bronchoscopy and esophagoscopya manual of peroral endoscopy and laryngeal surgery by jackson,...

8/14/2019 Bronchoscopy and EsophagoscopyA Manual of Peroral Endoscopy and Laryngeal Surgery by Jackson, Chevalier, 1

1/153

TheProjectGutenbergeBook,BronchoscopyandEsophagoscopy,byChevalierJackson

ThiseBookisfortheuseofanyoneanywhereatnocostandwithalmostnorestrictionswhatsoever.Youmaycopyit,giveitawayorre-useitunderthetermsoftheProjectGutenbergLicenseincludedwiththiseBookoronlineatwww.gutenberg.org

Title:BronchoscopyandEsophagoscopyAManualofPeroralEndoscopyandLaryngealSurgery

Author:ChevalierJackson

ReleaseDate:September13,2006[eBook#19261]

Language:English

Charactersetencoding:ISO-646-US(US-ASCII)

***STARTOFTHEPROJECTGUTENBERGEBOOKBRONCHOSCOPYANDESOPHAGOSCOPY***

Thisbookisoneofthepioneeringworksinlaryngology.TheoriginaltextisfromthelibraryofIndianaUniversityDepartmentofOtolaryngology-HeadandNeckSurgery,BruceMatt,MD.Itwasscanned,convertedtotext,andproofedbyAlexTawadros.

BRONCHOSCOPYANDESOPHAGOSCOPY

AManualofPeroralEndoscopyandLaryngealSurgery

by

CHEVALIERJACKSON,M.D.,F.A.C.S.ProfessorofLaryngology,JeffersonMedicalCollege,Philadelphia;ProfessorofBronchoscopyandEsophagoscopy,GraduateSchoolofMedicine,UniversityofPennsylvania;MemberoftheAmericanLaryngologicalAssociation;MemberoftheLaryngological,Rhinological,andOtologicalSociety;MemberoftheAmericanAcademy

ofOphthalmologyandOto-Laryngology;MemberoftheAmericanBronchoscopicSociety;MemberoftheAmericanPhilosophicalSociety;etc.,etc.

With114IllustrationsandFourColorPlates


2/153

PhiladelphiaAndLondonW.B.SaundersCompany1922Copyrights1922,byW.B.SaundersCompanyMadeinU.S.A.

TOMYMOTHERTOWHOSEINTERESTINMEDICALSCIENCETHEAUTHOROWESHISINCENTIVE,ANDTOMYFATHERWHOSECONSTANTADVICETO"EDUCATETHEEYEANDTHEFINGERS"SPURREDTHEAUTHORTOCONTINUALEFFORT,THISBOOKISAFFECTIONATELYDEDICATED.

PREFACE

Thisbookisbasedonanabstractoftheauthor'slargerwork,PeroralEndoscopyandLaryngealSurgery.Theabstractwaspreparedundertheauthor'sdirectionbyareader,inordertogetareader's

pointofviewonthepresentationofthesubjectintheearlierbook.Withthisabstractasastartingpoint,theauthorhasendeavored,sofaraslaywithinhislimitedabilities,toaccomplishthedifficulttaskofpresentingbywrittenwordthevariouspurelymanualendoscopicprocedures.Thelargenumberofcorrectionsandrevisionsfoundnecessaryhasconfirmedthewisdomoftheplanofgettingthereader'spointofview;andtheserevisions,togetherwithnumerousadditions,havebroughtthetreatmentofthesubjectuptodatesofarasispossiblewithinthelimitsofaworkingmanual.AcknowledgmentisduethepersonneloftheW.B.SaundersCompanyforkindlyhelp.

CHEVALIERJACKSON.

OCTOBER,1922.II

CONTENTSPAGE

CHAPTERIINSTRUMENTARIUM17CHAPTERIIANATOMYOFLARYNX,TRACHEA,BRONCHIANDESOPHAGUS,ENDOSCOPICALLYCONSIDERED52CHAPTERIIIPREPARATIONOFTHEPATIENTFORPERORALENDOSCOPY63CHAPTERIVANESTHESIAFORPERORALENDOSCOPY65

CHAPTERVBRONCHOSCOPICOXYGENINSUFFLATION71CHAPTERVIPOSITIONOFTHEPATIENTFORPERORAlENDOSCOPY73CHAPTERVIIDIRECTLARYNGOSCOPY82CHAPTERVIIIDIRECTLARYNGOSCOPY(Continued)91CHAPTERIXINTRODUCTIONOFTHEBRONCHOSCOPE97CHAPTERXINTRODUCTIONOFTHEESOPHAGOSCOPE106CHAPTERXIACQUIRINGSKILL117CHAPTERXIIFOREIGNBODIESINTHEAIRANDFOODPASSAGES126CHAPTERXIIIFOREIGNBODIESINTHELARYNXANDTRACHEOBRONCHIALTREE149


3/153

CHAPTERXIVREMOVALOFFOREIGNBODIESFROMTHELARYNX156CHAPTERXVMECHANICALPROBLEMSOFBRONCHOSCOPICFOREIGNBODYEXTRACTION158CHAPTERXVIFOREIGNBODIESINTHEBRONCHIFORPROLONGEDPERIODS177CHAPTERXVIIUNSUCCESSFULBRONCHOSCOPYFORFOREIGNBODIES181CHAPTERXVIIIFOREIGNBODIESINTHEESOPHAGUS183CHAPTERXIXESOPHAGOSCOPYFORFOREIGNBODY187CHAPTERXXPLEUROSCOPY199CHAPTERXXIBENIGNGROWTHSINTHELARYNX201CHAPTERXXIIBENIGNGROWTHSINTHELARYNX(Continued)203CHAPTERXXIIIBENIGNGROWTHSPRIMARYINTHETRACHEOBRONCHIALTREE207CHAPTERXXIVBENIGNNEOPLASMSOFTHEESOPHAGUS209CHAPTERXXVENDOSCOPYINMALIGNANTDISEASEOFTHELARYNX210CHAPTERXXVIBRONCHOSCOPYINMALIGNANTGROWTHSOFTHETRACHEA214CHAPTERXXVIIMALIGNANTDISEASEOFTHEESOPHAGUS216CHAPTERXXVIIIDIRECTLARYNGOSCOPYINDISEASESOFTHELARYNX221CHAPTERXXIXBRONCHOSCOPYINDISEASESOFTHETRACHEAANDBRONCHI224CHAPTERXXXDISEASESOFTHEESOPHAGUS235CHAPTERXXXIDISEASESOFTHEESOPHAGUS(Continued)245

CHAPTERXXXIIDISEASESOFTHEESOPHAGUS(Continued)251CHAPTERXXXIIIDISEASESOFTHEESOPHAGUS(Continued)260CHAPTERXXXIVDISEASESOFTHEESOPHAGUS(Continued)268CHAPTERXXXVGASTROSCOPY273CHAPTERXXXVIACUTESTENOSISOFTHELARYNX277CHAPTERXXXVIITRACHEOTOMY279CHAPTERXXXVIIICHRONICSTENOSISOFTHELARYNXANDTRACHEA300CHAPTERXXXIXDECANNULATIONAFTERCUREOFLARYNGEALSTENOSIS309BIBLIOGRAPHY311INDEX315

[17]CHAPTERI--INSTRUMENTARIUM

Directlaryngoscopy,bronchoscopy,esophagoscopyandgastroscopyareproceduresinwhichthelowerairandfoodpassagesareinspectedandtreatedbytheaidofelectricallylightedtubeswhichserveasspeculatomanipulateobstructingtissuesoutofthewayandtobringothersintothelineofdirectvision.Illuminationissuppliedbyasmalltungsten-filamented,electric,"cold"lampsituatedatthedistalextremityoftheinstrumentinaspecialgroovewhichprotectsitfromanypossibleinjuryduringtheintroductionofinstrumentsthroughthetube.Thebronchiandtheesophaguswillnotallowdilatationbeyondtheirnormalcaliber;

therefore,itisnecessarytohavetubesofthesizestofitthesepassagesatvariousdevelopmentalages.Ruptureorevenover-distentionofabronchusorofthethoracicesophagusisalmostinvariablyfatal.Thearmamentariumoftheendoscopistmustbecomplete,foritisrarelypossibletosubstitute,ortoimprovisemakeshifts,whilethebronchoscopeisinsitu.Furthermore,theinstrumentsmustbeofthepropermodelandwellmade;otherwisedifficultiesanddangerswillattendattemptstoseethem.

_Laryngoscopes_.--TheregulartypeoflaryngoscopeshowninFig.I


4/153

(A,B,C)ismadeinadult's,child's,andinfant'ssizes.Theinstrumentshavearemovableslideonthetopofthetubularportionofthespeculumtoallowtheremovalofthelaryngoscopeaftertheinsertionofthebronchoscopethroughit.Theinfantsizeismadeintwoforms,onewith,theotherwithoutaremovableslide;witheitherformthelarynxofaninfantcanbeexposedinbutafewsecondsandadefinitediagnosismade,withoutanesthesia,generalorlocal;athingpossiblebynoothermethod.Foroperativeworkonthelarynxofadults,suchastheremovalofbenigngrowths,particularlywhenthesearesituatedintheanteriorportionofthelarynx,aspecialtubularlaryngoscopehavingaheart-shapedlumenandabeveledtipisused.Withthisinstrumenttheanteriorcommissureisreadilyexposed,andbecauseofthisitisnamedtheanteriorcommissurelaryngoscope(Fig.1,D).Thetipoftheanteriorcommissurelaryngoscopecanbeusedtoexposeeitherventricleofthelarynxbyliftingtheventricularband,oritmaybepassedthroughtheadultglottisforworkinthesubglotticregion.Thisinstrumentmayalsobeusedasanesophagealspeculumandasapleuroscope.Aside-slidelaryngoscope,usedwithorwithouttheslide,isoccasionallyuseful.

_Bronchoscopes_.--Theregularbronchoscopeisahollowbrasstubeslantedatitsdistalend,andhavingahandleatitsproximalorocularextremity.Anauxiliarycanalonitsundersurfacecontains

thelightcarrier,theelectricbulbofwhichissituatedinarecessinthebeveleddistalendofthetube.Numerousperforationsinthedistalpartofthetubeallowairtoenterfromotherbronchiwhenthetube-mouthisinsertedintoonewhoseaeratingfunctionmaybeimpaired.Theaccessorytubeontheuppersurfaceofthebronchoscopeendswithinthelumenofthebronchoscope,andisusedfortheinsufflationofoxygenoranesthetics,(Fig.2,A,B,C,D).

Forcertainworksuchasdrainageofpulmonaryabscesses,thelavagetreatmentofbronchiectasisandforforeign-bodyorothercaseswithabundantsecretions,adrainage-bronchoscopeisusefulThedrainagecanalmaybeontop,orontheundersurfacenexttothelight-carriercanal.Forordinarywork,however,secretioninthebronchusisbest

removedbysponge-pumping(Q.V.)whichatthesametimecleansthelamp.Thedrainagebronchoscopemaybeusedinanycaseinwhichtheveryslightly-greaterareaofcrosssectionisnodisadvantage;butinchildrentheaddedbulkisusuallyobjectionable,andincasesofrecentforeign-body,secretionsarenottroublesome.

Asbeforementioned,thelowerairpassageswillnottoleratedilatation;therefore,itisnecessarynevertousetubeslargerthanthesizeofthepassagestobeexamined.Foursizesaresufficientforanypossiblecase,fromanewborninfanttothelargestadult.Forinfantsunderoneyear,thepropertubeisthe4mm.by30cm.;thechild'ssize,5mm.by30cm.,isusedforchildrenagedfromonetofiveyears.Forchildrensixyearsorover,the7mm.by40cm.

bronchoscope(theadolescentsize)canbeusedunlessthesmallerbronchiaretobeexplored.Theadultbronchoscopemeasures9mm.by40cm.

Theauthoroccasionallyusesspecialsizes,5mm.x45cm.,6mm.x35cm.,8mm.x40cm.

_Esophagoscopes_.-Theesophagoscope,likethebronchoscope,isahollowbrasstubewithbeveleddistalendcontainingasmallelectriclight.Itdiffersfromthebronchoscopeinthatithasno


5/153

perforations,andhasadrainagecanalonitsuppersurface,ornexttothelight-carriercanalwhichopenswithinthedistalendofthetube.Theexactsize,position,andshapeofthedrainageoutletsisimportantonbronchoscopes,andtoanevengreaterdegreeonesophagoscopes.Iftheproximaledgeofthedrainageoutletistoonearthedistalendoftheendoscopictube,themucosawillbedrawnintotheoutlet,notonlyobstructingit,but,mostimportant,traumatizingthemucosa.If,forinstance,theesophagoscopeweretobepusheduponwithafoldthusanchoredinthedistalend,theesophagealwallcouldeasilybetorn.Toadmitthelargestsizesofesophagoscopicbougies(Fig.40),specialesophagoscopes(Fig.5)aremadewithbothlightcanalanddrainagecanaloutsidethelumenofthetube,leavingthefullareaofluminalcross-sectionunencroachedupon.Theycan,ofcourse,beusedforallpurposes,buttheslightlygreatercircumferenceisattimesadisadvantage.Theesophagealandstomachsecretionsaremuchthinnerthanbronchialsecretions,and,iffreefromfood,arereadilyaspiratedthroughacomparativelysmallcanal.Ifthecanalbecomesobstructedduringesophagoscopy,thepositivepressuretubeoftheaspiratorisusedtoblowouttheobstruction.Twosizesofesophagoscopesareallthatarerequired--7mm.X45cm.forchildren,and10mm.X53cm.foradults(Fig.3,AandB);butvariousothersizesandlengthsareusedbytheauthorforspecialpurposes.*Largeesophagoscopescausedangerousdyspneainchildren.If,itisdesiredtoballoontheesophaguswithair,the

windowplugshowninFig.6,isinsertedintotheproximalendoftheesophagoscope,andairinsufflatedbymeansofthehandaspiratororwithahandbulb.Thewindowcanbereplacedbyarubberdiaphragmwithaperforationforforcepsifdesired.Itwillbenotedthatnoneoftheendoscopictubesarefittedwithmandrins.Theyaretobeintroducedunderthedirectguidanceoftheeyeonly.Mandrinsareobtainable,buttheiruseisobjectionableforanumberofreasons,chiefofwhichisthedangerofoverridingaforeignbodyoralesion,orofperforatingalesion,oreventhenormalesophagealwall.Theslantedendontheesophagoscopeobviatesthenecessityofamandrinforintroduction.Thelongertheslant,withconsequentacutingoftheangle,themoretheintroductionisfacilitated;buttooacuteanangleincreasestheriskofperforatingtheesophagealwall,and

necessitatestheutmostcaution.Insomeforeign-bodycasesanacuteanglegivingalongslantisuseful,inothersashortslantisbetter,andinafewcasesthesquarelycut-offdistalendisbest.Tohaveallofthesedifferentslantsonhandwouldrequiretoomanytubes.Thereforetheauthorhassettleduponamoderateanglefortheendofbothesophagoscopesandbronchoscopesthatiseasytoinsert,andservesallpurposesintheversionandothermanipulationsrequiredbythevariousmechanicalproblemsofforeign-bodyextraction.Hehas,however,retainedalltheexperimentalmodels,foroccasionaluseinsuchcasesashefallsheirtobecauseofaproblemofextraordinarydifficulty.

*A9mm.X45cm.esophagoscopewillreachthestomachofalmostall

adultsandissomewhateasiertointroducethanthe10mm.X53cm.,whichmaybeomittedfromthesetifeconomymustbepracticed.

[FIG.I.--Author'slaryngoscopes.Thesearethestandardsizesandfulfillallrequirements.Manyotherformshavebeendevisedbytheauthor,buthavebeenomittedfromthelistasunnecessary.Theinfantdiagnosticlaryngoscope(C)isnotforintroducingbronchoscopes,andisnotabsolutelynecessary,asthelarynxofanyinfantcanbeinspectedwiththechild'ssizelaryngoscope(B).


6/153

AAdult'ssize;B,child'ssize;C,infant'sdiagnosticsize;D,anteriorcommissurelaryngoscope;E,withdrainagecanal;17,intubatinglaryngoscope,largelumen.Allthelaryngoscopesarepreferredwithoutdrainagecanals.]

[FIG.2.--Theauthor'sbronchoscopesofthesizesregularlyused.Variousotherlengthsanddiametersareonhandforoccasionaluseforspecialpurposes.Withtheexceptionofa6mm.X35cm.sizeforolderchildren,thesespecialbronchoscopesareveryrarelyusedandnoneofthemcanberegardedasnecessary.Forspecialpurposes,however,specialshapesoftube-mouthareuseful,as,forinstance,theovalendtofacilitatethegettingofbothpointsofastapleintothetube-mouthTheillustratedinstrumentsareasfollows:

A,Infant'ssize,4mm.X30cm.;B,child'ssize,5mm.X30cm.;C,adolescent'ssize,7mm.X40cm.;D,adult'ssize,9mm.X40cm.;E,aspiratingbronchoscopemadeinalltheforegoingsizes,andinaspecialsize,5mm.X45cm.]

[FIG.3.--Theauthor'sesophagoscopesofthesizeshehasstandardizedforallordinaryrequirements.Heusesvariousotherlengthsandsizesforspecialpurposes,butnoneofthemarereallynecessary.Agastroscope,10mm.X70cm.,isusefulforadults,especiallyin

casesofgastroptosis.Drainagecanalsareplacedatthetoporatthesideofthetube,nexttothelight-carriercanal.

A,Adult'ssize,10mm.X53cm.;B,child'ssize,7mm.X45cm.;CandD,fulllumen,withbothlightcanalanddrainagecanaloutsidethewallofthetube,tobeusedforpassingverylargebougies.Thisinstrumentismadeinadult,child,andadolescent(8mm.by45cm.)sizes.Gastroscopesandesophagoscopesofthesizesgivenabove(A)and(B),canbeusedalsoasgastroscopes.AsmallformofC,5mm.X30cm.isusedininfants,andalsoasaretrogradeesophagoscopeinpatientsofanyage.E,windowplugforballooninggastroscope,F.]

[FIG.4.--Author'sshortesophagoscopesandesophagealspecula

A,Esophagealspeculumandhypopharyngoscope,adult'ssize;B,esophagealspeculumandhypopharyngoscope,child'ssize;C,heavyhandledshortesophagoscope;D,heavyhandledshortesophagoscopewithdrainage.]

[FIG.5.--Crosssectionoffull-lumenesophagoscopefortheuseoflargestbourgies.Thecanalsforthelightcarrierandfordrainagearesoconstructedthattheydonotencroachuponthelumenofthetube.]

[25]Thespecialsizedesophagoscopesmostoftenusefularethe8mm.X30cm.,the8mm.X45cm.,andthe5mm.X45cm.Thesearemadewiththedrainagecanalinvariouspositions.

Foroperationsontheupperendoftheesophagus,andparticularlyforforeignbodywork,theesophagealspeculumshownatAandB,inFig.4,isofthegreatestservice.Withit,theanteriorwallofthepost-cricoidalpharynxisliftedforward,andtheupperesophagealorificeexposed.Itcanthenbeinserteddeeper,andtheupperthirdoftheesophaguscanbeexplored.Twosizesaremade,theadult'sandthechild'ssize.Theseinstrumentsserve,veryefficientlyaspleuroscopes.Theyaremadewithandwithoutdrainagecanals,thelatterbeingthemoreusefulform.


7/153

[FIG.6.--Window-plugwithglasscapinterchangeablewithacaphavingarubberdiaphragmwithaperforationsothatforcepsmaybeusedwithoutallowingairtoescape.Valvesonthecanals(E,F,Fig.3)arepreferable.]

_Gastroscopes_.--Thegastroscopeisofthesameconstructionastheesophagoscope,withtheexceptionthatitismadelonger,inordertoreachallpartsofthestomach.Inordinarycases,theregularesophagoscopesforadultsandchildrenrespectivelywillaffordagoodviewofthestomach,buttherearecaseswhichrequirelongertubes,andfortheseagastroscope10mm.X70cm.ismade,andalsoone10mm.X80cm.,thoughthelatterhasneverbeenneededbutonce.

[26]_Pleuroscopes_.--Asmentionedabovetheanteriorcommissurelaryngoscopeandtheesophagealspeculamakeveryefficientpleuroscopes;butthreedifferentformsofpleuroscopeshavebeendevisedbytheauthorforpleuroscopy.Theretrogradeesophagoscopeservesverywellforworkthroughsmallfistulae.

_MeasuringRule_(Fig.7).--Itiscustomarytolocateesophageallesionsbydenotingtheirdistancefromtheincisorteeth.Thisisreadilydonebymeasuringthedistancefromtheproximalendoftheesophagoscopetotheupperincisorteeth,orintheirabsence,tothe

upperalveolarprocess,andsubtractingthismeasurementfromtheknownlengthofthetube.Thus,ifanesophagoscope45cm.longbeintroducedandwefindthatthedistancefromtheincisorteethtotheocularendoftheesophagoscopeasmeasuredbytheruleis20cm.,wesubtractthis20cm.fromthetotallengthoftheesophagoscope(45cm.)andthenknowthatthedistalendofthetubeis25cm.fromtheincisorteeth.Graduationmarksonthetubehavebeenused,butareobjectionable.

[FIG.7.--Measuringruleforgaugingincentimetersthedepthofanylocationbysubtractionofthelengthoftheuninsertedportionoftheesophagoscopeorbronchoscope.Thisispreferabletograduationsmarkedonthetubes,thoughthetubescanbemarkedwithascaleif

desired.]

_Batteries_.--Thesimplest,best,andsafestsourceofcurrentisadoubledrybatteryarrangedinthreegroupsoftwocellseach,connectedinseries(Fig.8).Eachsetshouldhavetwobindingpostsandarheostat.Thebindingpostsshouldhavedoubleholesfortwoadditionalcords,tobekeptinreserveforuseincaseacordbecomesdefective.*Thecommercialcurrentreducedthrougharheostatshouldneverbeused,becausethereisalwaysthepossibilityof"grounding"thecircuitthroughthepatient;ahighlydangerousaccidentwhenweconsiderthatthetubemakesalongmoistcontactintissuesclosetothecourseofboththevagiandtheheart.Theendoscopistshouldneverdependuponapocketbatteryasasourceofillumination,forit

isalmostcertaintofailduringtheendoscopy.Thewiresconnectingthebatteryandendoscopicinstrumentarecoveredwithrubber,sothattheymaybecleansedandsuperficiallysterilizedwithalcohol.Theymaybetotallyimmersedinalcoholforanylengthoftimewithoutinjury.

*Whenthisisdonecareisnecessarytoavoidattemptingtousesimultaneouslythetwocordsfromonepairofposts.

[FIG8.--Theauthor'sendoscopicbattery,heavilybuiltfor


8/153

reliability.

Itcontains6drycells,series-connectedin3groupsof2cellseach.Eachgrouphasitsownrheostatandpairofbindingposts.]

_AspiratingTubes_.--Independentaspiratingtubesinvolvedelayintheiruseascomparedtoaspiratingcanalsinthewalloftheendoscopictube;buttherearespecialcasesinwhichanindependenttubeisinvaluable.Threeformsareusedbytheauthor.The"velveteye"cannottraumatizethemucosa(Fig.9).Toholdaforeignbodybysuction,asquarelycutoffendisnecessary.Forusethroughthetracheotomicwoundwithoutabronchoscopeamalleabletube(Fig.10)isbetter.

[FIG.9.--Theauthor'sprotected-apertureendoscopicaspiratingtubeforaspirationofpharyngealsecretionsduringdirectlaryngoscopyandendotracheobronchialsecretionsatbronchoscopy,alsofordrainingretropharyngealabscesses.Thelaryngoscopesareobtainablewithdrainagecanals,butformostpurposestheindependentaspiratingtubeshownaboveismoresatisfactory.Thetubesaremadein2030,40,and60cm.lengths.Anapertureonbothsidespreventsdrawinginthemucosa.Itcanbeusedforinsufflationofetherifdesired.Anaspiratingtubeofthesamedesign,buthavingasquarelycutoffend,issometimesusefulforremovingsecretionslyingclosetoaforeign

body;forremovingpapillomata;andevenforwithdrawingforeignbodiesofasoftsurfaceconsistency.Itisnotoftenthattheforeignbodiescanbethuswithdrawnthroughtheglottis,butcloselyfittingforeignbodiescanatleastbewithdrawntoahigherlevelatwhichampleforcepsspaceswillpermitapplicationofforceps.Suchaspiratingtubes,however,arenotsosafetouseastheprotected,doubleaperturetubes.]

[FIG.10.--Theauthor'smalleabletracheotomicaspiratingtubeforremovalofsecretions,exudates,crusts,etc.,fromthetracheobronchialtreethroughthetracheotomicwoundwithoutabronchoscope.Thetubeismadeofcoppersothatitcanbebenttoanycurve,andthecopperwirestyletpreventskinking.Thestyletis

removedbeforeusingthetubeforaspiration.]

[28]_Aspirators_.--Thevariouselectricaspiratorssouniversallyusedinthroatoperationsshouldbeutilizedtowithdrawsecretionsinthetubesfittedwithdrainagecanals.They,however,havethedisadvantagesofnotbeingeasilytransported,andofoccasionallybeingoutoforder.ThehandaspiratorshowninFig.11is,therefore,anecessarypartoftheinstrumentalequipment.Itneverfailstowork,isportable,andaffordsbothpositiveandnegativepressures.Thepositivepressureissometimesusefulinclearingthedrainagecanalofanyparticlesoffood,tissue,clots,orsecretionwhichmayobstructit;anditalsoservestofillthestomachoresophaguswithairwhentheballooningprocedureisused.Themechanicalaspirator

(Fig.12)ishighlyefficientandistheoneusedintheBronchoscopicClinic.Thepositivepressurewillquicklyclearobstructeddrainagecanals,andmaybeusedwhiletheesophagoscopeisinsitu,bysimplydetachingtheminuspressuretubeandattachingthepluspressure.Inthelungs,however,highpluspressuresaresodangerousthatthepressurevalvemustbelowered.

[Fig.11--Portableaspiratorforendoscopywithadditionaltubeconnectedwiththepluspressuresideforuseincaseofocclusionofthedrainagecanal.Thisaspiratorhastheadvantageofgreatpower


9/153

withportability.Whereportabilityisnotrequiredtheelectricallyoperatedaspiratorisbetter.]

[FIG.12.--Robinsonmechanicalaspiratoradaptedforbronchoscopicandesophagoscopicaspirationbytheauthor.Thepositivepressureisusedforclearingobstructeddrainagecanalsandtubes.]

[FIG.13.--Apparatusforinsufflationofetherorchloroformduringbronchoscopy,forthosewhomaydesiretousegeneralanesthesia.ThemechanicalmethodsofintratrachealinsufflationanesthesiasubsequentlydevelopedbyMeltzerandAuer,Elsberg,Geo.P.Mullerandothershaverightlysupersededthisapparatusforallgeneralsurgicalpurposes.]

_Sponge-pumping_.--Whiletheusuallythin,wateryesophagealandgastricsecretions,iffreefromfood,arereadilyaspiratedthroughadrainagecanal,thesecretionsofthebronchiareoftenthickandmucilaginousandaspiratedwithdifficulty.Further-more,bronchialsecretionsasarulearenotcollectedinpools,butaredistributedoverthewallsofthelargerbronchiandcontinuouslywellupfromsmallerbronchiduringcough.Theaspiratingbronchoscopesshouldbeusedwhenevertheirveryslightadditionalareaofcross-sectionisunobjectionable.Inmostcases,however,themostadvantageouswaytoremovebronchialsecretionhasbeenfoundtobebyintroducingagauze

swabonalongspongecarrier(Fig.14),sothatthespongeextendsbeyondthedistalendofthebronchoscope,causingcough.Thenwithdrawalofthespongecarrierwillremoveallofthesecretioninthetubejustastheplungerinapumpwillliftallofthewateraboveit.Bythismaneuverthewallsofthebronchusarewipedfreefromsecretions,andthelampitselfiscleansed.

[FIG.14.--SpongecarrierwithlongcollarforcarryingthesmallspongesshowninFig.15.ThecollarscrewsdownasintheCoolidgecottoncarrier.Aboutadozenoftheseareneededandtheyshouldallbesmallenoughtogothroughthe4mm.(diameter)bronchoscopeandlongenoughtoreachthroughthe53cm.(length)esophagoscope,sothatonesetwilldoforalltubes.Theschemashowsmethodof

sponging.ThecarrierC,armedwiththesponge,S,whenrotatedasshownbythedart,D,wipesthefield,P,atthesametimewipingthelamp,L.Thelampdoesnotneedevertobewithdrawnforcleaningduringbronchoscopy.Itisprotectedinarecesssothatitdoesnotcatchinthesponges.]

[FIG15.--Exactsizetowhichthebandage-gauzeiscuttomakeendoscopicsponges.Eachrectangleisthesizeforthetubaldiametergiven.Thedimensionsoftherespectiverectanglesarenotgivenbecauseitiseasierforthenurseoranyonetocutacardboardpatternofeachsizedirectlyfromthisdrawing.ThegauzerectanglesarefoldedupendwiseasshownatA,thenonceinthemiddleasatB,thenstrungonedozenonasafetypin.InAmericagauzebandagesrun

about16threadstothecentimeter.Differentmaterialmightrequireaslightlydifferentsizeandthepatterncouldbemadetosuit.]

[32]ThegauzespongesaremadebytheinstrumentnurseasdirectedinFig.15,andarestrungonsafetypins,wrappedinpaper,thesizeindicatedbyafigureonthewrapper,andthensterilizedinanautoclave.Thesterilepackagesareopenedonlyasneeded.These"bronchoscopicsponges"arealsomadebyJohnstonandJohnston,ofNewBrunswick,N.J.andaresoldintheshops.


10/153

_Mouth-gag_.--Widegaggingpreventsproperexposureofthelarynxbyforcingthemandibledownonthehyoidbone.Themouthshouldbegentlyopenedandabiteblock(Fig.16)insertedbetweentheteethontheleftsideofthepatient'smouth,topreventclosingofthejawsonthedelicatebronchoscopeoresophagoscope.

[FIG.16.--Biteblocktobeinsertedbetweentheteethtopreventclosureofthejawsontheendoscopictube.ThisistheMcKee-McCreadymodificationoftheBoycethimblewiththeomissionoftheetherizingtube,whichisnolongerneeded.TheblockhasbeenimprovedbyDr.W.F.MooreoftheBronchoscopicClinic.]

_Forceps_.--Delicacyoftouchandmanipulationareanabsolutenecessityiftheendoscopististoavoidmortality;therefore,heavilybuiltandspring-opposedforcepsaredangerousaswellasuseless.Forforeign-bodyworkinthelarynx,andfortheremovalofbenignlaryngealgrowths,thealligatorforcepswithroughenedjawsshowninFig.17serveeverypurpose.

[FIG.17.--LaryngealgraspingforcepsdesignedbyMosher.FormyownuseIhavetakenofftheratchet-lockingdeviceforallgeneralwork,tobereappliedontherareoccasionswhenitisrequired.]

_Bronchoscopicandesophagoscopicgraspingforceps_areofthetubular

type,thatis,astyletcarryingthejawsworksinaslendertubesothattractiononthestyletdrawstheVoftheopenjawsintothelumenofthetube,thuscausingthebladestoapproximate.Theyareverydelicateandlight,yethavegreatgraspingpowerandwillsustainanydegreeoftractionthatitissafetoexert.Theypermitofthedelicacyoftouchofaviolinbow.Thetwotypesofjawsmostfrequentlyused,arethosewiththeforward-graspingbladesshowninFig.18,andthosehavingside-graspingbladesshowninFig.19.Theside-curvedforcepsareperhapsthemostgenerallyusefulofalltheendoscopicforceps;thesideprojectionofthejawsmakesthemreadilyvisibleduringtheirclosureonanobject;theirbroadergraspisalsoanadvantage.,Theprojectionofthebladesintheside-curvedgraspingforcepsshouldalwaysbedirectedtowardtheleft.Ifitis

desiredthattheyopeninanotherdirectionthisshouldbeaccomplishedbyturningthehandleandnotbyadjustingthebladeitself.Ifthisrulebefolloweditwillalwaysbepossibletotellbythepositionofthehandleexactlywherethebladesaresituated;whereas,ifthejawsthemselvesareturned,confusionissuretoresult.Theforward-graspingforcepsarealwayssoadjustedthatthejawsopeninanup-and-downdirection.Onrareoccasionsitmaybedeemeddesirabletoturnthestyletofeitherforcepsinsomeotherdirectionrelativetothehandle.

[FIG.18.--Theauthor'sforwardgraspingtubeforceps.Thehandlemechanismissosimpleanddelicatethatthemostexquisitedelicacyoftouchispossible.Twolocknutsandathumbscrewtakeupalllost

motionyetaffordperfectadjustabilityandeasyseparationforcleansing.AtAisshownasmallclipforkeepingthejawstogethertopreventinjuriousbendinginthesterilizer,orcarryingcase.Attheleftisshownahandle-clampforlockingtheforcepsonaforeignbodyinthesolutionofcertainrarelyencounteredmechanicalproblems.Thejawsareserratedandcupped.]

[FIG.19.--Jawsoftheauthor'sside-curvedendoscopicforceps.Theseworkasshownintheprecedingillustration,eachforcepshavingitsownhandleandtube.Originallytheendofthecannulaandstyletwere


11/153

squaredtopreventrotationofthejawsinthecannula.Thiswasfoundtobeunnecessarywithproperlyshapedjaws,whichwedgetightly.]

_RotationForceps_.--Itissometimesdesiredtomaketractiononanirregularlyshapedforeignbody,andyettoallowtheobjecttoturnintothelineofleastresistancewhiletractionisbeingmade.Thiscanbeaccomplishedbytheuseoftherotationforceps(Fig.20),whichhaveforbladestwopointedhooksthatmeetattheirpointsanddonotoverlap.Rotationforcepsmadeonthemodelofthelaryngealgraspingforceps,buthavingopposingpointsattheendoftheblades,aresometimesveryusefulfortheremovalofirregularforeignbodiesinthelarynx,orwhenusedthroughtheesophagealspeculumtheyareofgreatserviceintheextractionofsuchobjectsasbones,pin-buttons,andtooth-plates,fromtheupperesophagus.Theseforcepsaretermedlaryngealrotationforceps(Fig.31).Allthevariousformsofforcepsaremadeinaverydelicatesizeoftencalledthe"mosquito"or"extralight"forceps,40cm.inlength,foruseinthe4mm.andthe5mm.bronchoscopes.Forthe5mm.bronchoscopesheavierforcepsofthe40cm.lengtharemade.Forthelargertubestheforcepsaremadein45cm.,50cm.,and60cm.lengths.Asquare-cannulaforcepstopreventturningofthejawswasatonetimeusedbytheauthorbutithassincebeenfoundthatroundcannulapatternservesallpurposes.

[FIG.20.--Theauthor'srotationforceps.Usefultoallowturningofanirregularforeignbodytoasaferrelationforwithdrawalandfortheesophagoscopicremovalofsafetypinsbythemethodofpushingthemintothestomach,turningandwithdrawal,springup.]

_Upper-lobe-bronchusForceps_.--Foreignbodiesrarelylodgeinanupper-lobebronchus,yetwithsuchaproblemitisnecessarytohaveforcepsthatwillreacharoundacorner.Theupper-lobe-bronchusforcepsshowninFig.27havecurvedjawssomadeastostraightenoutwhilepassingthroughthebronchoscopeandtospringbackintotheiroriginalshapeonupfromthelowerjawemergingfromthedistalendofthebronchoscopictube,theradiusofcurvaturebeingregulatedby

theextentofemergencepermitted.Theyaremadeinextra-lightpattern,40cm.long,andtheregularmodel45cm.long.Thefull-curvedmodel,giving180degreesandreachingupintotheascendingbranches,ismadeinbothlightandheavypatterns.Forcepswithlesscurve,andwithoutthespiral,areusedwhenitisdesiredtoreachonlyashortdistance"aroundthecorner"anywhereinthebronchi.Thesearealsouseful,assuggestedbyWillisF.Manges,indealingwithsafetypinsintheesophagusortracheobronchialtree.

[FIG.21.--Tuckerjawsfortheauthor'sforceps.Thetinylipprojectingdownfromtheupper,andupfromthelowerjawpreventssidewiseescapeoftheshaftofapin,tack,nailorneedle.Theshaftisautomaticallythrownparalleltothebronchoscopicaxis.Drawing

aboutfourtimesactualsize.]

[36]_TuckerForceps_--GabrielTuckermodifiedtheregularside-curvedforcepsbyaddingalip(Fig.21)tothelefthandsideofbothupperandlowerjaws.Thispreventstheshaftofatack,nail,orpin,fromspringingoutofthegraspofthejaws,andissoefficientthatithasbroughtcertaintyofgraspneverbeforeobtainable.Withitthesolutionofthesafety-pinproblemdevisedbytheauthormanyyearsagohasafacilityandcertaintyofexecutionthatmakesitthemethodofchoiceinsafety-pinextraction.


12/153

[FIG.22.--Theauthor'sdown-jawesophagealforceps.Thedroppingjawisusefulforreachingbackwardbelowthecricopharyngealfoldwhenusingtheesophagealspeculumintheremovalofforeignbodies.Posteriorforceps-spacesareoftenscantyincasesofforeignbodieslodgedjustbelowthecricopharyngeus.]

[FIG.23.--Expansileforcepsfortheendoscopicremovalofhollowforeignbodiessuchasintubationtubes,trachealcannulae,caps,andcartridgeshells.]

_Screwforceps_.--ForthesecuregraspofscrewsthejawsdevisedbyDr.Tuckerfortacksandpinsareexcellent(Fig.21).

_ExpandingForceps_.--HollowobjectsmayrequireexpandingforcepsasshowninFig.23.Inusingthemitisnecessarytobecertainthatthejawsareinsidethehollowbodybeforeexpandingthemandmakingtraction.Otherwisesevere,evenfatal,traumamaybeinflicted.

[FIG.24.--Theauthor'sfenestratedpeanutforceps.Thedelicateconstructionwithlong,springyandfenestratedjawsgiveingentlehandsamaximumsecuritywithaminimumofcrushingtendency.]

[FIG.25--Theauthor'sbronchialdilators,usefulfordilatingstricturesaboveforeignbodies.Thesmallersize,shownattherightisalsousefulasanexpandingforcepsforremovingintubationtubes,andotherhollowobjects.Thelargersizewillgoovertheshaftofatack.]

[FIG.26.--Theauthor'sself-expandingbronchialdilator.Theextentofexpansioncanbelimitedbythesenseoftouchorbyanadjustablecheckingmechanismonthehandle.Theauthorfrequentlyusedsmoothforcepsforthispurpose,andfoundthemsoefficientthatthisdilatorwasdevised.Theedgesofforcepsjawsarelikelytoscratchtheepithelium.Occasionallytheinstrumentisusefulintheesophagus;butitisnotverysafe,unlessusedwiththeutmost

caution.]

_TissueForceps_.--WiththeforcepsillustratedinFig.28specimensoftissuemayberemovedforbiopsyfromthelowerairandfoodpassageswitheaseandcertainty.Theyhaveacrossintheouterbladewhichholdsthespecimenremoved.Theactionisverydelicate,therebeingnosprings,andthesenseoftouchimpartedisoftenofgreataidinthediagnosis.

[FIG.27.--Theauthor'supper-lobebronchusforceps.AtAisshownthefull-curvedform,forreachingintotheascendingbranchesoftheupper-lobebronchusAnumberofdifferentformsofjawsaremadeinthiskindofforceps.Only2areshown.]

[FIG28--Theauthor'sendoscopictissueforceps.Thelaryngeallengthis30cm.Foresophagealusetheyaremade50and60cm.long.Thesearethebestforcepsforcuttingoutsmallspecimensoftissueforbiopsy.]

ThelargebasketpunchforcepsshowninFig.33areusefulinremovinglargergrowthsorspecimensoftissuefromthepharynxorlarynx.Aportionorthewholeoftheepiglottismaybeeasilyandquicklyremovedwiththeseforceps,thelaryngoscopeintroducedalongthe


13/153

dorsumofthetongueintotheglossoepiglotticrecess,bringingthewholeepiglottisintoview.Theforcepsmaybeintroducedthroughthelaryngoscopeoralongsidethetube.Inthelattermethodagreaterlateralactionoftheforcepsisobtainable,thetubebeingusedforvisiononly.Theseforcepsare30cm.longandaremadeintwosizes;onewiththepunchofthelargestsizethatcanbepassedthroughtheadultlaryngoscope,andasmalleroneforusethroughtheanterior-commissurelaryngoscopeandthechild'ssizelaryngoscope.

[FIG.29.--Theauthor'spapillomaforceps.Thebroadbluntnosewillscalpoffthegrowthswithoutanyinjurytothenormalbasaltissues.Voice-destroyingandstenosingtraumaarethuseasilyavoided.]

[FIG.30.--Theauthor'sshortmechanicalspoon(30cm.long).]

_PapillomaForceps_.--Papillomatadonotinfiltrate;butsuperficialrepullulationsinmanycasesrequirerepeatedremovals.Ifthebasaltissuesaretraumatized,animpairedorruinedvoicewillresult.Theauthordesignedtheseforceps(Fig.29)toscalpoffthegrowthswithoutinjurytothenormaltissues.

[FIG.31.--Theauthor'slaryngealrotationforceps.]

[FIG.32.--Enlargedviewofthejawsoftheauthor'svocal-nodule

forceps.Largercupsaremadeforotherpurposesbutthesetinycupspermitofthatextremedelicacyrequiredintheexcisionofthenodulesfromthevocalcordsofsingersandothervoiceusers.]

[FIG33.-Extralargelaryngealtissueforceps.30cm.long,forremovingentiregrowthsorlargespecimensoftissue.Asmallersizeismade.]

_BronchialDilators_.--Itisnotuncommontofindastrictureofthebronchussuperjacenttoaforeignbodythathasbeeninsituforaperiodofmonths.Inordertoremovetheforeignbody,thisstricturemustbedilated,andforthisthebronchialdilatorshowninFig.25wasdevised.Thechannelineachbladeallowsthecloseddilatortobe

pusheddownoverthepresentingpointofsuchbodiesastacks,afterwhichthebladesareopenedandthestricturestretched.Asmallandalargesizearemade.Forenlargingthebronchialnarrowingassociatedwithpulmonaryabscessandsometimesfoundaboveabronchiectaticorforeignbodycavity,theexpandingdilatorshowninFig.26isperhapslessapttocauseinjurythanordinaryforcepsusedinthesameway.Thestretchingishereproducedbythespringofthebladesoftheforcepsandnotbymanualforce.Theclosedbladesaretobeinsertedthroughthestricturedarea,opened,andthenslowlywithdrawn.Forcicatricialstenosesofthetracheathemetallicbougies,Fig.40,areuseful.Forthelarynx,thoseshowninFig.41areneeded.

[FIG.34.--A,Mosher'slaryngealcurette;B,author'sflatblade

cauteryelectrode;C,pointedcauteryelectrode;D,laryngealknife.Theelectrodesareinsulatedwithhard-rubbervulcanizedontotheconductingwires.]

[FIG.35.--RetrogradeesophagealbougiesingraduatedsizesdevisedbyDr.GabrielTuckerandtheauthorfordilatationofcicatricialesophagealstenosis.Theyaredrawnupwardbyanendlessswallowedstring,andarethereforeonlytobeusedingastrostomizedcases.]

[FIG.36.--Author'sbronchoscopicandesophagoscopicmechanicalspoon,


14/153

madein40,50and60cm.lengths.]

[FIG.37.--Schemaillustratingtheauthor'smethodofendoscopicclosureofopensafetypinslodgedpointupwardThecloserispasseddownunderocularcontroluntilthering,R,isbelowthepin.TheringisthenerectedtothepositionshowndottedatM,bymovingthehandle,H,downwardtoLandlockingittherewiththelatch,Z.Thefork,A,istheninsertedand,engagingthepinatthespringloop,K,thepinispushedintothering,thusclosingthepin.Slightrotationofthepinwiththeforcepsmaybenecessarytogetthepointintothekeeper.Theupperinstrumentissometimesusefulasamechanicalspoonforremovinglarge,smoothforeignbodiesfromtheesophagus.]

_EsophagealDilators_.--Thedilatationofcicatricialstenosisoftheesophaguscanbedonesafelyonlybyendoscopicmethods.Blindesophagealbouginageishighlydangerous,forthelumenofthestrictureisusuallyeccentricandthebougieisthereforeapttoperforatethewallratherthanfindthesmallopening.Oftenthereispresentapouchingoftheesophagusaboveastricture,inwhichthebougiemaylodgeandperforate.Bougiesshouldbeintroducedundervisualguidancethroughtheesophagoscope,whichissoplacedthatthelumenofthestrictureisinthecenteroftheendoscopicfield.Theauthor'sendoscopicbougies(Fig.40)aremadewithaflexiblesilk-woventipsecurelyfastenedtoasteelshaft.Thisshaftlends

rigiditytotheinstrumentsufficienttopermititsaccurateplacement,anditssmallsizepermitstheeyetokeepthesilk-woventipinview.Theseendoscopicbougiesaremadeinsizesfrom8to40,Frenchscale.Thelargersizesareusedespeciallyforthedilatationoflaryngealandtrachealstenoses.Forthelatterworkitisessentialthatthebougiesbeinspectedcarefullybeforetheyareused,forshouldadefectivetipcomeoffwhileinthelowerairpassagesadifficultforeignbodyproblemwouldbecreated.Soft-rubberretrogradedilatorstobedrawnupwardfromthestomachbyaswallowedstringareusefulingastrostomizedcases(Fig.35).

[FIG38.--Halfcurvedhook,45cm.and60cm.Fullcurvedpatternsaremadebutcautionisnecessarytoavoidthembecominganchoredinthe

bronchi.Spiralformsavoidthis.Theauthormakesforhimselfsteelprobe-pointedrodsoutofwhichhebendshooksofanydesiredshape.Therodisheldinapin-visetofacilitatebendingofthepoint,afterheatinginanalcoholorbunsenflame.]

_Hooks_.--Nohookgreaterthanarightangleshouldbeusedthroughendoscopictubes;forshoulditbecomecaughtinsomeofthesmallerbronchiitsextractionmightresultinserioustrauma.ThehalfcurvedhookshowninFig.38isthesafesttype;betterstill,aspiraltwisttothehookwilladdtoitsuses,andbyreversingtheturningmotionitmaybe"unscrewed"outifitbecomescaught.Hooksmayeasilybemadefromrodsofmalleablesteelbyheatingtheendinaspiritlampandshapingthecurveasdesiredbymeansofapin-viseandpliers.

About2cm.oftheproximalendoftherodshouldbebentinexactlytheoppositedirectionfromthatofthehooksoastoformahandlewhichwilltellthepositionofthehookbytouchaswellasbysight.Coil-springhooksfortheupper-lobe-bronchus(Fig.39)willreacharoundthecornerintotheascendingbronchusoftheupper-lobe-bronchus,buttheutmostskillandcarearerequiredtomaketheirusejustifiable.

[FIG.39.--Author'scoil-springhookfortheupper-lobe,bronchus]


15/153

_Safety-pinCloser_.--Thereareanumberofmethodsfortheendoscopicremovalofopensafety-pinswhenthepointisup,oneofwhichisbyclosingthepinwiththeinstrumentshowninFig.37inthefollowingmanner.Theovalringispassedthroughtheendoscopeuntilitisbeyondthespringofthesafety-pin,theringisthenturnedupwardbydepressingthehandle,andbytheaidoftheprongthepinispushedintothering,whichactionapproximatesthepointofthepinandthekeeperandclosesthepin.Removalisthenlessdifficultandwithoutdanger.Thisinstrumentmayalsobeusedasamechanicalspoon,inwhichcaseitmaybepassedtothesideofadifficultlygraspedforeignbody,suchasapebble,theringelevatedandtheobjectwithdrawn.Elsewherewillbefoundadescriptionofthevarioussafety-pinclosersdevisedbyvariousendoscopists.TheauthorhasusedArrowsmith'scloserwithmuchsatisfaction.

_MechanicalSpoon_.--Whensoft,friablesubstances,suchasabolusofmeat,becomeimpactedintheupperesophagus,theshortmechanicalspoon(Fig.30)usedthroughtheesophagealspeculumisofgreataidintheirremoval.Thebladeinthisinstrument,asthenamesuggests,isaspoonandisnotfenestratedasisthesafety-pincloser,whichifusedforfriablesubstanceswouldallowthemtoslipthroughthefenestration.AlongerformforusethroughbronchoscopesandesophagoscopesisshowninFig.36.

Alaryngealcurette,cauteryelectrodes,cauteryhandle,andlaryngealknifeareillustratedinFig.34.Thecauteryistobeusedwithatransformer,orastoragebattery.

_Spectacles_.--Iftheoperatorhasnorefractiveerrorhewillneedtwopairsofplaneprotectivespectacleswithverylarge"eyes."Ifametropic,correctivelensesarenecessary,andduplicatespectaclesmustbeinchargeofanurse.Forpresbyopiatwopairsofspectaclesfor40cm.distanceand65cm.distancemustbeathand.Hooktempleframesshouldbeusedsothattheycanbeeasilychangedandadjustedbythenursewhenthelensesbecomespattered.Thespectaclenursehasreadyatalltimestheextraspectacles,cleanedandwarmedinapanofheatedwatersothattheywillnotbefoggedbythepatient's

breath,andshechangesthemwithoutdelayasoftenastheybecomesoiled.Theoperatorshouldworkwithbotheyesopenandwithhisrighteyeatthetubemouth.Theoperatingroomshouldbesomewhatdarkenedsoastofacilitatetheignoringoftheimageinthelefteye;anylightingshouldbeattheoperator'sback,andshouldbeinsufficienttocausereflectionsfromtheinnersurfaceofhisglasses.

[FIG.40.--Theauthor'sendoscopicbougies.Theendconsistsofaflexiblesilkwoventipattachedsecurelytoasteelshank.Sizes8to30Frenchcatheterscale.Ametallicformofthisbougieisusefulinthetrachea;butisnotsosafeforesophagealuse.]

[FIG.41.--Theauthor'slaryngealbougieforthedilatationofcicatriciallaryngealstenosis.Madein10sizes.Theshadedtriangleshowsthecross-sectionatthewidestpart.]

[FIG.42.--Theauthor'sbronchoscopicandesophagoscopictable.]

[46]_EndoscopicTable_.--Anyoperatingtablemaybeused,buttheworkisfacilitatedifaspecialtablecanbehadwhichallowstheplacingofthepatientinallrequiredpositions.Thetableillustratedinfig.42issoarrangedthatwhenthefalsetopisdrawn


16/153

forwardontherailroad,theheadpiecedropsandthepatientisplacedinthecorrect(Boyce)positionforesophagoscopyorbronchoscopy,i.e.,withtheheadandshouldersextendingovertheendofthetable.Bymeansofthewheeltheplaneofthetablemaybealteredtoanydesiredangleofinclinationorheightofhead.

_OperatingRoom_.--Allendoscopicproceduresshouldbeperformedinasomewhatdarkenedoperatingroomwhereallthedesiredmaterialsareathand.Anendoscopicteamconsistsofthreepersons:theoperator,theassistantwhoholdsthehead,andtheinstrumentassistant.Anotherpersonisrequiredtoholdthepatient'sarmsandstillanotherforthechangingoftheoperator'sglasseswhentheybecomespattered.Theendoscopicteamofthreemaintainsurgicalasepsisinthematterofhandsandgowns,etc.Thebattery,onasmalltableofitsown,isplacedatthelefthandoftheoperator.Beyonditisthetableforthemechanicalaspirator,ifoneisused.Allextrainstrumentsareplacedonasteriletable,withinreach,butnotintheway,whilethoseinstrumentsforuseintheparticularoperationareplacedonasmallinstrumenttablebackoftheendoscopist.Onlythoseinstrumentslikelytobewantedshouldbeplacedontheworkingtable,sothatthereshallbenoconfusionintheirselectionbytheinstrumentnursewhencalledfor.Eachmomentoftimeshouldbeutilizedwhentheendoscopicprocedurehasbeenstarted,notimeshouldbelostinthehuntingorseparatingofinstruments.Tohave

therespectivetablesalwaysinthesamepositionrelativetotheoperatorpreventsconfusionandavoidsdelay.

[FIG43.--Theauthor'sretrogradeesophagoscope.]

_OxygenTankandTracheotomyInstruments_.--Respiratoryarrestmayoccurfromshiftingofaforeignbody,pressureoftheesophagoscope,tumor,ordiverticulumfulloffood.Rareasthesecontingenciesare,itisessentialthatmeansforresuscitationbeathand.Noendoscopicprocedureshouldbeundertakenwithoutasetoftracheotomyinstrumentsonthesteriletablewithininstantreach.Inrespiratoryarrestfromtheabovementionedcauses,respiratoryeffortsarenotapttoreturnunlessoxygenandamylnitriteareblownintothe

tracheaeitherthroughatracheotomyopeningorbetterstillbymeansofabronchoscopeintroducedthroughthelarynx.Thelimpnessofthepatientrendersbronchoscopysoeasythatthewell-drilledbronchoscopistshouldhavenodifficultyininsertingabronchoscopein10or15seconds,ifproperpreparednesshasbeenobserved.Itisperhapsrelativelyrarelythatsuchaccidentsoccur,yetifpreparationsaremadeforsuchacontingency,alifemaybesavedwhichwouldotherwisebeinevitablylost.Theoxygentankcoveredwithasterilemuslincovershouldstandtotheleftoftheoperatingtable.

_Asepsis_.--Strictaseptictechnicmustbeobservedinallendoscopicprocedures.Theoperator,firstassistant,andinstrumentnursemust

usethesameprecautionsastohandsterilizationandsterilegownsaswouldbeexercisedinanysurgicaloperation.Theoperatorandfirstassistantshouldwearmasksandsterilegloves.Thepatientisinstructedtocleansethemouththoroughlywiththetoothbrushanda20percentalcoholmouthwash.Anydentaldefectsshould,iftimepermit,asinacourseofrepeatedtreatments,beremediedbythedentalsurgeon.Whenplacedonthetablewithneckbareandtheshouldersunhamperedbyclothing,thepatientiscoveredwithasterilesheetandtheheadisenfoldedinasteriletowel.Thefaceiswipedwith70percentalcohol.


17/153

Itistoberememberedthatwhilethepatientisrelativelyimmunetothebacteriahehimselfharbors,theimplantationofdifferentstrainsofperhapsthesametypeoforganismsmayprovevirulenttohim.Furthermorethetransferenceoflues,tuberculosis,diphtheria,pneumonia,erysipelasandotherinfectivediseaseswouldbeinevitableifsterileprecautionswerenottaken.

Allofthetubesandforcepsaresterilizedbyboiling.Thelight-carriersandlampsmaybesterilizedbyimmersionin95percentalcoholorbyprolongedexposuretoformaldehydegas.Continuoussterilizationbykeepingthemputawayinametalboxwithformalinpastillesorothersourceofformaldehydegasisanidealmethod.Knivesandscissorsareimmersedin95percentalcohol,andtherubbercoveredconductingcordsarewipedwiththesamesolution.

_ListofInstruments_.--Thefollowinglisthasbeencompiledasaconvenientbasisforequipment,towhichsuchspecialinstrumentsasmaybeneededforspecialcasescanbeaddedfromtimetotime.Theinstrumentslistedareoftheauthor'sdesign.1adult'slaryngoscope.1child'slaryngoscope.1infant'sdiagnosticlaryngoscope.1anteriorcommissurelaryngoscope.

1bronchoscope,4mm.X30cm.1bronchoscope,5mm.X30cm.1bronchoscope,7mm.X40cm.1bronchoscope,9mm.X40cm.1esophagoscope,7mm.X45cm.1esophagoscope,10mm.X53cm.1esophagoscope,fulllumen,7mm.X45cm.1esophagoscope,fulllumen,9mm.X45cm.1esophagealspeculum,adult.1esophagealspeculum,child.1forward-graspingforceps,delicate,40cm.1forward-graspingforceps,regular,50cm.1forward-graspingforceps,regular,60cm.

1side-graspingforceps,delicate,40cm.1side-graspingforceps,regular,50cm.1side-graspingforceps,regular,60cm.1rotationforceps,delicate,40cm.1rotationforceps,regular,50cm.1rotationforceps,regular,60cm.1laryngealalligatorforceps.1laryngealpapillomaforceps.10esophagealbougies,Nos.8to17French(largersizestoNo.36maybeadded).1specialmeasuringrule.6lightspongecarriers.1aspiratorwithdoubletubeforminusandpluspressure.

2endoscopicaspiratingtubes30and50cm.1halfcurvedhook,60cm.1triplecircuitbronchoscopybattery.6rubbercoveredconductingcordsforbattery.1boxbronchoscopicsponges,size4.1boxbronchoscopicsponges,size5.1boxbronchoscopicsponges,size7.1boxbronchoscopicsponges,size10.1biteblock,1adult.1biteblock,child.


18/153

2dozenextralampsforlightedinstruments.1extralightcarrierforeachinstrument.*4yardsofpipe-cleaning,worsted-coveredwire.

[*Messrs.GeorgeP.PillingandSonswhoarenowmakingtheseinstrumentssupplyanextralightcarrierand2extralampswitheachinstrument.]

_CareofInstruments_.--Theendoscopistmusteitherpersonallycareforhisinstruments,orhaveaninstrumentnurseinhisownemploy,foriftheyareintrustedtothegeneraloperatingroomroutinehewillfindthatsmallpartswillbelost;bladesofforcepsbent,broken,orrusted;tubesdinged;drainagecanalschokedwithbloodorsecretionswhichhavebeencoagulatedbyboiling,andelectricattachmentsrenderedunstableorunservicable,byboiling,etc.Thetubesshouldbecleansedbyforcingcoldwaterthroughthedrainagecanalswiththeaspiratingsyringe,thendriedbyforcingpipe-cleaningworsted-coveredwirethroughthelightanddrainagecanals.Gauzeonaspongecarrierisusedtocleanthemaincanal.Forcepsstyletsshouldberemovedfromtheircannulae,andthecannulaecleansedwithcoldwater,thendriedandoiledwiththepipe-cleaningmaterial.Thestyletshouldhaveanyroughplacessmoothedwithfineemeryclothanditsbladescarefullyinspected;thepartsarethenoiledandreassembled.Nickleplatingonthetubesis

apttopeelandthesescaleshavesharp,cuttingedgeswhichmayinjurethemucosa.Alltubes,therefore,shouldbeunplated.Roughplacesonthetubesshouldbesmoothedwiththefinestemerycloth,or,better,onabuffingwheel.Thedrycellsinthebatteryshouldberenewedaboutevery4monthswhetherusedornot.Lamps,lightcarriers,andcords,aftercleansing,arewipedwith95percentalcohol,andthelight-carrierswiththelampsinplacearekeptinacontinuoussterilizationboxcontainingformaldehydepastilles.Itisoftheutmostimportancethatinstrumentsbealwaysputawayinperfectorder.Notonlyarecleaningandoilingimperative,butanyneededrepairsshouldbeattendedtoatonce.Otherwiseitwillbeinevitablethatwhengottenoutinanemergencytheywillfail.Ingeneralsurgery,aspoonwillserveforaretractorandgoodworkcan

bedonewithmakeshifts;butinendoscopy,especiallyinthesmall,delicate,naturalpassagesofchildren,thehandicapofadefectiveorinsufficientarmamentariummaymakeallthedifferencebetweenasuccessandafatalfailure.Abronchoscopicclinicshouldatalltimesbeinthesamestateofpreparednessforemergencyasiseverywhererequiredofafire-enginehouse.

[PLATEI--AWORKINGSETOFTHEAUTHOR'SENDOSCOPICTUBESFORLARYNGOSCOPY,BRONCHOSCOPY,ESOPHAGOSCOPY,ANDGASTROSCOPY:A,Adult'slaryngoscope;B,child'slaryngoscope;C,anteriorcommissurelaryngoscope;D,esophagealspeculum,child'ssize;E,esophagealspeculum,adult'ssize;F,bronchoscope,infant'ssize,4

mm.X30cm.;G,bronchoscope,child'ssize,5mm.X30cm.;H,aspiratingbronchoscopeforadults,7mm.X40cm.;I,bronchoscope,adolescent'ssize,7mm.x40cm.,usedalsoforthedeeperbronchiofadults;J,bronchoscope,adultsize,gmm.x40cm.;K,child'ssizeesophagoscope,7mm.X45cm.;L,adult'ssizeesophagoscope,fulllumenconstruction,9mm.x45cm.;M,adult'ssizegastroscope.C,I,andEarealsohypopharyngoscopes.Cisanexcellentesophagealspeculumforchildren,andalongermodelismadeforadults.IftheutmosteconomymustbepractisedD,E,andMmaybeomitted.Thebalanceoftheinstrumentsareindispensableifadultsand


19/153

childrenaretobedealtwith.TheinstrumentsaremadebyCharlesJ.Pilling&Sons,Philadelphia.]

[52]CHAPTERII--ANATOMYOFLARYNX,TRACHEA,BRONCHIANDESOPHAGUS,ENDOSCOPICALLYCONSIDERED

The_larynx_isacartilaginousbox,triangularincross-section,withtheapexofthetriangledirectedanteriorly.Itisreadilyfeltintheneckandisalandmarkfortheoperationoftracheotomy.Weareconcernedendoscopicallywithfourofitscartilaginousstructures:theepiglottis,thetwoarytenoidcartilages,andthecricoidcartilage.The_epiglottis_,thefirstlandmarkindirectlaryngoscopy,isaleaf-likeprojectionspringingfromtheanterointernalsurfaceofthelarynxandhavingforitsfunctionthedirectingofthebolusoffoodintothepyriformsinuses.Itdoesnotclosethelarynxinthetrap-doormannerformerlytaught;afacteasilydemonstratedbythesimpleinsertionofthedirectlaryngoscopeandfurtherdemonstratedbytheabsenceofdysphagiawhentheepiglottisissurgicallyremoved,orisdestroyedbyulceration.Closureofthelarynxisaccomplishedbytheapproximationoftheventricularbands,arytenoidsandaryepiglotticfolds,thelatterhavingasphincter-likeaction,andbytheraisingandtiltingofthe

larynx.The_arytenoids_formtheupperposteriorboundaryofthelarynxandourparticularinterestinthemisdirectedtowardtheirmotility,fortherotationofthearytenoidsatthecricoarytenoidarticulationsdeterminesthemovementsofthecordsandtheproductionofvoice.Approximationofthearytenoidsisapartofthemechanismofclosureofthelarynx.

The_cricoidcartilage_wasregardedbyesophagoscopistsasthechiefobstructionencounteredontheintroductionoftheesophagoscope.Asshownbytheauthor,itisthecricopharyngealfold,andtheinconceivablypowerfulpullofthecricopharyngealmuscleonthecricoidcartilage,thatcausesthedifficulty.Thecricoidispulledsopowerfullybackagainstthecervicalspine,thatitishardto

believethatthismusclesisinsertedintothemedianrapheandnotintothespineitself(Fig.68).

The_ventricularbands_orfalsevocalcordsvicariouslyphonateintheabsenceofthetruecords,andassistintheprotectivefunctionofthelarynx.Theyformthefloorofthe_ventricles_ofthelarynx,whicharerecessesoneitherside,betweenthefalseandtruecords,andcontainnumerousmucousglandsthesecretionfromwhichlubricatesthecords.Theventriclesarenotvisiblebymirrorlaryngoscopy,butarereadilyexposedintheirdepthsbyliftingtherespectiveventricularbandswiththetipofthelaryngoscope.The_vocalcords_,whichappearwhite,flat,andribbon-likeinthemirror,whenvieweddirectlyassumeareddishcolor,andrevealtheirtrueshelf-like

formation.Inthesubglotticareathetissuesarevascular,and,inchildrenespecially,theyarepronetoswellwhentraumatized,afactwhichshouldbealwaysinmindtoemphasizetheimportanceofgentlenessinbronchoscopy,andfurthermore,thenecessityofavoidingthisregionintracheotomybecauseofthedangerofproducingchroniclaryngealstenosisbythereactionofthesetissuestothepresenceofthetracheotomiccannula.

The_trachea_justbelowitsentranceintothethoraxdeviatesslightlytotheright,toallowroomfortheaorta.Atthelevelof


20/153

thesecondcostalcartilage,thethirdinchildren,itbifurcatesintotherightandleftmainbronchi.Posteriorlythebifurcationcorrespondstoaboutthefourthorfifththoracicvertebra,thetracheabeingelastic,anddisplacedbyvariousmovements.Theendoscopicappearanceofthetracheaisthatofatubeflattenedonitsposteriorwall.Intwolocationsitnormallyoftenassumesamoreorlessovaloutline;inthecervicalregion,duetopressureofthethyroidgland;andintheintrathoracicportionjustabovethebifurcationwhereitiscrossedbytheaorta.Thislatterflatteningisrhythmicallyincreasedwitheachpulsation.Underpathologicalconditions,thetrachealoutlinemaybevariouslyaltered,eventoobliterationofthelumen.Themucosaofthetracheaandbronchiismoistandglistening,whitishincircularridgescorrespondingtothecartilaginousrings,andreddishintheinterveninggrooves.

Therightbronchusisshorter,wider,andmorenearlyverticalthanitsfellowoftheoppositeside,andispracticallythecontinuationofthetrachea,whiletheleftbronchusmightbeconsideredasabranch.Thedeviationoftherightmainbronchusisabout25degrees,anditslengthunbranchedintheadultisabout2.5cm.Thedeviationoftheleftmainbronchusisabout75degreesanditsadultlengthisabout5cm.Therightbronchusconsideredasastem,maybesaidtogiveoffthreebranches,theepiarterial,upper-orsuperior-lobebronchus;themiddle-lobebronchus;andthecontinuationdownward,

calledthelower-orinferior-lobebronchus,whichgivesoffdorsal,ventralandlateralbranches.Theleftmainbronchusgivesofffirsttheupper-orsuperior-lobebronchus,thecontinuationbeingthelower-orinferior-lobebronchus,consistingofastemwithdorsal,ventralandlateralbranches.

[FIG.44.--Tracheo-bronchialtree.LM,Leftmainbronchus;SL,superiorlobebronchus;ML,middlelobebronchus;IL,inferiorlobebronchus.]

Theseptumbetweentherightandleftmainbronchi,termedthecarina,issituatedtotheleftofthemidtrachealline.Itisrecognizedendoscopicallyasashort,shiningridgerunningsagitally,or,asthe

patientliesintherecumbentposition,wespeakofitasbeingvertical.Oneithersideareseentheopeningsoftherightandleftmainbronchi.InFig.44,itwillbeseenthatthelowerborderofthecarinaisonalevelwiththeupperportionoftheorificeoftherightsuperior-lobebronchus;withthecarinaasalandmarkandbydisplacingwiththebronchoscopethelateralwalloftherightmainbronchus,asecond,smaller,verticalspurappears,andaviewoftheorificeoftherightupper-lobebronchusisobtained,thoughalumenimagecannotbepresented.Onpassingdowntherightstembronchus(patientrecumbent)ahorizontalpartitionorspurisfoundwiththelumenofthemiddle-lobebronchusextendingtowardtheventralsurfaceofthebody.Allbelowthisopeningoftherightmiddle-lobebronchusconstitutesthelower-lobebronchusanditsbranches.

[FIG.45.--Bronchoscopicviews.S;Superiorlobebronchus;SL,superiorlobebronchus;I,inferiorlobebronchus;M,middlelobebronchus.]

[56]Comingbacktothecarinaandpassingdowntheleftbronchus,therelativelygreatdistancefromthecarinatotheupper-lobebronchusisnoted.Thespurdividingtheorificesoftheleftupper-andlower-lobebronchiisobliqueindirection,anditispossibletoseemoreofthelumenoftheleftupper-lobebronchusthanofits


21/153

homologueontheright.Belowthisareseenthelower-lobebronchusanditsdivisions(Fig.45).

_DimensionsoftheTracheaandBronchi_.--Itwillbenotedthatthebronchidividemonopodially,notdichotomously.Whiletheluminaoftheindividualbronchidiminishasthebronchidivide,thesumoftheareasshowsaprogressiveincreaseintotaltubularareaofcross-section.Thus,thesumoftheareasofcross-sectionofthetwomainbronchi,rightandleft,isgreaterthantheareaofcrosssectionofthetrachea.Thisfollowsthewellknowndynamiclaw.Therelativeincreaseinsurfaceasthetubesbranchanddiminishinsizeincreasesthefrictionofthepassingair,sothatanactualincreaseinareaofcrosssectionisnecessary,toavoidincreasingresistancetothepassageofair.

Thecadavericdimensionsofthetracheobronchialtreemaybeepitomizedapproximatelyasfollows:AdultMaleFemaleChildInfantDiametertrachea,14X2012X168X106X7Lengthtrachea,cm.12.010.06.04.0Lengthrightbronchus2.52.52.01.5Lengthleftbronchus5.05.03.02.5Lengthupperteethtotrachea15.023.010.09.0

Lengthtotaltosecondarybronchus32.028.019.015.0

Inconsideringtheforegoingtableitistoberememberedthatinlifemuscletonusvariesthelumenandonthewholerendersitsmaller.Intheselectionoftubesitmustberememberedthatthefulldiameterofthetracheaisnotavailableonaccountoftheglotticaperturewhichintheadultisatrianglemeasuringapproximately12X22X22mm.andpermittingthepassageofatubenotover10mm.indiameterwithoutriskofinjury.Furthermoreatubewhichfilledthetracheawouldbetoolargetoentereithermainbronchus.

Thenormalmovementsofthetracheaandbronchiarerespiratory,pulsatory,bechic,anddeglutitory.Thetwoformerarerhythmicwhile

thetwolatterareintermittentlynotedduringbronchoscopy.Itisreadilyobservedthatthebronchielongateandexpandduringinspirationwhileduringexpirationtheyshortenandcontract.Thebronchoscopistmustlearntoworkinspiteofthefactthatthebronchidilate,contract,elongate,shorten,kink,andaredingedandpushedthiswayandthat.Itisthisresiliencyandmovabilitythatmakebronchoscopypossible.Theinspiratoryenlargementoflumenopensuptheforcepsspaces,andthefacilebronchoscopistavailshimselfoftheopportunitytoseizetheforeignbody.

THEESOPHAGUS

Afewoftheanatomicaldetailsmustbekeptespeciallyinmindwhen

itisdesiredtointroducestraightandrigidinstrumentsdownthelumenofthegullet.Firstandmostimportantisthefactthattheesophagealwallsareexceedinglythinanddelicateandrequirethemostcarefulmanipulation.Becauseofthisdelicacyofthewallsandbecausetheesophagus,beingaconstantpassagewayforbacteriafromthemouthtothestomach,isneversterile,surgicalproceduresareassociatedwithinfectiverisks.Forsomeotherandnotfullyunderstoodreason,theesophagusis,surgicallyspeaking,oneofthemostintolerantofallhumanviscera.Theanteriorwalloftheesophagusisinapartofitscourse,incloserelationtothe


22/153

posteriorwallofthetrachea,andthisportioniscalledthepartywall.Itisthispartywallthatcontainsthelymphdrainagesystemoftheposteriorportionofthelarynx,anditislargelybythisroutethatposteriorlylocatedmalignantlaryngealneoplasmsearlymetastasizetothemediastinum.

[58][FIG46.--EsophagoscopicandGastroscopicChart

BIRTH1yr.3yrs.6yrs.10yrs.14yrs.ADULTS23273033364353Cm.GREATERCURVATURE18202225273440Cm.CARDIA19212324253136Cm.HIATUS13151618202427Cm.LEFTBRONCHUS12141516172123Cm.AORTA791011121416Cm.CRICOPHARYINGEUS0000000Cm.INCISORSFIG.46.--Theauthor'sesophagoscopicchartofapproximatedistancesoftheesophagealnarrowingsfromtheupperincisorteeth,arrangedforconvenientreferenceduringesophagoscopyinthedorsallyrecumbentpatient.]

ThelengthsoftheesophagusatdifferentagesareshowndiagrammaticallyinFig.46.Thediameteroftheesophageallumenvariesgreatlywiththeelasticityoftheesophagealwalls;its

diameteratthefourpointsofanatomicalconstrictionisshowninthefollowingtable:

ConstrictionDiameterVertebra

CricopharyngealTransverse23mm.(1in.)SixthcervicalAntero-posterior17mm.(3/4in.)AorticTransverse24mm.(1in.)FourththoracicAntero-posterior19mm.(3/4in.)Left-bronchialTransverse23mm.(1in.)FifththoracicAntero-posterior17mm.(3/4in.)DiaphragmaticTransverse23mm.(1in+)TenththoracicAntero-posterior23mm.(in.--)

Forpracticalendoscopicpurposesitisonlynecessarytorememberthatinanormalesophagus,straightandrigidtubesof7mm.diametershouldpassfreelyininfants,andinadults,tubesof10mm.

The4demonstrableconstrictionsfromabovedownwardareat1.Thecrico-pharyngealfold.2.Thecrossingoftheaorta.3.Thecrossingoftheleftbronchus.4.Thehiatusesophageus.Thereisadefinitefifthnarrowingoftheesophageallumennoteasilydemonstratedesophagoscopicallyandnotseenduringdissection,butreadilyshownfunctionallybythefactthatalmostallforeignbodies

lodgeatthispoint.Thisnarrowingoccursatthesuperiorapertureofthethoraxandisprobablyproducedbythecrowdingofthenumerousorganswhichenterorleavethethoraxthroughthisorifice.

_Thecrico-pharyngealconstriction_,asalreadymentioned,isproducedbythetoniccontractionofaspecializedbandoftheorbicularfibersofthelowermostportionoftheinferiorpharyngealconstrictormuscle,calledthecricopharyngealmuscle.Asshownbytheauthoritisthismuscleandnotthecricoidcartilagealonethatcausesthedifficultyintheinsertionofanesophagoscope.


23/153

Thismuscleisattachedlaterallytotheedgesofthesignetofthecricoidwhichitpullswithanincomprehensiblepoweragainsttheposteriorwallofthehypopharynx,thusclosingthemouthoftheesophagus.Itsotherattachmentisinthemedianposteriorraphe.Betweenthesecircularfibers(thecricopharyngealmuscle)andtheobliquefibersoftheinferiorconstrictormusclethereisaweaklysupportedpointthroughwhichtheesophagealwallmayherniatetoformtheso-calledpulsiondiverticulum.Itisatthisweakpointthatfatalesophagoscopicperforationbyinexperiencedoperatorsismostlikelytooccur.

_Theaorticnarrowing_oftheesophagusmaynotbenoticedatallifthepatientisplacedinthepropersequential"high-low"position.Itisonlywhenthetube-mouthisdirectedagainsttheleftanteriorwallthattheactivelypulsatingaortaisfelt.

Thebronchialnarrowingoftheesophagusisduetobackwarddisplacementcausedbythepassageoftheleftbronchusovertheanteriorwalloftheesophagusatabout27cm.fromtheupperteethintheadult.Theridgeisquiteprominentinsomepatients,especiallythosewithdilatationfromstenoseslowerdown.

Thehiatalnarrowingisbothanatomicandspasmodic.Thepeculiar

arrangementofthetendinousandmuscularstructureofthediaphragmactsonthishiatalopeninginasphincter-likefashion.Therearealsospecialbundlesofmusclefibersextendingfromthecruraofthediaphragmandsurroundingtheesophagus,whichcontributetotonicclosureinthesamewaythatapinch-cockclosesarubbertube.Theauthorhascalledthehiatalclosurethe"diaphragmaticpinchcock."

_DirectionoftheEsophagus_.--Theesophagusentersthechestinadecidedlybackwardaswellasdownwarddirection,paralleltothatofthetrachea,followingthecurvesofthecervicalandupperdorsalspine.Belowtheleftbronchustheesophagusturnsforward,passingthroughthehiatusinthediaphragmanteriortoandtotheleftoftheaorta.Thelowerthirdoftheesophagusinadditiontoitsanterior

curvatureturnsstronglytotheleft,sothatanesophagoscopeinsertedfromtherightangleofthemouth,whenintroducedintothestomach,pointsinthedirectionoftheanteriorsuperiorspineoftheleftileum.

Itisnecessarytokeepthisgeneralcourseconstantlyinmindinallcasesofesophagoscopy,butparticularlyinthosecasesinwhichthereismarkeddilatationoftheesophagusfollowingspasmatthediaphragmlevel.Insuchcasestheaidofthisknowledgeofdirectionwillgreatlysimplifythefindingofthehiatusesophageusinthefloorofthedilatation.

Theextrinsicortransmittedmovementsoftheesophagusare

respiratoryandpulsatory,andtoaslightextent,bechic.Therespiratorymovementsconsistinadilatationoropeningupofthethoracicesophageallumenduringinspiration,duetothenegativeintrathoracicpressure.Thenormalpulsatorymovementsareduetothepulsatilepressureoftheaorta,foundatthe4ththoracicvertebra(24cm.fromtheupperteethintheadult),andoftheheartitself,mostmarkedlyfeltatthelevelofthe7thand8ththoracicvertebrae(about30cm.fromtheupperteethinadults).Asthedistancesofallthenarrowingsvarywithage,itisusefultoframeandhangupforreferenceacopyofthechart(Fig.46).


24/153

Theintrinsicmovementsoftheesophagusareinvoluntarymuscularcontractions,asindeglutitionandregurgitation;spasmodic,thelatterusuallyhavingsomepathologiccause;andtonic,asthenormalhiatalclosure,intheauthor'sopinionmaybeconsidered.Swallowingmaybeinvoluntaryorvoluntary.Theconstrictorsareanatomicallynotconsideredpartofesophagusproper.Whentheconstrictorsvoluntarilydelivertheboluspastthecricopharyngealfold,theinvoluntaryorperistalticcontractionsoftheesophagealmuralmusculaturecarrythebolusondownward.Thereisnosphincteratthecardiacendoftheesophagus.Thesiteofspasmodicstenosisinthelowerthird,theso-calledcardiospasm,wasfirstdemonstratedbytheauthortobelocatedatthehiatusesophageusandthespasmodiccontractionsareofthespecializedmusclefibersthereencirclingtheesophagus,andmightbetermed"phrenospasm,"or"hiatalesophagismus."Regurgitationoffoodfromthestomachisnormallypreventedbythehiatalmusculardiaphragmaticclosure(calledbytheauthorthe"diaphragmaticpinchcock")plusthekinkingoftheabdominalesophagus.

Intheauthor'sopinionthereisnospasminthediseasecalled"cardiospasm."Itissimplythefailureofthediaphragmaticpinchcocktoopennormallyinthedeglutitorycycle.Abetternameisfunctionalhiatalstenosis.

Atretrogradeesophagoscopythecardiaandabdominalesophagusdonotseemtoexist.Thetopofthestomachseemstobeclosedbythediaphragmaticpinchcockinthesamewaythatthetopofabagisclosedbyapuckeringstring.

[63]CHAPTERIII--PREPARATIONOFTHEPATIENTFORPERORALENDOSCOPY

Thesuggestionsoftheauthorintheearliervolumesinregardtopreparationofthepatient,asforanyoperation,byabath,laxative,etc.,andespeciallybyspecialcleansingofthemouthwith25percentalcohol,havereceivedgeneralendorsement.Careshouldbetaken

nottosetupunduereactionbyvigorousscrubbingofgumsunaccustomedtoit.Artificialdenturesshouldberemoved.Evenifnoanestheticistobeused,thepatientshouldbefastedforfivehoursifpossible,evenfordirectlaryngoscopyinordertoforestallvomiting.Exceptinemergencycaseseverypatientshouldbegoneoverbyaninternistfororganicdiseaseinanyform.Ifanendolaryngealoperationisneededbyanephritic,preparatorytreatmentmaypreventlaryngealedemaorothercomplications.Hemophiliashouldbethoughtof.Itisquitecommonforthefirstsymptomofanaorticaneurysmtobeanimpairedpowertoswallow,orthelodgmentofabolusofmeatorotherforeignbody.Ifaneurysmispresentandesophagoscopyisnecessary,asitalwaysisinforeignbodycases,"tobefore-warnedistobeforearmed."Pulmonarytuberculosisisoftenunsuspectedin

veryyoungchildren.Thereisgreatdangerfromtrachealpressurebyanesophagealdiverticulumordilatationdistendedwithfood;orthefoodmayberegurgitatedandaspiratedintothelarynxandtrachea.Therefore,inallesophagealcasestheesophagusshouldbeemptiedbyregurgitationinducedbytitillatingthefauceswiththefingerafterswallowingatumblerfulofwater,pressureontheneck,etc.Aspirationwillsucceedinsomecases.Inothersitisabsolutelynecessarytoremovefoodwiththeesophagoscope.Iftheaspiratingtubebecomescloggedbysolidfood,themethodofswabaspirationmentionedunderbronchoscopywillsucceed.Ofcoursethereisusuallynocoughtoaid,


25/153

buttheinvoluntaryabdominalandthoraciccompressionhelps.Shouldapatientarriveinaseriousstateofwater-hunger,aspartofthepreparationthepatientmustbegivenwaterbyhypodermoclysisandenteroclysis,andifnecessarytheendoscopy,exceptindyspneiccases,mustbedelayeduntilthedangerofwater-starvationispast.

AspointedoutbyEllenJ.Pattersonthesizeofthethymusglandshouldbestudiedbeforeanesophagoscopyisdoneonachild.

Everypatientshouldbeexaminedbyindirect,mirrorlaryngoscopyasapreliminarytoperoralendoscopyforanypurposewhatsoever.Thisbecomesdoublynecessaryincasesthataretobeanesthetized.

[65]CHAPTERIV--ANESTHESIAFORPERORALENDOSCOPY

Adyspneicpatientshouldneverbegivenageneralanesthetic.Cocaineshouldnotbeusedonchildrenundertenyearsofagebecauseofitsextremetoxicity.Tothesetwopostulatesalwaysinmind,athirdone,applicabletobothgeneralandlocalanesthesia,istobeadded--totalabolitionofthecough-reflexshouldbeforshortperiodsonly.GeneralanesthesiaisneverusedintheBronchoscopicClinicforendoscopicprocedures.Thechoiceforeachoperatormust,however,be

amatterforindividualdecision,andwilldependuponthepersonalequation,anddegreeofskilloftheoperator,andhisabilitytoquiettheapprehensionsofthepatient.Inotherwords,theoperatormustdecidewhatisbestforhisparticularpatientundertheconditionsthenexisting.

_Children_intheBronchoscopicClinicreceiveneitherlocalnorgeneralanesthesia,norsedative,forlaryngoscopicoperationsoresophagoscopy.Bronchoscopyintheolderchildrenwhennodyspneaispresenthasinrecentyears,atthesuggestionofProf.Hare,beenprecededbyafulldoseofmorphinsulphate(i.e.,1/8grainforachildofsixyears)orafullphysiologicdoseofsodiumbromide.Theapprehensionisthussomewhatallayedandtheexcessivecough-reflex

quieted.Themorphineshouldbegivennotlessthananhourandahalfbeforebronchoscopytoallowtimefortheonsetofthesoporificandantispasmodiceffectswhicharethedesiderata,nottheanalgesiceffects.Dosageismoredependentontemperamentthanonageorbodyweight.Atropineisadvantageouslyaddedtomorphineinbronchoscopyforforeignbodies,notonlyfortheusualreasonsbutforitseffectasanantispasmodic,andespeciallyforitsdiminutionofendobronchialsecretions.True,itdoesnotdiminishpus,butbydiminishingtheoutpouringofnormalsecretionsthatdilutethepusthetotalquantityoffluidencounteredislessthanitotherwisewouldbe.Incasesoflargequantitiesofpus,asinpulmonaryabscessandbronchiectasis,however,nodiminutionisnoticeable.Nofoodorwaterisallowedfor5hourspriortoanyendoscopicprocedure,

whethersedativesoranestheticsaretobegivenornot.Ifthestomachisnotemptyvomitingfromcontactofthetubeinthepharynxwillinterferewithwork.

With_adults_noanesthesia,generalorlocal,isgivenforesophagoscopy.Forlaryngealoperationandbronchoscopythefollowingtechnicisused:

Onehourbeforeoperationthepatientisgivenhypodermaticallyafullphysiologicdoseofmorphinsulphate(from1/4,to3/8gr.)guarded


26/153

withatropinsulphate(gr.1/150).Caremustbetakenthattheinjectionbenotgivenintoavein.Ontheoperatingtabletheepiglottisandpharynxarepaintedwith10percentsolutionofcocain.Twoapplicationsareusuallysufficientcompletelytoanesthetizetheexteriorandinteriorofthelarynxbyblockingofthesuperiorlaryngealnervewithoutanyendolaryngealapplications.Thelaryngoscopeisnowintroducedandiffoundnecessarya20percentcocainsolutionisappliedtotheinteriorofthelarynxandsubglotticregion,bymeansofgauzeswabsfastenedtothespongecarriers.Herealsotwoapplicationsarequitesufficienttoproducecompleteanesthesiainthelarynx.Ifbronchoscopyistobedonethegauzeswabiscarrieddownthroughtheexposedglottistothecarina,thusanesthetizingthetrachealmucosa.Iffurtheranesthetizationofthebronchialmucosaisrequired,cocainmaybeappliedinthesamemannerthroughthebronchoscope.Inalltheselocalapplicationsprolongedcontactoftheswabismuchmoreefficientthansimplypaintingthesurface.

[67]Incasesinwhichcocainisdeemedcontraindicatedmorphinaloneisused.Ifgiveninsufficientdosagecocaincanbealtogetherdispensedwithinanycase.

Itisperhaps_saferforthebeginner_inhisearlycasesofesophagoscopytohavethepatientrelaxedbyanetheranesthesia,

providedthepatientisnotdyspneictobeginwith,ormadesobyfaultypositionorbypressureoftheesophagoscopictubemouthonthetracheoesophageal"partywall."Asproficiencydevelops,however,hewillfindanesthesiaunnecessary.Localanesthesiaisneedlessforesophagoscopy,andifusedatallshouldbelimitedtothelaryngopharynxandneverappliedtotheesophagus,fortheesophagusiswithoutsensation,asanyonemayobserveindrinkinghotliquids.

_Directlaryngoscopyinchildren_requiresneitherlocalnorgeneralanesthesia,eitherfordiagnosisorforremovalofforeignbodiesorgrowthsfromthelarynx.Generalanesthesiaiscontraindicatedbecauseofthedyspneaapttobepresent,andbecausethestrugglesofthepatientmightcauseadislodgmentofthelaryngealintruderand

aspirationtoalowerlevel.Thelatteraccidentisalsopronetofollowattemptstococainizethelarynx.

_TechnicforGeneralAnesthesia_.--Foresophagoscopyandgastroscopy,ifgeneralanesthesiaisdesired,ethermaybestartedbytheusualmethodandcontinuedbydroppinguponfoldedgauzelaidoverthemouthafterthetubeisintroduced.Endo-trachealadministrationofetheris,however,farsaferthanperoraladministration,foritovercomesthedangerofrespiratoryarrestfrompressureoftheesophagoscope,foreignbody,orboth,onthetrachea.Chloroformshouldnotbeusedforesophagoscopyorgastroscopybecauseofitsdepressantactionontherespiratorycenter.

Forbronchoscopy,etherorchloroformmaybestartedintheusualwayandcontinuedbyinsufflatingthroughthebranchtubeofthebronchoscopebymeansoftheapparatusshowninFig.13.

Incaseofparalysisofthelarynx,evenifonlymonolateral,ageneralanestheticifneededshouldbegivenbyintratrachealinsufflation.Iftheapparatusforthisisnotavailablethepatientshouldbetracheotomized.Hence,everyadultpatientshouldbeexaminedwithathroatmirrorbeforegeneralanesthesiaforanypurpose,andthenecessitybecomesdoublyimperativebeforegoiter


27/153

operations.Anumberoffatalitieshaveoccurredfromneglectofthisprecaution.

_Anesthetizingatracheotomizedpatient_isfreefromdangersolongasthecannulaiskeptfreefromsecretion.Etherisdroppedongauzelaidoverthetracheotomiccannulaandtheanesthesiawatchedintheusualmanner.Ifthelaryngealstenosisisnotcomplete,ether-saturatedgauzeistobeplacedoverthemouthaswellasoverthetracheotomytube.

_Endo-trachealanesthesia_isbyfarthesafestwayfortheadministrationofetherforanypurpose.Bymeansofthesilk-wovencatheterintroducedintothetrachea,ether-ladenairfromaninsufflationapparatusispipeddowntothelungscontinuously,andthestrongreturn-flowpreventsbloodandsecretionsfromenteringthelowerair-passages.Thecathetershouldbeofasize,relativetothatoftheglotticchink,topermitafreereturn-flow.Anumber24Frenchisreadilyaccommodatedbytheadultlarynxandlieswelloutofthewayalongtheposteriorwallofthelarynx.Becauseofthelittleroomoccupiedbytheinsufflationcatheterthismethodaffordsidealanesthesiaforexternallaryngealoperations.Operationsonthenose,accessorysinusesandthepharynx,apttobeattendedbyconsiderablebleeding,arerenderedfreefromthedangerofaspirationpneumoniaby

endotrachealanesthesia.Itisthesafestanesthesiaforgoiteroperations.Endo-trachealanesthesiahasrenderedneedlesstheintricatenegativepressurechamberformerlyrequiredforthoracicsurgery,forbyproperregulationofthepressureunderwhichtheetherladenedairisdelivered,alungmaybeheldinanydesireddegreeofexpansionwhenthepleuralcavityisopened.Itisindicatedinoperationsofthehead,neck,orthorax,inwhichthereisdangerofrespiratoryarrestbycentricinhibitionorperipheralpressure;inoperationsinwhichthereisapossibilityofexcessivebleedingandaspirationofbloodorsecretions;andinoperationswhereitisdesiredtokeeptheanesthetistawayfromtheoperatingfield.Variousformsofapparatusforthedeliveryoftheether-ladenvaporaresuppliedbyinstrumentmakerswithexplicitdirectionsastotheir

mechanicalmanagement.

Weareconcernedheremainlywiththetechnicoftheinsertionoftheintratrachealtube.Thelarynxshouldbeexaminedwiththemirror,preferablybeforethedayofoperation,forevidenceofdisease,andincidentallytodeterminethesizeofthecathetertobeintroduced,thoughthelattercanbedeterminedafterthelarynxislaryngoscopicallyexposed.Thefollowinglistofrulesfortheintroductionofthecatheterwillbeofservice(seeFig.59).

RULESFORINSERTIONOFTHECATHETERFORINSUFFLATIONANESTHESIA

1.Thepatientshouldbefullyundertheanestheticbytheopenmethodsoastogetfullrelaxationofthemusclesoftheneck.2.Thepatient'sheadmustbeinfullextensionwiththevertexfirmlypusheddowntowardthefeetofthepatient,soastothrowtheneckupwardandbringtheocciputdownascloseaspossiblebeneaththecervicalvertebrae.3.Nogagshouldbeused,becausethepatientshouldbesufficientlyanesthetizednottoneedagag,andbecausewidegaggingdefeatstheexposureofthelarynxbyjammingdownthemandible.4.Theepiglottismustbeidentifiedbeforeitispassed.


28/153

5.Thespeculummustpasssufficientlyfarbelowthetipoftheepiglottissothatthelatterwillnotslip.6.Toodeepinsertionmustbeavoided,asinthiscasethespeculumgoesposteriortothecricoid,andthecricoidislifted,exposingthemouthoftheesophagus,whichisbewilderinguntilsufficienteducationoftheeyeenablestheoperatortorecognizethelandmarks.7.Thepatient'sheadisliftedoffthetablebythespatulartipofthelaryngoscope.Actualliftingoftheheadwillnotbenecessaryifthepatientisfullyrelaxed;buttheideaofliftingconveystheproperconceptionoflaryngealexposure(Fig.55).

[71]CHAPTERV--BRONCHOSCOPICOXYGENINSUFFLATION

Bronchoscopicoxygeninsufflationisalife-savingmeasureequalledbynoothermethodknowntothescienceofmedicine,inallcasesofasphyxia,orapnea,presentorimpending.Itsespecialsphereofusefulnessisinseverecasesofelectricshock,hanging,smokeasphyxia,strangulation,suffocation,thoracicorabdominalpressure,apnea,acutetraumaticpneumothorax,respiratoryarrestfromabsenceofsufficientoxygen,orapneafromthepresenceofquantitiesofirrespirableorirritantgases.Combinedwithbronchoscopicaspirationofsecretionsitisthebestmethodoftreatmentforpoisoningby

chlorinegas,asphyxiating,andotherwargases.

Bronchoscopicoxygeninsufflationshouldbetaughttoeveryinterneineveryhospital.Theemergencyoraccidentwardofeveryhospitalshouldhavethenecessaryequipmentandaninternefamiliarwithitsuse.Themethodissimple,oncetheknackisacquired.Thepatientbeinglimpandrecumbentonatable,thelarynxisexposedwiththelaryngoscope,andthebronchoscopeisinsertedashereinafterdescribed.Theoxygenisturnedonatthetankandtheflowregulatedbeforetherubbertubefromthewash-bottleoftankisattachedtotheside-outletofthebronchoscope.Itisnecessarytobecertainthattheflowisgentle,sothat,withafreereturnflowtheintroducedpressuredoesnotexceedthecapillarypressure;otherwisetheblood

willbeforcedoutofthecapillariesandtheischemiaofthelungswillbefatal.Anotherdangeristhatoverdistensioncausesinhibitionofinspirationresultinginapneacontinuingaslongasthedistensionismaintained,ifnotlonger.Thereturnflowfromthebronchoscopeshouldbeinterruptedfor2or3secondsseveraltimesaminutetoinflatethelungs,buttheflowmustnotbeoccludedlongerthan3seconds,becausetheintrapulmonarypressurewouldrise.Apearlofamylnitritemaybebrokeninthewashbottle.Slowrhythmicartificialrespiratorymovementsareausefuladjunct,andunlesstheoperatorisveryskillfulingaugingthealternatepressuresandreleaseswiththethumbaccordingtotheoxygenpressure,itisvitallynecessarytofillanddeflatethelungsrhythmicallybyoneofthewellknownmethodsofartificialrespiration.Anyoneskilledin

theintroductionofthebronchoscopecandobronchoscopyinafewseconds,anditisespeciallyeasyincasesofrespiratoryarrest,becauseofthelimpconditionofthepatient.

Theforegoingappliestocasesinwhichapulmotorwouldbeused,suchasapneafromelectricshocks,etc.Forobstructivedyspneaandasphyxia,tracheotomyistheprocedureofchoice,andtheskillfultracheotomistwouldbejustifiedinpreferringtracheotomyfortheotherclassofcases,insufflatingtheoxygenandamylnitritethroughthetracheotomicwound.Thepulmotorandsimilarmechanismsare,


29/153

perhaps,thebestthingstheuseofwhichcanbetaughttolaymen;butascomparedtobronchoscopicoxygeninsufflationtheyarewoefullyinefficient,becausetheintraoralpressureforcesthetonguebackoverthelaryngealorifice,obstructingtheairwayinthis"deathzone."Bytheintroductionofthebronchoscopethisdeathzoneisentirelyeliminated,andafreeairwayestablishedforpipingtheoxygendirectlyintothelungs.

[73]CHAPTERVI--POSITIONOFTHEPATIENTFORPERORALENDOSCOPY

Itistheauthor'sinvariablepracticetoplacethepatientinthedorsallyrecumbentposition.Thesittingpositionislessfavorable.Whilelyingonawell-padded,flattablethepatientisreadilycontrolled,theheadisfreelymovable,secretionscanbeeasilyremoved,theviewobtainedbytheendoscopististrulydirect(withoutreversalofsides),and,mostimportant,theemploymentofonepositiononlyfavorssmootherandmoreefficientteamwork,andabetterendoscopictechnic.

_GeneralPrinciplesofPosition_.--AswillbeseeninFig.47thetracheaandesophagusarenothorizontalinthethorax,buttheirlongaxesfollowthecurvesofthecervicalanddorsalspine.Therefore,if

wearetobringthebuccalcavityandpharynxinastraightlinewiththetracheaandesophagusitwillbefoundnecessarytoelevatethewholeheadabovetheplaneofthetable,andatthesametimemakeextensionattheoccipito-atloidjoint.BythismaneuverthecervicalspineisbroughtinlinewiththeupperportionofthedorsalspineasshowninFig.55.Itwasformerlytaught,andofteninspiteofmybetterknowledgeIamstillunconsciouslypronetoallowtheheadandcervicalspinetoassumealowerpositionthantheplaneofthetable,theso-calledRoseposition.Withtheheadsoplaced,itisimpossibletoenterthelowerairorfoodpassageswitharigidtube,aswillbeshownbyastudyoftheradiographshowninFig.49.Extensionoftheheadontheoccipito-atloidjointisforthepurposeoffreeingthetubefromtheteeth,andtheamountrequiredwillvarywiththedegree

towhichthemouthcanbeopened.Whethertheheadbeextended,flexed,orkeptmid-way,thefundamentalprincipleintheintroductionofallendoscopictubesistheanteriorplacingofthecervicalspineandthehighelevationofthehead.Theesophagus,justbehindtheheart,turnsventrallyandtotheleft.Inordertopassarigidtubethroughthisventralcurvethedorsalspineisnowextendedbyloweringtheheadandshouldersbelowtheplaneofthetable.Thiswillbefurtherexplainedinthechapteronesophagoscopy.Inalloftheseprocedures,thenoseofthepatientshouldbedirectedtowardthezenith,andtheassistantshould_preventrotationofthehead_aswellas_preventloweringofthehead_.Thepatientshouldbeurgedasfollows:"Don'tholdyourselfsorigid."

"Letyourheadandneckgoloose.""Letyourheadrestinmyhand.""Don'ttrytoholdit.""Letmeholdit.""Relax.""Don'traiseyourchest."

[FIG.47.--Schematicillustrationofnormalpositionoftheintra-thoracictracheaandesophagusandalsooftheentiretracheawhenthepatientisinthecorrectpositionforperoralbronchoscopy.


30/153

Whentheheadisthrownbackward(asintheRoseposition)theanteriorconvexityofthecervicalspineistransmittedtothetracheaandesophagusandtheiraxesdeviated.Theanteriordeviationofthelowerthirdoftheesophagusshowstheanatomicalbasisforthe"highlow"positionforesophagoscopy]

[FIG.48.--Correctpositionofthecervicalspineforesophagoscopyandbronchoscopy.(_Illustrationreproducedfromauthor'sarticleJour.Am.Med.Assoc.,Sept.25,1909_)]

[FIG.49.--Curvedpositionofthecervicalspine,withanteriorconvexity,intheRoseposition,renderingesophagoscopyandbronchoscopydifficultorimpossible.Thedeviouscourseofthepharynx,larynxandtracheaareplainlyvisible.Theextensionisincorrectlyimpartedtothewholecervicalspineinsteadofonlytotheoccipito-atloidjoint.Thisistheusualandveryfaultyconceptionoftheextendedposition.(_Illustrationreproducedfromauthor'sarticle,Jour.Am.Med.Assoc.,Sept.25,1909._)]

[76]For_directlaryngoscopy_thepatient'sheadisraisedabovetheplaneofthetablebythefirstassistant,whostandstotherightofthepatient,holdingthebiteblockonhisrightthumbinsertedintheleftcornerofthepatient'smouth,whilehisextendedrighthandlies

alongtheleftsideofthepatient'scheekandhead,andpreventsrotation.Hislefthand,placedunderthepatient'socciput,elevatestheheadandmaintainsthedesireddegreeofextensionattheoccipito-atloidjoint(Fig.50).

[FIG50.--Directlaryngoscopy,recumbentpatient.ThesecondassistantissittingholdingtheheadintheBoyceposition,hisleftforearmonhisleftthighhisleftfootonastoolwhosetopis65cm.lowerthanthetable-top.Hislefthandisonthepatient'ssterile-coveredscalp,thethumbontheforehead,thefingersundertheocciput,makingforcedextension.Therightforearmpassesundertheneckofthepatient,sothattheindexfingeroftherighthandholdsthebite-blockintheleftcornerofthepatient'smouth.Thefingersof

theoperator'srighthandpullstheupperlipoutofalldangerofgettingpinchedbetweentheteethandthelaryngoscope.Thisisaprecautionoftheutmostimportanceandthetrainedhabitofdoingitmustbedevelopedbytheperoralendoscopist.]

_PositionforBronchoscopyandEsophagoscopy_.--Thedorsallyrecumbentpatientissoplacedthattheheadandshouldersextendbeyondthetable,theedgeofwhichsupportsthethoraxataboutthelevelofthescapulae.Duringintroduction,theheadmustbemaintainedinthesamerelativepositiontothetableasthatdescribedfordirectlaryngoscopy,thatis,elevatedandextended.Thefirstassistant,inthiscase,sitsonastooltotherightofthepatient'shead,hisleftfootrestingonaboxabout14inchesinheight,theleftknee

supportingtheassistant'slefthand,whichbeingplacedundertheocciputofthepatientmaintainselevationandextension.Therightarmoftheassistantpassesundertheneckofthepatient,thebiteblockbeingcarriedonthemiddlefingeroftherighthandandinsertedintotheleftsideofthepatient'smouth.Therighthandalsopreventsrotationofthehead(Fig.51).Asthebronchoscopeoresophagoscopeisfurtherinserted,theheadmustbeplacedsothatthetubecorrespondstotheaxisofthelumenofthepassagetobeexamined.Iftheleftbronchusisbeingexplored,theheadmustbebroughtstronglytotheright.Iftherightmiddlelobebronchusis


31/153

beingsearched,theheadwouldrequiresomeleftlateraldeflectionandaconsiderabledegreeoflowering,forthisbronchus,asbeforementioned,extendsanteriorly.Duringesophagoscopywhentheleveloftheheartisreached,theheadandupperthoraxmustbestronglydepressedbelowtheplaneofthetableinordertofollowtheaxisofthelumenoftheventrallyturningesophagus;atthesametimetheheadmustbebroughtsomewhattotheright,sincetheesophagusinthisregiondeviatesstronglytotheleft.

[FIG.51.--Positionofpatientandassistantforintroductionofthebronchoscopeandesophagoscope.Themiddleofthescapulaerestontheedgeofthetable;theheadandshoulders,freetomove,aresupportedbytheassistant,whoserightarmpassesundertheneck;therightmiddlefingerinsertsthebiteblockintotheleftsideofthemouth.Thelefthand,restingontheleftkneemaintainsthedesireddegreeofelevation,extensionandlateraldeflectionrequiredbytheoperator.Thepatient'svertexshouldbe10cm.higherthanthelevelofthetopofthetable.ThisistheBoyceposition,whichhasneverbeenimproveduponforbronchoscopyandesophagoscopy.]

[FIG.52.--Schemaofpositionforendoscopy.A.Normalrecumbencyonthetablewithpillowsupportingthehead.Thelarynxcanbedirectlyexaminedinthisposition,butabetterpositionisobtainable.

B.Headisraisedtoproperpositionwithheadflexed.Musclesoffrontofneckarerelaxedandexposureoflarynxthusrenderedeasier;but,formostendoscopicwork,acertainamountofextensionisdesired.Theelevationistheimportantthing.C.TheneckbeingmaintainedinpositionB,thedesiredamountofextensionoftheheadisobtainedbyamovementlimitedtotheoccipito-atloidarticulationbytheassistant'shandplacedasshownbythedart(B).D.Faultyposition.Unlessprevented,almostallpatientswillheaveupthechestandarchthelumbarspinesoastodefeattheobjectandtorenderendoscopydifficultbybringingthechestuptothehigh-heldhead,thusassumingthesamerelationoftheheadtothechestasexistsintheRoseposition(afaultyoneforendoscopy)as

willbeunderstoodbyassumingthatthedottedline,E,representsthetable.Ifthepelvisbenothelddowntothetablethepatientmayevenassumetheopisthotonouspositionbysupportinghisweightonhisheelsonthetableandhisheadontheassistant'shand.]

Inobtainingthepositionofhighheadwithoccipito-atloidextension,theeasiestandmostcertainmethod,aspointedouttomebymyassistant,GabrielTucker,isfirsttoraisethehead,stronglyflexed,asshowninFig.52;thenwhilemaintainingitthere,maketheoccipito-atloidextension.Thishasprovenbetterthantoelevateandextendinacombinedsimultaneousmovement.

Ifthepatientwouldrelaxtolimpnessexposureofthelarynxwouldbe

easilyobtained,simplybyliftingtheheadwiththelipofthelaryngoscopepassedbelowthetipoftheepiglottis(asinFig.55)andnoholdingoftheheadw

bronchoscopy and esophagoscopya manual of peroral endoscopy and laryngeal surgery by jackson,...

Documents