organs of the body; as, for example, in walking, skating, fencing, and performing on musical instruments. How important it must be then to pay attention to the training of the organs of articulation in early life; to take pains to aid children in acquiring the proper adjustment of the organs of speech; to take care that the child is not allowed to associate with one who stutters; and to attempt to check the defect as soon as it is noticed; firstly, by attending to the general health, so as to raise it to a normal standard; and secondly, by making the child speak slowly and distinctly, and especially perhaps by carefully teaching him to read aloud. In carrying the latter suggestion into practice, it is important that the lessons be not given in the company of other children. As an able writer observes" All scenes where speech is obligatory ought to be avoided; for example, I cannot too strongly reprehend the conduct of parents who send children who stammer badly to school, where, amidst the rest of the class, they are obliged to exhibit daily-a scene which is torture to those who have very sensitive minds. You may see the rush of blood to the face of the boy when called upon to construe: he may see the meaning of his lesson plainly, and yet be utterly unable to show his knowledge of it; he may be disgraced on account of this inability (for what public master can enter into all the internal emotions which cause paralysis of speech in one of a class of perhaps fifty boys!); he will feel a cold trickle at his head which tells him he is unlike others, and has no one to sympathize with him; he will care little for the undeserved punishment, but few can know how much for the source of all this, and of trials to come, to what amount he knows not. Scenes and reminiscences such as these may easily confirm an impediment in the speech."

When a habit of stammering has once been acquired, the anxiety and distress it occasions makes the difficulty of cure all the greater; but even under these circumstances special training and supervision, with a judicious study of elocution, will effect great improvement, more especially if the student will always try to think more of what he is saying than how to say it.

CHAPTER III.

ACCIDENTS, BURNS, &c.

I. FOREIGN BODIES IN THE AIR-PASSAGES.

General Observations.-The number and variety of articles that may enter the air-tubes and give rise to severe or fatal mischief is very remarkable. The substances which are most frequently met with are-seeds of all kinds, beans, peas, cherrystones, pieces of hard wood, buttons, pins, small coins, marbles, pebbles, bits of slate-pencil, beads, and small nails. The size of these articles is often such that it seems almost impossible they could have passed through the narrow chink of the glottis; yet that they do so is evident. Thus, Dr. Mott has recorded an instance in which a child only eleven months old inhaled a black shawl-pin two inches long, with a head nearly as large as a small marble: at Königsburg, in Germany, the larynx of a goose became impacted in the windpipe of a boy twelve years old: M. Bérard had to perform tracheotomy en a boy not quite seven years old, to remove a marble eight lines in diameter: and Sir William Fergusson has had to resort to the same operation to extract a plum-stone from the trachea of a girl seven years of age.

When the extraneous substance is of an animal or vegetable nature, it is apt to swell, owing to its imbibing moisture; so that a small bean or pea has been known to increase to thrice its original size in a few days. In some fortunate cases it has become softened and broken up, so as to permit of its expulsion piecemeal: when retained as it usually is the foreign body becomes incrusted with mucus, or with lymph, or even with a few grains of carbonate or phosphate of lime. The substance may get lodged in one of the ventricles of the larynx, or it may become fixed between the chordæ vocales, or it may be arrested in the trachea, or it may descend into one of the bronchial tubes, the right being that which is most commonly selected.

Symptoms.-The entrance of foreign bodies into the larynx usually occurs during a violent and sudden inspiration; it gives rise immediately to severe spasmodic cough, great dyspnoea, and a sense of impending suffocation: sometimes even sudden

death occurs by the arrest of respiration. Usually, after a few minutes, the violence of the first symptoms abates for a time, the cough and dyspnoea returning at variable intervals. Sometimes the calm lasts for many hours; but usually it is short, not exceeding twenty or thirty minutes. The subsequent symptoms will depend upon the situation in which the foreign body is retained. Thus, if it remains in the larynx, there will usually be violent, harassing, and suffocative cough; perhaps loss of voice, or inability to speak above a whisper; probably, pain in swallowing; tenderness over the part; and noisy hiss- . ing respiration, with more or less dyspnoea. When the substance descends below the larynx, it is seldom retained in the trachea, but passes on into one of the bronchial tubes-in the great majority of instances into the right, being directed to this by the bronchial septum. If, under these circumstances, auscultation and percussion be practiced, it will be found that air does not enter the obstructed lung at all; or if the obstruction is only partial, that it fills the lung incompletely. Hence there will be a complete loss or a diminution of resonance on percussion, with diminution or absence of the respiratory murmur on auscultation.

Sometimes the foreign body plays up and down the trachea, under the influence of fits of coughing. This change in position gives rise to severe spasmodic attacks of dyspnoea; while a peculiar sensation of movement is appreciable by the patient; and a sound of motion is detected by auscultation, as well as perhaps a flapping or valve-like sound, which is produced by the foreign body being forced against the rima glottidis in expiration.

Supposing that the substance is not expelled or removed, the patient will be liable to suffocation at any moment from the foreign body passing up into the larynx under the influence of a fit of coughing; or if he escapes this risk, there is the fear of inflammation either of the larynx, trachea, bronchial tubes, or lungs, with all its accompanying dangers.

After the subsidence of the immediate and earlier symptoms, the foreign body sometimes gives rise to no appreciable inconvenience for many weeks or months: Louis relates such an instance, where the patient did not-after the first few minutes. -experience any bad symptoms for twelve months; but at the end of that time he coughed up a cherry-stone, and this was followed by such copious expectoration, that he died from exhaustion in three days. Dr. Condie attended a child who continued free from all symptoms of disease for a week after the first symptoms had subsided: then pneumonia set in, and ended

fatally on the fifth day: on post-mortem examination a large bead was found obstructing the right bronchus.

Occasionally death occurs during the act of vomiting, owing to some of the ejected matters lodging against the rima glottidis, or even passing down into the windpipe. Thus, Corvisart being desirous of exercising a close supervision of the clinical wards at La Charité, visited them one evening unexpectedly. The steward, who had been indulging in a hearty meal, was taken by surprise, and became sick; but making a violent effort to repress the vomiting, he fell to the ground and expired. On examining the body, the larynx, trachea, and bronchial tubes were found filled with half-digested food. A case somewhat similar to this occurred at the Middlesex Hospital :-A man who had stolen a mutton-chop was running away, while his pursuers were shouting "Stop thief." To avoid discovery, he endeavored to hide the stolen goods by thrusting the chop into his mouth, and in the hurry and excitement of the circumstance, the chop "went the wrong way," and stuck in the top of, and partly within, his larynx, causing immediate death. The post-mortem examination revealed the evidence of his guilt, and the cause of his death; and the specimen, which is certainly a curiosity in its way, is now to be seen in the museum of that institution.

Diagnosis.-The symptoms of foreign bodies in the respiratory organs may be imitated to some extent by different diseases; but they may generally be distinguished by a careful scrutiny of the symptoms; thus in the case of croup, the diagnosis will turn upon the state of the pulse and skin, as these are rarely excited until the foreign substance has had time to set up inflammation; then again, in the case of a foreign body, the difficulty of breathing exists during expiration, and not, as in croup, most severely during inspiration. Moreover, the absence of the croupy character of voice, and the complete intermissions which occur in the case of foreign bodies, distinguishes these from cases of croup. From hooping-cough, the diagnosis turns upon the history, the absence of the peculiar hoop, and by the absence of great dyspnoea during inspiration. From spasm of the glottis, it is distinguished by the history and by the absence of any auscultatory signs. Lastly, from the impaction of extraneous substances in the pharynx and œsophagus, the diagnosis will be made by examining these passages with the finger and probang. The want of this latter precaution has proved fatal:-A man, while eating, was seized with symptoms of suffocation and difficult deglutition; the trachea was opened; but as nothing was found it was concluded that the

substance had descended into one of the bronchial tubes: after death the surgeon was surprised at discovering it fixed in the œsophagus.

There will, however, be but little difficulty in forming a correct diagnosis in the majority of cases, if the history be carefully attended to. The following remarks by Dr. Gross, of Philadelphia, will give a good idea of the accident in question. A child has perhaps been playing with a grain of corn, bean, pebble, or similar body, and has been suddenly seized with symptoms of suffocation, violent spasmodic cough, lividity of the face, pain in the upper part of the windpipe, and partial insensibility: the presumption will be strong that the substance, whatever it may have been, has slipped into the air passages, and is the immediate and only cause of the suffering which the surgeon has been sent for to relieve. The presumption will be converted almost into positive certainty if the person was just previously in the enjoyment of good health; if he was romping, jumping, or laughing at the moment of the accident, with the substance perhaps in his mouth, or while attempting to throw it into that cavity; and especially if the symptoms, after having been interrupted for a few minutes, continue to recur, with their former, or even with increased, intensity at longer or shorter intervals.

The most common Pathological Effects are, inflammation of the mucous membrane, perhaps going on to ulceration, though the latter effect is generally confined to the tissues in immediate contact with the extraneous substance. The normal secretion of mucus is always increased, and not unfrequently it becomes muco-purulent, while in some instances the bronchi have been found loaded with this kind of secretion. When the foreign body is retained in one of the bronchial tubes, it may either give rise to pulmonary collapse, if it completely obstructs the tube, or inflammation of the corresponding lung may be set up, giving rise to all the ordinary symptoms of pneumonia. Abscesses also may form at the seat of obstruction; while in a few instances pulmonary emphysema has been induced: in others, pleurisy, leading to effusion: and in a very small number, inflammation of the heart and its investing serous membrane. Mr. Herbert Mayo has recorded a case in which a boy twelve years old died in consequence of the inhalation of an ear of rye pulmonary irritation with the most fœtid expectoration followed, and hectic fever set in which proved fatal. On a post-mortem examination, the foreign body was found in an abscess between the lung and the liver; the latter having be