regular; but occasionally it was impelled against the larynx, and then great pain was produced by the percussion of the parts. The patient, believing that the substance would ultimately be expelled spontaneously, refused to submit to an operation for his relief. This state of things continued for five years, when the coin, becoming impacted in the bronchial tube, caused but little uneasiness. The patient was now obliged to go to India, where symptoms of phthisis gradually declared themselves. Ten years after the accident he died, and, on dissection, the coin was found imbedded in a tubercular excavation in the lung.

CASE 21.-Piece of ivory, consisting of four artificial teeth; man, aged thirty-five; retention of the foreign body for thirteen years; patient asthmatic from childhood; no material increase of suffering after the accident; death from pleurisy, the effect apparently of the presence of the artificial teeth. (Mr. W. G. Carpenter, Guy's Hospital Reports, vol. vii. p. 353, London, 1842.)

A man, aged thirty-five, an assistant in a chemical establishment in London, and an habitual asthmatic, swallowed, thirteen years ago, in a fit of coughing, a piece of ivory, wrought into four artificial teeth. The morning after the accident, he was advised to take an aperient, on the supposition that the foreign body had passed into the stomach; and, as there was no material increase of suffering, or inability to attend to his usual business, it was naturally concluded that the substance had been voided by the bowels. The circumstance was, therefore, gradually forgotten.

From the time when Mr. Carpenter first saw the patient, in the winter of 1841, until his death, a few months after, he was never free from fever. His pulse was always above one hundred, the skin was hot, and there were other symptoms of inflammation, which continued, without any intermission, until the following spring. On the 13th of April, he was seized with acute pleuritis in the right side, attended with excessive pain, distressing cough, and dulness on percussion on the anterior and posterior part of the chest, with absence of the respiratory murmur. To relieve these symptoms, blood was taken from the arm, and the bowels were moved with calomel, antimony, and colocynth. Subsequently, cups and blisters were employed, with various other remedies unnecessary to be specified. Death occurred on the 19th of April, about five days after Mr. Carpenter began his treatment.

On opening the right side of the chest, a very offensive gas gushed out. The cavity contained five pints of sero-purulent fluid; the lung was collapsed, and pressed flatly against the bodies of the vertebræ; and there were thick layers of lymph both on the pulmonary and costal portions of the pleura. On the outer surface of the lung was an old fistulous opening, large enough to admit the tip of the little finger, but not communicating with the bronchial tubes, or the interior of the organ, which contained a number of tubercles, some of them in a state of suppuration. The four artificial teeth, represented in the annexed sketch (Fig. 59), were acci

Fig. 59.

dentally found, after the examination was completed, in the right thoracic cavity, in sponging out the blood, and replacing the lung. They were covered with a brownish crust, and furnished with silver rivets, by which they had been adapted to the upper jaw.

The left lung was emphysematous, and contained miliary tubercles. The corresponding pleura was healthy; but the smaller bronchial tubes were filled with mucus. The heart was sound.

Mr. Carpenter supposes-and the conjecture is very plausiblethat the foreign body, in this case, gradually passed through the substance of the right lung by ulcerative action, and at length escaped into the right pleuritic sac, where its presence gave rise to the violent inflammation which immediately preceded dissolution. The fistulous opening, above alluded to, was, doubtless, the remains of the track pursued by the ivory. It is very remarkable, as observed by Mr. Carpenter, that the man never had any hæmoptysis.

CHAPTER XVI.

BRONCHOTOMY IN THE INFERIOR ANIMALS.

TRACHEOTOMY has occasionally been performed upon the inferior animals, and it is to be regretted that the operation is not more. frequently resorted to for their relief, as many, doubtless, perish that might thus be saved. In the subjoined case, which occurred in the hands of my friend, Dr. Kumpé, of La Grange, Alabama, the operation was crowned with the most gratifying result.

A valuable mare, the property of Mr. John McCain, in June, 1847, while eating sheaf-oats, became suddenly choked; her owner, having exhausted all his resources, sent the animal to Dr. Kumpé, and entreated his assistance. Twenty-four hours had elapsed since the occurrence of the accident. The animal was evidently in great distress; she labored under excessive dyspnoea, her head and neck were extended, she refused food and drink, and her breathing was audible at a distance of six or seven yards. On applying the ear to the windpipe, it was obvious that the obstruction was either in the larynx or in the upper portion of the trachea. Dr. Kumpé having provided himself with a strong scalpel, a sharp-pointed bistoury, and other instruments, together with a long probang, the animal was thrown upon her left side, and firmly secured, the head and neck being held in the extended position. The hair being shaved off in front of the windpipe, an incision, three inches in length, and commencing about an inch and a half below the cricoid cartilage, was made through the integuments along the median line, thus exposing the muscles in that situation, which were next separated from each other in the usual manner. Five of the rings. of the trachea were then divided with the bistoury, when the probang was introduced into the opening, and carried gently upwards through the larynx into the fauces. This proceeding had the effect of dislodging the foreign body, and of thrusting it into the

mouth, from which it was afterwards withdrawn with the hand. It proved to be a head of oats, at least three inches and a half in length, and proportionably thick.

Not more than five or six ounces of blood were lost during the operation, and, as no vessels of any importance were divided, not a single ligature was required. After the oozing had ceased, the edges of the wound were approximated by five interrupted sutures, when the mare was released, and soon commenced eating grass. A slippery elm poultice was constantly kept upon the wound for some days, for the twofold purpose of moderating inflammatory action, and preventing the attacks of flies. An active saline cathartic was given soon after the operation, and the most rigid diet enjoined. The wound healed very kindly, and sixteen days after the operation the mare was again in the harness.

In a recent paper on tracheotomy by Professor Eve, of Nashville, is a brief account of a case of foreign body in a horse, terminating fatally from the effects of pneumonia. The animal, while eating by the way-side, was suddenly seized with a violent fit of coughing, which continued, at irregular intervals, for a month or two, when he died. An examination being made, a portion of an oak leaf was found in one of the lungs, along with an abundance of purulent matter.

CHAPTER XVII.

GENERAL SUMMARY.

FROM the numerous facts and cases adduced in the preceding pages, and from the reasoning founded upon them, the following conclusions may be fairly and legitimately deduced. These conclusions may be arranged under different heads, according to their respective relations, as diagnostic, pathological, therapeutic and operative.

I. Diagnostic Signs.-Under this division of the subject may be briefly mentioned the nature and mode of entrance of foreign bodies, their liability to be arrested in different portions of the air-passages, and the symptoms commonly induced by their presence.

1. Any substance, whatever may be its form, provided it be not disproportionably large, may enter the larynx, and thence descend into the trachea and bronchial tubes.

2. The entrance of the foreign body is usually effected during a strong and sudden inspiration, while the epiglottis is off its guard, the glottis expanded, and the larynx quiescent.

3. The extraneous substance may be arrested in any portion of the air-passages, but not with equal frequency. Thus, in the larynx, it is, perhaps, most liable to be entrapped in the ventricles of Morgagni; and, when it descends into the bronchial tubes, it more frequently selects the right than the left. The trachea, on the contrary, rarely becomes its permanent receptacle; and the same is true in respect to the binary and tertiary divisions of the bronchial tubes.

4. The site of the foreign body is materially influenced, not generally, but frequently, by its size, weight, and configuration. Thus, a shot, ball, pea, bead, or pebble will be more likely to descend into the bronchial tubes than a rough, light, sharp, or angular substance.

5. The intruder may shift its place. Thus, it may pass from one bronchial tube into the other, or from these canals into the trachea,