—A rare condition of calculus formation is occasionally met with in the nose, the concretions being formed by precipitation of the mineral elements from the nasal mucus, and constituting the ordinary rhinoliths. These become, in effect, foreign bodies, and are to be recognized and treated as such. After syphilitic ulceration portions of bone may be loosened spontaneously, and dropped into locations where they are caught instead of being spontaneously expelled.

It is known, also, that, especially in tropical climates, there are several species of insects which enter the nostrils and there deposit their eggs, which later are hatched into the resulting larvæ, the latter sometimes being expelled, or perhaps developing and burying themselves further within the nasal recesses. Any living organism may be killed by administration of chloroform or ether, and then expelled as an ordinary foreign body; or, in most cases, such larvæ or eggs can be washed away with an irrigating stream to which a little extract of tobacco should be added. Thus maggots have been found buried within the nasal mucosa, and requiring extraction by means of forceps. When larvæ have invaded the sinuses the case becomes more serious, for it will require free exposure by perhaps a somewhat formidable operation on the interior of the sinus, which should then be carefully cleansed and suitably drained. Living organisms within the nasal cavity or the sinuses will cause headache, lacrymation, sneezing, nasal discharge, perhaps with epistaxis, and almost every possible expression of local discomfort.

Foreign Bodies in the Pharynx.

—Foreign bodies in the pharynx are usually, when small, lodged in the neighborhood of the tonsil, or caught in the lymphoid tissue of the tonsillar ring. According to their size they may become impacted at almost any point, and may even cause suffocation. They may be detected sometimes by the finger alone, or, at other times, only with good illumination and local anesthesia. The irritation which they produce leads to frequent acts of swallowing, the latter always exaggerating the former. Such objects as small fish-bones and the like, which may cause irritation, may easily escape or defy detection; moreover, such objects may be multiple.

For the sake of comfort pellets of ice may be frequently swallowed and cocaine may be used locally. Their extraction should be promptly practised. In rare instances emergency may call for prompt tracheotomy, but this is rarely the case unless the object be impacted below the epiglottis. Curious instances of impaction in the nasopharynx, of strange foreign bodies, have required the administration of anesthetics and even serious cutting operations for their removal, by combined manipulation through the nostril and the oropharynx. Such bodies, however, can be in some way always removed.

Liquids may be aspirated through the nose, and cause strangling attacks of coughing. They are then more easily drawn into the larynx or trachea, where they will cause reflex phenomena and actual obstruction, according to their nature. Again by free inhalation of steam, natural or superheated, burns and scalds of the respiratory passages may be produced, which will be followed by edema of the glottis or by pneumonia. The inhalation of extremely strong vapors, like that of ammonia, may cause spasm of the glottis. The entrance of blood, as from rupture of an aneurysm, or of pus, as from a bursting abscess, or the escape of pus from one side of the chest into the other lung by way of the trachea, may cause serious symptoms or may produce actual suffocation. In operations for pyopneumothorax, for instance, with one side of the chest well filled with pus, one should be careful to avoid turning the patient in such a way that pus may run over into the other lung and thus suffocate him. I have seen death occur on the operating table from this cause, in spite of every precaution, when the accident itself had been anticipated.

Solid objects may be of all shapes, sizes, and materials; living insects are occasionally aspirated and may not be at once killed, the local irritation caused by their presence producing intense spasm of the glottis. I have personally known of two cases of suffocation in restaurants, where men eating hastily died as the result of impaction of pieces of meat within the rima glottidis. Again, bodies may pass beyond the glottis proper and enter the trachea, or even one of the great bronchi; shoe-buttons, for instance; and in one case in my knowledge a small hat-pin passed down and was only removed after a low tracheotomy and careful search, aided by a skiagram. Owing to the anatomical arrangement the right bronchus is more frequently entered than the left. Immediate danger of suffocation, of obstruction, or spasm having passed, there is still serious menace from pneumonia, with or without abscess or gangrene of the lung. Such condition occurring in a young child, in the absence of the history of passage of a foreign body, may cause some difficulty in diagnosis. The greatest help would be afforded by the use of the Röntgen rays, although the laryngoscope alone will sometimes be sufficient. To use the latter to advantage it will probably be necessary to allay local irritation with the cocaine spray. (See [Figs. 476] and [477].)

Treatment.

—Treatment should be operative, although in some cases it is sufficient to invert the patient and slap him on the back. With an object impacted in the glottis relief may be afforded with the finger, but this may be exceedingly difficult, for in the later stages of suffocation the jaw may be convulsively shut and it will be almost impossible to effect entrance. In such case the jaw should be hastily pried open and the index finger carried down behind the base of the tongue, lifting the epiglottis and dislodging the object. If this fail and respiration have ceased, attempt should be made to hastily open the trachea, even with the blade of a penknife, and to follow this with artificial respiration. Under these circumstances the vessels of the neck will be engorged with venous blood, which will escape freely; this may, however, be disregarded, the primary indication being to get into the trachea, which may be held open by turning the knife-blade at right angles, while artificial respiration is practised, and until a couple of hair-pins, for instance, can be secured, bent into shape of blunt hooks and made to act as temporary retractors. This is an illustration of what may be done in emergencies.

Fig. 476