[58] [FIG 46.--Esophagoscopic and Gastroscopic Chart

BIRTH 1 yr. 3 yrs. 6 yrs. 10 yrs. 14 yrs.ADULTS 23 27 30 33 36 43 53 Cm. GREATER CURVATURE 18 20 22 25 27 34 40 Cm. CARDIA 19 21 23 24 25 31 36 Cm. HIATUS 13 15 16 18 20 24 27 Cm. LEFT BRONCHUS 12 14 15 16 17 21 23 Cm. AORTA 7 9 10 11 12 14 16 Cm. CRICOPHARYINGEUS 0 0 0 0 0 0 0 Cm. INCISORS FIG. 46.--The author's esophagoscopic chart of approximate distances of the esophageal narrowings from the upper incisor teeth, arranged for convenient reference during esophagoscopy in the dorsally rec.u.mbent patient.]

The lengths of the esophagus at different ages are shown diagrammatically in Fig. 46. The diameter of the esophageal lumen varies greatly with the elasticity of the esophageal walls; its diameter at the four points of anatomical constriction is shown in the following table:

Constriction Diameter Vertebra

Cricopharyngeal Transverse 23 mm. (1 in.) Sixth cervical Antero-posterior 17 mm. (3/4 in.) Aortic Transverse 24 mm. (1 in.) Fourth thoracic Antero-posterior 19 mm. (3/4 in.) Left-bronchial Transverse 23 mm. (1 in.) Fifth thoracic Antero-posterior 17 mm. (3/4 in.) Diaphragmatic Transverse 23 mm. (1 in+) Tenth thoracic Antero-posterior 23 mm. (in.--)

For practical endoscopic purposes it is only necessary to remember that in a normal esophagus, straight and rigid tubes of 7 mm. diameter should pa.s.s freely in infants, and in adults, tubes of 10 mm.

The 4 demonstrable constrictions from above downward are at 1. The crico-pharyngeal fold.

2. The crossing of the aorta.

3. The crossing of the left bronchus.

4. The hiatus esophageus.

There is a definite fifth narrowing of the esophageal lumen not easily demonstrated esophagoscopically and not seen during dissection, but readily shown functionally by the fact that almost all foreign bodies lodge at this point. This narrowing occurs at the superior aperture of the thorax and is probably produced by the crowding of the numerous organs which enter or leave the thorax through this orifice.

_The crico-pharyngeal constriction_, as already mentioned, is produced by the tonic contraction of a specialized band of the orbicular fibers of the lowermost portion of the inferior pharyngeal constrictor muscle, called the cricopharyngeal muscle. As shown by the author it is this muscle and not the cricoid cartilage alone that causes the difficulty in the insertion of an esophagoscope.

This muscle is attached laterally to the edges of the signet of the cricoid which it pulls with an incomprehensible power against the posterior wall of the hypopharynx, thus closing the mouth of the esophagus. Its other attachment is in the median posterior raphe.

Between these circular fibers (the cricopharyngeal muscle) and the oblique fibers of the inferior constrictor muscle there is a weakly supported point through which the esophageal wall may herniate to form the so-called pulsion diverticulum. It is at this weak point that fatal esophagoscopic perforation by inexperienced operators is most likely to occur.

_The aortic narrowing_ of the esophagus may not be noticed at all if the patient is placed in the proper sequential "high-low" position. It is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt.

The bronchial narrowing of the esophagus is due to backward displacement caused by the pa.s.sage of the left bronchus over the anterior wall of the esophagus at about 27 cm. from the upper teeth in the adult. The ridge is quite prominent in some patients, especially those with dilatation from stenoses lower down.

The hiatal narrowing is both anatomic and spasmodic. The peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion. There are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus, which contribute to tonic closure in the same way that a pinch-c.o.c.k closes a rubber tube. The author has called the hiatal closure the "diaphragmatic pinchc.o.c.k."

_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, pa.s.sing through the hiatus in the diaphragm anterior to and to the left of the aorta. The lower third of the esophagus in addition to its anterior curvature turns strongly to the left, so that an esophagoscope inserted from the right angle of the mouth, when introduced into the stomach, points in the direction of the anterior superior spine of the left ileum.

It is necessary to keep this general course constantly in mind in all cases of esophagoscopy, but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level. In such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation.

The extrinsic or transmitted movements of the esophagus are respiratory and pulsatory, and to a slight extent, bechic. The respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration, due to the negative intrathoracic pressure. The normal pulsatory movements are due to the pulsatile pressure of the aorta, found at the 4th thoracic vertebra (24 cm. from the upper teeth in the adult), and of the heart itself, most markedly felt at the level of the 7th and 8th thoracic vertebrae (about 30 cm. from the upper teeth in adults). As the distances of all the narrowings vary with age, it is useful to frame and hang up for reference a copy of the chart (Fig. 46).

The intrinsic movements of the esophagus are involuntary muscular contractions, as in deglut.i.tion and regurgitation; spasmodic, the latter usually having some pathologic cause; and tonic, as the normal hiatal closure, in the author's opinion may be considered. Swallowing may be involuntary or voluntary. The constrictors are anatomically not considered part of esophagus proper. When the constrictors voluntarily deliver the bolus past the cricopharyngeal fold, the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward. There is no sphincter at the cardiac end of the esophagus. The site of spasmodic stenosis in the lower third, the so-called cardiospasm, was first demonstrated by the author to be located at the hiatus esophageus and the spasmodic contractions are of the specialized muscle fibers there encircling the esophagus, and might be termed "phrenospasm," or "hiatal esophagismus." Regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure (called by the author the "diaphragmatic pinchc.o.c.k") plus the kinking of the abdominal esophagus.

In the author's opinion there is no spasm in the disease called "cardiospasm." It is simply the failure of the diaphragmatic pinchc.o.c.k to open normally in the deglut.i.tory cycle. A better name is functional hiatal stenosis.

At retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist. The top of the stomach seems to be closed by the diaphragmatic pinchc.o.c.k in the same way that the top of a bag is closed by a puckering string.

[63] CHAPTER III--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 endors.e.m.e.nt. Care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it. Artificial dentures should be removed. Even if no anesthetic is to be used, the patient should be fasted for five hours if possible, even for direct laryngoscopy in order to forestall vomiting. Except in emergency cases every patient should be gone over by an internist for organic disease in any form. If an endolaryngeal operation is needed by a nephritic, preparatory treatment may prevent laryngeal edema or other complications. Hemophilia should be thought of. It is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow, or the lodgment of a bolus of meat or other foreign body. If aneurysm is present and esophagoscopy is necessary, as it always is in foreign body cases, "to be fore-warned is to be forearmed." Pulmonary tuberculosis is often unsuspected in very young children. There is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food; or the food maybe regurgitated and aspirated into the larynx and trachea.

Therefore, in all esophageal cases the esophagus should be emptied by regurgitation induced by t.i.tillating the fauces with the finger after swallowing a tumblerful of water, pressure on the neck, etc. Aspiration will succeed in some cases. In others it is absolutely necessary to remove food with the esophagoscope. If the aspirating tube becomes clogged by solid food, the method of swab aspiration mentioned under bronchoscopy will succeed. Of course there is usually no cough to aid, but the involuntary abdominal and thoracic compression helps. Should a patient arrive in a serious state of water-hunger, as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis, and if necessary the endoscopy, except in dyspneic cases, must be delayed until the danger of water-starvation is past.

As pointed out by Ellen J. Patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child.

Every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. This becomes doubly necessary in cases that are to be anesthetized.

[65] CHAPTER IV--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 anesthesia, is to be added--total abolition of the cough-reflex should be for short periods only.

General anesthesia is never used in the Bronchoscopic Clinic for endoscopic procedures. The choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. In other words, the operator must decide what is best for his particular patient under the conditions then existing.

_Children_ in the Bronchoscopic Clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. Bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of Prof. Hare, been preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a child of six years) or a full physiologic dose of sodium bromide. The apprehension is thus somewhat allayed and the excessive cough-reflex quieted. The morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the a.n.a.lgesic effects. Dosage is more dependent on temperament than on age or body weight. Atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. True, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quant.i.ty of fluid encountered is less than it otherwise would be. In cases of large quant.i.ties of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. No food or water is allowed for 5 hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. If the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work.

With _adults_ no anesthesia, general or local, is given for esophagoscopy. For laryngeal operation and bronchoscopy the following technic is used:

One hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded with atropin sulphate (gr. 1/150). Care must be taken that the injection be not given into a vein. On the operating table the epiglottis and pharynx are painted with 10 per cent solution of cocain. Two applications are usually sufficient completely to anesthetize the exterior and interior of the larynx by blocking of the superior laryngeal nerve without any endolaryngeal applications. The laryngoscope is now introduced and if found necessary a 20 per cent cocain solution is applied to the interior of the larynx and subglottic region, by means of gauze swabs fastened to the sponge carriers. Here also two applications are quite sufficient to produce complete anesthesia in the larynx. If bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina, thus anesthetizing the tracheal mucosa. If further anesthetization of the bronchial mucosa is required, cocain may be applied in the same manner through the bronchoscope. In all these local applications prolonged contact of the swab is much more efficient than simply painting the surface.

[67] In cases in which cocain is deemed contraindicated morphin alone is used. If given in sufficient dosage cocain can be altogether dispensed with in any case.

It is perhaps _safer for the beginner_ in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia, provided the patient is not dyspneic to begin with, or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal "party wall." As proficiency develops, however, he will find anesthesia unnecessary. Local anesthesia is needless for esophagoscopy, and if used at all should be limited to the laryngopharynx and never applied to the esophagus, for the esophagus is without sensation, as anyone may observe in drinking hot liquids.

_Direct laryngoscopy in children_ requires neither local nor general anesthesia, either for diagnosis or for removal of foreign bodies or growths from the larynx. General anesthesia is contraindicated because of the dyspnea apt to be present, and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level. The latter accident is also p.r.o.ne to follow attempts to cocainize the larynx.

_Technic for General Anesthesia_.--For esophagoscopy and gastroscopy, if general anesthesia is desired, ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced. Endo-tracheal administration of ether is, however, far safer than peroral administration, for it overcomes the danger of respiratory arrest from pressure of the esophagoscope, foreign body, or both, on the trachea. Chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center.

For bronchoscopy, ether or chloroform may be started in the usual way and continued by insufflating through the branch tube of the bronchoscope by means of the apparatus shown in Fig. 13.

In case of paralysis of the larynx, even if only monolateral, a general anesthetic if needed should be given by intratracheal insufflation. If the apparatus for this is not available the patient should be tracheotomized. Hence, every adult patient should be examined with a throat mirror before general anesthesia for any purpose, and the necessity becomes doubly imperative before goiter operations. A number of fatalities have occurred from neglect of this precaution.

_Anesthetizing a tracheotomized patient_ is free from danger so long as the cannula is kept free from secretion. Ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner. If the laryngeal stenosis is not complete, ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube.

_Endo-tracheal anesthesia_ is by far the safest way for the administration of ether for any purpose. By means of the silk-woven catheter introduced into the trachea, ether-laden air from an insufflation apparatus is piped down to the lungs continuously, and the strong return-flow prevents blood and secretions from entering the lower air-pa.s.sages. The catheter should be of a size, relative to that of the glottic c.h.i.n.k, to permit a free return-flow. A number 24 French is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx. Because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations. Operations on the nose, accessory sinuses and the pharynx, apt to be attended by considerable bleeding, are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia. It is the safest anesthesia for goiter operations. Endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery, for by proper regulation of the pressure under which the ether ladened air is delivered, a lung may be held in any desired degree of expansion when the pleural cavity is opened. It is indicated in operations of the head, neck, or thorax, in which there is danger of respiratory arrest by centric inhibition or peripheral pressure; in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions; and in operations where it is desired to keep the anesthetist away from the operating field. Various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management.

We are concerned here mainly with the technic of the insertion of the intratracheal tube. The larynx should be examined with the mirror, preferably before the day of operation, for evidence of disease, and incidentally to determine the size of the catheter to be introduced, though the latter can be determined after the larynx is laryngoscopically exposed. The following list of rules for the introduction of the catheter will be of service (see Fig. 59).

RULES FOR INSERTION OF THE CATHETER FOR INSUFFLATION ANESTHESIA

1. The patient should be fully under the anesthetic by the open method so as to get full relaxation of the muscles of the neck.

2. The patient's head must be in full extension with the vertex firmly pushed down toward the feet of the patient, so as to throw the neck upward and bring the occiput down as close as possible beneath the cervical vertebrae.

3. No gag should be used, because the patient should be sufficiently anesthetized not to need a gag, and because wide gagging defeats the exposure of the larynx by jamming down the mandible.

4. The epiglottis must be identified before it is pa.s.sed.

5. The speculum must pa.s.s sufficiently far below the tip of the epiglottis so that the latter will not slip.

6. Too deep insertion must be avoided, as in this case the speculum goes posterior to the cricoid, and the cricoid is lifted, exposing the mouth of the esophagus, which is bewildering until sufficient education of the eye enables the operator to recognize the landmarks.

7. The patient's head is lifted off the table by the spatular tip of the laryngoscope. Actual lifting of the head will not be necessary if the patient is fully relaxed; but the idea of lifting conveys the proper conception of laryngeal exposure (Fig. 55).

[71] CHAPTER V--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, hanging, smoke asphyxia, strangulation, suffocation, thoracic or abdominal pressure, apnea, acute traumatic pneumothorax, respiratory arrest from absence of sufficient oxygen, or apnea from the presence of quant.i.ties of irrespirable or irritant gases. Combined with bronchoscopic aspiration of secretions it is the best method of treatment for poisoning by chlorine gas, asphyxiating, and other war gases.

Bronchoscopic oxygen insufflation should be taught to every interne in every hospital. The emergency or accident ward of every hospital should have the necessary equipment and an interne familiar with its use. The method is simple, once the knack is acquired. The patient being limp and rec.u.mbent on a table, the larynx is exposed with the laryngoscope, and the bronchoscope is inserted as hereinafter described. The oxygen is turned on at the tank and the flow regulated before the rubber tube from the wash-bottle of tank is attached to the side-outlet of the bronchoscope. It is necessary to be certain that the flow is gentle, so that, with a free return flow the introduced pressure does not exceed the capillary pressure; otherwise the blood will be forced out of the capillaries and the ischemia of the lungs will be fatal. Another danger is that overdistension causes inhibition of inspiration resulting in apnea continuing as long as the distension is maintained, if not longer. The return flow from the bronchoscope should be interrupted for 2 or 3 seconds several times a minute to inflate the lungs, but the flow must not be occluded longer than 3 seconds, because the intrapulmonary pressure would rise. A pearl of amyl nitrite may be broken in the wash bottle. Slow rhythmic artificial respiratory movements are a useful adjunct, and unless the operator is very skillful in gauging the alternate pressures and releases with the thumb according to the oxygen pressure, it is vitally necessary to fill and deflate the lungs rhythmically by one of the well known methods of artificial respiration. Anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds, and it is especially easy in cases of respiratory arrest, because of the limp condition of the patient.