Symptoms.—The irritation produced by the entrance of a foreign body into the trachea and bronchi varies greatly in different patients. Although in the majority of cases the suffering is extreme, in a few instances curiously little discomfort appears to be excited. It is important to be aware that violent dyspncea is not an unfailing symptom of this accident. In some recorded cases a little cough has been the only inconvenience complained of. Dr. Goodheart has stated that on two occasions in his experience in which dissection revealed gangrene of the lung set up by a spicula of bone in one of the bronchi no symptoms had been noted during life pointing to the entrance of a foreign substance into the air-tubes ; and thence con cludes that pulmonary disease is more often excited by this mischance than is commonly supposed.
Still, although in exceptional cases the suffering may be slight, as a rule the intrusion of any adventitious matter into the wind-pipe is a cause of immediate and extreme distress. If the substance be of large size it may completely occlude the glottis and cause sudden death. Many cases are on record in which the entrance of the wind-pipe has been blocked up by a lump of food with immediately fatal results. Smaller bodies which can pass readily into the air-tubes, if not arrested at the bifurcation of the tra chea, fall as a rule into the right bronchus. Mr. Goodall of Dublin pointed out many years ago that the septum of the division of the windpipe is placed considerably to the left of the mesial line, and that this position tends to deflect any substance falling against it into the right division of the air-tube.
The first consequence of the accident is usually a fit of severe clyspncea with sense of impending suffocation. The child shows all the symptoms of the most extreme distress. His eyes look wild ; his face is livid ; his flares work ; his chest heaves convulsively ; he tears with his hand at his throat, and bursts into a paroxysm of spasmodic cough. As a rule ex piration seems more difficult than inspiration, and the effort to discharge air from the lungs is laborious and painful. In some cases foam tinged with blood appears at the lips. The early symptoms are more severe if the object lodges sufficiently near to the glottis to keep up irritation of the vocal cords. The attacks of spasmodic cough are then almost inces sant and the difficulty of breathing extreme. In ordinary cases after some minutes the more urgent symptoms abate and may entirely subside, so that the child who a short time before had seemed on the very point of suffocation returns to his play as if nothing had happened ; but after a period of calm the paroxysms usually return with more or less violence.
The period of repose which follows the first access of dyspneea is of very variable duration. It may last from a few minutes to several hours ; and cases have been published in which no return of the distress was experi enced for many months. The degree of suffering in these cases, accord ing to Dr. Stokes, is dependent to a considerable extent upon the com pleteness with which the intruding body interferes with the passage of air through the tube. He states that in all cases which have come under his own observation the distress was great in proportion to the feebleness of respiratory murmur in the affected lung. A smooth body, therefore, such as a bean, by completely occluding the tube causes greater suffering than a more irregular substance will do ; for the latter, although it obstructs the passage, does not render it absolutely impermeable.
Often in addition to recurring attacks of dyspucea and spasmodic cough there is a fixed pain or soreness referred to the throat or some part of the chest, back, or side. This sensation is probably dependent upon the impaction of the intruding substance in some particular part of the bronchus, for it has been known suddenly to shift its place, passing from the throat to the chest or to the region of the nipple. In some cases the pain is accompanied by a sense of constriction. Often, also, there is ina bility to lie on one or the other side, such a position increasing the uneasy feeling and impeding the respiration. Sometimes the child can only breathe with ease in the sitting position, and has to be propped up in bed with pillows. The fits of coughing are of a peculiar character. They are usually excessively spasmodic and often resemble the cough of pertussis. They are accompanied by much congestion and lividity of the face, but are not followed by attempts to vomit. Sometimes the paroxysms are so violent as to lead to a convulsive seizure. If the object introduced is a fruit-stone or similar solid substance, and is free to move in the air-pas sages, the cough may be accompanied by a peculiar clicking or flapping noise heard in the direction of the larynx, and produced apparently by the impact of the object driven upwards against the glottis by the current of air. In many cases the impact may be felt as well as heard if the finger and thumb be applied during the cough to opposite sides of the larynx.