Mary Cappello

by Swallow: Foreign Bodies

  Reliably safe entry of instruments required a euphemistic “trial and error” period, but even after a technique for entering in was mastered, there still remained “the mechanical problems of the disentanglement, disimpaction or version of foreign bodies” (NMP, 51): the art of endoscopy had been mistakenly reduced to the (formidable) introduction of the instruments, according to Jackson, with little or no attention paid to the type of foreign body and the mechanical problem it represented. As an example, Jackson describes an experienced endoscopist proceeding with the illusory sense that a coin could simply be “lifted out” without recourse to a study of the mechanical principles that attended its residence inside the upper torso, thus failing to retrieve the coin with the patient under ether for an hour.

  In an attempt to drive home the necessity of treating each presentation of a fbdy as a new mechanical problem, Jackson asked his colleagues to think about the foreign body as they might a human infant, an analogy that is more interesting than it is accurate, since of course a fetus isn’t exactly stuck inside a uterus, childbirth needn’t rely on instruments, and a foreign body isn’t a living thing. (Or is it?) Just as an obstetrician would not attempt to deliver a baby without “studying . . . the position of the foetus and every part of its anatomy in relation to the material pelvis just so must the endoscopist study the position of the foreign body and the relation to its every part to the invaded bronchus or oesophagus,” Jackson urged. And “just as the obstetrician depends upon abdominal palpation to aid him in his interpretation of the presentation, so the endoscopist studies the roentgenogram” (NMP, 54).

  Perhaps obstetrics does apply to Jackson’s endoscopic work in this: his refinement of otherwise vulgar techniques was life-giving, but insofar as his technical virtuosity set him apart, it was impossible to forge analogies; instead, it risked separating him from the gang of his peers. Not wanting to claim a fame built on the failure of others, Jackson decided that when he bequeathed his fbdy collection to the College of Physicians of Philadelphia in 1924, he would not include the details of the history of damage performed by instruments, their makers, and practitioners. Explaining how to apply his grid as a field guide to fbdy prototypes in Foreign Bodies in the Air and Food Passages (Charted Experience in Cases from No. 631 to No. 1155), he concludes with what he has chosen not to include:

  As we could not always distinguish with certainty the instrumental trauma of our predecessors from the trauma inflicted by the foreign body itself, we deemed it best to omit mention even of the obviously instrumental trauma inflicted by our predecessors. This trauma, along with the resultant pathology, enormously increased our difficulties and in some instances added to our mortality. In about 40 per cent of the cases here tabulated removal had been attempted before the patients were sent to us. All mention of this has been omitted. We have recorded in each case our own work only.

  How an instrument is introduced into medical practice, how it enters into common usage and becomes eclipsed or is rendered obsolete, no doubt has as much to do with the history of attention to a particular body part, to one kind of medicine gaining ascendancy over another, to ways of seeing or touching, to diagnostic protocol and epistemic paradigm shifts as it does with economies and politics, both inside and outside the medical profession. Medical historian James Edmonson reminds us that the “technical advance of instrumentation did not always proceed in a unilinear fashion,” that the “standardization of instrumentation remains an elusive ideal,” and that “important changes in instrumentation have been prompted by technical advances occurring outside the recognized domain of gastrointestinal endoscopy, and even beyond medicine per se.”

  Edmonson delineates three phases of gastroscopic development: the “rigid endoscope” era that began as early as 1805 and ended in 1932 (these were the instruments that Jackson used); the “semi-flexible endoscope or Schindler era” running from 1932 to 1957; and from 1957 to the present, “the ‘fiberoptic’ era.” He cites L. Walk’s work in further identifying three principal kinds of endoscopes that vied for attention during the decades of the late nineteenth and early twentieth centuries, when Jackson’s work would have been coming into prominence: “straight open tubes without lenses” (it was this type that Jackson used), partially pliant endoscopes, and “rigid straight tubes with optical systems.”

  There is much that is vexing about this history, and some of its less-than-unilinear aspects are counterintuitive. For example, while flexibility might seem like an advance over rigidity, pliancy sometimes made for less visibility, and while flexibility seemed to guarantee easier entry into the body, it sometimes led to “instrument impaction,” as when the Hirschowitz Fiberscope “doubled back on itself to formaJwithin the stomach.” While fiber optics is the state of the art that we all have heard of and can’t imagine modern medicine without, fiberscopes, Edmonson explains, were slow to enter into actual practice because of client loyalty to particular endoscopic instrument companies.

  Where foreign-body work in particular is concerned, it seems to me that endoscopic methodology has moved in backward-turning ways. Chevalier Jackson would be appalled to know that the average duration of an endoscopic procedure to remove a foreign body is forty-six minutes, with anaesthesia; the procedure ranges from 5 to 260 minutes; operators use baskets and retrieval nets; surgery is often called upon; and the statistics on fatalities remain high—according to a group-authored article from 2008, “Foreign-body Ingestion: Characteristics and Outcomes in a Lower Socioeconomic Population with Predominantly Intentional Ingestion,” approximately 1,500 fatalities per year are attributed to fbdy ingestion in the United States. Current treatment modalities include the return to bougies to push foreign bodies further into the stomach, with the hope of a patient passing it via peristalsis, and the use of Foley catheters administered transnasally. The flexible, tubular device, which includes a balloon at one end, is inserted through the nose and into the esophagus in a procedure usually carried out by a radiologist. The aim is to push the catheter and its balloon past the esophageal foreign body and then inflate the balloon, which, when pulled back through the esophagus, retracts the foreign body into the upper throat, at which point the patient is instructed to spit it out. I can’t think of a procedure more foreign (forgiving the pun) to Chevalier Jackson’s exacting formulae and care.

  Transnasal esophagoscopy is described by Dr. Jonathan E. Aviv as the current state of the art for examination of the esophagus, but transnasal approaches to fbdy extraction using a Foley catheter as described elsewhere in the literature seem crude and potentially unsafe compared to Jackson’s meticulous protocols. The history that Aviv traces is telling. Esophagoscopies performed in Jackson’s clinics were usually carried out with the patient neither sedated nor anesthetized. Topical anesthesia and intramuscular sedation were practiced from the 1940s to the 1960s, while “transoral rigid esophagoscopy has been routinely performed in the operating room with the patient under general anesthesia” since the 1960s. Even though the new transnasal examination method seems convincingly safer, even “complication-free,” contemporary physicians might still lack the skill and confidence to attempt to view the esophagus of an unsedated patient. Is it possible that the ability to absent the patient anesthetically encouraged operators to be less careful than Jackson? While newfangled objects would pose fresh mechanical problems to Jackson—for example, the case of a patient swallowing five AA batteries and an audiocassette—history confirms that no one before or since Chevalier Jackson had the patience, mechanical genius, dexterity, fixity of purpose, and single-mindedness of mission to be able to remove foreign bodies with the consistently good results that he had. By his own account, he never made a single accidental perforation with one of his esophagoscopes, so adept was he in its use.

  Jackson’s instruments had no mirrors or prisms (Schindler’s early scope had twenty-six lenses), and while other esophagoscopists inflated the stomach in order to inspect it, according to L. Walk, Jackson rested content with the view
afforded by his scopes, which varied from “one third of the stomach to a complete view.” The bronchoscope does not magnify like a microscope or telescope, Jackson explains in a 1938 radio talk sponsored by Philadelphia’s Franklin Institute, but it does afford a direct view of the regions below the vocal cords that makes it possible to manipulate obstructing tissues out of the way and to bring others into the line of sight. The instrument had been specially designed “to facilitate its introduction; to provide a good view; to prevent injury to the tissues; and most important of all, to avoid asphyxiating the patient by shutting off all his airway.” It was nothing more than a hollow brass tube slanted at its distal end with a handle at “its proximal or ocular extremity,” Jackson wrote in Bronchoscopy and Esophagoscopy: A Manual of Peroral Endoscopy. It featured an auxiliary canal on its undersurface containing the light carrier, and numerous perforations at the end “to allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired.” The slant of the tube helps to introduce the instrument into a canal, but if the instrument is designed with too pronounced a slant, it will perforate what it enters. Nothing is standard about these scopes, but an esophagoscope nine millimeters wide by forty-five-centimeters long reaches the stomach of most adults. The tube itself has one kind of handle, which some commentators liken to a pistol grip, and the forceps that are inserted into the tube have another kind of handle resembling the handles on a pair of scissors. Because the bronchi and esophagus cannot be dilated—“rupture or even overdistension of a bronchus or of the thoracic esophagus is almost invariably fatal” (B&E, 17)—Jackson designed tubes of different sizes to meet the demands of bodies at different stages of development.

  “How can a straight and rigid tube be passed into, and through, the crooked passages from the lips to the bottom of the lung?” Jackson asked his radio audience in 1938, and he answered with a series of analogies. First was an ear speculum: the canal leading into the ear is crooked, and, in order to examine it, the physician “straightens the crooked canal by putting in a little funnel-shaped tube so he can look straight in to the region of the drumhead.” Or these specula work on the same principle as an arm when it straightens a “bent and crumpled coat sleeve.” Scores of forceps were designed to suit the nature of the foreign body, including forward-grasping, rotation, alligator, side-curved, square-built, long-jawed, spoon, and beaklike forceps. The method depended on one endoscopist accompanied by a team of assistants: one who held the patient’s head, one who attended the instruments, one who held the patient’s arms, and another who changed the endoscopist’s glasses when they became spattered with sputum backing up through the tube. But this isn’t surgery per se, and this is not exactly a surgical team: where surgery is bimanual and binocular, Jackson stressed time and again that bronchoscopy in the service of fbdy removal is “a monocular, depth-gauging procedure handicapped by limitations due to the smallness of the bronchi and the length and slenderness of the instruments” (NMP, 24).

  Training the eyes to work in uncommon ways, Jackson recommends that the operator proceed with both eyes open and with his right eye against the tube mouth. The scenario calls for a darkened, backlit room to help the operator ignore what he sees through his left eye and to prevent reflections from forming on the surface of his protective glasses. When these spectacles become fogged or spattered, they are immediately replaced by another pair that stand at the ready in a pan of heated water. Hand in hand with the eye of the tube mouth (see how the perceptual metaphors intersect and overlap), the mounted X-rays of the patient made by radiographer Willis F. Manges supply an indispensable visual field (Jackson places them upside down in a shadow box for a better conception of the relations in the recumbent patient). Jackson always credited Manges as a co-author in the development of the field of upper-bronchial work.

  The body’s interior fills up the doctor’s eye before the tube—it is all that there is in the world for that moment—and yet he enjoys a severely compromised view since he only sees what appears directly in front of him inside a contracting and expanding circumference. The doctor’s eyes are of the essence, as is his ability to project his knowledge of physiology into and through and down the scope, to see what he manipulates through his mind’s eye. But touch is not diminished—rather, it is heightened as the operator feels his way in, sensing rigidities and resistances in the body, sensing the intensity and direction of the instrument’s insertion, gauging depth so as not to go too deep, watching for collapsing walls and clamping folds. The eye must not mistake one opening for another, of course, but Jackson trained his students to feel anatomical parts, chinks, and byways with the distal end of the tube, and with practice to acquire what he called a “nerve-cell habit” in his fingers until manipulating human anatomy with these instruments is “made subconsciously as with the knife and fork in eating,” using forceps designed by him to “permit of the delicacy of touch of a violin bow” (B&E, 30, 32).

  Jackson attributes his tactile sensitivity to his practice as a toddler of patiently twisting slender strips of paper into lamplighters for the family. But from where did he derive his reassuring whisper, his voice’s soothing patter, the calming method (truly an instrument) of his modulated tones? He removed foreign bodies with singular dexterity, but he also subtracted fear from the equation with his voice. Movement and struggle in a fbdy case can cause the fbdy to move inside the patient, and that accidental displacement can have disastrous effects. The power of Jackson’s voice to still people must have been more than merely distracting; it must have been hypnotic. In Arlene Maloney’s recollection, the pair of Chevalier Jacksons, both the father and the son, had this ability that everyone tried to emulate: “They didn’t force it, they just took it easy, keeping up a sound of softly talking even if it was a little baby, they just kept on talking . . . if the secretary was taking notes . . . they never raised their voices, and the secretary just took down what they were saying.”

  A secretary is riveted by the voice; a patient is made drowsy. Where touch fails, sight enters in, and where sight fails, touch deftly registers. Voice acts as a support for the working of both, and all three serve a set of instruments as their extension inside another human body. To turn the pages of Jackson’s numerous guides to the application of these instruments is to be perpetually confronted with different orders of awe. First, where bronchoscopy is concerned, there is the awesomeness of the bronchial tree’s spontaneous movement, seemingly making the insertion of a rigid instrument impossible. Jackson’s account shows that, to the contrary, the instrument and a host of correlative bodily responses governing inspiration and expiration work as aids to one another. “The normal movements of the trachea and bronchi are respiratory, pulsatory, bechic, and deglutitory,” his account of the complex physiology of breathing begins. “The two former are rhythmic while the two latter are intermittently noted during bronchoscopy.” The breathing apparatus and windpipe serve a “respiratory” function, or, medically speaking, perform a ventilating movement; they work by way of a rhythmic vibration (“pulsatory”); they are protected by the cough (“bechic”) reflex; and they serve as an aid to the swallowing (“deglutitory”) process. Moreover, making things both more difficult and more amenable to the introduction of an instrument:

  It is readily observed that the bronchi elongate and expand during inspiration while during expiration they shorten and contract. The bronchoscopist must learn to work in spite of the fact that the bronchi dilate, contract, elongate, shorten, kink, and are dinged and pushed this way and that. It is this resiliency and movability that make bronchoscopy possible. The inspiratory enlargement of lumen opens up the forceps spaces, and the facile bronchoscopist avails himself of the opportunity to seize the foreign body. (B&E, 57)

  That the bronchoscopist who does fbdy work must recognize forceps spaces or create them (in other words, to gauge the amount of “wiggle room” around the fbdy) amps up the difficulty of his work. Previous doctors’ ignorance of the
need to allow for or create a forceps space around the fbdy could cause bleeding that obscured their view, the loss of the fbdy, and fatal harm to the patient. Physicians’ tendency to “futilely jam the forceps into the mucosa in an effort to force the forceps onto a foreign body” shows them losing sight of the human body as a three-dimensional plane. “With the jaws opening sagittally,” Jackson explains, they ignore “the lateral forceps spaces that would have facilitated grasping had the forceps been turned so the jaws would open in the coronal plane” (NMP, 55). The bronchi open and close in an immediate, not a gradual, way; nevertheless, the bronchoscopist has to intuit the start of the inspiratory phase and then and only then “promptly, though gently” insert the forceps jaws into the forceps spaces as they gape. He goes on: “the prompt collapse of the bronchial walls at the beginning of inspiration renders it necessary to start the insertion of the forceps jaws at the beginning of the inspiratory phase. If later, the jaws will be met and stopped by the collapsing walls” (B&E, 55).

  Bronchoscopy—and esophagoscopy, too—is a matter of timing; it’s a choreography of space and time that, while it might allow for invention, never allows for improvisation. Just as an athlete trains his body to move and reach in unimaginable ways, just as the sword swallower spends years practicing toward a habituation of seemingly impossible entry, Chevalier Jackson went to extraordinary lengths to make his fingers into receptors of vital information. The extent to which the athlete or sword swallower comes to know something as a result of his training is hard to judge, though it is clear that he learns to do something. For Jackson, repetition produced new knowledge as well as technique—but what was the nature of this knowledge? Jackson practiced and studied in order to know by touch exactly how much pressure a peanut kernel could withstand without being crushed, and he recommended that “the man who expects to be successful in removing peanut kernels” use “a delicate forceps well-oiled and working smoothly in his possession” to “crush a few quarts of peanut kernels to acquire the sense of tactile differentiation between the degree of forceps-pressure necessary securely to hold a peanut kernel during its withdrawal through the glottis and the degree of pressure that will crush it. This is a purely manual thing to be acquired only by feeling the peanuts crush and then feeling others against the tube-mouth while being withdrawn” (NMP, 72). He studied grains of maize to determine exactly how to avoid fragmentation, noticing that kernels of corn “usually present the germ end, the center of which is soft. If this germ is grasped it will come away leaving the ‘mouse-gnawed’ grain behind” (NMP, 74). He suggested that the grain be grasped at its midpoint rather than at its tip, using special forceps he had designed for the purpose that guaranteed a combination of “gentleness of grasp with sufficient holding power” (NMP, 74).