the operator devotes his attention to preventing the withdrawal of the
bronchoscope by holding the handle with his right hand. At the moment
of insertion of the bronchoscope through the glottis, an especially
strong upward lift on the beak of the spatula will facilitate the
passage. It is necessary to be certain that the axis of the
bronchoscope corresponds to the axis of the trachea, in order to avoid
injury to the subglottic tissue which might be followed by subglottic
edema (Fig. 47). If the subglottic region is already edematous and
causes resistance, slight rotation to the laryngoscope, and
bronchoscope will cause the bronchoscope to enter more easily.

[FIG. 59.--Insufflation anesthesia with Elsberg apparatus. Anesthetist
has exposed the larynx and is about to introduce the silk-woven
catheter. Note the full extension of the head on the table.]

[FIG. 60.--Schema illustrating the introduction of the bronchoscope
through the glottis, recumbent patient. The handle, H, is always
horizontally to the right. When the glottis is first seen through the
tube it should be centrally located as at K. At the next inspiration
the end B, is moved horizontally to the left as shown by the dart, M,
until the glottis shows at the right edge of the field, C. This means
that the point of the lip, B, is at the median line, and it is then
quickly (not violently) pushed through into the trachea. At this same
moment or the instant before, the hyoid bone is given a quick
additional lift with the tip of the laryngoscope.]

[FIG. 61.--Schema illustrating oral bronchoscopy. The portion of the
table here shown under the head is, in actual work, dropped all the
way down perpendicularly. It appears in these drawings as a dotted
line to emphasize the fact that the head must be above the level of
the table during introduction of the bronchoscope into the trachea. A,
Exposure of larynx; B, bronchoscope introduced; C, slide removed; D,
laryngoscope removed leaving bronchoscope alone in position.]

_Difficulties in the Introduction of the Bronchoscope_.--The beginner
may enter the esophagus instead of the trachea: this might be
a dangerous accident in a dyspneic case, for the tube could, by
pressure on the trachea, cause respiratory arrest. A bronchoscope thus
misplaced should be resterilized before introducing it into the air
passages, for while the lower air passages are usually free from
bacteria, the esophagus is a septic canal. If the given