When the foreign body remains in the larynx caught in one of the ven tricles, the resulting symptoms—aphonia, dyspncea, violent croupy cough, and sense of choking—may suggest stridulous laryngitis or membranous croup. In such a case the history of the seizure, especially the sudden oc currence of the distress in a child previously in a state of perfect health, is of great importance. In stridulous laryngitis, although the complaint often begins with much violence and quite suddenly, the spasm almost in variably occurs at night, the child starting from his sleep with urgent dyspncea ; and the symptoms subside completely after a short time. In the case of a solid substance in the larynx the access occurs while the child is awake and at play ; the dyspncea is more continuous ; and the remission, if it occur while the foreign body remains in the neighbourhood of the larynx, is far less complete.
In membranous croup the attacks of dyspncea come on gradually, and slowly increase in severity ; the voice is not whispering at the first ; and in many cases patches of false membrane may be seen in the fauces.
Prognosis.—If expulsion of the imprisoned body cannot be effected, the prognosis is very gloomy ; for although cases have been recorded in which the patient has continued for years to suffer little from the pres ence of the solid substance in his air-passages, such cases are very excep tional. Most commonly ill effects are not slow in making themselves evi dent. The prognosis is more favourable if the impacted object is of irreg ular shape, so as to allow air to pass and repass it in the tube. In such cases the patient may escape rapid death. In almost all the instances in which chronic phthisical changes have been developed as a consequence of the accident the substance has been of an irregular shape.
If expulsion is effected, the prognosis necessarily depends upon the changes which have been set up by the irritation of the substance during its retention. Chronic phthisical symptoms often subside in a surprising manner after the ejection of the offending body, and in such cases, unless disorganization have proceeded too far, recovery may be hoped for. If ab scess or gangrene have been set up in the lung, death generally ensues.
Treatment.—When we are satisfied that a foreign body is retained in the air-tubes treatment must be energetic. Emetics have been found of little value and may therefore be dispensed with ; but if we are certain that the solid substance is of small size, the child should be at once turned head downwards and shaken in the hope of dislodging the imprisoned body and aiding its escape from the tubes. Often violent cough comes on during the operation, and sometimes so much spasm is excited.in the glottis by the solid body pressing against it, that our efforts have to be promptly discontinued. This proceeding is more likely to be attended by good re
sults if the substance is small. A shot, a seed, or object of similar size, would be able to pass without difficulty between the vocal cords, while a larger one might become impacted in the glottis and cause speedy death by suffocation. Whenever, therefore, the foreign body is known to be of some size, it is wiser to postpone all violent measures, such as eversion and succussion, until an artificial opening has been established in the trachea. This procedure is equally important whether the imprisoned body be fixed or be free to move. If it be fixed, the air-tube can be directly searched by a long forceps, and the object may sometimes be seized and withdrawn in this manner. If it be free to move, an artificial opening in the trachea is a great aid to its escape, as under these altered conditions the glottis relaxes readily and there is no risk of dangerous spasm.
After the operation the imprisoned body may be ejected through the wound or may pass through the relaxed glottis. In the latter case it is apt to be swallowed. If, therefore, it be not found after the signs of suffering have subsided, the stools must be carefully examined.
If the early measures for promoting the escape of the solid body do not succeed, or if on account of the size of the substance we fear to employ them, it is seldom judicious to delay the operation of tracheotomy. It must be remembered that it is only in exceptional cases that the continued presence of a foreign substance in the air-tubes has been borne without dangerous injury to the lung. As long as it remains in the respiratory passages there is constant danger of suffocation from the lodging of the object in the larynx, and of serious disorganization of the lungs from the irritation set up in the tubes. Therefore, if we are satisfied that a solid body is impris oned in the passages, the fact that the resulting symptoms are not urgent should not induce us to postpone the operation. As Mr. has ob served, "If a body be impacted in the larynx or trachea, urgent symptoms will mean merely increased irritability and spasm of the glottis, and on re moval of the foreign body this will naturally cease. If the body be in the bronchus and do not move, urgent symptoms will mean the establishment of serious disease in the lung," and this may not disappear when the for eign substance is removed.
The operation is equally necessary whatever be the nature of the substance in the trachea. Soft matters, such as gristle, etc., will not be come disintegrated in the air-tubes ; and small vegetable substances, such as seeds and grains of corn, may swell up to a much larger size through absorption of moisture.