If the intruding substance be free to move, as is sometimes the case with a rounded body which does not so readily become impacted.in the air-tube, very curious consequences follow. When the object is carried against or into the larynx, it produces spasmodic cough and an agonizing feeling of suffocation. As it descends again into the lower tube there succeeds a period of comparative calm ; and the physical signs which have been described as indicating impaction of the substance in the bronchus may perhaps be noticed. This alternation of suffocative cough with intervals of more or less complete repose are very characteristic. It is in these cases that the presence of the foreign body can sometimes be detected by the ear and the touch. In the case of a little girl, aged two years, who was under my care in the East London Children's Hospital suffering from the presence of a haricot bean in the air-tubes; the physical signs noted by the House Surgeon, Mr. Scott Battams, on the evening of the day on which the accident happened were : " Air enters fairly well into both sides of the chest. apices expiration is prolonged and wheezing. On listening at the middle of the right back a sound is heard as if a solid body were drawn down in inspiration and carried away again in a forced expiration." The child, although not much troubled by dyspncea, suffered greatly from cough ; and when this was violent the finger and thumb placed on either side of the upper part of the trachea could feel a distinct impact as of some solid body striking this part of the tube with each im pulse of cough. Afterwards with the stethoscope placed upon the same part a dull thud-like sound was distinctly audible as the object was forced upwards by the current of air.
Diagnosis.—Whenever a foreign body has passed into the windpipe it is of the utmost importance to the patient that there should be no mystery as to the cause of his symptoms, for recovery will probably depend upon ready measures being taken for the expulsion of the offending substance.
The diagnosis rests upon the history of the accident and the sudden occur rence of the symptoms in a child previously healthy ; also, upon the nature and situation of the physical signs to be discovered on examination of the chest.
The history is not always to be obtained. Thus, in the case of a baby, unless the child have been seen to play with some small object immediately before the suffocative attack occurred, the likelihood of a foreign body hav ing passed into the trachea may not even be entertained. Again, the his tory may be misleading. Attacks of spasmodic laryngitis may occur in a young child while at play ; and if any small objects likely to produce such symptoms are found within his reach, the inference that a similar object has been introduced into the air-passage is sufficiently obvious. If the attack of laryngitis occurred first under such circumstances, this inference would be almost unavoidable. Still, although not necessarily conclusive,
a history of the probable introduction of a solid substance into the wind pipe is of great value. If a child while in his usual health has been eating stoned fruit, or playing with small articles such as peas, haricot beans, or grains of corn, and is seized all at once with violent oppression of breath ing and spasmodic cough, we should consider very carefully the evidence to be obtained from a physical examination of the chest. It must be re membered that the first distress is only temporary, and is succeeded by a period of calm, of variable duration. When called to such a case, there fore, we must not conclude because the child's suffering has subsided that all danger is at an end.
The physical signs in these cases may be indicative of pulmonary irrita tion or of more or less complete obstruction of a bronchus. The irritation set up in the air-tube leads quickly to increased secretion, so that more or less sibilant or sonorous rhonchus and bubbling rides are usually heard with the stethoscope. If in a case where the symptoms occurred suddenly under circumstances suggesting the introduction of a solid substance into the windpipe, the above signs of irritation are discovered ou one side only, and that side the right side, the evidence must be looked upon as impor tant.
Signs of plugging of a bronchus are, however, of the greater value. Complete absence of breath-sound and of respiratory movement over the whole of the affected side without alteration in the normal resonance—these signs occurring suddenly in a child in whom suffocative cough began all at once in the midst of perfect health, would be strong evidence of the pres ence of a foreign body in the air-tubes, even in the absence of any history pointing to such an accident. If in such a case violent suffocative cough breaks out again, and at the same time the morbid phenomena disappear from the chest, the vesicular murmur returning with natural loudness on the side previously silent, the phenomenon is very characteristic. These alternations of comparative calm and absence of breath-sound with violent spasmodic cough and perfectly normal physical signs may be looked upon as pathognomonic. If the impact of the imprisoned body can be felt and heard in the trachea during the cough, the evidence thus furnished of the presence of a solid substance in the air-passages is practically conclusive.
If the tube, instead of being perfectly closed is partially permeable, ap, preciable weakness of the vesicular murmur may be noticed on the affected side. Such a sign occurring alone may have little importance attached to it ; but if with weak breathing over the right lung we notice sonoro-sibi lant rhonchus or bubbling rifles over the upper part of the same side, the other lung being healthy, the combination is of some value.