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Bronchoscopy and Esophagoscopy in Small Hospital


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									VOL. 47, No. 2                                         March, 1955                                              101

                Bronchoscopy and Esophagoscopy in a Small Hospital*
                                             MARCUS W. MOORE, M.D.
                                                   Baltimore, Maryland

 BRONCHOSCOPY and esophagoscopy are                             local irritation with routine studies, should be
       relatively new devolpments which render                  investigated by bronchoscopy. Pathology may be
 extensive aid in the diagnosis and therapy of pul-             uncovered in the bronchial tree which has been
 monary and esophageal diseases.' The instruments               unsuspected. Hemoptysis may occur in bronchiec-
 used have opened a new field in medical science                tasis, tumor formation, lung abscess,15 bronchitis,
 for future exploration and development.                        asthmatics, and aspirations of foreign bodies. It
    The accurate localization of disease of seg-                is important to perform bronchoscopy to rule out
 mental bronchial orifices and sections of the                  the more serious lesions.
 esophagus can be made via the bronchoscope2, 3, 4                 Esophagoscopy5 is indicated in all cases of
 and the esophagoscope.                                        esophageal obstruction. Difficulty in swallowing
    Schwartz5 states that bronchial and esophageal             solid food, regurgitation of saliva, water and food
 endoscopy has become one of the most important                are common symptoms of obstruction. Esophago-
 procedures used now for the examination and                   scopy is indicated in cases where x-ray examina-
treatment of certain chest conditions. One may                 tion is inconclusive and in cases where a positive
improve the drainage of the bronchial tree with                microscopic diagnosis is desired. Esophagoscopy
the use of a bronchoscope. With this instrument,               is often indicated for diagnosis and treatment in
a new understanding of the bronchial obstructive               benign inflammatory strictures, lye strictures, webs,
mechanism has been obtained. Treatment by direct               and achalasia. In cases of suspected foreign body
application of medicines can be made accurately                in the esophagus, esophagoscopy is definitely in-
with the bronchoscope and with the esophagoscope.              dicated. Bleeding from the esophagus manifested
   Tucker6 states that the endobronchial approach              by hematemesis or melena may be coming from
to the study and treatment of bronchial diseases               esophagitis, hiatus hernia, esophageal ulcer,
by means of the bronchoscope is of the utmost im-              varices,16 benign or malignant tumor or foreign
portance in the understanding, prevention and                  body. Esophagoscopy is indicated in these types
cure of these diseases. The use of the bronchoscope            of cases where x-ray examination is negative, but
is indicated in a number of conditions and many                where symptoms referable to the esophagus per-
combinations of symptoms.7 8 The presence of a                 sist. When x-ray examination shows only spasm
tracheal or bronchial wheeze constitutes one of the            of the esophagus, there may be some serious
most important indications for bronchoscopy.                   underlying disease which can be demonstrated by
Wheezing may be caused by incomplete obstruction               esophagoscopy.
to the bronchus, by benign tumor of the bronchus,                  Color motion pictures of a bronchoscopic pro-
polypoid malignant bronchial tumors,9' 10, 11 or               cedure were shown. The motion pictures were
even by excessive secretions seen in bronchitis or             made at Provident Hospital operating room
bronchiectasis.12                                              under the direction of the author of this paper.
   Stenotic proliferative, or ulcerative tuberculous'3         The techniques of local anesthesia, positioning of
lesions may also cause a wheeze. Bronchial ob-                 the patient, and the passing of the bronchoscope
struction, which may be complete or incomplete,                were demonstrated.
is a very important indication for bronchoscopy.14                 As stated by Pembleton and Vinson,17 the
Bronchoscopy is necessary to determine the nature              majority of peroral endoscopic examinations can
and extent of the obstruction. Cough which is                  be made with local anesthesia or without anes-
persistent and not determined to be caused by a                thesia. The patient does not experience a great
                                                               deal of discomfort and satisfactory operative re-
 Read before the Ear, Nose and Tlhroat Section at the Fifty-   sults can be obtained. The technique of bron-
 Ninth Annual Convention of the National Medical Asso-
 ciation, Washington, D. C., August 12, 1954.                  choscopy used in this series was similar to that
 102                      JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION                                  MARCH, 1955

 used in other clinics.18 1`1 The patient lies in the      were 63 single bronchoscopies and 16 patients
 recumbent position with the head held in the              had two or more examinations. One case of mul-
 hands of a trained assistant. The head must be            tiple lung abscesses received a total of nine thera-
 held forward with extension at the occipito-atloid        peutic bronchoscopies over a period of 14 months
 joint. With the aid of the larnygoscope, the epi-         with excellent results. There were 17 single
 glottis is exposed, the tip of it is lifted, the larynx   esophagoscopies, and one patient had two pro-
 brought into view, and the arytenoids and vocal           cedures performed. Of the bronchoscopies, 58
 cords are examined as to size, shape and mobility.        were diagnostic and 56 were operative. There
 The bronchoscope is next introduced through the           were 8 procedures performed with biopsy. Thir-
 laryngoscope, which is then removed, leaving the          teen of the bronchoscopies were therapeutic for
 bronchoscope in place. The patient's head is              atelectasis and 34 for toilet procedure. One bron-
 lowered, and the inspection of the tracheobron-           choscopy was done for removal of foreign bodies.
 chial tree is inspected. In the usual examination,           Fifteen of the esophagoscopies were diagnostic
 a 7mm-40cm bronchoscope is used, for this per-            and four were operative. There were two pro-
mits adequate visualization and instrumentation.           cedures performed with biopsy. Two esophago-
    In performing esophagoscopy, the patient lies          scopies were performed for removal of foreign
 recumbent with head extended. The distal half             bodies.
of the esophagoscope is well lubricated with min-             In many of the patients analyzed, bronchoscopy
eral oil. The scope is inserted in an almost ver-          and esophagoscopy revealed no positive findings.
tical direction posterior to the base of the tongue.       The absence of lesions in many cases was of im-
The instrument is introduced slightly forward              portant significance in obtaining a final diagnosis.*
under direct vision toward the right piriform                * When this paper was read, color motion pictutres
sinus, thence downward in the midline to the               were shown of cases in which bronchoscopy or cso-
cricopharyngeus. The scope should pass th-ie crico-        phagoscopy had been performed. The cases were:
pharyngeus readily and into the esophagus.
                                                           CASE 1: MULTIPLE LUNG ABSCESSES
    We wish to present a preliminary analysis of
                                                             A 47-year-old male admitted in critical condition.
 133 procedures done in a small hospital over a            Extensive clearing and healing was obtained with re-
period of 30 months. The procedures were per-              peated therapeutic bronchoscopy.
formed at Provident Hospital, Baltimore, Mary-
                                                           CASE II: POSTOPERATIVE ATELECTASIS
land, during the period from January, 1952 to
June, 1954. This is a small hospital of 130 bed              A 30-year-old female who developed massive post-
                                                           operative atelectasis following pelvic surgery. Immediate
capacity, which had total admissions of 12,883             therapeutic bronchoscopy achieved excellent results, Figs.
patients in the 30 month period. The sources of            1 and 2.
the cases were from the surgical, medical and              CASE III: ANEURYSM OF ASCENDING AORTA
pediatric services, the out-patient department, pri-         A 44-year-old male with a large superior mediastinal
vate practitioners, and the Baltimore City Public          mass. Diagnostic bronchoscopy and esophagoscopy were
Health Service, Bureau of Tuberculosis.                    performed.
   There was a total of 133 procedures performed
                                                           CASE IV: CARCINOMA OF THE LUNG
on 97 patients. Of the 97 cases, 77 were male
                                                             A 62-year-old male in which bronchoscopic washings
patients and 20 were females. The age groups               contained carcinoma cells and a definite diagnosis was
ranged from eight months to 71 years of age.               established.
There were three patients between one month
                                                           CASE V: CARCINOMA OF THE LUNG
and ten years of age; two between 10 and 20
                                                              A 65-year-old male in which bronchoscopy with bi-
years of age; two between 20 and 30 years of age;          opsy of a tumor in the left main stem bronchus proved
12 between 30 and 40 years of age; 20 between              to be carcinoma.
40 and 50 years of age; 28 between 50 and 60
                                                           CASE VI: FOREIGN BODY IN THE ESOPHAGUS
years of age; 29 between 60 and 70 years of age
and one patient over 70 years of age.                         A 5-year-old female with an embedded foreign body
                                                           (coin) in the esophagus for over thre. months. The
   There were 80 single procedures performed               coin was successfully removed by therapeutic esophago-
and 17 cases had multiple examinations. There              scopy, Fig. 3.
VOL. 47, No. 2              Brol7choscopy and Esophagoscopy in a Smnall Hospital                                   103

                                                               *d~~~~~~~~~~~~~~~~~~~~~~~. .

Fl   I    Po toperative atelectasis right lower lobe of    Fig. 2 X-ray        immediately following therapeutic bron-
                        the lung.                                                         choscopy.
   An eight-month-old infant had swallowed a large iron       A 25-year-old female with severe saccular bronchi-
ball bearing, developed marked cyanotic. Immediate         ectasis of the left lower lobe of the lung. Therapeutic
tratclheotomy was performed, miraculously saving the       bronchoscopies were performed, Fig. 4.
infant's life. The ball bearing which fitted the hypo-
pharynx as if in an encased socket, was removed with       CASE XI: BRONCHIECTASIS WITH
tremendous difficulty.                                     BRONCHO-PLEURAL FISTULA
                                                              A 47-year-old male admitted critically ill with bron-
CASE VIII: ANEURYSM OF THE INNOMINATE ARTERY               chiectasis and broncho-pleural fistula with severe pneu-
  A 48-year-old male with a tumor in the right upper       monitis. Patient responded well with multiple therapeutic
thorax and superior mediastiuLm. Diagnostic bronchoscopy   bronchoscopies.
and esophagoscopy were performed.                          CASE XII: INFECTED LUNG CYST
                                                              A 42-year-old male complaining of repeated attacks
                                                           of pneumonitis, chronic coughing, hemoptysis and pains
   A 32-year-old male with anterior neck tumor. Diag-      in the chest. Routine diagnostic studies revealed an
nostic bronchoscopy and esophagoscopy were performed.      infected lung cyst in the right lower lobe.

         Fig. 3-Foreign body (coin) embedded
         in the esophagus for over three months             Fig. 4 Bronchogram demonstrating saccular bron-
         whilch was removed by esophagoscopy.                       chiectasis of the left lower lobe.
104                      JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION                                 MARCH, 1955

                     SUMMARY                                9. BETTS, R. H. Carcinoma of the Lungs-Broncho-
                                                               scopic Aspects, New England Journal of Medicine,
   Bronchoscopy and esophagoscopy are important                225: 519 (October), 1941.
procedures used for the examination and treat-             10. BROYLES, E. N. Bronchoscopic Experiences with
ment of certain chest diseases. The indications                Tumors of the Lower Respiratory Tract, Annals of
for bronchoscopy and esophagoscopy are described.              Otology, Rhinology, and Laryngology, 57: 129
A preliminary analysis is made of one hundred                   (March), 1948.
                                                           11. HOCHBERG, L. A. and A. MACKLES. The Early
and thirty-three procedures in a small hospital.               Diagnosis of Bronchogenic Carcinoma, Clinical Sym-
                                                               posia, 2: 103-126, (April), 1950.
                  LITERATURE CITED                         12. CLERF, L. H. Bronchoscopy in Bronchiectasis, Dis-
                                                               eases of the Chest, 9: 56-62, 1943.
1. JACKSON and JACKSON. Bronchoscopy, Esophago-            13. BELL, F. G. and B. SCHAFF. Bronchoscopy-Its
   scopy, and Gastroscopy; A Manual of Peroral En-             Role in the Diagnosis and Treatment of Pulmonary
   doscopy and Laryngeal Surgery, Third Edition, W.            Tuberculosis, Journal of The Missouri State Medi-
   B. Saunders, Philadelphia, 1934.                            cal Association, 42: 549 (September), 1945.
2. HOLLINGER, P. H. Recent Advances in Broncho-            14. LELL, W. A. Bronchoscopy in the Treatment of
   scopic Technic, Diseases of the Chest, 11: 427-430          Postoperative Pulmonary Atelectasis, Pennsylvania
    (September-October), 1945.                                 Medical Journal, 44: 1551 (September), 1941.
3. SAMSON, P. C. Bronchoscopy in Relation to Tho-          15. MOERSCH, H. J. and A. M. OLSEN. The Role of
   racic Surgery, West. J. Surgery, 47: 687-91, 1939.          Bronchoscopy in the Treatment of Pulmonary Ab-
4. WOODWARD, F. D. and W. W. WADDELL. Bron-                    scess, Surgery, 9: 905 (June), 1941.
   choscopy in the Newborn Infant, Journal of Pedi-        16. SAMSON, P. C. and L. FOREE. Direct Injection of
   atrics, 23: 79 (July), 1943.                                Esophageal Varices through the Esophagoscope,
5. SCHWARTZ, V. J. Phases of Bronchoscopy and                  Western Journal of Surgery, Obstetrics and Gyne-
   Esophagoscopy of Importance in General Practice,            cology, 50: 73 (February), 1942.
   Minnesota Medicine, 21: 601 (September), 1938.          17. PEMBLETON, W. E. and P. P. VINSON. Anesthesia
6. TUCKER, G. Bronchoscopic Aspects of Bronchiec-              in Peroral Endoscopy, Especially General Anesthesia
   tasis, Archives of Otolaryngology, 34: (November),          in Esophagoscopy and Gastroscopy, Archives of
   1941.                                                       Otololaryngology, 50: 561 (November), 1949.
7. HOLLINGER, P. H. Indications for Bronchoscopy in        18. WESISEL, W. and A. TELLA. Reaction of Tetra-
   Pulmonary Disease, Journal-Lancet, 65: 235 (July),          caine (Pontocaine) Used as Topical Anesthetic in
   1945.                                                       Bronchoscopy. Study of 1,000 cases, Journal of
8. BENEDICT, E. B. Endoscopy, First Edition, Williams          American Medical Association, 147: 218 (Septem-
   and Wilkins Company, Baltimore, 33-137, 1951.               ber 15), 1951.

                             1954 YEAR OF HIGHEST BIRTH AND LOWEST DEATH RATES
       The lowest death rate in the history of the country and the largest annual number of births were forecast
 for 1954 by Dr. Leonard A. Scheele, Surgeon General of the Public Service of the U. S. Department of Health,
 Education, and Welfare. Dr. Scheele made his statement on the basis of vital statistics reports for the first 10
 months of the year.
      The death rate for the year is expected to close at 9.2 deaths per 1,000 population, a substantial drop
 from the rates of 9.6 or 9.7 which have prevailed over the past five years. The absence of any reported out-
 break of influenza in 1954, with consequent low death rates for the chronic cardiovascular diseases, was cited
 as a principal reason for the decline. Infant and maternal deaths were also expected to hit new lows.
      Births will top the 4-million mark for the first time, according to preliminary estimates. The expected
 birth rate of 25.2 per 1,000 population is the second highest in twenty-eight years, and only 5.3 per cent
 below the peak year of 1947. A continuing rise in the births of third, fourth, and fifth children is probably
 responsible for the birth increases in 1953 and 1954. No increase in births of first children was expected
 because of falling marriage rates since 1951.
      The marriage rate sank to 9.2 per 1,000 population in the first 10 months of 1954, compared with 9.7
 for the same period the year before. Low birth rates during the 1930's, resulting in relative scarcity of young
 people of marriageable age in the present decade, were held chiefly responsible for the marriage decline.
      Divorces in the first nine months of 1954 were down 4 per cent from the comparable 1953 period, on the
 basis of reports from twenty-five areas. Since the 1946 peak, divorce rates have dropped over 40 per cent.

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