presentation, the forceps
spaces, or the location of branch-bronchial orifices into which one
blade of the forceps may go. Dilatation of a stricture may be
necessary, and may be accomplished by the forms of bronchial dilators
shown in Fig. 25. The hollow type of dilator is to be used in cases in
which the foreign body is held in the stricture (Fig. 83). This
dilator may be pushed down over the stem of such an object as a tack,
and the stricture dilated without the risk of pushing the object
downward. It is only rarely, however, that the point of a tack is
free. Dense cicatricial tissue may require incision or excision.
_Internal bronchotomy_ is doubtless, a very dangerous procedure,
though no fatalities have occurred in any of the three cases in the
Bronchoscopic Clinic. It is advisable only as a last resort.

[181] CHAPTER XVII--UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES

The limitations of bronchoscopic removal of foreign bodies are usually
manifested in the failure to find a small foreign body which has
entered a minute bronchus far down and out toward the periphery. When
localization by means of transparent films, fluoroscopy, and
endobronchial bismuth insufflation has failed, the question arises as
to the advisability of endoscopic excision of the tissue intervening
between the foreign body and bronchoscope with the aid of two
fluoroscopes, one for the lateral and the other the vertical plane.
With foreign bodies in the larger bronchi near the root of the lung
such a procedure is unnecessary, and injury to a large vessel would be
almost certain. At the extreme periphery of the lung the danger is
less, for the vessels are smaller and serious hemorrhage less
probable, through the retention and decomposition of blood in small
bronchi with later abscess formation is a contingency. The nature of
the bridge of tissue is to be considered; should it be cicatricial,
the result of prolonged inflammatory processes, it may be carefully
excised without very great risk of serious complications. The blood
vessels are diminished in size and number by the chronic productive
inflammation, which more than offsets their lessened contractility.

The possibility of the foreign body being coughed out after
suppurative processes have loosened its impaction is too remote; and
the lesions established may result fatally even after the expulsion of
the object. Pulmonary abscess formation and rupture into the pleura
should not be awai