While we are not going to be able, by means of these tubes, to remove all foreign bodies from the trachea and bronchi, or esophagus, or to treat all diseased conditions of these organs, yet I think that their ingenious invention is a step in the right direction, and that they will prove a valuable addition to our armamentarium. I wish to report briefly a few cases of foreign body which I have seen, some before I had these tubes, and a few since. CASE I-Case one was that of a child two years old, who had a sudden attack of choking and dyspnea at intervals of a few hours to several days. The parents feared a foreign body might have been swallowed. The sudden attacks of dyspnea were the only symptoms. A tracheotomy was done, but nothing was found to account for the attacks. The child died several months later during one of these attacks. The post-mortem showed the presence of enlarged bronchial glands, one of which had suppurated and bursting into the trachea had caused death by strangulation. CASE II.-Case two was a child eighteen months old that suddenly became dyspneic while playing about on the floor. The child was almost dead when I saw the case. An immediate tracheotomy was done and a button was found lodged under the vocal cords. The child died before relief could be given. CASE III.-Case three was that of a child four years of age with a jackstone lodged about midway of the esophagus. The foreign body was located by means of the X-ray plate. All attempts at removal having proved fruitless, an esophagotomy was performed and the jack removed. The child died some six weeks later from stricture of the esophagus. CASE IV.-Case four was a child two years old who, while at play on the floor, suddenly had a severe attack of dyspnea. The mother supposed the child had accidentally inspired a watermelon seed. Dr. George Knapp, the family physician, saw the case that evening, but the symptoms were not alarming, and the following morning I saw the case in consultation. There were no urgent symptoms, but the child was restless and refused food. Upon probing the esophagus I could detect the presence of a metallic foreign body, but could not grasp it with anything sufficiently strong to remove it. Dr. John A. Thompson was called in consultation, but by this time the foreign body seemed to have disappeared. After probing several times with negative results, we decided the foreign body, whatetver it was, had disappeared and had likely been pushed into the stomach. Dr. Frank Hegner was asked to make a radio graph, the plate of which I will show you. You can plainly see the jack located just below the clavicle. It clearly illustrates how elastic the esophagus in a two-year-old child is, when repeated probing, in the dark, failed to locate a foreign body of this size. The following morning, while Dr. Marion Whitacre directed my forceps by the aid of the fluoroscope, I succeeded in grasping the jackstone and removing it. This child died very suddenly twelve hours later. Just why it should have died I do not know, unless it was from shock, and the fact that the foreign body had been in the esophagus for forty-eight hours before it was removed. All of these cases occurred before the days of bronchoscopy and esophagoscopy, and you can see that our results were most discouraging. In the light of our past experience, and with the use of these tubes, I feel safe in saying that to-day every one of these foreign bodies could be quickly diagnosed and easily removed without jeopardizing the life of the patient. CASE V.-Case five is that of a young woman twenty-five years old, with the history of having swallowed a small white-headed pin about two inches in length the day before. A radiograph by Dr. Sidney Lange, which I will show, located the pin in the right upper bronchus. As you can see, the pin lies with its head downward. Under chloroform anesthesia the bronchoscope was passed and the bronchus explored, but with negative results. Dr. N. P. Dandridge then did a tracheotomy, but even then we were not able to locate the pin. The case left the hospital with the pin in the bronchus, and apparently none the worse for our attempt at removal. However, I feel sure that the presence of the foretgn body in this position must eventally prove disastrous. March, 1906. Patient died one year later. CASE VI.-Case six is that of a young married woman, with the history of while eating oyster soup a piece of shell became lodged in the esophagus, causing great pain. Under local anesthesia of cocaine the esophagoscope was passed and the foreign body easily removed. CASE VII.-Mr. W., aged sixty-five years, while partaking of a veal pot-pie, suddenly choked on some foreign body. The family physician failing to extract the offending body, I was asked to see the case. I found this body firmly imbedded just below the cricoid in the esophagus. It seemed to be a portion of the thin shoulder-blade of the veal. CASE VIII.-Mr. H. was referred by Dr. A. C. Busch, with the history of while eating soup a bone became lodged in the throat. He was suffering excruciating agony, especially on at tempting to swallow. Under local anesthesia of cocaine the esophagoscope was passed and a foreign body was located just below the cricoid in the esophagus. I was not able to grasp it with the forceps, as it seemed slippery and would get away from me. I finally succeeded in getting a hook below it and extracted this foreign body, which proved to be a large-sized burr. Doubtless this had gotten into the soup with the vegetables. The patient naturally supposed it was a sliver of bone. CASE IX.-Miss M., aged twenty-two years, was referred by her family physician with the history that the day before, while attempting to remove a fibrous tonsil by means of the wire snare, the wire pulled out of the snare and before it could be recovered was swallowed by the patient. The patient experienced great pain in swallowing, and could locate the pain about two inches below the cricoid. Under choroform anesthesia the esophagoscope was passed and this No. 5 piano wire was removed from the esophagus. CASE X.-Miss D., aged sixteen, was referred by Dr. K. L. Stoll, with the history of having swallowed a button, such as is worn on the coat sleeve of boys' coats, some three weeks before. Her family physician had seen the case, but assured her that the button had likely passed into the stomach and would cause no further trouble. Her only symptom now was a slight cough at times and some hoarseness, and it was for this reason that she consulted Dr. Stoll. By the aid of the laryngeal mirror a dark object could be seen about two inches below the vocal cords, on the anterior wall of the trachea, surrounded by granulating tissue. Under local anesthesia several attempts were made to grasp it with the laryngeal forceps, but it was like attempting to grasp a piece of ice-it was so slippery. An anesthetic was then given and an attempt was made to pass the bronchoscope. As the patient had recently partaken of a full meal, the retching and vomiting became so annoying that we were forced to desist. Two days later, under local anesthesia, the.bronchoscope was passed and another attempt at extraction made. Several times the button was in the grasp of the forceps, but each time they would slip off. Owing to the granulation tissue present in the trachea, the hemorrhage became so free that our field of vision was entirely obscured, and once more we were compelled to desist, as it is never safe to grope blindly in this region. The following morning the patient was feeling fine, the cough was gone and all symptoms of a foreign body were gone. The parents and patient were delighted and insisted that nothing further be done. The important question now to decide was, had the foreign body been coughed up during the night and possibly swallowed into the stomach or lost in the bronchial secretions, now quite free from the granulations and attempts at extraction? To settle beyond doubt this important point, the patient was subjected to the X-ray, and several radiographs taken by Dr. Lange were all negative. This was positive proof to the parents that the Stricture of the esophagus. The dark spot is a mixture of bismuth lodged just at the beginning of the stricture. button was gone. However, Dr. Stoil and I were not convinced, as possibly the button was of such a composition as not to show on the radiographic plate. A companion button to the one swallowed was obtained, and by attaching a string to it both Dr. Stoll and myself attempted by swallowing the button to cause it to lodge in the esophagus, and while in this position a radiograph was made. These two plates showed negative. Still there was room for error, as we had no means of knowing at what point we had that was of such composition as not to show by means of the X-ray. Several days were consumed in these experiments, during which the patient's condition continued to improve. In the absence of cough and no abnormal chest symptoms on auscultation, we, too, were almost persuaded that the button had disappeared. That no serious mistake was being made, I finally persuaded the parents to allow me to take the patient to Pittsburg, to have Dr. Chevalier Jackson see the Bronchi filled with shot showing the bifurcations, where foreign bodies may lodge. been able to lodge the button in the esophagus. I then secured a flexible catheter containing a steel stylet, and by drawing the thread up through this catheter, the button was firmly fixed at the eye of the catheter. With the stylet in position, by swallowing a large bolus of banana, to open up the esophagus, I was able to place the button at the fixed point in my own esophagus and hold it there till a radiograph was secured. On the plate the steel stylet could be easily traced to its termination, but no button was to be seen. This experiment proved positively that we were dealing with a button case in consultation. Dr. Jackson first had two expert medical men go over the chest, and both reported that they were unable to make a diagnosis of any foreign body in the trachea or bronchi. Under chloroform anesthesia Dr. Jackson passed the bronchoscope and succeeded in locating the button in the right bronchus. After some difficulty he finally succeeded in tilting the button so the forceps could grasp it by the edge, when tube, forceps and button were drawn out as one body. The patient was able to return to her home the following morning and was none the worse for her experience. I have reported this case in detail, as it emphasizes several important points: First, that a foreign body can be in the respiratory tract and produce little or no symptoms; second, that a negative X-ray picture is not positive proof that no foreign body is present; and third, that a careful bronchoscopic examination may locate the foreign body when no symptoms are present. A CONSIDERATION OF SOME FEATURES OF FEMORAL HERNIA.* The subject of hernia has been selected, first, because it holds an interest in common for the physician and surgeon; second, because of the manifold manifestations, signs and symptoms; third, because of the great importance of early recognition and reduction. For practical consideration we may regard Poupart's ligament as the dividing line between the inguinal and femoral regions. We shall limit ourselves to a working description of that part of Scarpa's triangle which concerns us in dealing with femoral hernia, viz., the upper portion, bounded by Poupart's ligament above, internally by the adductor longus, and externally by the inner margin of the sartorious. The floor of the space is covered by the iliac, psoas and pectineus muscles. Disregard for a moment the skin, fascia, glands, nerves and vessels and think of an oval space half an inch in length, lying between the femoral vein on the outer side and Gimbernat's ligament on the inner side; above and anteriorly we have Poupart's ligament, while posteriorly we have the pubic bone, pectineus muscle and pubic portion of the fascia lata; this gives us a complete anatomic picture of the femoral ring. The space is covered by a thin nonresistant alveolar tissue designated the septum crurale, which is nothing more or less than a reflection from the femoral sheath. It is frequently the site of a lymph node known as Rosenmüller's gland. This oval space is one of the "weak points" in the anatomy of man, hence a favorable site for hernia. inward to avoid wounding important vesvels. The iliac and pubic portions of the fascia lata converge to form an oval opening a little lower, half an inch, known as the saphenous opening, for the transmission of the internal saphenous vein. This space is covered by loose cribriform fascia, which permits the escape of the gut, and corresponds to the external opening in the inguinal canal as does the femoral ring to the internal inguinal opening. In some instances of femoral hernia the point of greatest constriction is at the saphenous opening; this is due to the rigid falciform process which guards the opening. Connecting the femoral ring and saphenous opening we have the femoral canal, which is a canal in name only in the normal state. To recapitulate, we have, beginning in the peritoneal cavity, peritoneum, subserous alveolar tissue, septum crurarle, femoral canal and sheath connecting with the saphenous opening, cribriform fascia, superficial (lata) fascia and skin. With a clear concept of these structures, one is really surprised to learn that, notwithstanding the frequent increase of intra-abdominal pressure (lifting, coughing, etc.), only about one in seventeen (Coley) hernias occurring in the male is of the femoral variety. These figures are based upon the review of 14,092 operations for hernia, and are in keeping with the relative percentage of other surgeons. The causative factors in the production of hernia are numerous; prominent features in this category are heredity, occupation, too much abdominal contents, loss of abdominal wall power and loss of proper angularity of the intra-abdominal pressure lines. Gimbernat's ligament is the only strong and resistant part of the boundary of this oval space, and as it is the chief factor in the prevention of hernia, so it becomes the chief obstacle to the return of the gut after it has passed through this opening. Indeed, it not infrequently becomes necessary to incise the ligament in order to return the hernial contents. In doing this, the knife should be directed upward and * Read before the First Councilor District Medical Society of Ohio, December 13, 1907. Family facial expressions, temperament, and anatomical anomalies are so frequently transmitted from one generation to another as to fix the important rôle of heredity. While certain occupations-ath letes and others-entailing an exhibition of unusual feats of strength, are frequently subjects of hernia, they are so affected in consequence of some anatomical defect rather than the special occupation. That is to say, where the intra-abdominal pressure lines do not fall at proper angles, instead of meeting these naturally weak points in the abdominal wall, the so-called openings, at a right angle, they form an obtuse angle at the point of contact, and pressure is brought to bear more or less directly in line with the long axis of the femoral canal. The broad pelvis, and, if you will permit the somewhat ungainly expression, too much contents for the abdominal cavity, are conducive to this loss of angularity. This in a measure accounts for the relative frequency of femoral hernia in women. Again, the distorting influence of pregnancy, deposition of fat in the abdomina! wall and tendency to enteroptosis, constipation and lack of abdominal wall resistance, are also subsidiary factors in the frequency of femoral hernia in women. Faulty construction of the ring, wide. space between Gimbernat's ligament and the femoral sheath, like diastasis of the recti, need only be mentioned to enforce their claims as positive factors in the causation of hernia. CONGENITAL MALFORMATION. Russell, of Melbourne, insists on the congenital origin of hernia, or rather a predisposition, although the hernia may not appear until later in life. In the inguinal variety, it refers to the persistence of the canal of Nuck, or incomplete separation of the vaginal process of the peritoneum, which remains with the testicle as the body grows away from it, whose tip, when properly separated, forms the tunica vaginalis. When sacculated, we have the congenital hydrocele of the cord or round ligament as an interesting complication of hernia. Russell traces the relation of the peritoneal pouches and principal bloodVessels, and shows how the former are constantly associated with the points of exit of the latter. Peritoneum is carried with the vessels, and the position of this congenital defect and size of sac determine the variety of hernia which may follow later in life. The size and position of the sac depends upon its relation with the femoral and epigastric vessels, the sac and vessels being intimately associated in developmental changes. A tumor at the site of the femoral opening should always be regarded as hernia until conclusive evidence is adduced to the contrary. Fatty tumors, enlarged glands, sarcomata and aneurism are the most probable sources of confusion from without. If the mass has its origin within the peritoneal cavity, one of a number of conditions may confront the examiner. The writer has encountered a tumor in the tip of the great omentum which completely filled the femoral canal, and although no portion of the intestine had descended, still great pain, vomiting, collapse and other symptoms of strangulation presented, and on three different occasions a prolapsed ovary was found in the femoral canal. Surgeons have reported cases where the appendix or urinary bladder had found their way into the femoral canal. Ordinarily, we say if the hernial protrusion is below Poupart's ligament, it is femoral; this does not always hold, as the gut will travel along the line of least resistance; hence if the protrusion after clearing the femoral opening meets with a highly resistant cribriform fascia, the gut may be directed upward, pass beneath Poupart's ligament and appear as a tumor near the internal inguinal ring. Instances have been recorded wherein the sac forced its way directly through Gimbernat's ligament, closely hugging the pubic bone. The history will materially assist one in coming to a definite conclusion. In the absence of strangulation, the impulse of coughing is always present, the tumor is freely movable and readily reducible. These diagnostic features are absent in strangulated cases, but the presence of pain, vomiting, rapid pulse, shock, etc., will assist in putting you right. Reducible femoral hernia may and often does escape the attention of the examiner, and ordinarily gives the patient little concern, but an occasional reduction en bloc, to be followed by symptoms of ileus, does occur, and one should always remember this in dealing with a seemingly innocent condition. The chief anatomical obstacles to reduction in the strangulated cases are Gimbernat's ligament and the falciform process. These hold the gut in a vice-like grip, which is increased in potential force with the influx of peritoneal fluid and inflammatory exudate. In young people pain is seemingly greater, tympanites and vomiting occur earlier, and the whole process is more |