ROYAL SOCIETY OF MEDICINE

1908 The Lancet  
288 operation, but it forcibly illustrates the utility of such a safe and simple surgical procedure where any one muscle or group of muscles is similarly affected by this form of intractable spasm. THIS interesting case with its happy issue 1 raises the question of the proper treatment of foreign bodies in the food and air passages and affords me an opportunity of again putting in a plea for more precise and modern methods of treatment in this important branch of surgery. I agree with Dr. J. S.
more » ... Manson that in the case he reports it was impossible to get the pin up by means of a probang. But there is a method, unhappily almost entirely ignored in this country, which is scientific, accurate, and safe, by which the extraction of the body might be carried out. I allude to the direct method or ossophagoscopy. I have already discussed its general technique, and in the case in question I need only say that the passage of an œsophagoscopic tube would at once disclose the relations of the foreign body in the gullet. Having ascertained the situation of the point of the pin-in this instance directed tipwards-a long fine tube, such as that used in the Killian broncboscopic forceps, could be passed over it and left in Sit1t. Having thus protected the point, the straight forceps which I described in THE LANCET of July 21st, 1906 (p. 155), could be passed alongside of it and the other limb of the pin seized and drawn into the 03sophagoscopic tube. If Dr. Manson will try the experiment through a Killian tube he will probably be surprised at the ease and safety with which it can be accomplished. The attempt to push it down into the stomach and hope for the best" is not without risk, though one recognises that it is difficult to do otherwise when the armamentarium of most of our hospitals, not excepting the large teaching hospitals, is generally limited to a probang and a more dangerous coincatcher. I have known serious damage done to the gullet by a probang and I have extracted sharp-pointed bodies which were so situated at the cardiac end of the oesophagus that an effort to push them down would inevitably have caused grave injury. On the other hand, an attempt to pull them up by a coin-catcher is often more dangerous. With small rounded bodies such as coins which can be localised by a skiagram its use may be justifiable, but where sharp substances such as pieces of bone lie in the gullet serious damage may be inflicted and cases have occurred when fatal results have followed a rent made in the oesophageal wall. But whether these efforts are successful or not is a matter of pure chance ; they are done in the dark, and therefore to be discountenanced, for it is surely preferable to work under control of the eye. These remarks apply with even more force to foreign bodies in the air passages. Their rational treatment makes but slow progress. A collection of 200 cases of bronchoscopy for foreign body made from medical literature from its inception nine years ago to the present time shows few, very few, from English sources. For this our teaching authorities have to bear some responsibility. The newer methods are not put into practice, and so long as surgeons in our teaching centres 1 IN view of the correspondence in the columns of THE LANCET it may be of interest to record another case of acute pulmonary oedema. The patient, a girl, aged 14 years, was brought to my notice on Jan. 4th with a slight tonsillitis. This was the fourth patient in that house who was affected with tonsillitis, but the affection, so far as the first two were concerned, was of a severe type and almost entirely unilateral in character. The patient to whom this note refers had nothing more than a slight congestion of the throat with a temperature of 99° F. Incidentally it was mentioned that during the last four weeks she was at times short of breath on exertion and occasionally puffy about the face and legs. The heart and lungs were examined and were then found to be normal; there was no cedema anywhere to be seen. A specimen of the urine was not sent on that day as requested but on the evening of the 5th ; it was then found to be loaded with urates and about one-eighth albumin. As soon as the albuminous nature of the urine was discovered the patient, who had previously kept in her room, was ordered to bed and the case was treated as one of Bright's disease. On the 7th (the fourth day of my attendance on her) there was distinct puffiness of the face and both legs ; fine crepitations were discernible in the lungs but only at the bases. That examination was made at 1.30 P M. The quantity of urine collected in the previous 24 hours was about 12 ounces, but as there was diarrhoea that quantity was below the real amount passed. About four hours after that visit an urgent message came for me to go to the patient as she was much worse. She was then found sitting up in bed gasping for breath and extremely cyanosed, whilst from her mouth and nostrils a profuse frothy blood-stained fluid was pouring. A 1/400th of a grain of nitro-glycerine was administered subcutaneously and as the case was regarded as one in which venesection was called for the patient was left for 20 minutes while I fetched suitable instruments. On my return she seemed better, but relapsed again, so from eight to ten ounces of blood were drawn off from the right median basilic vein. No real improvement followed the venesection, so two more hypodermic injections of nitroglycerine (1/250th of a grain each) were administered at intervals of half an hour. The patient died at 9 45 P M., about four and a quarter hours after the onset of the attack. The only thing which seemed to benefit the condition was the first hypodermic injection of nitroglycerine. The previous history of the patient was diphtheria three years ago and chorea about 15 months ago. Southgate-road, N. -Medical Societies.
doi:10.1016/s0140-6736(01)76791-8 fatcat:tapqizl6xffpnaen5j2hgrqn2m