Bronchoscopy and Esophagoscopy | Page 9

The
stretching is here produced by the spring of the blades of the forceps
and not by manual force. The closed blades are to be inserted through
the strictured area, opened, and then slowly withdrawn. For cicatricial
stenoses of the trachea the metallic bougies, Fig. 40, are useful. For the
larynx, those shown in Fig. 41 are needed.
[FIG. 34.--A, Mosher's laryngeal curette; B, author's flat blade cautery
electrode; C, pointed cautery electrode; D, laryngeal knife. The
electrodes are insulated with hard-rubber vulcanized onto the
conducting wires.]
[FIG. 35.--Retrograde esophageal bougies in graduated sizes devised
by Dr. Gabriel Tucker and the author for dilatation of cicatricial
esophageal stenosis. They are drawn upward by an endless swallowed
string, and are therefore only to be used in gastrostomized cases.]
[FIG. 36.--Author's bronchoscopic and esophagoscopic mechanical
spoon, made in 40, 50 and 60 cm. lengths.]
[FIG. 37.--Schema illustrating the author's method of endoscopic
closure of open safety pins lodged point upward The closer is passed
down under ocular control until the ring, R, is below the pin. The ring
is then erected to the position shown dotted at M, by moving the handle,
H, downward to L and locking it there with the latch, Z. The fork, A, is
then inserted and, engaging the pin at the spring loop, K, the pin is
pushed into the ring, thus closing the pin. Slight rotation of the pin with
the forceps may be necessary to get the point into the keeper. The upper

instrument is sometimes useful as a mechanical spoon for removing
large, smooth foreign bodies from the esophagus.]
Esophageal Dilators.--The dilatation of cicatricial stenosis of the
esophagus can be done safely only by endoscopic methods. Blind
esophageal bouginage is highly dangerous, for the lumen of the
stricture is usually eccentric and the bougie is therefore apt to perforate
the wall rather than find the small opening. Often there is present a
pouching of the esophagus above a stricture, in which the bougie may
lodge and perforate. Bougies should be introduced under visual
guidance through the esophagoscope, which is so placed that the lumen
of the stricture is in the center of the endoscopic field. The author's
endoscopic bougies (Fig. 40) are made with a flexible silk-woven tip
securely fastened to a steel shaft. This shaft lends rigidity to the
instrument sufficient to permit its accurate placement, and its small size
permits the eye to keep the silk-woven tip in view. These endoscopic
bougies are made in sizes from 8 to 40, French scale. The larger sizes
are used especially for the dilatation of laryngeal and tracheal stenoses.
For the latter work it is essential that the bougies be inspected carefully
before they are used, for should a defective tip come off while in the
lower air passages a difficult foreign body problem would be created.
Soft-rubber retrograde dilators to be drawn upward from the stomach
by a swallowed string are useful in gastrostomized cases (Fig. 35).
[FIG 38.--Half curved hook, 45 cm. and 60 cm. Full curved patterns are
made but caution is necessary to avoid them becoming anchored in the
bronchi. Spiral forms avoid this. The author makes for himself steel
probe-pointed rods out of which he bends hooks of any desired shape.
The rod is held in a pin-vise to facilitate bending of the point, after
heating in an alcohol or bunsen flame.]
Hooks.--No hook greater than a right angle should be used through
endoscopic tubes; for should it become caught in some of the smaller
bronchi its extraction might result in serious trauma. The half curved
hook shown in Fig. 38 is the safest type; better still, a spiral twist to the
hook will add to its uses, and by reversing the turning motion it may be
"unscrewed" out if it becomes caught. Hooks may easily be made from

rods of malleable steel by heating the end in a spirit lamp and shaping
the curve as desired by means of a pin-vise and pliers. About 2 cm. of
the proximal end of the rod should be bent in exactly the opposite
direction from that of the hook so as to form a handle which will tell
the position of the hook by touch as well as by sight. Coil-spring hooks
for the upper-lobe-bronchus (Fig. 39) will reach around the corner into
the ascending bronchus of the upper-lobe-bronchus, but the utmost skill
and care are required to make their use justifiable.
[FIG. 39.--Author's coil-spring hook for the upper-lobe, bronchus]
Safety-pin Closer.--There are a number of methods for the endoscopic
removal of open safety-pins when the point is up, one of which is by
closing the pin with the instrument shown in Fig. 37 in the following
manner. The oval ring is passed through the endoscope until it is
beyond the spring of the