Foreign body localization and extraction

FOREIGN BODY LOCALIZATION DESCRIPTION

OF A METHOD

MORE

AND EXTRACTION

ACCURATE

THAN

THAT

USED BY THE

ARMY

LEWIS GREGORY COLE, DipIomate

of the American

M.D.

Board of RadioIogy; Roentgenologist New York WHITE

PLAINS,

T

HE detection of a metaIlic foreign body in the h uman body is a very simpIe probIem for the roentgenoIogist; its accurate IocaIization is much more d&uIt, and the search for and extraction of su.ch a foreign body is often a very perpIexing probIem for the surgeon. A needIe in the paIm of a hand as seen in the x-ray fiIm Iooks simpIe to remove but, Iike the Army “buck,” it is usuaIIy passed from the chief surgeon to his assistant, then to the junior surgeon, and so on down the Iine, because its remova is without gIory if successfu1, and with a razzing if not. The most notoriousIy evasive foreign body of recent times is a smaI1 fragment of stee1 in a man’s arm that was recentIy reported and then quoted and requoted from coast to coast. Even though this fragment was only I cm. beneath the skin, two proIonged operations faiIed to remove it. I have seen these scars and stuck my fingers in them. This superficia1 foreign body was an idea1 case for the magnetic method of IoCaIization and extraction, but the “diviner or detoner ” did not even quiver when used to locate the foreign body deepIy embedded in the identica1 wax mode1 which is the theme of this communication. The subject of IocaIization was given very IittIe civiIian attention in time of peace, but the Army did consider it then and prepared for war by deveIoping an Army x-ray fieId unit and IocaIizing device.

NEW

to Hudson City HospitaI,

Hudson,

YORK

With unIimited financia1 backing for experimenta work this probIem was undertaken with enthusiasm by the roentgenoIogic staff of the Army and a corps of Army engineers and draftsmen. In due time a fieId unit was deveIoped and mass production was accompIished. This new field unit is very powerfu1, and is adaptabIe for base hospitaIs or for hospitaIs where transportation by truck or train is avaiIabIe. The Army aIso designed an eIaborate IocaIizing device consisting of a sturdy horizonta1 tabIe which embodies many principIes of IocaIizations deveIoped in the Iast war, notabIy a convenient method of a very accurateIy shifting of a shock proof tube to faciIitate Auoroscopic search for the foreign body and to determine its depth from a point on the surface. The depth of the foreign body may be read from a scaIe on the side of the apparatus. It has an ingenious gadget for marking one point on the surface of the body directIy above the foreign body with indeIibIe ink. A phantom is provided with the equipment, so that the depth determining device can be readjusted on the fieId to assure its accuracy. This phantom has a ffat base so that it rests firmIy on the Auoroscopic tabIe; its upper surface is aIso flat and paraIIe1 with the base. The marking device is such that a singIe point on the upper 3

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sur faIce of the phantom or human part is recorded. ver ‘Y accurately I t is planned by the Army to do onIy

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essing fihns or paper are provided. It is not the intention of the Army to have surg tical extractions done in this x-ray tent.

FIG. I. Test Object: Wax mode1 containing a foreign bodv used to determine the accuracy of the Army method of locahzation compared with another method. The Iarge hoIe to the left was made in an unsuccessful attempt to remove a foreign body by the Army method. The ima hoIe to the right Ieads directlv to the foreign bodv. located by anoyher method. The”white spot in toheck% of the smaI1, diamond-shaped hole, is the foreign body. This photograph conveys no sense of depth of the holes, so Figures z through 3 are presented to give the depth and width of the two holes.

ffuoroscopic examinations for the IocaIization of foreign bodies, therefore, a Iarge bIack tent having fIaps provided with zippers rendering it Iightproof and airtight, is part of the equipment. A written report on special forms to insure uniformity, and an indelibIe mark on the upper surface of the part, is the manner in which the IocaIizing data are transmitted to the surgeon. Roentgenograms on fiIms or even on paper to show the surgeon the actual size, shape and reIative position of the foreign body, are to be specificaIIy avoided. No faciIities for proc-

The Army is so proud of this fieId unit and Iocalizing device that some of them were sent to Russia. It is a beautifuIIy constructed apparatus, but there is just “one fly in’ this aIab&ter jar of ointment,” nameIy, it is not accurate for localizing bullets in the human body. When this inaccuracy, or at Ieast the ineffrciency, of the Army apparatus for Iocalizing foreign bodies in the body rather than in the Aat base phantoms was recognized, it was suggested that a Iocalization be done on a human body, preferabIy a Ieg, arm or head. However, as no such patient was avaiIabIe,

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it was suggested that a wax model, similar in size and shape to the human thigh, be substituted for the Army’s fiat-based phantom, and that a foreign body embedded in this wax model be locahzed by the one who had designed the Army apparatus. This cylindrical wax model was so constructed that it has the same tendency to roll outward as does the human leg when the subject is Iying on his back. This tendency was discussed and overcome by propping it into position when the localization was done. In order to avoid any possible error, the localization was repeated on this wax model, and the accuracy of the original localization was confirmed. It was then suggested that the foreign body be extracted through as smal1 a hole as was practical in order to estabIish the accuracy of this method of localization. This extraction was undertaken with great enthusiasm by the one who had actualIy done the localization with the Army apparatus he had designed. A request was made that this procedure be reported to the NationaI Council of Defense, where the subject was to be discussed in the near future. This request was gladly granted but it was considered reciprocal. The enthusiasm waned as the procedure progressed and the foreign body was not encountered or extracted. A photograph of the wax model (Fig. I) and a series of roentgenograms tell the rest of the story better than words. In this futile search for the foreign body a hole was made in the wax model large enough to admit three fingers, yet the foreign body was not found by the Army method of IocaIization. The size and shape of this hole are more accurately recorded by the fuII-sized reproductions of roentgenograms of the wax mode1 made in two directions after the hoIe had been HIed with a barium mixture. (Figs. 2 and 3.) What if there had been a human thigh or head avaiIabIe for this Iocahzation, instead of a wax modeI? If this were the best that couId be done by anyone

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using any method of localization, it would be unwise to reveal these facts, but this is not the case. ImmediateIy after this failure to extract the foreign body on the basis of the data determined by the Army method, the same model was employed to illustrate how readiIy the identical foreign body could be extracted when undertaken on data obtained by another method of localization. A smal1 diamond-shaped incision was made in the adhesive tape surrounding the wax model, and through this smaI1 incision, foIIowing the Iine indicated by a specialIy constructed apparatus, the one who had faiIed to extract the foreign body by the Army method and who had never seen this instrument before, used it according to instructions, rapidIy evacuated the wax, and hit the foreign body “square on the nose.” This was accomplished through a conica hole that was not nearly as Iarge as one’s little hnger, as shown in Figures 2 and 3. This smaI1 conical hole was immediateIy adjacent to the large hole which had been previously made in the unsuccessful attempt. The smalI size and shape of this conical hole, indicating the accuracy of this method, is shown even more vividIs by fuII-sized reproductions of roentgenograms (Figs. 4 and 3) than by the photograph of the wax model. (Fig. I.) Critics might justly say that the Army method is all right for Aat bottomed phantoms and that this method may be all right for wax models, even though they are cyIindrica1, but what evidence is there that it will work on human beings? The following case, referred by a surgeon who said, “This is a hard nut to crack,” is the answer to that question: A colored woman, weighing nearly 200 pounds, felt a sharp pain in her shouIder as she threw a rug over it. She then threw the rug to the floor, and picked a fragment of needIe from her shouIder. A roentgenogram made at the City HospitaI reveaIed two smaI1 fragments of a fine needIe located high up in the axilla, just beIow the Iower lip of the head of the humerus and about haIfway between the

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FIG. 2.

FIG. 3.

2 AND 3. Unsuccessfd Approach: FuII sized reproductions of roentgenograms in two directions show the Army hole f&d with barium paste. These two roentgenograms accurateIy indicate the mutiIation of the mode1 in the unsuccessfu1 attempt at extraction. Compare with Figures 4 and 5.

FIGS.

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FIG. 4.

FIG. 5.

FIGS. 4 AND 5. Successj~l Approach: Full sized reproductions of roentgenograms in two directions show a smal1 conica hoIe Ieading directIy to the foreign body. This hoIe indicates the minima1 amount of mutiIation caused by the successful extraction.

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anterior and posterior surfaces of a relativeIy Iarge shouIder. The Iocalization was accompIished with the aid of instruments which were

FIG. 6. Sighting Device: Roentgenogram shows two smaI1 fragments of a needle located deep in the human shouIder, one is directIy in the center of a sighting device; this one was extracted within forty-seven seconds. so smaI1 as to be carried in one’s pocket. They were adapted to an oId horizontal fluoroscope and the IocaIization was undertaken under most adverse conditions, with a gaIIery of doctors waiting to see it fai1. Figure 6 shows the two fragments of the needIe as they come within the fieId of the Iocalizing apparatus. The patient was transferred from the fluoroscopic tabIe to the operating tabIe; the companion surgica1 instrument was adjusted according to instructions, based on the roentgenoIogic Iocalization data, and the specific fragment which is in the center of the IocaIizing device (Fig. 6) was removed in forty-seven seconds. The other fragment, sIightly off to the side of the fieId, was not spec&caIIy IocaIized and it required nearIy twenty minutes to find it, even though the surgeon was searching within its immediate vicinity.

Even this might be considered “happen stance” if it were not for the fact that this method of IocaIization empIoyed a basic

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principIe that was not empIoyed in the Army method. The principIes underIying these two methods might be termed the “one-point method” as empIoyed by the Army, in contradistinction to the “twopoint method” by which the foreign body in the cyIindrica1 wax mode1 and the needIe in the human shouIder were accurateIy located. The basic principles empIoyed in these two methods can be more readiIy conveyed to the reader by drawings than by wordy descriptions. The basic principIes of the one point method is shown in Figures 7~, B, c, D and E. A wooden bIock contains a foreign body that is deeply situated in it, but it is nearer one end than the other. By Auoroscopic examination, with the tube underneath the square bIock and the ffuoroscopic screen above it, a point on the upper surface, directIy above the foreign body, can be accurateIy determined and marked with an “X” by the Army method. (Fig. 7A.) If the same bIock were set on a firm tabIe, a good carpenter couId bore a vertica1 hoIe directIy at the point indicated by the cross (X) and hit the foreign body nine times out of ten; the onIy time he wouId miss wouId be if he tiIted his bit one way or the other. (Fig. 7~~) A foreign body eccentricaIIy embedded in a cyIindrica1 bIock, Iike the Iimb of a tree, Iikewise couId be detected by ffuoroscopic examination and its Iocation indicated by an “X” on the upper surface of the bIock, the same as it was on the square bIock. This couId be done with the Army method. (Fig. 7c.) If this IocaIization were done by a roentgenoIogic architect with the statement that the foreign body was 3% inches directIy beneath a singIe mark, “X,” on the surface, and the wooden cyIinder then sent to a carpenter with specifications to bore a hoIe 3$/4 inches deep directIy beneath this “X” with no specific instructions as to positioning the bIock when he bored the hoIe, the carpenter wouId not pIace the bIock “off center” as shown in Figure 7~, in the same position as it was when the IocaIization was

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0; the One-point Method: Drzwings which illustrate the fallacy of tht. method of IocaIization used by the Army. “X” on the upper surface of the block. B, if the square bIock sat firmIy on the table a carpenter couId bore a hoIe straight down and hit the foreign body nine times out of ten. c, a foreign body embedded off center in one end of a cyIindrica1 bIock couId likewise be Iocated by x-ray and its position indicated by an “X” on the upper surface of the block. n, a carpenter instructed to bore directly down would find it diffrcuIt to do SO because the block wouId roII, and so m&s instructed otherwise wouId roI1 it on center, as shown in E. E, thus with the “X” on center, if he bored directIy down, he would miss the foreign body by a finger’s breadth; thus the fallacs of the onepoint method.

FIGS. 74

one-point

B, G D *ND E. Basic Principles

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done, first because he wouId not know what that position was, and secondIy because with the “X” off center, it wouId tend to

A

B

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any combination of the four. In these instances the probIem becomes immenseIy more compIicated.

C

FIGS. 8~, B AND c. Basic Principles of Two-point Method: Drawings that iIIustrate the accuracy of the two point method rejected by the Army. A, a foreign body embedded deep in acyIindricaI bIock, a wax cylinder or a human Ieg, can be detected and its Iocation indicated by one mark “X” on its upper surface and another on the under surface. The upper mark is readily made by any method, incIuding the Army. The Iower mark “X” is established by a ring marker that is moved about beneath the part unti1 its image on the screen encircIes the foreign body. Thus the foreign body is directIy in Iine between the upper and lower marks “X.” B, roentgenologic caliper: A convenient device or caIiper for making the upper and Iower marks at one time. By Auoroscopy or on a Mm one sees the ring marker, foreign body and square with the cross wires a11 in line, as shown in Figure 6. c, surgical caliper: A surgica1 instrument that is the counterpart of the x-ray caliper, is so designed that the distal end of the Iower arm is attached to the skin at the lower mark “X” and then the part is adjusted so that the pointer at the dista1 end of the upper arm rests on the “X” on the upper surface. A knitting-needIe-like pointer in the upper arm points directIy to the Iower mark and thus to the bullet and guides the surgeon to the foreign body. A stop on the pointer indicates the depth previously determined by a doubIe shift of the tube, using any one of several mathematical formulas, or a sliding square to eIiminate computation.

roII as he put pressure on the bit. Therefore, if not instructed otherwise, he wouId roI1 the bIock “on center,” as shown in Figure 7~, and then bore straight down, because it wouId be more convenient for him to bore a hoIe with the bIock in that position, and in doing so he would miss the foreign body by a finger’s breadth or more. So wouId the surgeon working on a Ieg put the Ieg in the most convenient position for his surgica1 approach, unless instructed otherwise. He wouId ffex the knee sIightIy, rotate the Ieg outward, and like the carpenter with the bit, he wouId miss the buIIet by the same distance as the carpenter wouId have missed it in the wooden cyIinder. The Army officer did miss it in the wax mode1 where this identica1 principIe was invoIved. When onIy a singIe mark on the surface is used as a guide, this same source of error is present in a11 extremities and in irreguIarIy spherica1 parts, such as the head which can be rotated in four directions instead of two or

The basic principle of the two-point method is Shown in Figures 8~, B, and c. With the two-point method, two marks (two “X’s”) are made on the cyIindrica1 bIock of wood or on the cyIindrica1 wax modeI, or on the human part. (Fig. 8~.) One of these marks is on the upper surface and the other is on the undersurface, each in Iine with the foreign body, as observed fIuoroscopicaIIy with the tube beneath the tabIe. The mark on the upper surface wouId be recorded in exactIy the same manner that it is the onepoint method, but in addition to this if a ring pointer were pIaced beneath the part and moved into such a position that the shadow cast by it on the ffuoroscopic screen perfectIy encircIes the image of the foreign body, and another mark were pIaced on the under surface of this part directly where the ring pointer was Iocated, the two-point method of Iocalization wouId be estabIished. A Iine drawn through these two

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points wouId transect the foreign body. (Fig. 8~.) An x-ray caIiper (Fig. 8~) has been designed and constructed to faciIitate making both of these marks, one on the under surface and the other on the upper surface. The accuracy with which the roentgenologist does this is recorded on a smaI1 roentgenogram made either on fiIm or on paper. Such a roentgenogram is shown in Figure 6 in which the two fragments of a needIe are seen within the same fieId. A companion surgica1 caliper (Fig. 8c) is so constructed that when it is adapted to the part by the surgeon, the part can be repositioned in exactIy the same position that it was at the time the Iocalization was done by the roentgenoIogist. This is accomplished by fixing the distaI end of the Iower arm of the surgica1 caIiper on the under marker and repositioning the Ieg or part so that the distaI end of the upper arm of the caIiper rests exactIy on the upper mark. Therefore, the foreign body must be in a direct Iine between the end of the upper arm and the end of the Iower arm of the In the upper arm of surgica1 caIiper. this caIiper there is a knitting-needIeIike pointer that acts as a guide to direct the surgeon toward the foreign body. Furthermore, there is a stop on the pointer which indicates the exact depth of the foreign body beneath the surface. This surgica1 cahper was the instrument used by the Army officer in his successfu1 search for the foreign body in the wax mode1 and was aIso used by the surgeon in his successfu1 search for the smaI1 fragment of needle in the shouIder. A tabuIated comparison of the new Army x-ray fieId unit and IocaIizing device, and the one herein suggested is as foIIows: One-point

Army Method

Valuable only as a compIete unit. LocaIizing device and necessary equipment weigh approximately 1000 pounds. 3. The x-ray unit and IocaIizing apparatus weigh more than a ton (estimated). 4. Can be shipped only by boat, train or truck. 5. Fluoroscopic examination only. I.

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6. Can be used only in total darkness in Iightproof and suffocating bIack tent. 7. Surgeon has onIy the roentgenoIogist’s say-so in word description. 8. No mechanical device to guide surgeon. 9. Cost $4,000 (approximate). IO. Speed for examination said to be 20 per hour. I I. Used for a11 kinds of x-ray work but patient must be brought to apparatus. 12. FIuoroscopy onIy; surgeon must take roentgenoIogist’s word. Two-point

Method

I. UsabIe on any horizontal fluoroscope. 2.

3. 4. 5. 6. 7. 8. 9. IO.

I I. IZ.

LocaIizing apparatus and fiIm processing equipment weight approximately 50 pounds. The x-ray unit and IocaIizing equipment weigh approximateIy 150 pounds. Can be flown anywhere. Both fluoroscopic and roentgenoIogic examinations. Used in any moderately light pIace, in the open if necessary, where one does not beg for air. Surgeon can see size and shape of foreign body for himseIf. Very accurate guide for surgeon. Cost $500 (estimate). Speed same. AI1 kinds of diagnostic work, portabIe unit can be taken to patient without disturbing him. Surgeon and roentgenoIogist can study roentgenograms together and segregate serious cases from simpIe ones.

If al1 these facts concerning the accuracy of the two-point method, its adaptibihty to any apparatus that may be avaiIabIe, its portabihty, Iow cost and its convenience be true, one wouId expect the Army to weIcome this device as a soIution to their perpIexing probIem of foreign body Iocalization and extraction, especiaIIy in inaccessibIe pIaces, but this is not the case. Advice concerning the Iocalization and extraction of foreign bodies couId have been obtained by the Army from any one of scores of experienced roentgenoIogists throughout the country who had been trained intensiveIy in the underIying principIes of foreign body Iocalization at one or another of the ten schooIs that were estabIished with the consent of the Surgeon Genera1 in the previous war. These schooIs gave speciaI training in foreign body IocaIization and other phases of mihtary roentgenoIogy. The instructors were the most experienced roentgenoIogists of their time. Furthermore, hundreds of these men

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had months and even years of actuaI experience in appIying the basic principIes during active service overseas in the first WorId War. Their advice, particuIarIy the advice of those who had been speciaIIy interested in the subject of foreign body IocaIization during the previous war was not sought. One fortunate fact, however, is that there are so many of these men stiI1 avaiIabIe to do accurate IocaIizations in these boys after they are discharged from the army stiI1 carrying their foreign bodies. An accessory device to the Army IocaIizing unit is a horizonta1 marker used as a substitute for the bipIane Auoroscopy. This device simpIy marks a point on the IateraI surface of the body, at the depth of the foreign body from the upper mark. This apparatus is intended especiaIIy for the torso. The procedure is a step in the right direction but onIy a short one, because it does not aid the surgeon in repositioning the patient, and it offers him no accurate mechanica device to guide him directIy to the foreign body. In order to co-operate with the Army and to put at their disposa1 the apparatus and what experience had been gained in deveIoping it, a fuI1 set of instruments, incIuding a set of roentgen caIipers, sIiding square scale for determining the depth of the foreign body, a set of surgica1 caIipers for aiding the surgeon in adjusting the part and the body, and the knitting-needIe-Iike pointer to guide him, wax modeIs for testing the accuracy of this apparatus, and a fuI1 set of instructions were sent. These

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were to be used by the Army any way they saw fit, to test them out themseIves or they were to have sent them to any one or any group of experts they desired. These instruments were sent on ApriI 15, 1942, and returned June 21, 1942; but there was evidence that very IittIe attention had been paid to them during this time. It is not suggested to the Army that this two-point method shouId be adopted by them as a substitute for the method which they have specified. It is onIy suggested that the two methods should be set up side-by-side, at some pIace not in the Army schoo1, and that a11 the data obtained by a series of competitive tests to show the accuracy of the two-point method compared with the one-point method shouId be recorded by a third party, and presented to a jury of totaIIy unbiased civiIians, not a court martia1 by Army officers, not even a tria1 by a jury of doctors, but a tria1 by a jury seIected from a pane1 of good, hardheaded carpenters, pIumbers, instrument makers with a few mothers who have boys at the front. They shouId be given the data and aIIowed to judge their vaIue. For 150 years such a jury has been good enough to decide the question of life or death of thousands of persons; if it is good enough for that, such a jury is certainIy quaIified to make a recommendation to their Congressmen and Senators, especiaIIy if it is impossibIe to accompIish anything from within the Army-with thanks to Jim and Joe and others who have encouraged this reveIation.