November 20th. Low tracheotomy and removal of nail by the writer. (Description by Dr. H. M. Silver.*)

From the time the trachea was opened the pus and escaping air had a decided fetid odor. Tube removed November 23d.

November 28th. Wound smaller and healing satisfactorily. Over right upper lobe anteriorly breathing of a cavernous type with many large and small moist râles. General condition greatly improved. Temperature coming down to normal.

X-ray plate showing foreign body and condition of lung.

December 6th. Wound healed. Child is still troubled with paroxysmal cough, particularly when disturbed.

January 26, 1907. For the past seven days the temperature has been irregular, ranging from 98° to 103°, probably due to a mild infection from the pulmonary abscess.

February 20, 1907. Temperature had been normal for several weeks. To-day it rose to 101°F.; pulse, 128; respiration, 30. Following day temperature, 103°F. About this time a small abscess

I would herewith gratefully acknowledge my obligations to my colleague for his valuable assistance and suggestions.

appeared at the site of the thoracotomy done October 7th. This was incised the following day and a small amount of pus escaped, revealing a small sinus leading to the pleura. Two ribs were resected to allow the chest wall to fall in and thus favor contraction of the pulmonary abscess.

March 17th. For the past three weeks temperature varied between normal and 103°F. Wound in chest wall gradually closing. General condition very much improved. Physical signs over upper portion of right lung anteriorly and posteriorly reveal large and small moist râles. Breathing diminished posteriorly, anteriorly somewhat bronchial in type.

June 9th. Progress favorable since last note. Sent to Willard Parker Hospital on account of severe nasal diphtheria and laryngeal symptoms.

July 1st. Returned to hospital in good condition. Temperature, 98°F.; pulse, 120; respiration, 30. Wound in chest wall discharging a little. Pulmonary signs about the same.

September 9th. child doing nicely.

For the past two months temperature normal, Small sinus remains. To-day the temperature rose to 105°F., due to a slight involvement of left lung, which ran a favorable course in about five days.

September 17th. A small piece of bone discharged from

wound.

September 29th. Wound entirely closed.

December 2, 1907. Since September 16th the temperature has been normal; great improvement in general health. Physical signs those of fibrosis of upper and middle lobe with dilated bronchi. The secondary result of the obstructed circulation is shown in the clubbing of the fingers and toes, with moderate cyanosis of the mucous membrane.

With a definite history and typical symptoms, little difficulty is met with in arriving at a diagnosis of a foreign body in the bronchi. The case is different when no such history is obtainable. In recent years the X-Ray has afforded valuable assistance, not only in establishing the presence, but also the location, of the body, provided it casts a shadow. The bronchoscope is the most recent addition to the appliances for examining the larynx, trachea and bronchi. With its aid the operator, in a large number of instances, is in a position to locate and remove the object accidentally inhaled.

In this part of the paper the principal and main features of

interest center in the diagnosis. The history of a foreign body having been inhaled, was not developed until later on, the physical signs pointing to a more or less diffuse process in the upper and middle lobe of the right lung.

In general, in this class of cases, we are told that the child had been ailing for a longer or shorter period; the temperature is usually irregular in type, more or less dyspnea is present and

X-ray photo taken about March 16, 1908, by Dr. I. S. Hirsch, shows distinctly the characteristics of the chest walls from which several ribs were resected, and the changes in the lung. Compare with first radiograph.

cyanosis may or may not be found. Septic manifestations, as pallor, sweating, loss of appetite, diarrhea and emaciation are noted. Cough is common.

A very characteristic symptom, one which should arouse our suspicions at once, is ordinarily not interpreted correctly. I refer to the paroxysmal cough, during which the child grows red in the face and frequently vomits. The act is very distressing and is attended with a good deal of exhaustion. The spells are re

peated at irregular periods, the child being comfortable in the interval. The attacks are more apt to occur during crying or excitement, and generally recur with greater frequency when the patient is placed on the healthy side. "The position assumed by the patient may effect the symptoms, especially if the body be movable. Naturally the position is assumed in which the foreign body is least disturbed." (Modern Medicine, Vol III., page 708.)

The severe coughing spells shift the body from place to place and even cause it to enter the other lung. This has occurred with a heavy object, such as a bullet. The paroxysms simulate whooping-cough very closely, now and then even the inspiratory whoop is observed.

The expectoration may be purulent, now and then it is streaked with blood. In a case under the writer's observation, the recurring hemorrhages ceased only when an iron nail was coughed out several years later. In some cases there is the characteristic odor of gangrene. The odor may be a prominent feature or may be noticed only during the paroxysmal coughing spell. Now and then, if our suspicion is aroused, a very careful inquiry regarding the onset of the illness may elicit the story of a sudden choking spell, attended by cyanosis, the patient appearing to be in imminent danger of suffocation. Such an attack may have been but of a few seconds duration or may have lasted for several minutes, but from this time on the "whooping-cough-like attacks" develop at irregular intervals. To bring out this point clearly and forcibly the following quotation taken from Carr's Practice of Pediatrics (page 681) is appended. "In some cases the presence of a foreign body is quite unsuspected, the child being brought some years after the accident on account of the expectoration of foul pus. On examination a unilateral fibroid lung with bronchiectasis is found, and by questioning the parents a history of whooping-cough at the onset may be elicited. This seems to agree well with the etiology of a simple fibrosis of the lung, and it may well be overlooked that the so-called 'whoopingcough' represented in reality the spasmodic attacks set up by the foreign body before it became impacted."

A. McPhedran writes: "The most difficult cases are those in which there is no history of the entrance of a foreign body. These cases often present the most anomalous symptoms. In all cases, especially children, with such unusual symptoms, more than half the difficulty may be overcome by bearing in mind the possibility

of a foreign body. This cause should be present to the mind in all cases showing signs of local septic pneumonia, or gangrene of the lung, or of general pyemia with signs of early involvement of the lungs." (Osler's Modern Medicine, Vol. III., page 708.)

The prominent symptoms, then, are dyspnea, paroxysmal cough, septic temperature and possibly the expectoration of pus, or blood, or a fetid odor to the breath, particularly during the cough. Such a symptom complex points to a septic bronchopneumonia, localized abscess with or without gangrene, and, in the absence of other well-recognized causes, suggests a foreign body. To establish a positive diagnosis, an X-Ray examination must be resorted to. The method, however, is only of value when the object casts a shadow.

The physical examination reveals dullness, or even flatness, absence of respiratory murmur with diminution or loss of vocal fremitus and more or less restricted movement of the affected side. The signs are apt to vary in different cases and at different times in the same patient.

They will vary with the size and location of the pulmonary area involved, and the presence and absence of bronchial patency or communication. When a bronchus is occluded or the cavity. is temporarily filled, the percussion will give a dull or flat note.

If, on the other hand, there is a direct opening, we may succeed in getting a cracked pot sound. Upon auscultation the sound will vary, depending upon the presence or absence of bronchial communication. In the former case, we may have bronchial, cavernous or amphoric breathing.

In general terms, in the overlooked cases, we have the usual evidences of a localized abscess with or without gangrene or the signs of a more or less complete consolidation of one or more lobes on the affected side, and, finally, if the infection is less virulent a chronic inflammation resulting in interstitial changes and possibly bronchiectasis, especially in cases in which there is only partial occlusion of the bronchus.

The diagnosis of abscess, with or without gangrene, or of a septic bronchopneumonia, etc., having been established, we must go a step further and look for the primary etiological factor. In the differential diagnosis the following pathological conditions must be considered: Localized empyema, an empyema discharging into a bronchus, interlobar empyema, pulmonary tuberculosis with rapid caseation, embolic processes from an old heart lesion,