The voice may be unaltered unless the object be arrested in the neigh bourhood of the glottis, as in one of the ventricles of the larynx, in which case there may be any degree of hoarseness even to complete aphonia.
On inspection of the chest considerable recession of the soft parts is usually to be noticed in inspiration, and there may be a swelling of the neck and upper part of the chest from surgical emphysema. Often a phy sical examination at an early period detects little or no deviation from a healthy state. There may be perfect resonance; the respiration may be normal, and nothing may be heard but a little sonorous or sibilant rhon chus over the lung in connection with the occluded bronchus. If the foreign substance be impacted and immovable in the air-tube, signs of collapse may be noticed at some part of the lung a few days after the ac cident ; or there may be absolute suppression of the respiratory murmur over the whole of the affected side.
Whenever irritation is excited in the air-passages there is fever, and the general health of the child necessarily suffers from the constant dis tress and interference with sleep. Food can, however, be taken without difficulty.
some cases after a few hours or a day or two a spontaneous expel, sion of the offending substance takes place during a fit of coughing and the patient is instantly relieved. If, however, the child is less fortunate and the foreign body remains in the tubes, its presence being unknown or efforts to procure its removal having proved fruitless, serious consequences ensue. The object may become impacted in the larynx, causing death by suffocation ; it may set up a violent catarrhal pneumonia and the patient may quickly die ; it may give rise to suppuration and gangrene ; or it may lead to chronic phthisis which ends fatally after a more or less lingering illness.
Spontaneous expulsion usually takes place, as has been said, during a violent fit of coughing. It may occur after a short or a long interval ; and in some cases a period of years has elapsed before the offending substance has been ejected. The completeness of recovery in such cases depends upon the degree to which the lung has suffered from the presence of the intruder. If foreign body have only given rise to irritation in the lung, its removal is followed by instant and permanent relief. If, however, pneu
monia have been set up, or an abscess have formed, or chronic phthisical changes have been induced, the patient may die, although the original cause of his suffering has disappeared.
In cases where the foreign body remains in the tubes, a constant source of irritation and of interference with the function'of the affected organ, the physical signs depend upon the form of lesion which is produced. In some cases profound disorganization of the lung follows, and extra-costal sup puration may be set up leading to the formation of a large superficial ab scess.
A little boy, aged seven years, whose family history showed no tendency to phthisis, was in his usual health when, on March 28th, he returned from school saying he had swallowed a date-stone. He complained of difficulty of breathing and pain in the side, and coughed a great deal. The symptoms apparently were not very severe, for the child was only brought to the hos pital on April 8th. On his admission it was noted : " Much recession of the lower parts of the chest on inspiration ; intercostal spaces move equally on the two sides. Resonance good over both sides, but on the left the inspi ration is everywhere high-pitched and bronchial, and is as loud below as above. No rhonchus or friction. Heart's apex between the fifth and sixth ribs just outside the nipple line. A faint double friction-sound at the base of the heart and a soft systolic murmur at the apex." At this time nothing was known of the accident ; and as there was but little oppres§id of breathing and the cough soon after admission was found to be spasmodic, the boy was thought to be developing whooping-cough and was sent out by the House Surgeon. • On April 22d, the child was brought back to the hospital with a full account of the origin of the illness. It was stated that after his discharge he had continued to cough in a spasmodic manner and to whoop occasion ally. He had often complained of pain in his stomach and left side and his breathing had been oppressed. He had little appetite. His skin. had. been hot with occasional perspirations. Shortly before his return to the hospital the aspirator had been used to the chest by a practitioner of the neighbourhood, but no fluid had escaped.