1. The lamp may not be firmly screwed into the light-carrier.

Withdraw the light-carrier and try s.c.r.e.w.i.n.g it in, though not too strongly, lest the central wire terminal in the lamp be bent over.

2. The light-carrier may be defective.

3. The cord may be defective or its terminals not tight in the binding posts. If s.c.r.e.w.i.n.g down the thumb nuts does not produce a light, test the light-carrier with lamp on the other cords. Reserve cords in each pair of binding posts are for use instead of the defective cords. The two sets of cords from one pair of binding posts should not be used simultaneously.

4. The lamp may be defective. Try another lamp.

5. The battery may be defective. Take a cord and light-carrier with lamp that lights up, detaching the cord-terminals at the binding posts, and attach the terminals to the binding posts of the battery to be tested.

_Efficient use of forceps_ requires previous practice in handling of the forceps until it has become as natural and free from thought as the use of knife and fork. Indeed the coordinate use of the bronchoscopic tube-mouth and the forceps very much resembles the use of knife and fork. Yet only too often a pract.i.tioner will telegraph for a bronchoscope and forceps, and without any practice start in to remove an entangled or impacted foreign body from the tiny bronchi of a child. Failure and mortality are almost inevitable. A few hundred hours spent in working out, on a bit of rubber tubing, the various mechanical problems given in the section on that subject will save lives and render easily successful many removals that would otherwise be impossible.

It is often difficult for the beginner to judge the distance the forceps have been inserted into the tube. This difficulty is readily solved if upon inserting the forceps slowly into the tube, he observes that as the blades pa.s.s the light they become brightly illuminated. By this _light reflex_ it is known, therefore, that the forceps blades are at the tube-mouth, and distance from this point can be readily gauged. Excellent practice may be had by picking up through the bronchoscope or esophagoscope black threads from a white background, then white threads from a black background, and finally white threads on a white background and black threads on a black background. This should be done first with the 9 mm. bronchoscope. It is to be remembered that the majority of foreign body accidents occur in children, with whom small tubes must be used; therefore, practice work, after say the first 100 hours, should be done with the 5 mm.

bronchoscope and corresponding forceps rather than adult size tubes, so that the operator will be accustomed to work through a small calibre tube when the actual case presents itself.

[120] _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 Prof. J. Parsons Schaeffer for the Bronchoscopic Clinic courses, has proved very satisfactory: Sodium carbonate--1 1/2 lbs.

White a.r.s.enic--2 1/2 lbs.

Pota.s.sium nitrate--3 lbs.

Water--5 gal.

Boil until a.r.s.enic is dissolved. When cold add: Carbolic acid 1500 c.c.

Glycerin 1250 c.c.

Alcohol (95%) 1250 c.c.

For each body use about 3 gal. of fluid.

The method of introduction of the endoscopic tube, and its various positions can be demonstrated and repeatedly practiced on the cadaver until a perfected technic is developed in both the operator and a.s.sistant who holds the head, and the one who pa.s.ses the instruments to the operator. In no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically, and in no other way can the pupil be taught to avoid killing his patient. The danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality. Laryngeal growths may be simulated, foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected.

_Practice on the Rubber-tube Manikin_.--This must be carried out in two ways.

1. General practice with all sorts of objects for the education of the eye and the fingers.

2. Before undertaking a foreign body case, practice should be had with a duplicate of the foreign body.

It is not possible to have a cadaver for daily practice, but fortunately the eye and fingers may be trained quite as effectually by simulating foreign body conditions in a small red rubber tube and solving these mechanical problems with the bronchoscope and forceps.

The tubing may be placed on the desk and held by a small vise (Fig.

72) so that at odd moments during the day or evening the fascinating work may be picked up and put aside without loss of time. Complicated rubber manikins are of no value in the practice of introduction, and foreign body problems can be equally well studied in a piece of rubber tubing about 10 inches long. No endoscopist has enough practice on the living subject, because the cases are too infrequent and furthermore the tube is inserted for too short a s.p.a.ce of time. Practice on the rubber tube trains the eye to recognize objects and to gauge distance; it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired. Before attempting the removal of a particular foreign body from a living patient, the antic.i.p.ated problem should be simulated with a duplicate of the foreign body in a rubber tube. In this way the endoscopist may precede each case with a practical experience equivalent to any number of cases of precisely the same kind of foreign body. If the object cannot be removed from the rubber tube without violence, it is obvious that no attempt should be made on the patient until further practice has shown a definite method of harmless removal. During practice work the value of the beveled lip of the bronchoscope and esophagoscope in solving mechanical problems will be evidenced. With it alone, a foreign body may be turned into favorable positions for extraction, and folds can always be held out of the way.

Sufficient combined practice with the bronchoscope and the forceps enable the endoscopist easily to do things that at first seem impossible. It is to be remembered that lateral motion of the long slender tube-forceps cannot be controlled accurately by the handle, this is obtained by a change in position of the endoscopic tube, the object being so centered that it is grasped without side motion of the forceps. When necessary, the distal end of the forceps may be pushed laterally by the manipulation of the bronchoscope.

[FIG. 72.--A simple manikin. The weight of the small vise serves to steady the rubber tubing. By the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body, any mechanical problem can he simulated for solution or for practice, study of all possible presentations, etc.]

_Practice on the Dog_.--Having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube, experience should be had in the living lower air and food pa.s.sages with their pulsatory, respiratory, bechic and deglut.i.tory movements, and ever-present secretions. It is not only inhuman but impossible to obtain this experience on children. Fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice. A small dog the size of a terrier (say 6 to 10 pounds in weight) should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight, given about 45 minutes before the time of practice. Dogs stand large doses of morphin without apparent ill effect, so that repeated injection may be given in smaller dosage until the desired degree of relaxation results. The first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation and stupor. The dog is normal and hungry in a few hours. Dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal. Other forms of anesthesia have been tried in my teaching, and none has proven so safe and satisfactory. Phonation may be prevented during esophagoscopy by preventing approximation of the cords, through inserting a silk-woven cathether in the trachea. The larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy. A very comfortable and safe mouth gag is shown in Fig. 73. Great gentleness should be exercised, and no force should be used, for none is required in endoscopic work; and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child. He should remember he is not learning how to do endoscopy on the dog; but learning on the dog how safely to do bronchoscopy on a human being.

The degree of resistance during introduction can be gauged and the color of the mucosa studied, while that interesting phenomenon, the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration, is readily observed and always forms subject for thought in its possible connection with pathological conditions. Foreign body problems are now to be solved under these living conditions, and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least 100 foreign bodies from the dog without harming the animal. Dogs have the faculty of easily ridding their air-pa.s.sages of foreign objects, so that one need not be alarmed if a foreign body is lost during practice removal. It is to be remembered that dogs swallow very large objects with apparent ease. The dog's esophagus is relatively much larger than that of human beings.

Therefore a small dog (of six to eight pounds' weight) must be used for esophagoscopic practice, if practice is to be had with objects of the size usually encountered in human beings. The bronchi of a dog of this weight will be about the size of those of a child.

[FIG. 73.--Author's mouth gag for use on the dog. The thumb-nut serves to prevent an uncomfortable degree of expansion of the gag. A bandage may be wound around the dog's jaws to prevent undue spread of the jaws.]

_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. Moreover the interior of the larynx of the dog is quite different from that of the human larynx. The technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as, for instance, tonsillectomy, to see that the larynx and laryngopharynx are free of clots. To perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible; but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications.* Diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases. No anesthesia, general or local, is required. Much clinical material is neglected. All cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means. Invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage.

* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has recently collected statistics of 202 cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism (Moore, W. F., Pulmonary Abscess. Journ. Am. Med. a.s.sn., April 29, 1922, Vol. 78, pp. 1279-1281).

In acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought.

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 repet.i.tion.

Let your left hand know what your right hand does and how to do it.

Nature helps, but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria.

[126] CHAPTER XII--FOREIGN BODIES IN THE AIR AND FOOD Pa.s.sAGES

The air and food pa.s.sages 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); introduced from without by way of the natural pa.s.sages (aspirated or swallowed objects); or it may enter by penetration (bullet, dart, drainage tube from the neck).

_Prophylaxis_.--If one put into his mouth nothing but food, foreign body accidents would be rare. The habit of holding tacks, pins and whatnot in the mouth is quite universal and deplorable. Children are p.r.o.ne to follow the bad example of their elders. No small objects such as safety pins, b.u.t.tons, and coins should be left within a baby's reach; children should be watched and taught not to place things in their mouths. Mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect, because the molar teeth are not erupted. It might be made a dictum that: "No child under 3 years of age should be allowed to eat nuts, unless ground finely as in peanut b.u.t.ter." Digital efforts at removal of foreign bodies frequently force the object downward, or may hook it forward into the larynx, whereas if not meddled with digitally the intruder might be spat out. Before general anesthesia the mouth should be searched for loose teeth, removable dentures, etc., and all unconscious individuals should be likewise examined. When working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments.

[126] Objects that have lodged in the esophagus, larynx, trachea, or bronchi should be endoscopically removed.

_Foreign Bodies in the Insane_.--Foreign bodies may be introduced voluntarily and in great numbers by the insane. Hysterical individuals may a.s.sert the presence of a foreign body, or may even volitionally swallow or aspirate objects. It is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence.

Such "cures" are ephemeral.

_Foreign Bodies in the Stomach_.--Gastroscopy is indicated in cases of a foreign body that refuses to pa.s.s 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 epitomized as given below; but it must be kept in mind, that certain symptoms may not be manifest immediately after intrusion, and others may persist for a time after the pa.s.sage, removal, or expulsion of a foreign body.

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 penetration of a sharp foreign body, by inflammation secondary thereto, by impaction of a large object, or by spasmodic closure of the hiatus esophageus.

4. The subjective sensation of foreign body is usually present, but cannot be relied upon as a.s.suring the presence of a foreign body for this sensation often remains for a time after the pa.s.sage onward of the intruder.

5. All of these symptoms may exist, often in the most intense degree, as the result of previous violent attempts at removal; and the foreign body may or may not be present.

SYMPTOMS OF LARYNGEAL FOREIGN BODY

1. Initial laryngeal spasm followed by wheezing respiration, croupy cough, and varying degrees of impairment of phonation.

2. Pain may be a symptom. If so, it is usually located in the laryngeal region, though in some cases it is referred to the ears.

3. The larynx may tolerate a thin, flat, foreign body for a relatively long period of time, a month or more; but the development of increasing dyspnea renders early removal imperative in the majority of cases.

SYMPTOMS OF TRACHEAL AND BRONCHIAL FOREIGN BODY

1. Tracheal foreign bodies are usually movable and their movements can usually be felt by the patient.

2. Cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. In recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing.

3. Sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body.

4. Dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder.

5. Dyspnea is usually absent in bronchial foreign bodies.

6. The respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive.

7. The asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. It is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it.

8. Pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body.