There are three places in the esophagus that are most liable to be the lodging place of foreign bodies: first, at the introitus or month of the esophagus; second, where the esophagus passes through the diagphram, and third, just at the cardiac entrance to the stomach. At each of these places the esophagus is constricted. It is rather the rule, however, that if a foreign body passed the introitus, it will usually pass on without much difficulty into the stomach. It has been our experience that all the foreign bodies finding lodgment in the esophagus have been halted just at the introitus on a level with the sixth cervical vertebra. The curious arrangement anatomically of the introitus, the looseness of the membrane just above the constricted part allows foreign bodies, such as pennies and flat articles, to form a temporary pouch, slipping down behind the constricted part, therefore in the manipulation of the tubes, if exceeding great care is not exercised in having the patient's head and position exact, and the introduction of the speculum exact, the mucous membrane will fold over the foreign body, and it will be impossible to see it. Such an accident frequently happens even with the very best of operators. I have in mind a little girl of foreign extraction, aged six, who swallowed a penny She was brought to the clinic some three days after the accident. The skiagraph showed the penny lodged just at the sixth vertebra and the symptoms pointed to the esophagus. Dr. Owen passed the esophageal tubes and could not find the penny, not even a trace of it. Several attempts were made on the succeeding few days, not only by Dr. Owen, but by several men doing this kind of work, yet the penny remained securely hidden, the skiagraph each time showing it unmoved. Dr. Jonas was called in and made an external opening, and even then the penny was not found. For three months this penny remained at the same place, when one day it passed on down and was passed in the stool. During its lodgement at the introitus the child became more and more tolerant of it, and got so she could swallow quite well.

Another patient of about 2 years swallowed a penny; the skiagraph revealed its presence at the sixth vetebra, yet eosphagoscopy failed to find it. After many attempts the patient was seated upright and with the finger the penny could be felt, and by the means of a long laryngeal forceps it was removed.

I do not wish to convey the idea that most of these cases present these difficulties, because with our present improved technic many of the awkward problems formerly presented are

now easily solved. I do, however, want to especially emphasize the relative frequency of this pseudo-pouch like formation that so securely hides its guest, and urge upon those doing this work the necessity of care and exact observance of the new technic.

Many problems demanding skillful manipulation are presented in removing these foreign particles lodged in and around the esophagous; the tissues are easily torn, and when the invading object has prongs, or such like, buried into the membranes, the grave problem is not so much their detection as their successful removal without tearing. I have in mind a little girl of some 10 years of age who had swollowed her mother's fleur-delis broach. The skiagraph showed it lodged just at the sixth vertebra, with the broad side down, the sharp prongs projecting laterally. Esophagoscopy quickly revealed its situation, but considerably over an hour was consumed in carefully dislodging it, which was successfully done without any tear.

The mucous membrane of the esophagus is very easily torn, and it is this susceptibility that renders esophagoscopy a more hazardous procedure than bronchoscopy, although the introduction of the esophagoscope is the easier of the two. Jackson has collected some 620 esophagoscopies for foreign bodies with a morality of 30 per cent, and he says these represent cases from large clinics in skilful hands. If to this is added all those cases, legion in number, done by unskilful hands. it is reasonable to presume that the mortality would be much higher.

Though primarily for the removal of foreign bodies, the esophagoscope as well as the bronchoscope, have of late been used more and more for purposes of diagnosis, and as a means for treatment.

Jackson and other investigators, through their careful and intimate observation, are broadening greatly the field of usefulness of these methods.

Not long ago, in reading an article on this same subject, the author said that, with such definite means of precision at our command, it seemed most unreasonable that some of us still adhered to the same hereditary principles of conservatism that characterized medicine years ago. Although this may seem a radical statement, yet in the light of the research work done in this branch of medicine, it is eminently desirable that we familiarize ourselves with the intricacies of the movement.

Localization and Extraction of Foreign Bodies From The Lower Air Passages. Bronchoscopy.

*By JAMES M. PATTON, A. M., M. D., Omaha.

The presence of a foreign body in the deeper air passages is always an alarming condition and until within recent years. little could be done for the relief of the sufferer. Accurate localization was usually impossible and even with the X-Ray many foreign bodies could not be localized owing to lack of density; even when the foreign body could be localized the surgeon was handicapped by lack of proper instruments and sufficient illumination.

Since the introduction of the direct method of localization and extration of foreign bodies the mortality has been reduced from 50 to 75 per cent to less than 10 per cent. The literature of the direct method has been most abundant. Killian in a review to the close of 1910 reports 672 articles on laryngotracheo-bronchoscopy, less than 100 of which had appeared prior

to 1905.

As numerous valuable productions have appeared since Killian's review, one would hesitate to present this subject were it not for the fact that we all too frequently hear of cases in which no attempt has been made to locate or extract the foreign body or where expectant treatment has been instituted and the bronchosocopist only called as a last resort; with the patient in extremes and the dangers and difficulties of the operation correspondingly increased.

Although endoscopy had been attempted as early as 1868 (Kussmaul) it made slight progress until taken up by the laryngologist; in fact bronchoscopy and esophagoscopy are the logical development of the direct study of the larnyx so ably presented by Dr. Wherry. It was but natural that the investigator should follow up the advantage gained and explore the deeper structures of the trachea and esophagus.

Despite the splendid experimental work of such men as Killian, Bruning, Kierstein, Coolidge and many others, statistics show that prior to 1896 but 5 cases had been reported in which foreign bodies had been treated by bronchoscopy, and but 36 to the end of 1904. Since then progress has been very rapid, nearly 300 cases being reported from 1909-1911.

(This rapid advance is due not alone to the skill and en

*Read before the Nebraska State Medical Association, Omaha, May 13-15, 1913.

thusiasm of the surgeons who have brought this work to our attention, but credit must also be given to the cooperation of the instrument makers in perfecting instruments for endoscopic work).

Two froms of endoscopes are in general use-one developed by the German and Austrian schools in which the source of illumination is external and the light reflected into the tube-the other devised by Jackson, in which the light is in a small depression at the distal end of the tube. Both have their advantages and disadvantages the individual operator preferring the instrument with which he is most familiar. The operator must not neglect to supply himself with a full equipment, for example; tubes of suitable sizes, forceps, sponge holders, etc.

When employing local anesthesia in adults the patient is seated in a low chair, the head slightly extended. Cocaine varying in strength from 10% upward is usually employed. When examining in the prone position, with or without general anesthesia, it was formerly considered necessary to have the head in the Rose position, but Johnson of Baltimore, has demonstrated that the tubes can be introduced more easily and safely with the head on the same plane as the body.

As in other fields of surgery the anesthetic of choice is a disputed point. Cocaine is not well tolerated by young children and as general anestretics are frequently undesirable owing to existing complications, some operators use no anesthetic in children under 6 years and report that the patients suffer very little inconvenience during the operation, and no bad after effects.

When general anesthesia is used, ether apparently has the preference, the stimulating action on the secvretions being counteracted by a hypodermic of atropine and morphine.

In some instances, for example, mal-formations or ankylosis of the jaws, affections of the base of the tongue, laryngeal stenosis, etc., upper bronchoscopy or entrance through the mouth and larnyx is not feasible, in these cases the tubes are introduced through a low tracheotomy. Upper bronchoscopy is employed in the large percentage of cases.

While all authorities agree that the removal of a simple foreign body from the deeper air passages should not present great difficulties to an experienced operator, they likewise emphasize the vital importance of early diagnosis and prompt action on the part of the bronchoscopist. The majority of the fatalities reported are in cases where the bronchoscopist has

been consulted several days and, in some instances, weeks after the accident.

One of our most skilful American operators (F. Ingals, J. A. M. A. LVIII-467), reports having worked for an hour and a half in at least two instances, the foreign body being so hidden by granulations as to greatly hinder the operator. Other men of equal experience have reported similar difficulties in these neglected cases.

Open safety pins, tacks, etc., present special difficulties and many, ingenious instruments have been devised to facilitate their extraction.

Diagnosis is based on the history, objective symptoms, e. g. coughing, dyspnoea, cyanosis, etc. physical signs, modified lung sounds indicating obstruction of certain areas, and on the X-Ray findings, though the latter are of value only when the foreign body is of sufficient density to be recorded on the plate.

Ingals (see above) emphasizes the importance of careful after treatment with special reference to the ever present possibility of oedema of the upper air passages and lungs, bronchitis and broncho-pneumonia, and advises placing the patient in a croup tent for the first 48 hours with generous administrations of ammonium acetate.

I wish to refer to the following cases on account of the rather unusual nature of the foreign bodies and also the severity of the post operative complications in the one case and their entire absence in the other.

Case 1. Oscar A. Age 2, was referred by Dr. Zeller of Hooper, Neb. The child had been playing about the barn and the parents supposed he had drawn a kernal of corn into the trachea. Dr. Zeller recognizing the gravity of the condition urged the parents to lose no time, with the result that I saw the case at the Clarkson Hospital within five hours of the accident. The child was well developed physically. There was a constant hacking cough, some dyspnoea and slight evidences of cyanosis about the lips and tips of the fingers. Under ether anesthesia the larynx and trachea were found to be normal and the right bronchus unobstructed and functionating. As I was looking for a grain of corn I was surprised to find the left bronchus completely blocked by a fleshy looking substance which on being grasped by the forceps came away in a mass the size of the end of the thumb. This was followed by a quantity of broth like fiuid containing numerous particles of the same material. With