fever, with the most fetid expectoration. The boy gradually sunk; and, on dissection, the extraneous body was discovered in an abscess, which was common to the lung and liver, the latter of which had become involved by an extension of the morbid action across the diaphragm.

it

Finally, when abscesses form after this accident, whether as a consequence of simple pneumonia, or of the softening of tubercular deposits, the matter is either retained, or, as more generally happens, passes into the bronchial tubes, whence it is afterwards discharged by coughing or expectoration. Occasionally, as in several of the cases mentioned in the present treatise, it points externally at one of the intercostal spaces, where it sometimes forms an opening through which the foreign body, which induced the mischief, ultimately escapes. In a most interesting and instructive case, recently communicated to me by Dr. John L. Atlee, of Lancaster, Pennsylvania, a large abscess, situated in the left lung, was ruptured during the attempts which were made to extract the foreign body, a piece of the kernel of a hickory-nut, which was ejected along with the purulent fluid. The patient, a boy, five years old, soon recovered from the accident, which had occurred ten weeks and a half before he was tracheotomized.

CHAPTER IV.

SYMPTOMS OF FOREIGN BODIES.

THE symptoms which follow and accompany this accident, may be divided into those which take place at the moment of the introduction of the foreign body, and into those which arise in consequence of its sojourn in the air-passages. This distinction, although recognized by most writers, has not, it seems to me, received the consideration to which its importance, practically speaking, entitles it. It will be my object, in the succeeding remarks, to place the subject, if possible, in its true light.

The moment a foreign substance, however small, touches the windpipe, it is sure to excite severe distress and coughing, on account of the spasmodic action of the muscles of the larynx. We have a familiar illustration of this in the suffering which occurs when a drop of water, a crum of bread, or a particle of salt accidentally slips into the glottis. Instantly the most violent distress is excited, which generally continues until the intruder is dislodged from a situation which Nature never intended it to occupy, and where it could not remain long without causing serious structural mischief. But these symptoms are, in general, slight and transient compared with those that attend the intromission of a foreign body, properly so called. In the latter case the patient is usually in imminent danger of suffocation, and he may, indeed, regard himself as being very fortunate if he escapes with his life. Cases without number might be cited, were it deemed necessary, to confirm the truth of this remark. In the great majority of instances, the patient is seized with a feeling of annihilation; he gasps for breath, looks wildly around him, coughs violently, and almost loses his consciousness. His countenance immediately becomes livid, the eyes protrude from their sockets, the body is contorted in every possible manner, and froth, and, sometimes, even blood issue from the mouth and nose. Sometimes he grasps his throat, and utters

the most distressing cries. The heart's action is greatly disturbed, and not unfrequently the individual falls down in a state of insensibility, unable to execute a single voluntary function. In short, he is like one who has been choked by the hand, or by the rope of the executioner. Sometimes a disposition to vomit, or actual vomiting, occurs immediately after the accident, especially if it take place soon after a hearty meal. The relief occasionally experienced from this source is very great. In some instances, again, there is an involuntary discharge of feces and even of urine.

Several instances are mentioned in which the patients threw up a considerable quantity of pure blood during the violent coughing immediately consequent upon the accident. This occurred in a case observed by Mr. Cock, of London, in which a sixpence slipped down the throat, and at first lodged in the larynx, but afterwards fell into the trachea. Violent coughing, with the most distressing sense of suffocation, instantly took place, and during the paroxysm the patient threw up a quantity of blood.

The duration of the first paroxysms varies from a few seconds to several minutes, or, in severe cases, as when the foreign body is arrested in the larynx, even to several hours. With the restoration of the respiration, the features resume their natural appearance, and the patient recovers his consciousness and power of speech. The voice, however, frequently remains somewhat altered, the breathing is more or less embarrassed, and the individual is harassed with frequent paroxysms of coughing, attended often with a recurrence of all, or nearly all, the original symptoms. Thus the case may progress for an indefinite period, until the foreign body is expelled, or until it produces death by functional or organic disease of the air-passages.

The calm which ensues after the first paroxysms have passed away varies very much in its duration. Occasionally it lasts for many hours, or, perhaps, even a whole day and night; but generally it is comparatively short, not exceeding fifteen, twenty, or thirty minutes. The paroxysm then recurs, and after having continued a few seconds, probably with great violence, the parts become again tranquil, only, however, to be again excited into action by the irritation of the extraneous substance.

Should the obstruction be kept up, even if it be only for a few days, the patient will be in twofold danger; for he will not only be liable to be suffocated at any moment by the foreign body passing

up into the larynx, during a paroxysm of coughing, but the probability is that the lungs will resent its presence by taking on inflammation, which no skill, however well directed, can always effectually arrest. The symptoms denotive of these secondary affections are liable to much diversity, and it is, therefore, necessary that they should be examined somewhat in detail; otherwise it will be impossible to appreciate their due practical import. The most prominent and important of these symptoms are cough, an altered state of the voice, expectoration of different kinds of fluids, pain in the larynx, trachea, and chest, changes in the respiration, as evinced by auscultation and percussion, emphysema, inability to lie in certain postures, and impairment of the general health.

1. Absence of Symptoms.-The symptoms just enumerated do not come on with any regularity; and cases occasionally occur in which their appearance is postponed for an unusually long period. The foreign body, under such circumstances, seems to be in a state of latency, causing little or no inconvenience by its contact with the living tissues, which do not, consequently, resent its intrusion by taking on disease. The length of time during which the sojourn of such a substance may continue without the supervention of serious symptoms, is strikingly illustrated by several of the cases narrated in the present work. Louis, for example, gives an instance in which, after the first few minutes, the patient did not experience a bad symptom for an entire year. At the end of that time he coughed up a cherry-stone, followed by such a copious expectoration that he died exhausted in three days. In a case mentioned by Dr. Struthers, of Scotland, the only symptom, for three months, of there being anything amiss in the chest was the occasional occurrence of a slight cough and wheezing, resulting, most probably, from simple irritation of the mucous membrane, and from the substance becoming loose in the air-passages. At the distance even of fifteen months, so slight was the disturbance of the respiration, and so equivocal the evidence of the existence of an extraneous body, that several surgeons, among others Sir Benjamin C. Brodie, expressed the opinion that the case was one altogether of chronic cough, from which recovery might soon take place. It was not

1 Memoir on Bronchotomy, in Memoirs of the Royal Academy of Surgery, translated by Ottley, p. 277, London, 1848.

2 Dublin Medical Press, Nov. 1852.

until a month after the man had left London, and sixteen months after the accident, that the sputa became bloody and fetid, indicating that the disorganizing process had commenced in the lungs.

M. Renauldin met with a curious case in which a fragment of a nail was found in the lung, and yet no symptoms denotive of its presence had existed during life.'

Dr. D. F. Condie, of Philadelphia, author of the learned and excellent Treatise on the Diseases of Children,2 mentions an instance where, upon dissection, a small glass ball, of the size of a large bead, was discovered deep in the right bronchus, the presence of which had not been suspected during life, owing to all absence of the symptoms which usually denote the existence of foreign bodies in the air-tubes. After the first day, there was a complete intermission of the dyspnoea, spasmodic cough, and every other phenomenon, the child continuing nearly a week free from all disease, except an occasional hoarseness and a short hacking cough. Gradually, however, pneumonia came on, and terminated fatally in five days. Upon inquiry, subsequent to the autopsy, it was ascertained that the bead, found in the right bronchus, had been given to the child to amuse him, on the day he was first attacked, and had been missed from that period.

A child was brought to Mons. Guersant,3 of Paris, fourteen days after having inhaled a kidney-bean; the symptoms of suffocation occurred at intervals only, and for a few days the case was subjected to medical treatment merely in the belief that there was no foreign body in the air-passages. The operation was not performed until the eighteenth day after the accident. As soon as the trachea was opened, the bean appeared at the wound, and was immediately extracted. Complete recovery was the result.

An instance similar to the preceding occurred, some years ago, in the practice of Dr. Kreider, of Ohio. The patient, a child, had swallowed a grain of corn. The symptoms were those merely of laryngeal irritation, and no one had suspected the existence of the foreign body until three weeks after the accident. Tracheotomy was immediately performed, and was followed by prompt recovery.

American Journal of the Medical Sciences, N. S. vol. i. p. 231.

2 Third edition, p. 366, 1850.

Provincial Medical Journal, April 16, 1842; Philad. Med. Examiner, N. S. vol. i. p. 463, 1842.

Dr. Drake, in Western Journ. of Med. and Surgery, vol. iv.