performed by his professional attendants, Dr. Winlock and Dr. Moore; the breathing was much improved, but the foreign substance did not appear. A few days now passed with occasional paroxysms of partial suffocation, when the boy was removed to Louisville, where he arrived on the 4th of June.

Fig. 38.

I was requested to see the patient at 11 o'clock in the morning, but being obliged to go into the country, it was nearly four in the afternoon before I reached him. As I was approaching his lodgings, a messenger met me, stating that the lad had just ejected the grain of corn by the mouth, in a violent paroxysm of coughing, as he was lying with his head over the edge of the bed. A careful examination of the chest satisfied me of the existence of a high grade of inflammation of the lungs, especially the right. I therefore at once bled him copiously at the arm, and ordered a dose of purgative medicine. The next morning his breathing was much relieved, but there was still sufficient embarrassment to justify the application of leeches and the use of tartar emetic. The following Monday, that is, four days after I first saw the boy, he was, contrary to my wishes, taken home, where his symptoms soon assumed the most formidable character. Hectic fever rapidly supervened, and the lower lobe of the right lung gave evidence, on percussing the chest, of being in a state of hepatization. Fourteen days after he left Louisville he threw up, in a fit of coughing, a large quantity of offensive matter, which continued to be discharged freely until the 11th of July, the day of his death. No post-mortem examination was made.

CASE 3.-Grain of corn; boy, aged six years; ordinary symptoms; laryngotomy soon after the occurrence of the accident; death about ten days after the operation; situation of the foreign body in the larynx. (Communicated to the author by Dr. John Shackleford, of Maysville, Kentucky.)

A negro boy, aged six years, on the 1st of June, 1838, inadvert ently inhaled a grain of corn. He was seen soon after the occurrence of the accident by Dr. McAdow, of Mason County, who found him laboring under the usual symptoms. At a consultation, it was agreed that the only remedy was laryngotomy, which was accordingly performed by Dr. Shackleford. The foreign substance not making its appearance, the wound was kept open in the hope that

it might be expelled in a violent paroxysm of coughing. Gradually, however, the wound closed, and about ten days after the operation the boy died of suffocation. An examination was made by Dr. McAdow, who found the grain of corn in the larynx, near the incision, in a very swollen and sprouting condition.

CASE 4.-Piece of birch bark; girl, aged eight years; cough and. suffocation; probable lodgement of the substance in the left bronchial tube; laryngotomy on the sixteenth day; etherization; vain attempts at extraction; inversion of the body; death at the end of a month and a half after the accident; inflammation of the left lung and pleura; bark in the trachea. (Communicated to the author, by J. Mason Warren, M.D., of Boston.)

On the 26th of November, 1850, a girl, eight years old, while engaged in chewing a bit of birch bark, for the purpose of making "red spittle," in a fit of laughter allowed it to slip into the windpipe. The accident was instantly followed by a paroxysm of coughing and suffocation, which continued to recur at intervals for nearly a week A sudden change in the position of the substance, on the 1st of December, was succeeded by a return of such violent coughing and strangulation as to excite fears as to the immediate result. At the end of the paroxysm the bark settled down into one of the bronchial tubes, with a mitigation of the severe symptoms. Dr. Warren saw the child for the first time on the 9th of December, when the breathing was much oppressed, and she had a constant dry cough; she looked haggard, and the countenance had a livid hue, indicative of imperfect aeration of the blood; the skin was hot and dry; the pulse one hundred, and the appetite lost. The left side of the chest was rather more flat on percussion than the right, and scarcely any respiratory murmur could be detected in the posterior part of the corresponding lung; some mucus râle existed on a level with the bifurcation of the trachea. In front, however, especially above, the breathing was still performed, though very feebly. On the right side the respiration was puerile. All these circumstances denoted that the substance was lodged in the left bronchial tube.

The night after the examination the girl had a renewed paroxysm of coughing, during which she received the impression that the substance had become again dislodged, and passed up into the larynx. The attack was attended with slight epistaxis.

Laryngotomy was performed on the 12th of December, the patient being fully etherized. A pair of forceps, six inches in length, and so constructed as to open only an inch at the end, was then carried down into the left bronchial tube, but without grasping the offending substance. The operation was thrice repeated, the instrument being retained each time about one minute, without apparently the slightest inconvenience to the child. The patient was next suspended by the heels, at the same time that the throat was irritated to provoke free vomiting; without avail, however, as it regarded the object in view. Finally, the abdomen was compressed, and the air in the lungs suddenly and violently expelled by the hands applied to the chest. The child, considerably exhausted, was put into bed, a piece of gauze being placed over the opening. She spent a quiet night, her cough being much mitigated; and the wound manifested a disposition to close, the air issuing through it only during violent respiratory efforts.

After having remained in Boston several weeks, much in the above condition, except with an increased disposition to general pulmonary engorgement, the child was taken home and placed under the care of Dr. Morrison, of Athol, New Hampshire. She expired on the 9th of January, 1851, nearly a month after the operation, and nearly one month and a half after the accident. The right lung was found in a healthy state, there being only some slight pleuritic adhesions. The left lung, which was dark-colored and pitted on pressure, was firmly attached to the diaphragm, and excessively loaded with blood and serum. The bronchial canals were filled with muco-purulent matter, and those on the left side were in a state of high inflammation. The offending body, which had the appearance of being much swollen, and which was threequarters of an inch long by a quarter of an inch in breadth, was found lying loose in the trachea, having evidently been accidentally pushed up, during the examination, from the left bronchial tube, as there were marks of its having been impacted in its interior.

CHAPTER XI.

TRACHEOTOMY.

SECTION I.

CASES OF TRACHEOTOMY, FOLLOWED BY THE EXPULSION OF THE FOREIGN BODY AND THE RECOVERY OF THE PATIENT.

THE subjoined cases, sixty in number, are offered as illustrations of the effects of tracheotomy. The operation, performed at a variable period after the accident, was followed in every instance by the ejection or removal of the extraneous substance, and the recovery of the patient. It will be perceived that the longest time which intervened, in any one case, between the occurrence of the accident and the operation, was seven months, while in the majority of instances it did not exceed a week, ten days, or a fortnight.

The foreign bodies consisted, in fourteen of the cases, of beans, in five of pebbles, in five of water-melon seeds, in four of grains of corn, in two of bone, in two of nails, and in the remainder, respectively, of a piece of crystal, a piece of silver tube, the larynx of a goose, a grain of coffee, pipe-stem, plum-stone, a piece of earthen cup, shawl-pin, button-mould, glass bead, jawbone of a mackerel, prune-stone, citron-melon seed, brass button, kernel of a hickory nut, hazel-nut shell, acorn, piece of the claw of a lobster, brass ring, cherry stone, half sovereign, persimmon seed, piece of cocoa-nut, a fiddle-peg, a gravel, and the stopper of an inkstand. In three of the above cases, the bodies were multiple; consisting, in one, of a water-melon seed and the shank of a plum, in another, of a gravel and several fragments of beans, and in the third, of two citron-melon seeds.

The sex is stated in only fifty-one of the cases, of which twentyseven were males, and twenty-four females. Twenty-nine of the

cases were under five years of age, seventeen under ten years, five under fifteen, two under twenty, one under thirty, and one under forty. In five, the age is not stated.

The prominent symptoms, in nearly all the cases, were violent coughing, and a sense of suffocation; these, after having lasted from a few minutes to half an hour or upwards, were generally succeeded by a calm, and this, in its turn, by a reproduction of the former distress. In some of the cases, especially in those in which the foreign body was arrested in the larynx, there was aphonia, with hoarseness, hissing, or croupy sound in breathing. A very common occurrence was dyspnoea. In a few of the cases, the symptoms exhibited an asthmatic character; in five, the body moved up and down the trachea.

The treatment, previous to the operation, consisted, in eight cases, of emetics and other means; of emetics alone in three; of inversion and other means in two; of errhines and emetics in two; of emetics and inversion in one; of inversion alone in one; of anodynes and expectorants in one; of bleeding in one; of anthelmintics in one; and of "various means" in one. The probang was passed into the œsophagus in two cases. In the other cases no mention is made of any preliminary treatment.

The time of operation is noted in all the cases. In eighteen it was performed before the end of the second day; in three at the end of the second day; in four at the end of the third day; in one after several days; in one on the fourth day; in four on the fifth day; in two on the sixth; in three on the seventh; in three on the eighth; in one on the tenth; in one on the eleventh; in one on the thirteenth; in one on the fifteenth; in two on the nineteenth; in one on the twenty-first; in one on the twenty-fourth; in one on the twentyeighth; in one on the thirty-fifth; in one on the forty-second; in one on the fifty-eighth; and in one on the sixty-fifth day. In the remaining eight cases the operation was performed at two and a half, three, three and a half, four, six, six and a half, and seven months.

In nine of the cases the operation was attended with hemorrhage. In four, the bleeding was very copious; in one so much so as to cause syncope. In one of the latter cases the hemorrhage was

venous.

The time of the ejection of the foreign body is specified in all the cases. In forty-one it took place immediately, in one