The boy appeared to be excessively ill. He complained much of pain in the abdomen and lay with his knees drawn up. The abdominal pari etes were somewhat retracted. Over the left back reaching from the poste rior axillary line nearly to the spine, and from a little above the lower angle of the scapula to the tenth rib, was a large superficial collection of matter. This on being opened was found to consist of very offensive pus. The abscess evidently communicated with the pleural cavity, for air was sucked in through the wound at each inspiration. The boy's breathing was laboured and his voice whispering. An examination of the chest was diffibult on account of the tenderness of the side. It was however, ascer tained that resonance of the left back, although impaired, was not quite lost, and that the respiratory sounds were concealed by loud creaking and gurgling rhonchus.
The boy remained very prostrate and in great distress. He was exces sively restless and occasionally screamed in a very hoarse voice. The discharge from the wound was inexpressibly fetid. He died on April 25th. His temperature after readmission varied between 100° and 102.4°.
On examination of the body, seventeen hours after death, the super ficial abscess cavity was found to extend from the middle line of the right clavicle across the chest and round the left side to the spine. The skin over it was sodden and seemed almost decomposed. The body was much emaciated. On opening the chest the right lung was generally adherent to the chest-wall, although not very firmly. Its substance was somewhat congested but otherwise normal. The bronchi were injected and their mucous lining oedematous.
The left lung, firmly adherent on its posterior surface, was extensively disorganized. Its substance tore easily and the smell was almost insup portable. The surface of the diaphragm had the appearance of an abscess. In the eighth interspace, about one inch behind the posterior axillary line, was a large ulcerated depression rather more than an inch in diameter, at the bottom of which was a perforation communicating through the intercostal space with the superficial abscess. The trachea was injected, and in the left bronchus was a date-stone impacted about an inch and a half from the bifurcation. The lining membrane of the bronchus was red and oedematous, but the air-passages contained no excess of fluid. On account of the disorganized state of the it was impossible to say whether an abscess had originally formed in the neighbourhood of the date-stone. There was no peritonitis. The left ventricle of the heart was hypertrophied, and the edges of the mitral valve were much thick ened.
This case is peculiar on account of the situation of the foreign body, which had passed into the left bronchus instead of the right. When the child was first brought to the hospital no mention was made of his acci dent, and nothing in his symptoms suggested the presance of a solid substance in his lung. There was no great distress of breathing, and the
physical signs, such as they were, were limited to the left lung, the right side of the chest being healthy.
The foreign body after passing the rime glottidis may be caught in oue of the ventricles of the larynx ; it may become fixed in the trachea ; or may pass further clown and lodge in one of the primary divisions of the air-tube. There are, therefore, certain varieties in the symptoms according to the position of the obstruction.
If the solid substance remain in the larynx, the voice is suppressed ; the dyspncea is continuous ; the cough is generally violent and croupy ; the child feels as if he should choke ; and there is often pain referred to the situation of the cricoid cartilage. It may, however, be remarked that aphonia is not limited to these cases, and that a hoarse whispering voice does not necessarily indicate that the obstacle is fixed in the larynx. In the case just narrated, although the fruit-stone was impacted in the left bronchus and the larynx was free, the voice was hoarse and almost sup pressed.
If the substance lodge in the trachea below the larynx, the suffering produced is not very great, as a rule, so long as the passage remains pervious. In the often-quoted case related by Mr. McNamara of Dublin, in which a boy who had constructed a whistle out of a plum-stone, inad vertently drew the toy by a strong inspiration through the glottis, the object remained fixed transversely in the lower part of the larynx, and gave rise to a whistling sound as the air passed through it in expiration. The only inconvenience produced by the accident while the obstacle re mained in this situation was an occasional suffocative cough ; but this did not prevent the boy from running about and playing as usual.
In the bronchus the symptoms produced by the presence of a foreign body vary according as this is fixed or is free to move. If a smooth sub stance, such as a fruit-stone, become fixed in the bronchus, it causes great distress by plugging the air-tube and arresting the function of the corre sponding lung. The air cannot enter or escape. Consequently the patient experiences great dyspncea from-sudden loss of half his breathing surface. He has attacks of spasmodic cough from the irritation induced at the seat of obstruction, and on the affected side the vesicular murmur is weakened or suppressed. Catarrhal pneumonia in this case follows very quickly. If the impacted body be irregular in shape, so as still to allow the passage of air through the tube, there is less oppression of breathing, and in many cases less irritation in the lung ; also, the pathological results are more chronic in their course.