Bronchoscopy and Esophagoscopy | Page 2

substitute, or to improvise makeshifts, while the bronchoscope is in situ. Furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them.
Laryngoscopes.--The regular type of laryngoscope shown in Fig. I (A, B, C) is made in adult's, child's, and infant's sizes. The instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. The infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. For operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. With this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (Fig. 1, D). The tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be passed through the adult glottis for work in the subglottic region. This instrument may also be used as an esophageal speculum and as a pleuroscope. A side-slide laryngoscope, used with or without the slide, is occasionally useful.
Bronchoscopes.--The regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. An auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. Numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. The accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).
For certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful The drainage canal may be on top, or on the under surface next to the light-carrier canal. For ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (Q.V.) which at the same time cleans the lamp. The drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome.
As before mentioned, the lower air passages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the passages to be examined. Four sizes are sufficient for any possible case, from a newborn infant to the largest adult. For infants under one year, the proper tube is the 4 mm. by 30 cm.; the child's size, 5 mm. by 30 cm., is used for children aged from one to five years. For children six years or over, the 7 mm. by 40 cm. bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. The adult bronchoscope measures 9 mm. by 40 cm.
The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35 cm., 8 mm. x 40 cm.
Esophagoscopes.-The esophagoscope, like the bronchoscope, is a hollow brass tube with beveled distal end containing a small electric light. It differs from the bronchoscope in that it has no perforations, and has a drainage canal on its upper surface, or next to the light-carrier canal which opens within the distal end of the tube. The exact size, position, and shape of the drainage outlets is important on bronchoscopes, and to an even greater degree on esophagoscopes. If the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube, the mucosa will be drawn into the outlet, not only obstructing it, but, most important, traumatizing the mucosa. If, for instance, the esophagoscope were to be pushed upon with a fold thus anchored in the distal end, the esophageal wall could easily be torn. To admit the largest sizes of esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are made with both light canal and drainage canal outside the lumen of the tube, leaving the full area of luminal cross-section unencroached upon. They can, of course, be used for all purposes, but the slightly greater circumference is