very early stage of the affection, but generally it does not come until some time has elapsed, and occasionally it is postponed until a very late period. As a general rule, it may be observed that the patient finds it most comfortable to maintain the erect or semi-erect posture; as soon as he attempts to lie down he is seized with an increase in the embarrassment of breathing, with a disposition to cough and a feeling of suffocation. During sleep he is consequently obliged to be propped up in bed, and not unfrequently he is compelled to take what sleep he may be able to obtain in a chair. Sometimes he rests best on his back, and sometimes, again, upon one side. In a case narrated by Dr. Jewett,' of St. Johnsbury, Vermont, the patient, a child three years old, lay constantly on the right side, with his head elevated by pillows. His coughing and breathing, however, were not quickly affected by posture. In Mr. Gilroy's' case, alluded to in another chapter, the patient, was most comfortable when she lay perfectly quiet, with her shoulders depressed. As soon as she raised herself in the least, or turned on either side, a violent fit of coughing came on, which she could thus always excite at pleasure. In a case, treated by Dr. M. S. Perry, the patient, a boy, five years old, was never able to lie down in bed from the time of the accident until the expulsion of the foreign body, a water-melon seed, four months afterwards.3 In the case of Dr. Webster, of London, the patient, for the first fortnight, could lie only on the left side; whenever he attempted to sit up there was immediately an increase of the dyspnoea and sense of suffocation, which were, throughout, such prominent symptoms. On the twentieth day after the accident, he could lie only on his back, feeling as if he should be choked whenever he attempted to move. Subsequently to this date, no mention is made of the patient's posture, though the reporter adds that the symptoms varied very little until the ejection of the foreign body, a piece of cherry-stone, at the expiration of the sixty-eighth day. In a case recorded by Mr. Samuel Solly," of London, the man 1 Boston Med. and Surg. Journ. vol. xvi. p. 88, 1837. 2 Edinburgh Med. and Surg. Journ. vol. xxxv. p. 294, 1831. 3 Dr. J. B. S. Jackson's Descriptive Catalogue of the Anatomical Museum of the Boston Society for Medical Improvement, p. 119, 1847. The London Medical and Physical Journal, vol. lvi. p. 430, 1826. 5 London Lancet, vol. i. p. 480; May 5, 1849. was obliged to lie either on his back or right side. Whenever he attempted to turn on the left side he experienced great dyspnoea, with cough and impending suffocation. In an instance mentioned by the late Mr. Key, of London, in which an English sixpence was inhaled, the patient, a man aged thirty-five years, was unable to stoop, or lie with his head down, without exciting cough; and at such times he always experienced a sensation in his chest as if something were suspended there. 10. Emphysema.—It is not often that foreign bodies give rise to emphysema. M. Louis, in his celebrated Memoir, already several times referred to, was the first to notice this phenomenon, which has occasionally been witnessed since by other practitioners. The illustrious French surgeon appears to have met with it only once, but the case is so interesting and instructive that I shall take the liberty of condensing it for the benefit of the reader. It places the whole subject of this form of emphysema in a most striking light, and Louis in a most favorable position as a shrewd observer and an accurate pathologist. The patient was a girl, seven years old, who, in playing with some kidney-beans, threw one of them into her windpipe. She was immediately attacked with difficulty of breathing and a convulsive cough, which greatly exhausted her. She suffered some pain in the trachea, midway between the larynx and sternum, and pointed to that spot as the place where the foreign body was lodged. Two days had elapsed when Louis was called to see her in consultation. He found her laboring under great dyspnoea, attended by a rattling noise in the chest and the expectoration of a frothy mucus. Haying carefully examined the case, he went home to prepare for the operation of tracheotomy. He returned in two hours, when he found the child a little better, but well-marked emphysema now existed on each side above the clavicles, which was not present before. The operation was resisted by the parents, and the patient died three days after the accident.1 "It was the presence of this emphysema," says Louis, "which, more than all my arguments, led to the general conviction that the bean was in the trachea. I do not think that any of those who witnessed the case had a clear idea as to the mode in which this symptom arose. It might be supposed that the foreign body, by 1 Memoir on Bronchotomy, in op. cit. p. 257. the obstacle it had offered to the free passage of air for eight-andforty hours, had led to the laceration of the membrane, uniting the rings of the trachea. The examination of the body, however, served to dispel this illusion. The tumor had not originated in the neighborhood of the trachea. This merely formed the boundary of the emphysema; the body of the lung and the mediastinum were emphysematous. The retention of air caused by the foreign body, in each movement of expiration, and especially in the fits of cough, produced a violent impulse of the elastic fluid towards the surface of the lung, and into the spongy tissue of the organ; it then passed into the cellular tissue uniting the lung to the pleura which covers it, and, passing from one cell to another, prodigiously distended the cellular tissue, separating the layers of the mediastinum, and finally exhibiting itself above the clavicles. This distension of the lung and of the neighboring parts by the air, which had insinuated itself into the spongy and cellular tissues, was one very manifest cause of the suffocation; and this swelling seems so natural an effect of the presence of a foreign body in the trachea that one can scarcely believe but that it is a necessary symptom, though not alluded to by any author." Dr. James Copland' met with an instance, in a child upwards of eight years of age, in which the emphysema was above the clavicles; and several similar cases are mentioned in different parts of this monograph. On the whole, however, the occurrence, as was before intimated, is very rare. 11. Headache.-Patients laboring under foreign bodies in the windpipe are liable to suffer from headache, owing to the frequent determination of blood to the brain, and the violence with which this fluid is impelled against the delicate fibres of this organ. The amount of pain thus induced will necessarily vary in different cases and under different circumstances. Old persons, and such as are habitually predisposed to cerebral congestion are, probably, more likely to suffer in this way than the young and those who have naturally only a moderate quantity of blood. Occasionally, though rarely, the violent coughing and straining, consequent upon this accident, have produced apoplexy. 12. General Health.-The general health is variously affected; 1 Op. cit. p. 274. * Dict. of Practical Medicine, by Dr. Lee, vol. ii. p. 804; New York, 1846. sometimes slightly, sometimes severely, and sometimes, again, not at all. In most cases, however, even in those in which the foreign substance is not retained beyond a few days, the system is apt to become feverish, and the patient suffers from want of appetite and sleep, attended with an anxious expression of the features. If the irritation continues, inflammation of the lungs and air-tubes soon takes place, with an aggravation of the cough, emaciation, and loss of strength. In a remarkable instance, mentioned by Louis, the patient, although subject to hæmoptysis and a variety of pulmonary symptoms, retained her embonpoint until the age of twenty-four, when she began to decline rapidly, and died several years after, having in the interval ejected the foreign body. This case is, of course, an exception; for, under such circumstances, the general health usually suffers very much, the symptoms being, in every respect, similar to those which attend phthisis. In a case reported in the Provincial Medical and Surgical Journal, a British periodical, for September 1843, the patient, although she recovered her health, never attained her full development, the body always remaining stunted. The foreign substance, a beech-nut, was spontaneously ejected, in a fit of coughing, after having caused much suffering for nine years and a half, having been inhaled in early childhood. CHAPTER V. DIAGNOSIS OF FOREIGN BODIES. SECTION I. GENERAL OBSERVATIONS. ALTHOUGH the symptoms which denote the intromission and presence of a foreign body in the air-tubes are, in general, sufficiently well-marked to enable us to arrive at a satisfactory conclusion regarding the true nature of the accident, yet occasionally the most thorough examination of the patient and the most minute inquiry into the history of the case fail to afford the requisite light for the formation of a correct opinion. Such a state of uncertainty is always to be deeply lamented, for it is not only a source of great and painful embarrassment to the practitioner, but it may be, and indeed often is, followed by the worst consequences to the poor sufferer, inasmuch as it prevents the prompt employment of the means which are necessary for his safety and relief. It is for this reason that every case, involving the question of the presence of a foreign body in the air-passages, should be most carefully investigated at the earliest possible moment, in order that no time may be lost in applying the proper treatment, and thus obviating the risk of suffocation, from the long and mischievous sojourn of the obnoxious substance in structures so essential to the well-being and the life of the individual. The rule, in all cases of this kind, is to act in the most prompt and efficient manner, on the well-known principle that, although the foreign body may not immediately prove fatal, yet the longer it is retained in the parts the greater will be the probability that it will ultimately destroy the patient, by keeping up an amount of irritation, the effects of which the respiratory apparatus and the system at large cannot permanently resist. I have |