

Tracheal growths require the insertion of the bronchoscope for their removal.

_Papillomata in the larynx of adults_ are, on the whole, much more amenable to treatment than similar growths in children. Tracheotomy is very rarely required, and the tendency to recurrence is less marked.

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

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

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

Extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. True primary growths of the tracheobronchial tree, though not frequent, are by no means rare. These primary growths include primary papillomata and fibromata as the most frequent, aberrant thyroid, lipomata, adenomata, granulomata and amyloid tumors.

Chondromata and osteochondromata may be benign but are p.r.o.ne to develop malignancy, and by sarcomatous or other changes, even metaplasia. Edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered.

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

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

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

CHAPTER XXIV--BENIGN NEOPLASMS OF THE ESOPHAGUS

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