below this point, over a space of about three square inches, the respiratory murmur was entirely wanting. These signs, however, varied, and, at times, the sound accompanying the ingress of air could be distinguished at every part of the chest.

After the patient had been in the hospital a few days, he was bound, inverted, to a table, the operator frequently striking him with his hand on the chest and back. The dyspnoea and spasmodic cough, however, forbade the maintenance of this position beyond forty or fifty seconds. This mode of procedure having produced no effect upon the position of the pebble, the trachea was next opened, and the man again inverted, without any better result. Severe bronchitis ensued, and was twice subdued by repeated cupping, and the use of mercury. At last, the patient suddenly left the hospital, and died eight days after. Six days before this event, he was seized with a violent fit of coughing, in which he was nearly suffocated, and in which he thought he felt the stone change its position. The expectoration was very copious the last week of his life, and he had three convulsions shortly before his death.

An examination of the body revealed extensive inflammation and suppuration in the pleura on the left side, and an abscess in the substance of the lung on the right side. The pebble, which weighed one hundred and fourteen grains, and which measured three-quarters of an inch in its long axis by half an inch in the short, was firmly wedged in one of the first divisions of the left bronchial tube; but there was no ulceration of the mucous membrane around it, indicating that it had been long resident there.

From the history of the case, and the morbid appearances, Mr. Solly is of opinion that the stone was ejected from its original position when the fit of spasmodic coughing came on, two days after the man left the hospital, and that it immediately after passed into the left bronchial tube, where it was found after death. He observes that he had been prepared to use forceps for the extraction of the substance, but that the introduction of a long steel probe occasioned such violent spasm, without affording any evidence as to its situation, that he did not consider himself justified in employing them. It is to be regretted that the history of this case is so defective in regard to its chronology.

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CHAPTER XII.

LARYNGO-TRACHEOTOMY.

SECTION I.

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

THE operation of laryngo-tracheotomy consists, as has been already seen, in making the opening for the removal of the extraneous body partly into the larynx and partly into the trachea. It is a kind of compound procedure, commenced occasionally in the one, and sometimes in the other of these portions of the wind pipe, the surgeon, perhaps, not intending, at the moment, to interfere with more than one, but finding it necessary, as he proceeds, to divide both.

The cases included under this division of the subject are ten in number. Of these five were males, and five females. The ages were, respectively, four, five, six, six and a half, seven, eight, nine and a half, ten, eleven, and twenty-four years. The foreign bodies were a grain of corn, bone, plum-stone, almond-shell, glass bead, water-melon seed, bean, pebble, grain of coffee, and a buttonmould. The previous treatment is stated in only five of the cases, in four of which it consisted of emetics, and in the other of emetics, errhines, and other means. The time at which the operation was performed, after the occurrence of the accident, was, in one "soon," in three the "day after," in two several days, in two on the fifth and ninth day, respectively, in one in five weeks, and in one in six weeks.

In one of the cases, that of Dr. W. H. Mussey, swooning and asphyxia occurred during the operation, and it was necessary to employ artificial respiration to revive the patient. In three, hemor

rhage took place; in one to such an extent as to compel the operator to desist from further proceedings until two days after.

The time which intervened between the operation and the removal of the substance was as follows: in four immediately, in three "soon after," in one in two hours, in two on the next day, and in one on the third day. The mode of extrusion was, in four cases, with the forceps, in one with the probe, in one by coughing, in one by a violent expiratory effort caused by irritating the nose, in one by sneezing, and in two spontaneously. In one of the cases no mention is made of the circumstance.

The symptoms varied so much as to render precise analysis almost impracticable. In several of the cases they were very alarm. ing. In two there was aphonia, dependent, in one certainly, and probably also in the other, upon the presence of the foreign body in the larynx. In one, the voice was altered and hissing, although the substance was moving up and down the windpipe. In another case, in which the body was likewise loose, there was a shrill, croupy cough. In the case of Pelletan, the patient referred most of his distress to the larynx, in which the extraneous substance, a button-mould, was lodged. In Dr. Morehouse's case there was not only aphonia, but a whistling sound in the larynx, and feeble respiratory murmur in both lungs. In one of the cases there was hectic fever, although the foreign body was removed at the end of five weeks.

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

CASE 1.-Grain of corn; lad, aged eight years; laryngotomy first, and immediately after tracheotomy; prompt removal of the foreign body; recovery. (Dr. Abner Hopton, Amer. Journ. Med. Sciences, vol. iv. p. 534. Phil. 1829.)

A boy, eight years old, accidentally inhaled a grain of corn, followed instantly by the most alarming symptoms of suffocation. Laryngotomy was promptly performed, but the aperture thus made was found to be too small to admit of the extrusion of the foreign body; and Dr. Hopton, therefore, determined at once to open the trachea instead of dividing the cricoid cartilage and the isthmus of the thyroid gland, which, as he supposed, might endanger the superior thyroid artery, and thus occasion a troublesome hemorrhage. The grain of corn was now removed without any further embarrassment, and the patient speedily recovered.

CASE 2.--Piece of bone; boy, aged seven years; violent cough, dysp noa, and aphonia; laryngo-tracheotomy the day after the accident; artificial respiration; use of a canula; expulsion of the body at the end of the third day in a fit of coughing; recovery. (W. H. Mussey, M. D., Western Lancet, November, 1853.)

John Wildey, aged seven years, on the 8th of August, while eating soup, was seized with a violent fit of coughing, which was followed by great difficulty of breathing and inability to speak above a whisper. When first seen by Dr. Mussey, twenty-two hours after the accident, he was greatly prostrated, and the countenance had an anxious, livid appearance. The symptoms being in every respect most urgent, laryngo-tracheotomy was promptly resorted to, but before the windpipe could be opened the patient swooned twice. The cricoid cartilage and two rings of the trachea were divided, but the admission of air to the lungs did not produce reaction. Separating the edges of the wound with a bivalve speculum, the operator found that the windpipe was loaded with mucus, which, along with a considerable quantity of blood, he immediately removed by suction with his own mouth, and then, as there was no improvement, he introduced a silver tube,