1. Tracheal foreign bodies are usually movable and their movements can usually be felt by the patient. 2. Cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. In recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing. 3. Sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body. 4. Dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder. 5. Dyspnea is usually absent in bronchial foreign bodies. 6. The respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive. 7. The asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. It is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it. 8. Pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body.
EARLY SYMPTOMS OF IRRITATING FOREIGN BODY SUCH AS A PEANUT KERNEL IN THE BRONCHUS
1. Initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. 2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24 hours in children under 2 years. 3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are promptly shown. 4. The child is unable to cough up the thick mucilaginous pus through the swollen larynx and may "drown in its own secretions" unless the offender be removed. 5. "Drowned lung," that is to say natural passages idled with pus and secretions, rapidly forms. 6. Pulmonary abscess develops sooner than in case of mineral foreign bodies. 7. The older the child the less severe the reaction.
SYMPTOMS OF PROLONGED FOREIGN BODY SOJOURN IN THE BRONCHUS
1. The time of inhalation of a foreign body may be unknown or forgotten. 2. Cough and purulent expectoration ultimately result, although there may be a delusive protracted symptomless interval. [130] 3. Periodic attacks of fever, with chills and sweats, and followed by increased coughing and the expulsion of a large amount of purulent, usually more or less foul material, are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care. 4. Emaciation, clubbing of the fingers and toes, night sweats, hemoptysis, in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude, even to the gain in weight by an out-door regime. 5. Tubercle bacilli have never been found, in the cases at the Bronchoscopic Clinic, associated with foreign body in the bronchus.* In cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis. One point of difference was the almost invariably rapid recovery after removal of the foreign body. The statement in all of the text-books, that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown, hence the foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused with the true pulmonary tuberculosis of bacillary origin. 6. The subjective sensation of pain may allow the patient accurately to localize a foreign body. 7. Foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum. 8. Offensive odored sputum should always suggest bronchial foreign body; but absence of sputum, odorous or not, should not exclude foreign body. 9. Sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating. [131] 10. Complete obstruction of a bronchus is followed by rapid onset of symptoms. 11. The physical signs usually show limitation of expansion on the affected side, impairment of percussion, and lessened trans-mission or absence of breath-sounds distal to the foreign body.
* The exceptional case has at last been encountered. A boy with a tack in the bronchus was found to have pulmonary tuberculosis.
SYMPTOMS OF GASTRIC FOREIGN BODY
Foreign body in the stomach ordinarily produces no symptoms. The roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis.
DIAGNOSIS OF FOREIGN BODY IN THE AIR OR FOOD PASSAGES
The questions arising are: I. Is a foreign body present? 2. Where is it located? 3. Is a peroral endoscopic procedure indicated? 4. Are there any contraindications to endoscopy?