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lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, H. If the swollen mucosa, H, has been replaced by fibrous tissue from many months' sojourn of the tack, the stenosis may require dilatation with the divulsor.]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.