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or secondary to a septic process in a distal vein, or chronic suppurating bone disease in the jaw, ear, etc., bronchiectasis, cysts (echinococcus or dermoid), and pneumonic changes due to pressure upon bronchi by enlarged glands, etc.

A careful consideration of the symptoms and progress of the case, with microscopic examination of the sputum and the use of the X-Ray, will materially assist in arriving at a correct diagnosis.

The diagnosis of pulmonary abscess having been established, the question of treatment arises, whether expectant and palliative or surgical. It is, of course, understood that the general condition must be improved by good food, fresh air and tonics. In view of the danger of tuberculous infection, the patient should be given guaiacol in regular and appropriate doses.

The surgical treatment will depend upon the size and location of the abscess and, furthermore, upon the presence or absence of pleural adhesions.

"Should there be an absence of adhesion and the lung collapse when the pleura is opened, and if the abscess communicates with a bronchus, it would seem from a theoretical standpoint that it should drain or close. Thoractomy in this manner is so easily performed that it appears to me applicable in the class of cases in which pneumotomy is most dangerous, i.e., where there is an absence of adhesions. It allows of (1) drainage through the bronchus; (2) contraction of the cicatricial abscess wall; (3) peripneumonic compression from the air in the pleural cavity. All of these should favor the repair of the abscess.” (J. B. Murphy's Surgery of the Lung, page 64.)

According to Tuffier 11 per cent. of abscesses of the lung are caused by foreign bodies. Now in the operative treatment of chronic purulent processes in the lung by pneumotomy, healing is slow and there is a possibility of a prolonged or permanent fistula remaining. In view of this danger the following suggestion of J. B. Murphy might be favorably considered.

"Abscesses without adhesions and with bronchial communications should not be treated by incision and drainage through the chest wall, but by producing collapse of the lung by injecting nitrogen gas or a liquid into the pleural cavity, thus compressing the lung and allowing the connective tissue in the wall of the abscess to contract and obliterate the cavity with the aid of the bronchial drain."

As the abscesses due to foreign bodies usually communicate

with a bronchus, the discussion of the treatment of other varieties is foreign to our subject.

Expectant Treatment.-In reviewing the literature, numerous cases are reported in which a successful result followed the waiting plan. The risks, however, are great, not only from the inherent danger due to the presence of the object, but from the secondary and later changes in the organ itself, with the subsequent possible development of tuberculosis.

Note.-Patient seen in October, 1908; general condition excellent, although fibrosis of lung still persists.

PART II.

SURGICAL COMMENTS.

BY HENRY MANN SILVER, M.D.,

New York. Surgeon to Gouverneur and Beth Israel Hospitals ; Consulting Surgeon to the

New York Infirmary for Women and Children.

Since Professor Killian, of Freiberg, read his paper on bronchoscopy before the British Medical Association in 1902, the method of treating foreign bodies in the air passages has been completely changed. No longer are children turned upside down, slapped on the back to dislodge the foreign body, some cases even dying from spasm of the glottis during the procedure when surgical aid was not at hand. When the inversion method was not successful, the trachea was opened, tickled with feathers, or forceps, wires or hooks were introduced blindly in hopes to dislodge or extract the foreign body.

In order to make the diagnosis complete and the operation for removing the foreign body as simple as possible, every case should be examined with the fluoroscope as soon as possible, and a plate exposed. Do not depend too much on a negative fluoroscopic report-it is dangerously unreliable. Do not depend too much on a negative plate report, as cases are on record of pins in the bronchi showing no shadow until the fourth plate was made, others with two plates, as in our own case. Some non-metallic bodies do not cast a shadow, but they will cause a circumscribed shadow of inflamed tissue after they have been in a bronchus for some time. The advantages of an X-ray plate are the showing of the nature and position of the foreign body, thus enabling the surgeon to select a bronchoscope of the proper length. These advantages were very clearly demonstrated on the plate of our own

case.

An operation for removal having been decided on, the little patient was placed on a table with a small pillow under his shoulder to make the neck more prominent, and chloroform very carefully administered. Dr. Huber made an incision an inch and a half long in the median line of the neck beginning at the upper margin of the sternum, dividing skin and superficial fascia ; some superficial veins were clamped, divided and ligated, the deep fascia cut through on a director, the sterno-thyroid muscles separated and the trachea exposed. As the thymus gland appeared in the lower angle of the wound it was pushed down behind the sternum and held in place with a catgut suture. A needle armed with fine linen thread was carried through the trachea on each side of the median line and looped. Slight traction on the loops brought the trachea forward, which was then fixed above by a double tenaculum and three rings divided. When the trachea was opened large quantities of bloody pus escaped. When this was wiped away an endoscopic tube in the shape of a Burrage urethral and cervical speculum, 7 mm. in diameter, was introduced after the child had been placed in Rose's position. The endoscope was wiped out and a small electric light introduced. It was difficult to obtain a clear view of the bronchus on account of the pus welling up into the tube, but a dark spot surrounded with pus could be seen; this was grasped with a Noyes alligator forceps. When traction was made a sense of pressure was conveyed to the endoscope, which was withdrawn with the forceps. The foreign body, a wire nail two inches long, head downward, covered with black pus, was found to be in the grasp of the forceps. After the withdrawal of the nail, violent coughing spells caused more pus to be thrown out of the opening in the trachea. When the coughing became less violent a tracheal tube was introduced and the external wound diminished by one suture of silkworm gut below and two above the tube. The tube was removed in forty-eight hours and the patient's convalescence was uneventful. During the adininistration of the chloroform before the operation, it was noticed that the character of the respirations changed—they became labored—coarse tracheal râles were heard and the face was cyanosed. The anesthetic was immediately stopped and the head thrown forward; this diminished the cyanosis and difficulty of

breathing, but did not remove the tracheal râles. A pulmonary abscess, ruptured early in the course of the anesthesia, without doubt, caused the above distressing symptoms, as was shown by the escape of a large quantity of pus when the trachea was opened. The experience gained from this case emphasizes the following :

First.-Have everything ready before the anesthesia is started in order to be prepared to meet any emergency that may arise. This includes the presence of plenty of assistants and nurses.

Second.Use chloroform as the anesthetic, as but a small quantity is required, and it does not cause a large flow of mucus. The chloroform should be administered with the greatest care by one skilled in its use, and it is well not to extend the head until the operation is about to begin, if the foreign body has been in the bronchus for any length of time. Jackson considers the "preliminary use of morphine, with its prolonged abolition of the cough reflex unsafe. The cough reflex is the watch-guard of the lungs, by which infective or deleterious materials are removed. The preliminary use of atropine to lessen secretion, as suggested by Ingals, is a good, safe procedure. It has the additional advantage of protecting the circulation from shock."

Third. In addition to the ordinary instruments used to open the trachea, special instruments will be needed. The experience derived from our case leads me to put some form of an aspirating apparatus first on the list, for had it not been for the discovery of a dark spot in the pus, which proved to be the foreign body, it would have been very difficult with the means we had at hand to have removed such large quantities of pus from the trachea and bronchus sufficiently to have found the foreign body. Specialists and large hospitals can afford to have an apparatus operated with an electric pump. But a Dieulafoy or Tiemann's aspirator with suitable attachments, with an assistant to control the valves, or even a bulb-syringe can be used for this purpose. Cotton on holders can be used to remove small quantities of blood or mucus, or to apply adrenalin solution, 1-1000 if needed. Next, some form of bronchoscope will be needed, the use of the Burrage urethral and cervical speculum, together with the small electric light in our case, was perfectly satisfactory, because the foreign body was high up in the bronchus. In case of emergency, almost any endoscopic tube with a diameter of from 7 to 10 mm. can be used through an opening in the trachea. It is better, if possible, both in upper as well as in lower tracheobronchoscopy, to use Chevalier Jackson's modification of Killian's bronchoscope. The advantages of the Jackson instrument are illumination by a small cold lamp carried down to the extremity by a light carrier, thus doing away with the constant readjustment of a head lamp. The light being in the tube is always illuminating the object, regardless of the movements of the patient or operator. A small bubble or mass of secretion, or an instrument introduced into the tube, does not cut off any light, as the light is beyond. The tubes are also fitted with an auxiliary drainage canal, which maintains a dry, clean condition at the distal end of the tube. Both the lamp and drainage canal can be easily removed for cleansing. The operator should always take the precaution to have extra lamps on hand. The tubes should be perforated on the sides at lower end. When the foreign body is located, how can it best be removed? In our case the foreign body was easily removed with a Noyes alligator forceps. If it is situated low down in a bronchus, Coolidge's or Jackson's forceps are very useful. If it is an open safety pin, Mosher's or Jackson's safety pin closer can be used with advantage.

Fourth.In young children giving a history of a foreign body lodged in the lower air passages for some time, it is much easier, in fact safer, to pass the bronchoscope through a low tracheotomy wound. The opening in the trachea does not complicate or add to the danger of the operation.

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