Bronchoscopy and Esophagoscopy / A Manual of Peroral Endoscopy and Laryngeal Surgery

by Chevalier Jackson

[158] CHAPTER XV—MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION*

* For more extensive consideration of mechanical problems than is here possible the reader is referred to the Bibliography, page 311, especially reference numbers 1, 11, 37 and 56.

The endoscopic extraction of a foreign body is a mechanical problem pure and simple, and must be studied from this viewpoint. Hasty, ill-equipped, ill-planned, or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal, is never justifiable. While the lodgement of an organic foreign body (such as a nut kernel) in the bronchus calls for prompt removal and might be included under the list of emergency operations, time is always available for complete preparation, for thorough study of the patient, and localization of the intruder. The patient is better off with the foreign body in the lung than if in its removal a mediastinitis, rupture into the pleura, or tearing of a thoracic blood vessel has resulted. The motto of the endoscopist should be "I will do no harm." If no harm be inflicted, any number of bronchoscopies can be done at suitable intervals, and eventually success will be achieved, whereas if mortality results, all opportunity ceases.

The first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes; (1) anteroposterior, (2) lateral, and (3) the plane corresponding to the greatest plane of the foreign body. The next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to, and try to simulate the probable position shown by the ray, so as to get an idea of the bronchoscopic appearance of the probable presentation. Then the duplicate foreign body is turned into as many different positions as possible, so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient. For each of these presentations a method of disimpaction, disengagement, disentanglement or version and seizure is worked out, according to the kind of foreign body. Prepared by this practice and the radiographic study, the bronchoscope is introduced into the patient. The location of the foreign body is approached slowly and carefully to avoid overriding or displacement. A study of the presentation is as necessary for the bronchoscopist as for the obstetrician. It should be made with a view to determining the following points: 1. The relation of the presenting part to the surrounding tissues. 2. The probable position of the unseen portion, as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study, and by inspection of the ray plate upside down on view in front of the bronchoscopist. 3. The version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement. 4. The best instruments to use, and which to use first, as, hook, pincloser, forceps, etc. 5. The presence and position of the "forceps spaces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion space" for any other instrument.

Until all of these points are determined it is a grave error to insert any kind of instrument. If possible even swabbing of the foreign body should be avoided by swabbing out the bronchus, when necessary, before the region of the intruder is reached. When the operator has determined the instrument to be used, and the method of using it, the instrument is cautiously inserted, under guidance of the eye.

[160] The lip of the bronchoscope is one of the most valuable aids in the solution of foreign-body problems. With it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps; edematous mucosa may be displaced, angles straightened and space made at the side of the foreign body for the forceps' jaw. It forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body. With the bronchoscopic lip and the forceps or other instrument inserted through the tube, the bronchoscopist has bimanual, eye-guided control, which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork, will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments.

The relation of the tube mouth and foreign body is of vital importance. Generally considered, the tube mouth should be as near the foreign body as possible, and the object must be placed in the center of the bronchoscopic field, so that the ends of the open jaws of the forceps will pass sufficiently far over the object. But little lateral control is had of the long instruments inserted through the tube; sidewise motion is obtained by a shifting of the end of the bronchoscope. When the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping, it is important that this position be maintained by anchoring the tube to the upper teeth with the left, third, and fourth fingers hooked over the patient's upper alveolus (Fig. 63)

The Light Reflex on the Forceps.—It is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. On slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. It is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. This assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination.

Hooks are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. Hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed. A right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (Bib. 11, p. 311).

The Use of Forceps in Endoscopic Foreign Body Extraction.—Two different strengths of forceps are supplied, as will be seen in the list in Chapter 1. The regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. For more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. Spring-opposed forceps render any delicacy of touch impossible. Forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. These fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in Fig. 78. It is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. The impulse to seize the object as soon as it is discovered must be strongly resisted. A careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. The most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open V, a sufficient distance to afford a good grasp. The blades are then closed and the foreign body is drawn against the tube mouth. Few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together.

[FIG. 78.—Proper hold of forceps. The right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. All traction is made with the index finger, the ring fingers being used only to open and close the forceps. If any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.]

Anchoring the Foreign Body Against the Tube Mouth.—If withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. This is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in Fig. 79. The left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. Thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis.

[FIG. 79—Method of anchoring the foreign body against the tube mouth After the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube, the other fingers of the left hand encircle the tube. Withdrawal is then done with the left hand; the fingers of the right hand maintaining closure of the forceps.]

[164] Bringing the Foreign Body Through the Glottis.—Stripping of
the foreign body from the forceps at the glottis may be due to:
1. Not keeping the object against the tube mouth as just mentioned.
2. Not bringing the greatest diameter of the foreign body into the
sagittal plane of the glottic chink.
3. Faulty application of the forceps on the foreign body.
4. Mechanically imperfect forceps.

Should the foreign body be lost at the glottis it may, if large become impacted and threaten asphyxia. Prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps. The object may be dropped or expelled into the pharynx and be swallowed. It may even be coughed into the naso-pharynx or it may be re-aspirated. In the latter event the bronchoscope is to be re-inserted and the trachea carefully searched. Care must be used not to override the object. If much inflammatory reaction has occurred in the first invaded bronchus, temporarily suspending the aerating function of the corresponding lung, reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus, by reason of the greater inspiratory volume of air entering that side. This may produce sudden death by blocking the only aerating organ.

Extraction of Pins, Needles and Similar Long Pointed Objects.—When searching for such objects especial care must be taken not to override them. Pins are almost always found point upward, and the dictum can therefore be made, "Search not for the pin, but for the point of the pin." If the point be found free, it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube. It may then be seized with the forceps and withdrawn. Should the pin be grasped by the shaft, it is almost certain to turn crosswise of the tube mouth, where one pull may cause the point to perforate, enormously increasing the difficulties by transfixation, and perhaps resulting fatally (Fig. 80).

[FIG. 80.—Schematic illustration of a serious phase of the error of hastily seizing a transfixed pin near its middle, when first seen as at M. Traction with the forceps in the direction of the dart in Schema B will rip open the esophagus or bronchus inflicting fatal trauma, and probably the pin will be stripped off at the glottic or the cricopharyngeal level, respectively. The point of the pin must be disembedded and gotten into the tube mouth as at A, to make forceps traction safe.]

[FIG. 81.—Schema illustrating the mechanical problem of extracting a pin, a large part of whose shaft is buried in the bronchial wall, B. The pin must be pushed downward and if the orifice of the branches, C, D, are too small to admit the head of the pin some other orifice (as at A) must be found by palpation (not by violent pushing) to admit the head, so that the pin can be pushed downward permitting the point to emerge (E). The point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps, as shown at F.]

Inward Rotation Method.—When the point is found to be buried in the mucosa, the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps, then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees. The point is thus disengaged, and the shaft of the pin is brought parallel with that of the forceps, after which the point may be drawn into the tube mouth. The lips added to the side-curved forceps by my assistant Dr. Gabriel Tucker I now use exclusively for this inward rotation method. They are invaluable in preventing the escape of the pin during the manipulation. A hook is sometimes useful in disengaging a buried point. The method of its use is illustrated in Fig. 82.

[FIG. 82.—Mechanical problem of pin, needle, tack or nail with embedded point. If the forceps are pulled upon the pin point will be buried still deeper. The side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube. If the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above The side curved forceps may be used instead of the hook for freeing the point, the author's "inward rotation" method. The very best instrument for the purpose is the forceps devised by my assistant, Dr. Gabriel Tucker (Fig. 21). The lips prevent all risk of losing the pin from the grasp, and at the same time bring the long axis of the pin parallel to that of the bronchoscope.]

Pins are very prone to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration. At other times, pins not dropping so deeply may show the point only during expiration or cough, at which times the bronchi are shortened. In such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible; the forceps are now inserted, opened, and the next emergence watched for, the point being grasped as soon as seen.

Extraction of Tacks, Nails and Large Headed Foreign Bodies from the Tracheobronchial Tree.—In cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. The author's inward-rotation method when executed with the Tucker forceps is ideal. The large head, however, presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis (Fig. 83). The extraction problems of tacks are illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various tacks are dealt with in the same manner by the author's "inward rotation" method.

Hollow metallic bodies presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in Figs 23 and 25, or its edge may be grasped by the regular side-grasping forceps. The latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps; but with care it is the best method. Should the closed end be uppermost, however, it may be necessary to insert a hook beyond the object, and to coax it upward to a point where it may be turned for grasping and removal with forceps.

[FIG. 83.—"Mushroom anchor" problem of the upholstery tack. If the tack has not been in situ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma, provided axis-traction only be used. If the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor. Otherwise traction may rupture the bronchial wall. The stenotic tissue in cases of a few months' sojourn maybe composed of granulations, in which case axis-traction will safely withdraw it. The point of a tack rarely projects freely into the lumen as here shown. More often it is buried in the wall.]

[168] [FIG. 84.-Schema illustrating the "mushroom anchor" problem of the brass headed upholstery tack. At A the tack is shown with the head bedded in swollen mucosa. The bronchoscopist, looking through the bronchoscope, E, considering himself lucky to have found the point of the tack, seizes it and starts to withdraw it, making traction as shown by the dart in drawing B. The head of the tack catches below a chondrial ring and rips in, tearing its way through the bronchial wall (D) causing death by mediastinal emphysema. This accident is still more likely to occur if, as often happens, the tack-head is lodged in the orifice of the upper lobe bronchus, F. But if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction, as shown at C, the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage. If necessary, in addition, the lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, H. If the swollen mucosa, H, has been replaced by fibrous tissue from many months' sojourn of the tack, the stenosis may require dilatation with the divulsor.]

[FIG. 85.—Problem of the upholstery tack with buried point. If pulled upon, the imminent perforation of the mediastinum, as shown at A will be completed, the bronchus will be torn and death will follow even if the tack be removed, which is of doubtful possibility. The proper method is gently to close the side curved forceps on the shank of the tack near the head, push downward as shown by the dart, in B, until the point emerges. Then the forceps are rotated to bring the point of the tack away from the bronchial wall.]

[169] Removal of Open Safety Pins from the Trachea and Bronchi.— Removal of a closed safety pin presents no difficulty if it is grasped at one or the other end. A grasp in the middle produces a "toggle and ring" action which would prevent extraction. When the safety pin is open with the point downward care must be exercised not to override it with the bronchoscope or to push the point through the wall. The spring or near end is to be grasped with the side-curved or the rotation forceps (Figs. 19, 20 and 31) and pulled into the bronchoscope, thus closing the pin. An open safety pin lodged point up presents an entirely different and a very difficult problem. If traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced. The pin may be closed with the pin-closer as illustrated in Fig. 37, and then removed with forceps. Arrowsmith's pin-closer is excellent. Another method (Fig. 87) consists in bringing the point of the safety pin into the bronchoscope, after disengaging the point with the side curved forceps, by the author's "inward rotation" method. The forceps-jaws (Fig. 21) devised recently by my assistant, Dr. Gabriel Tucker, are ideal for this maneuver. As the point is now protected, the spring, seen just off the tube mouth, is best grasped with the rotation forceps, which afford the securest hold. The keeper and its shaft are outside the bronchoscope, but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin. Care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly, for the reason that the base of the glottic triangle is posterior, and that the posterior wall of the larynx is membranous above the cricoid cartilage, and will yield. A small safety-pin may be removed by version, the point being turned into a branch bronchial orifice. No one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin. This practice should be carried out by anyone expecting to do endoscopy, because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body. Then, when a safety pin case is encountered, the bronchoscopist will be prepared to cope with its difficulties, and he will be able to determine which of the methods will be best suited to his personal equation in the particular case.

[FIG. 86.—Schema illustrating the "upper-lobe-bronchus problem," combined with the "mushroom-anchor" problem and the author's method for their solution. The patient being recumbent, the bronchoscopist looking down the right main bronchus, M, sees the point of the tack projecting from the right upper-lobe-bronchus, A. He seizes the point with the side-curved forceps; then slides down the bronchoscope to the position shown dotted at B. Next he pushes the bronchoscopic tube-mouth downward and medianward, simultaneously moving the patient's head to the right, thus swinging the bronchoscopic level on its fulcrum, and dragging the tack downward and inward out of its bed, to the position, 1). Traction, as shown at C, will then safely and easily withdraw the tack. A very small bronchoscope is essential. The lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over, and the lip must be brought close to the tack just before the prying-pushing movement. S, right stem-bronchus.]

[FIG. 87.—One method of dealing with an open safety pin without closing it.]

Removal of Double Pointed Tacks.—If the tack or staple be small, and lodged in a relatively large trachea a version may be done. That is, the staple may be turned over with the hook or rotation forceps and brought out with the points trailing. With a long staple in a child's trachea the best method is to "coax" the intruder along gently under ocular guidance, never making traction enough to bury the point deeply, and lifting the point with the hook whenever it shows any inclination to enter the wall. Great care and dexterity are required to get the intruder through the glottis. In certain locations, one or both points may be turned into branch bronchi as illustrated in Fig. 88, or over the carina into the opposite main bronchus. Another method is to get both points into the tube-mouth. This may be favored, as demonstrated by my assistant, Dr. Gabriel Tucker, by tilting the staple so as to get both points into the longest diameter of the tube-mouth. In some cases I have squeezed the bronchoscope in a vise to create an oval tube-mouth. In other cases I have used expanding forceps with grooved blades.

[FIG. 88.-Schema illustrating podalic version of bronchially-lodged staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa covering points of staple. At E the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices, B, C. Traction being made in the direction of the dart (F), by means of the rotation forceps, and counterpressure being made with the bronchoscopic lip on the points of the staple, the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind (K).]

The Extraction of Tightly Fitting Foreign Bodies from the Bronchi. Annular Edema.—Such objects as marbles, pebbles, corks, etc., are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter. The air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. A ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. A forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body; but usually the attempt to apply forceps when there are no spaces between the presenting part of the foreign body and the bronchial wall, will result only in pushing the foreign body deeper.* A better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point, so that a hook may be introduced below the foreign body, which then can be worked up to a wider place where forceps may be applied (Fig. 89). Sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted. For this the unslanted tube-mouth is used.

* The author's new ball forceps are very successful with ball-bearing balls and marbles.

[FIG. 89.—Schema illustrating the use of the lip of the bronchoscope in disimpaction of foreign bodies. A and B show an annular edema above the foreign body, F. At C the edematous mucosa is being repressed by the lip of the tube mouth, permitting insinuation of the hook, H, past one side of the foreign body, which is then withdrawn to a convenient place for application of the forceps. This repression by the lip is often used for purposes other than the insertion of hooks. The lip of the esophagoscope can be used in the same way.]

Extraction of Soft Friable Foreign Bodies from the Tracheobronchial Tree.—The difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps space. There is usually in these cases an abundance of purulent secretion which further hinders the work. The great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view, must always be kept in mind. Extremely delicate forceps with rather broad blades are required for this work. The fenestrated "peanut" forceps are best for large pieces in the large bronchi. The operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal, yet not so firmly as to crush them. Nipping off an edge by not inserting the forceps far enough is also to be avoided. Small fragments under 2 mm. in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping. It is, however, never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled, for these may be aspirated into small bronchi, and cause multiple abscesses. A hook may be found useful in dealing with round, friable, foreign bodies; and in some cases the mechanical spoon or safety-pin closer may be used to advantage. The foreign body is then brought close to, but not crushed against the tube mouth.

[174] Removal of animal objects from the tracheobronchial tree is readily accomplished with the side-curved forceps. Leeches are not uncommon intruders in European countries. Small insects are usually coughed out. Worms and larvae may be found. Cocaine or salt solution will cause a leech to loosen its hold.

Foreign bodies in the upper-lobe bronchi are fortunately not common. If the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps (Fig. 90), guided by the collaboration of the fluoroscopist. These forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus. Full-curved coil-spring hooks will reach high, but must be used with the utmost caution, and the method of their disengagement must be practiced beforehand.

Penetrating Projectiles.—Foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus (see Bibliography, 43)

[FIG. 90.—Schematic illustration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. T, Trachea; UL, upper-lobe bronchus; LB, left bronchus; SB, stem bronchus. These forceps are made to extend around 180 degrees.]

RULES FOR ENDOSCOPIC FOREIGN BODY EXTRACTION

1. Never endoscope a foreign body case unprepared, with the idea of taking a preliminary look. 2. Approach carefully the suspected location of a foreign body, so as not to override any portion of it. [175] 3. Avoid grasping a foreign body hastily as soon as seen. 4. The shape, size and position of a foreign body, and its relations to surrounding structures, should be studied before attempting to apply the forceps. (Exception cited in Rule 10.) 5. Preliminary study of a foreign body should be from a distance. 6. As the first grasp of the forceps is the best, it should be well planned beforehand so as to seize the proper part of the intruder. 7. With all long foreign bodies the motto should be "Search, not for the foreign body, but for its nearer end." With pins, needles, and the like, with point upward, search always for the point. Try to see it first. 8. Remember that a long foreign body grasped near the middle becomes, mechanically speaking, a "toggle and ring." 9. Remember that the mortality to follow failure to remove a foreign body does not justify probably fatal violence during its removal. 10. Laryngeally lodged foreign bodies, because of the likelihood of dislodgment and loss, may be seized by any part first presented, and plan of withdrawal can be determined afterward. 11. For similar reasons, laryngeal cases should be dealt with only in the author's position (Fig. 53). 12. An esophagoscopy may be needed in a bronchoscopic case, or a bronchoscopy in an esophageal case. In every case both kinds of tubes should be sterile and ready before starting. It is the unexpected that happens in foreign body endoscopy. 13. Do not pull on a foreign body unless it is properly grasped to come away readily without trauma. Then do not pull hard. 14. Do no harm, if you cannot remove the foreign body. 15. Full-curved hooks are to be used in the bronchi with greatest caution, if used at all, lest they catch inextricably in branch bronchi. [176] 16. Don't force a foreign body downward. Coax it back. The deeper it gets the greater your difficulties. 17. The watchword of the bronchoscopist should be, "If I can do no good, I will at least do no harm."

Fluoroscopic bronchoscopy is so deceptively easy from a superficial, theoretical, point of view that it has been used unsuccessfully in cases easily handled in the regular endoscopic way with the eye at the proximal tube-mouth. In a collected series of cases by various operators the object was removed in 66.7 per cent with a mortality of 41.6 per cent. In the problem of a pin located out of the field of bronchoscopic vision, the fluoroscopist will yield invaluable aid. An extremely delicate forceps is to be inserted closed into the invaded bronchus, the grasp on the object being confirmed by the fluoroscopist. It is to be kept in mind that while the object itself may be in the grasp of the forceps, the fluoroscope will not show whether there may not be included in the forceps' grasp a bronchial spur or other tissue, the tearing of which may be fatal. Therefore traction must not be sufficient to lacerate tissue. If the foreign body does not come readily it must be released, and a new grasp may then be taken. All of the cautions in faulty seizure already mentioned, apply with particular force to fluoroscopic bronchoscopy. The fluoroscope is of aid in finding foreign bodies held in abscess cavities. The fluoroscope should show both the lateral and anteroposterior planes. To accomplish this quickly, two Coolidge tubes and two screens are necessary. Fluoroscopic bronchoscopy, because of its high mortality and low percentage of successes, should be tried only after regular, ocularly guided, peroral bronchoscopy has failed, and only by those who have had experience in ocularly guided bronchoscopy.