[FIG 43.—The author's retrograde esophagoscope.]
Oxygen Tank and Tracheotomy Instruments.—Respiratory arrest may occur from shifting of a foreign body, pressure of the esophagoscope, tumor, or diverticulum full of food. Rare as these contingencies are, it is essential that means for resuscitation be at hand. No endoscopic procedure should be undertaken without a set of tracheotomy instruments on the sterile table within instant reach. In respiratory arrest from the above mentioned causes, respiratory efforts are not apt to return unless oxygen and amyl nitrite are blown into the trachea either through a tracheotomy opening or better still by means of a bronchoscope introduced through the larynx. The limpness of the patient renders bronchoscopy so easy that the well-drilled bronchoscopist should have no difficulty in inserting a bronchoscope in 10 or 15 seconds, if proper preparedness has been observed. It is perhaps relatively rarely that such accidents occur, yet if preparations are made for such a contingency, a life may be saved which would otherwise be inevitably lost. The oxygen tank covered with a sterile muslin cover should stand to the left of the operating table.
Asepsis.—Strict aseptic technic must be observed in all endoscopic procedures. The operator, first assistant, and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation. The operator and first assistant should wear masks and sterile gloves. The patient is instructed to cleanse the mouth thoroughly with the tooth brush and a 20 per cent alcohol mouth wash. Any dental defects should, if time permit, as in a course of repeated treatments, be remedied by the dental surgeon. When placed on the table with neck bare and the shoulders unhampered by clothing, the patient is covered with a sterile sheet and the head is enfolded in a sterile towel. The face is wiped with 70 per cent alcohol.
It is to be remembered that while the patient is relatively immune to the bacteria he himself harbors, the implantation of different strains of perhaps the same type of organisms may prove virulent to him. Furthermore the transference of lues, tuberculosis, diphtheria, pneumonia, erysipelas and other infective diseases would be inevitable if sterile precautions were not taken.
All of the tubes and forceps are sterilized by boiling. The light-carriers and lamps may be sterilized by immersion in 95 per cent alcohol or by prolonged exposure to formaldehyde gas. Continuous sterilization by keeping them put away in a metal box with formalin pastilles or other source of formaldehyde gas is an ideal method. Knives and scissors are immersed in 95 per cent alcohol, and the rubber covered conducting cords are wiped with the same solution.
List of Instruments.—The following list has been compiled as a
convenient basis for equipment, to which such special instruments as
may be needed for special cases can be added from time to time. The
instruments listed are of the author's design.
1 adult's laryngoscope.
1 child's laryngoscope.
1 infant's diagnostic laryngoscope.
1 anterior commissure laryngoscope.
1 bronchoscope, 4 mm. X 30 cm.
1 bronchoscope, 5 mm. X 30 cm.
1 bronchoscope, 7 mm. X 40 cm.
1 bronchoscope, 9 mm. X 40 cm.
1 esophagoscope, 7 mm. X 45 cm.
1 esophagoscope, 10 mm. X 53 cm.
1 esophagoscope, full lumen, 7 mm. X 45 cm.
1 esophagoscope, full lumen, 9 mm. X 45 cm.
1 esophageal speculum, adult.
1 esophageal speculum, child.
1 forward-grasping forceps, delicate, 40 cm.
1 forward-grasping forceps, regular, 50 cm.
1 forward-grasping forceps, regular, 60 cm.
1 side-grasping forceps, delicate, 40 cm.
1 side-grasping forceps, regular, 50 cm.
1 side-grasping forceps, regular, 60 cm.
1 rotation forceps, delicate, 40 cm.
1 rotation forceps, regular, 50 cm.
1 rotation forceps, regular, 60 cm.
1 laryngeal alligator forceps.
1 laryngeal papilloma forceps.
10 esophageal bougies, Nos. 8 to 17 French (larger sizes to No. 36
may be added).
1 special measuring rule.
6 light sponge carriers.
1 aspirator with double tube for minus and plus pressure.
2 endoscopic aspirating tubes 30 and 50 cm.
1 half curved hook, 60 cm.
1 triple circuit bronchoscopy battery.
6 rubber covered conducting cords for battery.
1 box bronchoscopic sponges, size 4.
1 box bronchoscopic sponges, size 5.
1 box bronchoscopic sponges, size 7.
1 box bronchoscopic sponges, size 10.
1 bite block, 1 adult.
1 bite block, child.
2 dozen extra lamps for lighted instruments.
1 extra light carrier for each instrument.*
4 yards of pipe-cleaning, worsted-covered wire.
[* Messrs. George P. Pilling and Sons who are now making these instruments supply an extra light carrier and 2 extra lamps with each instrument.]
Care of Instruments.—The endoscopist must either personally care for his instruments, or have an instrument nurse in his own employ, for if they are intrusted to the general operating room routine he will find that small parts will be lost; blades of forceps bent, broken, or rusted; tubes dinged; drainage canals choked with blood or secretions which have been coagulated by boiling, and electric attachments rendered unstable or unservicable, by boiling, etc. The tubes should be cleansed by forcing cold water through the drainage canals with the aspirating syringe, then dried by forcing pipe-cleaning worsted-covered wire through the light and drainage canals. Gauze on a sponge carrier is used to clean the main canal. Forceps stylets should be removed from their cannulae, and the cannulae cleansed with cold water, then dried and oiled with the pipe-cleaning material. The stylet should have any rough places smoothed with fine emery cloth and its blades carefully inspected; the parts are then oiled and reassembled. Nickle plating on the tubes is apt to peel and these scales have sharp, cutting edges which may injure the mucosa. All tubes, therefore, should be unplated. Rough places on the tubes should be smoothed with the finest emery cloth, or, better, on a buffing wheel. The dry cells in the battery should be renewed about every 4 months whether used or not. Lamps, light carriers, and cords, after cleansing, are wiped with 95 per cent alcohol, and the light-carriers with the lamps in place are kept in a continuous sterilization box containing formaldehyde pastilles. It is of the utmost importance that instruments be always put away in perfect order. Not only are cleaning and oiling imperative, but any needed repairs should be attended to at once. Otherwise it will be inevitable that when gotten out in an emergency they will fail. In general surgery, a spoon will serve for a retractor and good work can be done with makeshifts; but in endoscopy, especially in the small, delicate, natural passages of children, the handicap of a defective or insufficient armamentarium may make all the difference between a success and a fatal failure. A bronchoscopic clinic should at all times be in the same state of preparedness for emergency as is everywhere required of a fire-engine house.
[PLATE I—A WORKING SET OF THE AUTHOR'S ENDOSCOPIC TUBES FOR LARYNGOSCOPY, BRONCHOSCOPY, ESOPHAGOSCOPY, AND GASTROSCOPY: A, Adult's laryngoscope; B, child's laryngoscope; C, anterior commissure laryngoscope; D, esophageal speculum, child's size; E, esophageal speculum, adult's size; F, bronchoscope, infant's size, 4 mm. X 30 cm.; G, bronchoscope, child's size, 5 mm. X 30 cm.; H, aspirating bronchoscope for adults, 7 mm. X 40 cm.; I, bronchoscope, adolescent's size, 7 mm. x 40 cm., used also for the deeper bronchi of adults; J, bronchoscope, adult size, g mm. x 40 cm.; K, child's size esophagoscope, 7 mm. X 45 cm.; L, adult's size esophagoscope, full lumen construction, 9 mm. x 45 cm.; M, adult's size gastroscope. C, I, and E are also hypopharyngoscopes. C is an excellent esophageal speculum for children, and a longer model is made for adults. If the utmost economy must be practised D, E, and M may be omitted. The balance of the instruments are indispensable if adults and children are to be dealt with. The instruments are made by Charles J. Pilling & Sons, Philadelphia.]