upper part of the pharynx by the finger nail. If a foreign body is beyond reach of the finger, an attempt must be made to extract it by forceps, or by some of the various forms of coincatchers or the expanding horse-hair extractor. If, after a thorough trial, with the patient under chloroform, these means fail, pharyngotomy must be performed, and the body removed through the opening in the neck. When situated lower down the œsophagus, and it cannot be extracted by gentle means, it had better be left alone, in the hope that it may become loosened in a day or two by ulceration, and be expelled or pass down into the stomach. Should this not occur, an endeaver may again be made to extract it, or to push it onward into the stomach. In these manipulations the greatest care must be taken, as, if the body is sharp, the oesophagus will easily be lacerated. If it has been pushed into the stomach the patient should be fed on oatmeal porridge, and made to swallow portions of hair, and the like, in the hope that the body, if angular, may become surrounded by this soft material and travel through the intestines without injuring them. Should it be too large to pass the pyloric valve, gastrotomy is the only resource.

FOREIGN BODIES IN THE AIR PASSAGES.-A foreign body may become lodged in the larynx, the trachea, or in one of the bronchi.

Foreign Bodies in the Larynx.-A foreign body may be lodged above, below, or between the vocal cords, or in the ventricles. When a voluminous body, as a piece of meat, becomes impacted at the entrance of the larynx, it may block up the passage, causing instant suffocation. Smaller bodies, wherever situated, may also cause fatal dyspnoea by setting up reflex spasm of the muscles of the glottis; though in some cases a foreign body, such as a tooth-plate, may be so lodged between the cords as to prevent them closing. A foreign body in the ventricle may cause the same urgent symptoms; at other times the foreign body may give rise to severe, but not fatal, attacks of dyspnoea and spasmodic cough, though, if not removed, inflammation and dema may be set up and the patient ultimately succumb. Treatment. -Where the symptoms are urgent and the body cannot be removed by the finger, instant laryngotomy should be performed. But when less urgent, a deliberate attempt should be made to remove it by means of laryngeal forceps aided by the laryngoscope. Sometimes, where extraction would be otherwise impossible, this may be accomplished by cutting the body in two by the use of the laryngeal cutting-pliers. These means having failed, an external operation must be undertaken. Thus, when the foreign body is above the cords, it may be removed by sub

FIG. 83.

The

hyoid pharyngotomy; when between the cords or in the ventricle, by thyrotomy; when below the cords, by laryngo-tracheotomy or tracheotomy, the forceps in the last instance being passed up through the wound in the trachea. Foreign Bodies in the Trachea and Bronchi.-Small objects, such as coins, buttons, orange-pips, and fruit-stones, are liable to be drawn into the trachea during a sudden inspiration, while the patient is swallowing or holding such in his mouth. The accident is most common in children. foreign body may remain free, or become impacted either in the trachea or a bronchus (Fig. 83). It usually enters the right bronchus, that being the larger, and the spur-like projection at the bifurcation of the trachea directing it that way, although the left is the more direct route. The symptoms vary somewhat, according as the body is free or impacted. When it is free, and, as is usually the Foreign body in the right case, has fallen into the right bronchus, there will be sudden and paroxysmal attacks of suffocative cough and dyspnea, in consequence of the foreign body being driven upward against the glottis, which then closes spasmodically. On listening over the trachea it may be heard to strike the cords, while a whistling sound may be detected as it passes up and down. During the intervals of the cough and dyspnoea, while the body is at rest in the bronchus, as is also the case when it is permanently impacted in it, there will be an absence of the breathing sounds over the whole or part of the lung on that side, according as the main bronchus or one of the secondary ones is obstructed; the resonance, however, will be normal. If any air can pass the obstructing body, rhonchial or sibilant sounds may be heard, due to the bronchitis set up by it. Over the opposite lung puerile breathing may be detected. When the foreign body is of a rounded shape, it may act as a ball-valve, i. e., it may allow air from the lung to be forced past it during expiration, but then fall back into the narrower part of the bronchus, and so prevent air entering during inspiration. In this way collapse of the lung is brought about. If the foreign body is not removed, or does not escape spontaneously, sudden death may occur during an attack of spasmodic dyspnea; or it may set up bronchitis, pneumonia, or gangrene or abscess of the lung.

At

other times it induces more chronic changes, such as phthisis, or it may become encysted and no harm follow. In rare instances it may make its way out through the chest-walls by perforation or ulceration.

Treatment. The patient should be inverted. Before doing this, however, everything should be in readiness for instant tracheotomy, in case the foreign body becomes lodged in the larynx and gives rise to spasm of the glottis. Children may be held up by the legs, but for adults some special contrivance may be necessary, as, for instance, Brunell's table. Inversion failing, tracheotomy should be performed, as the patient is in danger of suffocation at any instant. On opening the trachea, should the foreign body not be expelled at once, either through the wound, or, as sometimes happens, through the mouth, the patient may be again inverted, or search made for it through the wound with the tracheal forceps, wire variously bent, etc. These means failing, the tracheotomy wound must be kept open to allow of future trials being made if the foreign body is not expelled during the interval.

PHARYNGOTOMY, or ESOPHAGOTOMY, is the operation of opening the lower part of the pharynx or upper part of the œsophagus for the purpose of removing a foreign body. As the oesophagus inclines to the left, the operation by choice is done on that side, unless the body be felt distinctly on the right side. Make an incision about four inches long, having its centre opposite the cricoid cartilage, parallel to the sterno-mastoid, over the interspace between the great vessels and the larynx. Divide the platysma and deep fascia; draw the sterno-mastoid outward, and the sterno-hyoid and sterno-thyroid inward; and divide the omo-hyoid if in the way. Gently draw the larynx and trachea across the middle line in order to separate them from the great vessels; and then open the pharynx or oesophagus, as the case may be, by cutting on the foreign body if felt, or on the point of a sound passed through the mouth and made to project in the wound. Avoid injuring the superior and inferior thyroid arteries and the recurrent laryngeal nerve.

INJURIES OF THE BACK.

SPRAINS of the spine are exceedingly common, and may be caused by any violent twist or bend of the back. The pathology of these injuries is hardly known. They are said to depend upon a partial tearing or rupture of the spinal ligaments, muscles, or fascia, but opportunities for verifying these statements seldom Occur. Sprains of the back may be complicated with concussion of the spinal cord, extravasation of blood in the subcuta

neous tissues, or contusion or rupture of the kidney. They may, moreover, be followed by inflammation of the intervertebral joints and fibrous tissue about the spine; the inflammation may then at times spread to the membranes and cord, or be the starting-point of vertebral caries. Symptoms.-The patient usually complains of having ricked his back, i. e., of severe pain localized to one spot, commonly the lumbar region, and increased on movement and pressure. On examination no definite injury, beyond, perhaps, some obscure swelling about the tender spot, or blood extravasation, is discoverable. In the cervical region a sprain may sometimes simulate a dislocation, the pain causing the patient to hold the head in a fixed and one-sided position, thus rendering the transverse process on one side of the neck more prominent than natural. In the lumbar region a severe sprain may sometimes simulate an injury of the spinal cord, inasmuch as the patient may complain of a weakness of the legs, or inability to move them, or may even experience some difficulty in defecating or passing urine. It will be found, however, that in these cases no true paralysis exists, but that the apparent loss of power is due to the pain which is induced on attempts at movement. The treatment consists in rest, and the application of hot fomentations to relieve pain, and later of stimulating liniments. In severe cases the patient should be kept in bed for a week or so, and subsequently shampooing, massage, and galvanism may have to be employed to overcome the pain and stiffness which often last for some time.

WOUNDS OF THE SPINAL MEMBRANES AND CORD may be inflicted by stabs in the back, falls on sharp bodies, etc. When the membranes alone are wounded, there may be no signs at first, except, perhaps, an escape of cerebro-spinal fluid; but later, should inflammation be set up, there will be the usual signs of spinal meningitis. A wound of the spinal nerves may be known by the paralysis of the parts which they supply; a division of the cord, by complete paralysis of the parts below the seat of injury. The treatment consists in placing the patient at absolute rest, and in keeping the wound perfectly aseptic to prevent inflammation; but if the cord has been divided, permanent paralysis will almost inevitably ensue. Should inflammation occur, the appropriate remedies for meningitis must be administered. (See Work on Medicine.)

DISLOCATION AND FRACTURE.-Dislocation of the spine without fracture is exceedingly rare; indeed, except in the cervical region, it is said never to occur. Fracture unaccompanied by dislocation is also uncommon; but uncomplicated cases of fracture of the spinous processes and laminæ, and more rarely of

the transverse and articular processes, are sometimes met with. In the majority of cases fracture and dislocation are combined. Thus, usually there is fracture of the body and articular processes of one or more of the vertebræ, with dislocation of the whole of the spine above the seat of injury from the spine below. This common form of injury is in the context spoken of as fracture dislocation.

FRACTURE DISLOCATION.-Causes.-It is either the result of direct violence applied to the spine, or indirect violence, as a fall upon the head. 1. When the result of direct violence, which can only be applied to the posterior part of the spine, one or more of the spinous processes may be detached without implicating the vertebral canal. When the violence is very great, as a fall from a height on the back across a beam or rail, or a severe blow, as from a crane, the spine is bent violently backward, tearing asunder the structures forming the anterior segment of the column, and crushing those forming the posterior. Hence the vertebral bodies are generally uninjured, but wrenched apart, the intervertebral cartilages are ruptured, the anterior common ligament is torn, and the arches of the vertebræ, and the articular and spinous processes are crushed. The vertebræ above the injury are dislocated forward, as the articular processes being fractured and the intervertebral cartilages torn, nothing remains to keep them in position. 2. In fracture from indirect violence (Fig. 84), such as may be received in a fall from a height upon the head, or catching the head while passing under a tunnel, or from a weight falling upon the head or shoulders, the spine is bent violently forward, crushing the anterior part of the column and tearing the posterior asunder. Here one or more of the bodies and intervertebral cartilages are crushed between the vertebræ above and the vertebræ below, one of the fragments of the fractured body being frequently driven backward into the vertebral canal, while the arches and the spinous and articular processes are wrenched asunder. Fracture of the sternum is occasionally combined with this injury, in consequence of the chin, it is said, coming into violent contact with the sternum as the spine is doubled forward.

FIG. 84.

Fracture Dislocation of the Spine.-(From St. Bartholomew's Hospital Museum.)

Condition of the Spinal Cord.-The importance of fracture dislocation of the spine lies not so much in