[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 safety-pin, the ring is then turned upward by depressing the handle, and by the aid of the prong the pin is pushed into the ring, which action approximates the point of the pin and the keeper and closes the pin. Removal is then less difficult and without danger. This instrument may also be used as a mechanical spoon, in which case it may be passed to the side of a difficultly grasped foreign body, such as a pebble, the ring elevated and the object withdrawn. Elsewhere will be found a description of the various safety-pin closers devised by various endoscopists. The author has used Arrowsmith's closer with much satisfaction.
Mechanical Spoon.—When soft, friable substances, such as a bolus of meat, become impacted in the upper esophagus, the short mechanical spoon (Fig. 30) used through the esophageal speculum is of great aid in their removal. The blade in this instrument, as the name suggests, is a spoon and is not fenestrated as is the safety-pin closer, which if used for friable substances would allow them to slip through the fenestration. A longer form for use through bronchoscopes and esophagoscopes is shown in Fig. 36.
A laryngeal curette, cautery electrodes, cautery handle, and laryngeal knife are illustrated in Fig. 34. The cautery is to be used with a transformer, or a storage battery.
Spectacles.—If the operator has no refractive error he will need two pairs of plane protective spectacles with very large "eyes." If ametropic, corrective lenses are necessary, and duplicate spectacles must be in charge of a nurse. For presbyopia two pairs of spectacles for 40 cm. distance and 65 cm. distance must be at hand. Hook temple frames should be used so that they can be easily changed and adjusted by the nurse when the lenses become spattered. The spectacle nurse has ready at all times the extra spectacles, cleaned and warmed in a pan of heated water so that they will not be fogged by the patient's breath, and she changes them without delay as often as they become soiled. The operator should work with both eyes open and with his right eye at the tube mouth. The operating room should be somewhat darkened so as to facilitate the ignoring of the image in the left eye; any lighting should be at the operator's back, and should be insufficient to cause reflections from the inner surface of his glasses.
[FIG. 40.—The author's endoscopic bougies. The end consists of a flexible silk woven tip attached securely to a steel shank. Sizes 8 to 30 French catheter scale. A metallic form of this bougie is useful in the trachea; but is not so safe for esophageal use.]
[FIG. 41.—The author's laryngeal bougie for the dilatation of cicatricial laryngeal stenosis. Made in 10 sizes. The shaded triangle shows the cross-section at the widest part.]
[FIG. 42.—The author's bronchoscopic and esophagoscopic table.]
[46] Endoscopic Table.—Any operating table may be used, but the work is facilitated if a special table can be had which allows the placing of the patient in all required positions. The table illustrated in fig. 42 is so arranged that when the false top is drawn forward on the railroad, the head piece drops and the patient is placed in the correct (Boyce) position for esophagoscopy or bronchoscopy, i.e., with the head and shoulders extending over the end of the table. By means of the wheel the plane of the table may be altered to any desired angle of inclination or height of head.
Operating Room.—All endoscopic procedures should be performed in a somewhat darkened operating room where all the desired materials are at hand. An endoscopic team consists of three persons: the operator, the assistant who holds the head, and the instrument assistant. Another person is required to hold the patient's arms and still another for the changing of the operator's glasses when they become spattered. The endoscopic team of three maintain surgical asepsis in the matter of hands and gowns, etc. The battery, on a small table of its own, is placed at the left hand of the operator. Beyond it is the table for the mechanical aspirator, if one is used. All extra instruments are placed on a sterile table, within reach, but not in the way, while those instruments for use in the particular operation are placed on a small instrument table back of the endoscopist. Only those instruments likely to be wanted should be placed on the working table, so that there shall be no confusion in their selection by the instrument nurse when called for. Each moment of time should be utilized when the endoscopic procedure has been started, no time should be lost in the hunting or separating of instruments. To have the respective tables always in the same position relative to the operator prevents confusion and avoids delay.