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| T he halved joint is frequently known as half-lapping, and sometimes as checking and half-checking. In the majority of cases it is made by halving the two pieces, i.e., by cutting half the depth of the wood away. There are, however, exceptions ... Read more of The Halved Joint at Wood Workings.ca | Informational Privacy |
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Introduction Of The EsophagoscopeCategory: INTRODUCTION OF THE ESOPHAGOSCOPE Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery The esophagoscope is to be passed only with ocular guidance, never blindly with a mandrin or obturator, as was done before the bevel-ended esophagoscope was developed. Blind introduction of the esophagoscope is equally as dangerous as blind bouginage. It is almost certain to cause over-riding of foreign bodies and disease. In either condition perforation of the esophagus is possible by pushing a sharp foreign body through the normal wall or by penetrating a wall weakened by disease. Landmarks must be identified as reached, in order to know the locality reached. The secretions present form sufficient lubrication for the instrument. A clear conception of the endoscopic anatomy, the narrowings, direction, and changes of direction of the axis of the esophagus, are necessary. The services of a trained assistant to place the head in the proper sequential high-low positions are indispensible (Figs. 52 and 70). Introduction may be divided into four stages. 1. Entering the right pyriform sinus. 2. Passing the cricopharyngeus. 3. Passing through the thoracic esophagus. 4. Passing through the hiatus. The patient is placed in the Boyce position as described in Chapter VI. As previously stated, the esophagus in its upper portion follows the curves of the cervical and dorsal spine. It is necessary, therefore, to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head--the high position (Figs. 66-71). [PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY THE AUTHOR: 1, Direct view of the larynx and laryngopharynx in the dorsally recumbent patient, the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum. The spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands. Posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition. The esophagoscope should be passed to the right of the median line into the right pyriform sinus, represented here by the right arm of the dark crescent. 2, The right pyriform sinus in the dorsally recumbent patient, the eminence at the upper left border, corresponds to the edge of the cricoid cartilage. 3, The cricopharyngeal constriction of the esophagus in the dorsally recumbent patient, the cricoid cartilage being lifted forward with the esophageal speculum. The lower (posterior) half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall. (Compare Fig. 10.) This view is not obtained with an esophagoscope. 4, Passing through the right pyriform sinus with the esophagoscope; dorsally recumbent patient. The walls seem in tight apposition, and, at the edges of the slit-like lumen, bulge toward the observer. The direction of the axis of the slit varies, and in some instances it is like a rosette, depending on the degree of spasm. 5, Cervical esophagus. The lumen is not so patulent during inspiration as lower down; and it closes completely during expiration. 6, Thoracic esophagus; dorsally recumbent patient. The ridge crossing above the lumen corresponds to the left bronchus. It is seldom so prominent as in this patient, but can always be found if searched for. 7, The normal esophagus at the hiatus. This is often mistaken for the cardia by esophagoscopists. It is more truly a sphincter than the cardia itself. In the author's opinion there is no truly sphincteric action at the cardia. It is the failure of this hiatal sphincter to open as in the normal deglutitory cycle that produces the syndrome called cardiospasm. 8, View in the stomach with the open-tube gastroscope. The form of the folds varies continually. 9, Sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years. Seen through the esophageal speculum, patient sitting. The lumen of the mouth of the esophagus, much encroached upon by the sarcomatous infiltration, is seen at the lower part of the circle. 10, Coin (half-dollar) wedged in the upper third of the esophagus of a boy aged fourteen years. Seen through the esophageal speculum, recumbent patient. Forceps are retracting the posterior lip of the esophageal mouth preparatory to removal. 11, Fungating squamous-celled epithelioma in a man of seventy-four years. Fungations are not always present, and are often pale and edematous. 12, Cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years. Below tile upper stricture is seen a second stricture. An ulcer surrounded by an inflammatory areola and the granulation tissue together illustrates the etiology of cicatricial tissue. The fan-shaped scar is really almost linear, but it is viewed in perspective. Patient was cured by esophagoscopic dilatation. 13, Angioma of the esophagus in a man of forty years. The patient had hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the esophagus 26 cm. from the upper teeth in a woman of thirty-eight years. Two scars from healed ulcerations are seen in perspective on the anterior wall. Branching vessels are seen in the livid areola of the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four years. 16, Leukoplakia of the esophagus near the hiatus in a man aged fifty-six years.] The hypopharynx tapers down to the gullet like a funnel, and the larynx is suspended in its lumen from the anterior wall. The larynx is attached only to the anterior wall, but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx, and particularly by its specialized portion--the cricopharyngeus muscle. A bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses, the recesses seen on either side of the larynx. But little of the food bolus passes posterior to the larynx during the act of swallowing. It is through the pyriform sinus that the esophagoscope is to be inserted, thereby following the natural food passage. To insert the esophagoscope in the midline, posterior to the arytenoids, requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall, or to both. The esophagoscope is steadied by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooked over the upper teeth, while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth. The right hand holds the tube in pen fashion at the collar of the handle, not by the handle. During introduction the handle is to be pointed upward toward the zenith. Next: Stage I Entering The Right Pyriform Sinus Previous: Entering The Bronchi
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