Soft Rubber Catheter Research Articles

Kluth type I3 and intra-abdominal variants of esophageal atresia: A case series

Background: Esophageal atresia (EA) encompasses a group of congenital anomalies (one in 2500 live births) comprising an interruption in the continuity of the esophagus combined with or without a persistent communication with the trachea. It is confirmed by passing no. 10 sterile, blunt‑tipped red rubber catheter into the esophagus, which gets failed to pass beyond 10 cm. Case Series: We describe two male neonates in whom the infant feeding tube could be passed to 18-20 cm in the upper esophageal pouch. A babygram with a blunt-tipped soft red rubber catheter in situ confirmed the esophageal atresia (EA) with the long upper pouch in the first case and EA with obstruction at the gastroesophageal junction in the second one. Conclusion: The importance of recognizing rare Kluth variants of EA is stressed. A low threshold for performing a red rubber catheter test is stressed.

Congenital bilateral choanal atresia- Endonasal endoscopic surgery- Report of two cases

Congenital choanal atresia (CCA) is the development failure of the nasal cavity to communicate with nasopharynx. It is an uncommon congenital anomaly of nose with an incidence of approximately 1 in 5000-7000 live births. Choanal atresia is caused by failure of resorption of the nasobuccal membrane during embryonic development. Choanal atresia has a significant association with CHARGE syndrome. Surgical intervention is recommended in the first weeks of life in bilateral cases because this is a life threatening condition. Two cases of congenital bilateral choanla atresia (CCA) was admitted in the department of Otolaryngology & Head-Neck Surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU) with the complaints of intermittent attacks of cyanosis, dyspnea, respiratory distress and history of inability to take feeds. On examination both babies had respiratory distress, mucoid discharge from both nasal cavities. A soft rubber catheter was passed into both nares revealed the diagnosis of bilateral CCA which was confirmed by flexible nasoendoscopy. Bilateral CCA was managed with a nasopharyngeal airway. Surgery is the definitive treatment with two main approaches namely transnasal and transpalatal. We discuss successful management of two neonates with bilateral CCA by endonasal endoscopic approach.
 Bangladesh J Otorhinolaryngol; April 2018; 24(1): 85-89

One layer end-to-side pancreaticojejunostomy using reinforcing suture on the pancreatic stump.

Pancreaticoduodenectomy is associated with a high incidence of postoperative morbidity, and pancreatic fistulas are the most important complication. We therefore designed a modified method of pancreaticojejunostomy using reinforcing suture on the pancreatic stump. The procedure is performed as follow: first, insert a soft rubber catheter into the pancreatic duct, then make reinforcing sutures with 3-0 vicryl. These sutures are parallel to the cut edge of the pancreatic stump, and 5mm from the cut edge. The whole layer of jejunum is sewed to the pancreas including the reinforcing sutures. Between July 2002 and November 2011, 52 consecutive cases of pancreaticoduodenectomy were performed using this method. We used The International Study Group for Pancreatic Surgery (ISGPS) severity grading for postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). There was 1 grade A fistula (1.9%), 16 grade B fistulas (30.8%), and 2 grade C fistulas (3.8%). This method of one layer anastomosis is straightforward and practicable; hence it saves operative time, and is not much affected by lack of familiarity with the surgical technique. Even if it does not actually prevent pancreatic fistula formation, it does prevent the life-threatening complete breakdown of the pancreaticojejunostomy.

Transcervical drainage of epidural and retropharyngeal abscess

This report describes treatment of concurrent epidural and retropharyngeal abscesses and presents a novel surgical approach to treating this pathology. The treatment of epidural and retropharyngeal prevertebral abscesses requires surgical drainage in addition to systemic antibiotics. After the patient’s airway is secured, urgent otolaryngologic surgery consultation is obtained for transoral drainage of the retropharyngeal abscesses to minimize risk to vascular and nervous structures within the neck. If epidural extension is also present, urgent neurosurgical evaluation and decompression may be necessary. We report a patient with an epidural and prevertebral abscess. A posterior approach was taken for wide decompression of the cervical spine and evacuation of the epidural collection. During this procedure, under fluoroscopic guidance, an 8 Fr soft rubber catheter was slowly advanced ventrally in the epidural space through the C5–6 intervertebral disk into the retropharyngeal abscess with evacuation of this collection as well. Using a single, wide posterior approach, the dorsal epidural, the ventral epidural, and prevertebral abscesses were all successfully evacuated. This report describes a novel approach for evacuation of prevertebral abscess concurrent with multilevel laminectomy for epidural abscess evacuation.

Experience with a hybrid, minimally invasive gastrostomy for children with abnormal epigastric anatomy

Purpose This communication is an analysis of the experience with a new type of gastrostomy. It was developed for patients with pronounced epigastric anatomical abnormalities, such as dense adhesions, in whom the conventional “open” gastrostomy could prove difficult and the percutaneous endoscopic, the imaging-guided, and the laparoscopically assisted methods would be unsafe. Method A large, soft rubber catheter is inserted in the child's mouth and advanced into the stomach. A small epigastric incision is made. With the help of the catheter, the anterior gastric wall is identified and the stoma site chosen. One of the curved needles of a double-armed monofilament suture is passed through the gastric wall and through the catheter. The needle is then cut off. The other needle is passed through the abdominal wall, from the inside out at the most suitable skin stoma site. When the catheter (with the embedded suture) is withdrawn from the mouth, a tract is established. The suture is replaced by a guide wire, which allows a percutaneous endoscopic gastrostomy–type catheter to be placed by the percutaneous endoscopic gastrostomy “pull” technique. Results This approach was used in 15 patients (14 children—ages 1 month to 7 years and one 19 years old) with: status post (s/p) necrotizing enterocolitis and bowel loss (n = 4); s/p gastroschisis and short-gut syndrome (n = 3); cerebral palsy, s/p ventriculo-peritoneal shunt infections (n = 2); s/p complex omphalocele; dwarfism; morphologic abnormalities; repaired prune-belly syndrome; s/p duodenal atresia with malrotation; severe scoliosis with s/p multiple shunt infections (one each). There were no complications. The technique also proved useful in several other children in whom a laparotomy incision for unrelated conditions was remote from the gastrostomy site. Conclusion Using a very small incision, this hybrid method permits safe and precise gastric and abdominal wall site selection and gastrostomy catheter placement. Gastrotomy as well as purse-string and peritoneal fixation sutures are not needed, and the danger of accidental catheter dislodgement is minimized.

More about Telescoping for Nasotracheal Intubation in Children

We thank the authors of both letters for their thought-provoking comments. In the first letter, Dr. Mahajan et al . refer to the incidence of nasopharyngeal bleeding after native tubes in our study1(56%) and the incidence after warmed tubes and a vasoconstrictor in the study by Elwood et al .2(29%). Although these were both “control” groups, the two treatments have no common basis for comparison. Considering the incidence of bleeding associated with warmed tubes in the two studies,1,2Dr. Mahajan et al . posit that the 0.5-mm-larger tube diameter in our study contributed to the greater incidence of bleeding. This is a possibility that we did not test. Whether the larger tube diameters in our study contributed to the incidence of bleeding with native and warm tubes is a moot point because the incidence of bleeding with a larger diameter tube telescoped into a soft rubber catheter seems to be trivial (5%).1Further direct comparisons between the results of the two studies should be limited because we did not test the effect of oxymetazoline in our study. Although the larger-diameter uncuffed tubes may have contributed to the incidence of bleeding in our study, this was a compromise rooted in our other concern to minimize the magnitude of the endotracheal tube leak. The authors correctly point out that we did not report complications from nasotracheal intubation that occurred in the postanesthesia care unit and thereafter. We can state categorically, though, that whereas surrogate markers for complications may have occurred, neither ear, nose, and throat consultation nor admission to or delayed discharge from the hospital occurred as a result of nasopharyngeal bleeding.Dr. Wu also questions the sizes of the tubes that we used and the magnitude of the endotracheal tube leak. We did not change any of the tubes because the tracheal leak was too large. This is not to suggest that such a situation cannot occur. However, during dental surgery, we minimize the clinical impact of a small endotracheal tube leak by maintaining spontaneous ventilation and by packing the throat with gauze. There is no evidence that the size of the larynx in children in the United States varies geographically. Dr. Wu describes a modification to the proximal end of a cuffed straight nasal tube to facilitate its use in dental surgery, which is analogous to using the old-fashioned metal “nasal” connectors. However, we urge caution when considering the use of “homemade” modifications to airway devices that have not been tested under rigorous conditions to identify the risks of failure and disconnect during anesthesia.*Women and Children’s Hospital of Buffalo, State University of New York at Buffalo, Buffalo, New York. jerroldlerman@gmail.com

Nasal mucociliary clearance in health and disease

"Standard saccharine test is used to detect nasal mucociliary clearance time in healthy individuals both adults and children. The length of the nose was measured radiologically and with the help of a soft malleable rubber catheter. For healthy individuals, mean nasal mucociliary clearance lime is 8.2 minutes in children and 9.5 minutes in adults. The mean nasal mucociliary clearance rates were 11.1 mm/min for children and 12.7 mm/min for adults.Deviated nasal septum, chronic sinusitis, allergic rhinitis, atrophic rhinitis, chronic smokers and patients with recent nasal packings were taken as diseased conditions in adults, whereas children with adenoid hyperplasia were taken for the study. In all of these, nasal mucociliary clearance was significantly prolonged."

The “Penny pincher”: A new technique for fast and safe removal of esophageal coins

Background/Purpose: Considerable debate surrounds the choice of technique for the removal of esophageal coins: endoscopic extraction versus dislodgement with a Foley balloon versus dislodgement using bougienage. The “penny-pincher” (PP) technique was developed as an alternative, incorporating the main advantages of these various approaches.Method. The PP technique is based on the insertion of a fluoroscopically guided device that consists of a grasping endoscopic forceps covered by a soft rubber catheter. The forceps provides a firm hold on the coin. The catheter protects the oropharynx and aligns the device with the coin. Once the tip of the catheter is close to the upper edge of the coin, the previously retracted radiopaque prongs of the grasping forceps are deployed and the edge of the coin firmly grasped and extracted. The procedure is done without anesthesia or sedation.Results: Twenty coins were removed from 19 consecutive children with a mean age of 34 months. Average lip-to-lip removal (including fluoroscopy) time was 41 seconds. There were no complications, and all patients were discharged shortly after coin removal.Conclusion: The penny-pincher method for the removal of upper esophageal coins combines the simplicity, speed, and cost effectiveness of balloon catheter or bougie coin dislodgement with the safety and secure grasping of endoscopic or forceps removal.

A simple technique for removing a silastic gel-filled breast implant through the axillary approach

We present a simple, atraumatic technique for removing a breast implant through a small incision following transaxillary breast augmentation, using straight artery forceps with jaws covered with a length of soft rubber catheter. This provides a gentle but firm grasp on the silicone gel-filled prosthesis for easy removal, without rupture.

Intraoperative diagnostic pneumoperitoneum (Goldstein test) in the infant and child with unilateral inguinal hernia

Over a 3 year period, 191 infants and children underwent operative repair of inguinal or communicating hydroceles or both. Of these patients, 131 underwent the Goldstein test to determine the presence or absence of a contralateral hernia sac. The Goldstein test was performed by introducing a soft rubber catheter through the hernia sac into the abdominal cavity and distending the peritoneal cavity with air. The contralateral groin and, in males, the scrotum were then palpated for crepitance. The Presenting Positive Result Sex Side Total n % Male Right 65 17 26.15 Left 26 5 19.23 Female Right 24 10 41.67 Left 16 6 37.5 Total 131 38 29 presence of crepitance constituted a positive test result. Of the 131 tests performed, the results were positive in 38 (29 percent) and negative in 93 (71 percent). There was one false-positive test result (2 percent) and no false-negative results. The test was not performed in 60 patients because of technical problems in passing the catheter (22 percent), presence of a ventriculoperitoheal shunt (2 percent), previous contralateral herniorrhaphy (1.6 percent), presentation with bilateral hernias (26 percent), and patient age of 12 years (1 percent). Continued differences in approaches to the management of pediatric patients who present with unilateral groin hernias prompted this study. We believe that the Goldstein test represents a safe, economical, rapid, accurate, and humane approach to this common problem.

LARYNGEAL REFLEXES IN CHILDREN UNDER KETAMINE ANAESTHESIA

SUMMARY Laryngeal reflex activity was studied in 8 children under ketamine anaesthesia by placing a radiopaque contrast medium in the pharynx through a soft rubber catheter via the nose or mouth. Laryngeal spasm developed in 4 patients. In no case was contrast medium detected in the lung fields in subsequent chest radiographs. The risks of the use of ketamine in patients with a full stomach are discussed, and atropine premedication is advised. Ketamine should only be used in the presence of experienced personnel, and when appropriate resuscitation equipment is immediately available.

Colostomy enema. Description of a catheter-nipple device.

The use of an infant feeding nipple with an enlarged hole through which a soft rubber catheter has been placed is recommended to prevent leakage during a barium enema examination in a patient with a colostomy. The catheter-nipple assembly may also be used for cleansing irrigations.

Preliminary observations in the rabbit on the anti-ovulatory activity present in Taxus baccata linn. leaves.

Possible antiovulatory activity of different extracts of leaves of Taxus baccata was tested on 58 adult non-pregnant rabbits. The rabbits were housed in independent cages for at least 3 weeks before use. The air-dried powdered leaves of T. baccata were extracted with petroleum ether (b.p. 60 to 80 degrees C) alcohol (95%) and distilled water. The extracts were administered as a suspension with gum acacia by a soft rubber catheter at different intervals before induction of ovulation. Ovulation was induced by injecting copper acetate iv (4 mg/kg). To assess ovulation laparotomies were carried out on the rabbit 48 hours after the copper acetate injection and the bleeding points on each ovary were noted. When administered at a dose of 200mg/kg for 2 days the petroleum ether and alcoholic extracts of the leaves of T. baccata did not prevent ovulation to any marked degree. When the aqueous extract of the leaves was administered at a dose of 400 mg/kg for 2 days maximal antiovulatory activity was detected (100%). There was no antiovulatory activity when the same dose of aqueous extract was administered for only 1 day. Activity was also detected when doses of 200 and 250 mg/kg were administered for 2-3 days before induction of ovulation. When the average numbers of bleeding points (ovulation points) in the different groups of animals were compared it appeared that there were fewer in rabbits when T. baccata had been administered at a dose of 200 mg/kg for 3 days (1) 250 mg/kg for 2 days (1.6) and 400 mg/kg for 1 day (1.8). However bleeding points were present after administration of copper acetate in these animals while there were no bleeding points seen in 10 rabbits when T. baccata had been administered at a dose of 400 mg/kg for 2 days. The results indicated that the aqueous extract of Taxus baccata possesses antiovulatory activity.

Emergency x-ray examinations in paediatric practice.

DIFFICULTY IN SWALLOWING This may, inter alia, be due to (a) oesophageal atresia, (b) pharyngo-oesophageal inco-ordination of swallowing or (c) retro-pharyngeal abscess. In oesophageal atresia early diagnosis is essential if the child's life is to be saved. The history is one of excessive salivation, with attacks of choking and coughing if feeding is attempted. Aspiration pneumonia follows feeding, especially affecting the right upper lobe. The greater the lung involvement the poorer is the prognosis. It is usually sufficient to pass a soft rubber catheter into the oesophagus from the mouth, with or without fluoroscopic control, and take films with this in situ. Some surgeons do not approve of the instillation of a positive contrast medium but if this is employed, all the contrast medium should be sucked out before the catheter is removed. The two main types of oesophageal atresia are (a) those with a distal oesophageo-tracheal fistula, showing air in the gastro-intestinal tract, and (b) those without a fistula. The latter have the more serious prognosis as the gap between the segments is usually greater. In the rarer types there may be a fistula between the upper sac and the trachea, or fistulae between both sacs and the trachea or bronchi. Tracheo-oesophageal fistula without atresia rarely presents as an emergency problem and calls for specialised investigational techniques. Recently MacEwan, Dunbar and Murphy (1960) have successfully used cinefluorography to demonstrate high tracheo-oesophageal fistulae. Children with birth injury to the basal cerebral ganglia may present with difficulty in swallowing and often regurgitation of the feed through the nose, with excess of mucus. The symptoms may mimic those of oesophageal atresia but this can be excluded by the passage of a rubber catheter into the stomach. If the baby is fit enough for the examination to be continued, a Dionosil swallow can be carried out; the baby will usually suck Dionosil through a rubber teat attached to a warmed bottle of the substance. The opaque medium tends to be held up in the mouth and pharynx, and whilst a little will pass into the oesophagus and stomach, some will be returned to the mouth, pass into the nasal cavity and spill over into the trachea (Fig. 1). Severe oral and oesophageal thrush infection will give a similar picture. Oxygen and suction apparatus should be at hand during the X-ray examination. A retropharyngeal abscess may not be very obvious clinically but will cause difficulty in swallowing and the child is acutely ill. A lateral teleradiograph of the neck with the head extended will provide the diagnosis. The film must be taken in full inspiration as the prevertebral tissues in infants are normally redundant and widen during expiration so that they may give a deceptive appearance. An abscess will show as a curved prevertebral swelling, displacing anteriorly the larynx, trachea and sometimes the upper oesophagus. It is important that the trachea should show as a straight airfilled structure on the film; buckling of the trachea shows that the radiograph was taken in expiration. A cervical neuroganglioma may also cause a prevertebral swelling but this condition is rare and the child is not acutely ill.

AN ALTERNATIVE TECHNIQUE FOR BRONCHIAL ASPIRATION THROUGH A TRACHEOSTOMY.

A technique for aspirating the bronchi of a patient with a tracheostomy is described. Modified Magil's endotracheal tubes are used to serve as a guide for a soft rubber catheter with a single terminal opening.The efficacy of the method in the prevention and treatment of pulmonary collapse is illustrated.The method is particularly applicable in the treatment of the acute tetraplegic patient in whom movement of the head and neck are prohibited.

EQUIPMENT FOR CATHETERIZATION OF FEMALE INFANTS

THE IMPORTANCE of examining the urine of infants, especially females, cannot be overemphasized. It is getting a fresh specimen that sometimes presents the problem. This is true for the pediatrician making a home call and sometimes in office work. The apparatus to be described offers a sort of one-man catheter set that can be used in the home or office. Figure 1 shows that the apparatus can be carried in a medical bag; the 4-ounce, wide-neck bottle makes a small package. The equipment consists of a 4-ounce, wide-neck, Americantype bottle; a two-hole rubber stopper; two pieces of glass rod and a No. 8 soft rubber catheter. The apparatus is assembled, wrapped in a towel and autoclaved. Several of these sets can be kept ready. It is not often necessary to catheterize male infants. The catherization of female infants can be done in the home with the mother as the only assistant. The vaginal area is cleansed with soap, preferably Phisoderm®. The apparatus does not allow for the escape of the first few drops of urine before collecting; our experience has led us to believe that this is not necessary, if proper cleansing and inspection has been done. It is well to remember that the urethra of the female infant baby is "C" shaped. The meatus represents the bottom end of the "C." The catheter should be started downward. The thighs should be widely abducted but held fully extended, not flexed on the abdomen. This position will not angulate the "C" curve of the urethra. The specimen is collected in the stoppered bottle which does not require holding. This allows free use of both hands. The specimen is collected in a closed apparatus and offers a fresh specimen for study and culture.

PREMATURE AND NEWBORN INFANTS

Participating in the seminar's first session were Dr. William R. Richardson, Kings County Hospital, Brooklyn, New York, who served as moderator, Dr. Thomas Santulli, Children's Surgeon at Columbia-Presbyterian Hospital, New York City, Dr. Marel H. Harmel, Anesthesiologist at Kings County Hospital, and Dr. Lawrence K. Pickett, Chief of Surgery at the State University of New York Medical Center in Syracuse. All speakers emphasized the importance of closely co-operative effort by pediatricians, surgeons, radiologists, anesthesiologists and nursing personnel to facilitate early recognition, diagnosis and effective treatment of neonatal complications requiring surgery. Diagnosis Early recognition of surgical problems usually depends upon the observations of well-trained nurses. Any history of obstetric complications especially breech presentation, a maternal history of hydramnios, any signs of respiratory distress, difficulty in swallowing at the time of the first feeding, emesis of bile-stained fluid, abdominal distention, or failure of the appearance of the first stool within 24 hours after birth should alert all observers to the possibility of complications which will require surgery. As soon as respiratory or gastrointestinal complications are suspected, Dr. Pickett requests radiologic consultation. A roentgenogram of the chest, taken at this time, will delineate not only the infant's pulmonary status, but also the gas pattern of the intestinal tract. When the clinical picture suggests gastrointestinal obstruction, Dr. Pickett and his colleagues employ a No. 8 to 10 French soft rubber catheter, specially prepared by punching several holes in its terminal 1 cm portion. This tube is inserted under fluoroscopic control and passed cautiously to avoid traumatic puncture of any obstructing tissue which may be encountered When esophageal atresia is recognized the proximal esophageal pouch is carefully aspirated to remove pooled saliva.

Roentgen study of urethrovesical relationships in female urinary stress incontinence.

This report is based upon comparative roentgen studies of the female urethra and bladder in three distinct groups. Group 1 was made up of normal non-parous women. The patients of group 2 had no urinary complaints but did show varying degrees of relaxation of the support of the lower urinary tract as the result of parturition. Group 3 was composed of patients complaining of urinary stress incontinence. Two phases of bladder physiology were investigated—resting and straining. Both anteroposterior and lateral roentgenograms were taken, and, when operation was performed, preoperative and postoperative urethrocystograms were studied. A modified urethrocystographic technic was used, which furnished excellent contrast in both the lateral and anteroposterior views. It had the further advantages of simplicity, accuracy of detail, and avoidance of distortion. This procedure required the cooperation of the Departments of Gynecology and Radiology. The patient was prepared for roentgen examination in the gynecological clinic. Skiodan was used for demonstration of the bladder outline. The configuration of the urethra was demonstrated by means of a metallic bead chain of the type commonly used for carrying keys. This chain measured 25 cm. in length. The beads were 3 mm. in diameter and were separated by connecting rods 1.5 mm. in length. For insertion of the chain, an 18 French soft rubber catheter was bisected longitudinally. The other apparatus consisted of the usual instruments for sterile catheterization of the female. The procedure for insertion of the chain was easily mastered. The patient was draped as for sterile catheterization. The chain was fitted into the inside lumen of the bisected catheter with the first bead extending over the catheter tip. The entire catheter was lightly lubricated with jelly and inserted into the urethra for a distance of 12 cm. As the catheter was further introduced, the external end of the chain was held taut to liberate it from the catheter, which could then be withdrawn, leaving the chain in place in the urethra and bladder. The bladder was emptied of urine with a glass catheter, and 60 c.c. of 15 per cent Skiodan was instilled. A metallic marker applied to the side of the external urinary meatus served to identify the terminal end of the urethra. The patient was then transported by wheel chair to the radiological department. The first important factor in obtaining a satisfactory roentgen examination is a sympathetic attitude on the part of the technician, so that she can gain the confidence of the patient. Not only is the patient uncomfortable, but she has the added fear of expelling the contents of the bladder. All of the films are exposed with the patient standing. Exposures are made in the anteroposterior and lateral positions with the tube focused at the level of the upper border of the symphysis pubis.

PERFORATION OF COLOSTOMY LOOP BY SOFT RUBBER CATHETER

We recently encountered case of perforation of the bowel by soft rubber catheter that occurred in patient who was employing an enema for colostomy evacuation. None of us has ever seen similar accident. A careful search of the records of the Michael Reese Hospital for the last 20 years failed to show any case of perforation of the bowel with soft catheter. Drs. E. I. Greene and J. M. Greene, in recent article, report similar case and say that a review of the literature for the last eighteen years reveals only one report of similar complication's. They refer to the article of Dr. Carl Davis Jr., who reported three cases. REPORT OF A CASE A 55-year-old man was brought to Michael Reese Hospital with perforated bowel. Four months previously, he had had an abdominoperineal bowel resection for cancer of the rectum. The

Congenital Atresia of the Esophaqus

Congenital atresia of the esophagus as usually been regarded as an uncommon condition. In 1931, Rosenthal (to) recorded 255 cases from the literature, including a number of his own. Since then numerous additional cases have been published. We recently encountered two examples, associated with tracheo-esophandgeal fistula, within a month. During the previous ten years there had been 12,285 deliveries on the maternity service of Metropolitan Hospital, but among these the records fail to show a single case of esophageal atresia. Nor is it likely that any cases were overlooked, as a very high percentage of autopsies on the newborn is obtained at this institution, particularly in cases with unusual symptoms. The purpose of the present communication is to present our cases, to review briefly the salient clinical and radiographic features, and to describe a new and simple diagnostic procedure-aeroesophagography- for establishing a diagnosis of congenital atresia of the esophagus. A number of excellent reviews have appeared in the American and English literature, notably those of Griffith and Lavenson (3) in 1909, Cautley (2) in 1917, Plass (9) in 1919, Vogt (14) in 1929, Rosenthal (to) in 1931, Mathieu and Goldsmith (8) in 1933, and Lanman (.5) in 1940. Vogt classifies congenital atresia of the esophagus into the following categories: Type 1: Complete absence of the esophagus (extremely rare). Type 2: Complete atresia with no tracheo-esophageal fistula (rare). Type 3A: The upper esophageal segment communicates with the trachea (rare). Type 3B: The upper segment terminates blindly ; the lower communicates with the trachea or with the bronchi near the level of bifurcation of the trachea (the commonest type). Type 3C: Both esophageal segments communicate with the trachea or bronchi rare). Our cases are both of Type 3B (Type 3 of Ballantyne, 1). Case Reports Case 1: R. K., a white male, was born Oct . 1, 1940, after a normal pregnancy and labor. The family history is irrelevant. The infant appeared normal at birth but shortly thereafter drooling and the presence of a large amount of thick, frothy mucus in the mouth and pharynx were observed, and repeated aspiration became necessary to keep the pharynx clear. On the following day the ternperature rose to 101°, the respiratory rate increased, and many medium and coarse râles were heard throughout the chest. A roentgenogram showed consolidation of the upper lobe of the right lung. Regurgitation of all feedings occurred, and several attempts at gavage proved unsuccessful. It appeared, however, as if some of the food was retained when a Breck feeder was used . The pneumonia was considered the sole cause of coughing, respiratory difficulty, and vomiting. Clyses and whole blood transfusions helped to maintain fair hydration, adding to this impression. The persistence of symptoms, however, led to the consideration of esophageal atresia as the underlying condition, and a roentgen investigation was requested. On Oct. 5 a soft rubber catheter was introduced into the esophagus, and under fluoroscopic guidance was passed down toward the stomach.