Chapter 2

_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 esophagus, spasmodic or organic, normal, or pathologic. 5. Paralysis of the normal esophageal propulsory mechanism.

The lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature; a large bolus of food, poorly masticated and hurriedly swallowed, may, however, become impacted in a perfectly normal esophagus.

Carelessness is the cause of over 80 per cent of the foreign bodies in the esophagus (see Bibliography, 29).

_Site of Lodgement_.--Almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax. A physiologic narrowing is present at this level, produced in part by muscular contraction, and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture. If dislodged from this position the foreign body usually passes downward to be arrested at the next narrowing or to pass into the stomach. The esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold. Such, however, is almost never the case. The cricopharyngeus muscle functionates in starting the foreign body downward as if it were food; but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor.

_Symptoms_.--_Dysphagia_ is the most frequent complaint in cases of esophageally lodged foreign bodies. A very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. Intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-passages by food arrested by the foreign body. _Dyspnea_ may be present if the foreign body is large enough to compress the trachea. _Cough_ may be excited by reflex irritation, overflow of secretions into the larynx, or by perforation of the posterior tracheal wall, traumatic or ulcerative, allowing leakage of food or secretion into the trachea. (See Chapter XII for discussion of symptomatology and diagnosis.)

_Prognosis_.--A foreign body lodged in the esophagus may prove quickly fatal from _hemorrhage_ due to perforation of a large vessel; from _asphyxia_ by pressure on the trachea; or from _perforation_ and _septic mediastinitis_. Slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia. Sooner or later, if not removed, the foreign body causes death. It may be tolerated for a long period of time, causing abscess, cervical cellulitis, fistulous tracts, and ultimately extreme stenosis from cicatricial contraction. Perichondritis of the laryngeal or tracheal cartilages may follow, and result in laryngeal stenosis requiring tracheotomy. The damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal. If the foreign body becomes dislodged and moves downward, the danger of intestinal perforation is encountered. The _prognosis_, therefore, must be guarded so long as the intruder remains in the body.

_Treatment_.--It is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie. Sounding the esophagus with bougies to determine the level of the obstruction, or to palpate the nature of the foreign body, is unnecessary and dangerous. Esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus, except for urgent reasons. The level of the stenosis, and usually the nature of the foreign body, can thus be decided. Blind instrumentation is dangerous, and in view of the safety and success of esophagoscopy, reprehensible.

If for any reason removal should be delayed, bismuth sub-nitrate, gramme 0.6, should be given dry on the tongue every four hours. It will adhere to the denuded surfaces. The addition of calomel, gramme 0.003, for a few doses will increase the antiseptic action. Should swallowing be painful, gramme 0.2 of orthoform or anesthesin will be helpful. Emetics are inefficient and dangerous. Holding the patient up by the heels is rarely, if ever, successful if the foreign body is in the esophagus. In the reported cases the intruder was probably in the pharynx.

_External esophagotomy_ for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists. It has been the observation in the Bronchoscopic Clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way, unless it has already perforated the esophageal wall, in which event it is no longer a case of foreign body in the esophagus. The mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent, while that of esophagoscopy is less than two per cent, if the foreign body has not already set up a serious complication before the esophagoscopy. Furthermore, external esophagotomy can be successful only with objects lodged in the cervical esophagus and, moreover, it has happened that after the esophagus has been opened, the foreign body could not be found because of dislodgement and passage downward during the relaxation of the general anesthesia. Should this occur during esophagoscopy, the foreign body can be followed with the esophagoscope, and even if it is not overtaken and removed, no risk has been incurred.

Esophagoscopy is the one method of removal worthy of serious consideration. Should it repeatedly fail in the hands of two skillful endoscopists, which will be very rarely, if ever, then external operation is to be considered in cervically lodged foreign bodies.

[187] CHAPTER XIX--ESOPHAGOSCOPY FOR FOREIGN BODY

_Indications_.--Esophagoscopy is demanded in every case in which a foreign body is known to be, or suspected of being, in the esophagus.

_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 inadvisable. Should the patient be in bad condition from previous ill-advised or blind attempts at extraction, endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved. It is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the passage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient. Moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false passage into the mediastinum or overriding the foreign body is great. Water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. The esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder: Rx. Anesthesin...gramme 0.12 Bismuth subnitrate...gramme 0.6 Calomel, gramme 0.006 to 0.003 may be added to each powder for a few doses to increase the antiseptic effect. If the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done. This will give time for nature to repair the damage and render the removal of the object more certain and less hazardous. Perforation of the esophagus by the foreign body, or by blind instrumentation, is a contraindication to esophagoscopy. It is manifested by such signs as subcutaneous emphysema, swelling of the neck, fever, irritability, increase in pulsatory and respiratory rates, and pain in the neck or chest. Gaseous emphysema is present in some cases, and denotes a dangerous infection. Esophagoscopy should be postponed and the treatment mentioned at the end of this chapter instituted. After the subsidence of all symptoms other than esophageal, esophagoscopy may be done safely. Pleural perforation is manifested by the usual signs of pneumothorax, and will be demonstrated in the roentgenogram.

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 laryngoscopy, bronchoscopy or tracheotomy should be prepared as a matter of routine, however rarely they may be needed.

Sponging should be done cautiously lest the foreign body be hidden in secretions or food accumulation, and dislodged. Small food masses often lodge above the foreign body and are best removed with forceps. The folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. If the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great.

_"Overriding" or failure to find a foreign body known to be present_ is explained by the collapsed walls and folds covering the object, since the esophagoscope cannot be of sufficient size to smooth out these folds, and still be of small enough diameter to pass the constricted points of the esophagus noted in the chapter on anatomy. Objects are often hidden just distal to the cricopharyngeal fold, which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object, so that the contact at the side of the tube is not felt as the tube passes over the foreign body (Fig. 91). The chief factors in overriding an esophageal foreign body are: 1. The chute-like effect of the plica cricopharyngeus. 2. The chute-like effect of other folds. 3. The lurking of the foreign body in the unexplored pyriform sinus. 4. The use of an esophagoscope of small diameter. 5. The obscuration of the intruder by secretion or food debris. 6. The obscuration of the intruder by its penetration of the esophageal wall. 7. The obscuration of the intruder by inflammatory sequelae.

[FIG. 91.--Illustrating the hiding of a coin by the folding downward of the plica cricopharyngeus. The muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has passed over the foreign body. Other folds may in rare instances act similarly in hiding a foreign body from view. This overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall.]

_The esophageal speculum for the removal of foreign bodies_ is useful when the object is not more than 2 cm. below the cricoid in a child, and 3 cm. in the adult. The fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found. The author's down-jaw forceps (Fig. 22) are very useful to reach down back of the cricopharyngeal fold, because of the often small posterior forceps space. The speculum has the disadvantage of not allowing deeper search should the foreign body move downward. In infants, the child's size laryngoscope may be used as an esophageal speculum. General anesthesia is not only unnecessary but dangerous, because of the dyspnea created by the endoscopic tube. Local anesthesia is unnecessary as well as dangerous in children; and its application is likely to dislodge the foreign body unless used as a troche. Forbes esophageal speculum is excellent.

MECHANICAL PROBLEMS OF ESOPHAGOSCOPIC REMOVAL OF FOREIGN BODIES

The bronchoscopic problems considered in the previous chapter should be studied.

_The extraction of transfixed foreign bodies_ presents much the same problem as those in the bronchi, though there is no limit here to the distance an object may be pushed down to free the point. Thin, sharp foreign bodies such as bones, dentures, pins, safety-pins, etcetera, are often found to lie crosswise in the esophagus, and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made (Fig. 92). Should the intruder be grasped in the center and traction exerted, serious and perhaps fatal trauma might ensue.

[191] [FIG. 92.--The problem of the horizontally transfixed foreign body in the esophagus. The point, D, had caught as the bone, A, was being swallowed. The end, E, was forced down to C, by food or by blind attempts at pushing the bone downward. The wall, F, should be laterally displaced to J, with the esophagoscope, permitting the forceps to grasp the end, M, of the bone. Traction in the direction of the dart will disimpact the bone and permit it to rotate. The rotation forceps are used as at K.]

[FIG. 93.--Solution of the mechanical problem of the broad foreign body having a sharp point by version. If withdrawn with plain forceps as applied at A, the point B, will rip open the esophageal wall. If grasped at C, the point, D, will rotate in the direction of F and will trail harmlessly. To permit this version the rotation forceps are used as at H. On this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal.]

The extraction of broad, flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in Fig. 93.

_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 pin point. The coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. An open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. A roentgenogram should always be made in the plane showing the widest spread of the pin. It is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. It may be best to close the safety pin with the safety-pin closer, as illustrated in Fig. 37. For this purpose Arrowsmith's closer is excellent. In other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the Tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. The rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. The sense of touch will aid the sense of sight in the execution of this maneuver (Fig. 87). When the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. In certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. This, however, is a dangerous method and applicable in but few cases. It is better to disengage the point by downward and inward rotation with the Tucker forceps.

_Version of a Safety Pin_.--A safety pin of very small size may be turned over in a direction that will cause the point to trail. An advancing point will puncture. This is a dangerous procedure with a large safety pin.

_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 rotated so that the spring is uppermost. It can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. Only very small safety-pins can be withdrawn through the esophagoscope.

_Spatula-protected Method_.--Safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. The keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. Instruments and foreign body are then removed together. Often the pin point will catch in the light-chamber where it is very safely lodged. If the pin be then pulled upon it will straighten out and may be withdrawn through the tube.

[FIG. 94.--Endogastric version. One of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach, where they are turned and removed. The first illustration (A) shows the rotation forceps before seizing pin by the ring of the spring end. (Forceps jaws are shown opening in the wrong diameter.) At B is shown the pin seized in the ring by the points of the forceps. At C is shown the pin carried into the stomach and about to be rotated by withdrawal. D, the withdrawal of the pin into the esophagoscope which will thereby close it. If withdrawn by flat-jawed forceps as at F, the esophageal wall would be fatally lacerated.]

_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 prone 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 passing 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 circumstances 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 circumstances 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 passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening. To avoid entering a false passage 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 bismuth 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 passed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly passed 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 canal 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 Association, 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 constitute a benign, self-limited disease. There are two classes 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 classes 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 prone 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. Associated 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 mass of papillomata held by the negative pressure at the canal inlet orifice.