and it is lifted away from the arch. The spinous processes are cut off with forceps close to their bases, the laminæ are divided on each side with the rongeur, and the dura is exposed. In some cases the fragments will be found on exposing the vertebræ, or the blood-clot will be seen between the dura and the bone; in other cases the dura must be opened with scissors vertically in the middle line. while it is grasped with rat-toothed forceps. After reaching and removing the compressing cause, or after failing to find or remove it, close the dura with catgut, drain the length of the wound with a tube, stitch the superficial parts with silkworm gut, and dress antiseptically.'

XXIV. SURGERY OF THE RESPIRATORY
ORGANS.

I. DISEASES AND INJURIES OF THE NOSE AND ANTRUM. Foreign bodies in the nose are usually introduced through the anterior nares, but in rare instances they enter by way of the posterior nares. Small particles are often expelled spontaneously; larger pieces gather mucus and become fixed. Some materials swell after lodgment.

Treatment.-Illuminate the nostril, and, if the foreign body can be seen, insert a hook back of it and effect its removal by means of forceps. In many cases anæsthesia is required. Some foreign bodies require to be pushed back into the naso-pharynx. Occasionally expulsion may be effected by inserting a rubber tube into the unblocked nostril and telling the patient to blow forcibly through it. In serious cases a specialist should be summoned to remove a portion of the turbinated bone or to perform whatever operation he thinks best.

Inflammation and Abscess of the Antrum of High1 See J. W. White's admirable description in the Annals of Surgery, July, 1889.

more (Maxillary Antrum).-The source of this disease may be inflammation of the nose or periostitis around the roots of the teeth. The symptoms are pain, œdematous swelling of the face, and thinning of the bone so that it crepitates under pressure. When pus exists, certain positions of the head will cause a purulent flow from the nose, and pus may be seen by a speculum as it flows into the nose. In severe cases the jaw expands, the eye protrudes, and great tenderness of the alveolus exists. Percussion exhibits a dull note. In the diagnosis it may be well to employ an electric light in the closed mouth and note the limitations of light-transmission.

Treatment.-Before pus forms, leech and use hot fomentations. When pus has formed, evacuate it at once. If the disease arises from a carious tooth, pull the tooth and push a trocar through its socket into the antrum. If the teeth are sound, bore a hole with a large gimlet or with a bonedrill above the root of the second bicuspid tooth and one inch above the edge of the gum. A counter-opening should be made into the inferior nasal meatus. A drainage-tube is pulled from the first opening into the nose and is allowed to protrude from the nostril. Irrigate daily with peroxide of hydrogen. In three or four days discontinue through-andthrough drainage, but prevent the first opening from closing until the discharge ceases to be purulent.

2. DISEASES AND INJURIES OF THE LARYNX AND TRACHEA. Edema of the Larynx (Edema of the Glottis).—The causes of oedema of the larynx are-acute laryngitis; chronic diseases, such as tuberculosis or syphilis; inflammatory disorders, such as diphtheria and erysipelas; acute infectious diseases; Bright's disease; aneurysm; whooping-cough; pneumonia; quinsy; wounds of the larynx; wounds of the neck; scalds and burns of the larynx. The symptoms are

sudden and rapidly increasing dyspnoea, respiratory stridor, huskiness of the voice, and finally aphonia. The epiglottis may be felt with the finger and may be seen with a mirror.

Treatment. In cases of oedema of the larynx which are not excessively acute, make multiple punctures into the epiglottis and favor bleeding by the inhalation of steam. In severe cases perform intubation or tracheotomy.

Wounds and Injuries of the Larynx.-The larynx may be injured internally by foreign bodies, and externally by blows and cuts. A condition often met with is cut throat, the result usually of a suicidal attempt on the part of the patient or a homicidal effort on the part of an assailant. The cut of the suicide is usually in front; it misses the great vessels, but divides the crico-thyroid or thyro-hyoid membrane. The epiglottis may be incised, or even be cut off. If a large vessel is cut, death rapidly occurs. The immediate dangers of cut throat are hemorrhage, suffocation by blood, entrance of air into veins, and suffocation by displacement of parts. The secondary dangers are pneumonia, infection. and sepsis, exhaustion, and secondary hemorrhage. The remote dangers are stricture and fistula (Keetley).

Treatment. In wounds of the throat, arrest hemorrhage, remove clots from the larynx and trachea, bring about reaction, asepticize the parts as well as possible, suture the deeper structures with catgut and the superficial parts with silkworm gut, dress antiseptically, and place a bandage around the head and chest, so as to pull the chin toward the sternum. If laryngeal breathing is much interfered with, perform tracheotomy. Feed the patient through a tube until union has well advanced. The old method of leaving the wound open is to be condemned. When sutures are used, primary union may be obtained.

Foreign Bodies in the Air-passages.-The lodgement. of foreign bodies in the air-passages is a frequent accident.

Small solid bodies are usually expelled by coughing. Liquids and solids rarely pass beyond the larynx (except in laryngeal disease or palsy, wounds of the floor of the mouth, cut throat, and in people unconscious or comatose). In post-ether vomiting or in the vomiting of drunkards the vomited matter may find its way into the larynx. In most instances of foreign bodies lodged in the air-passages it will be found that the object was being held in the mouth when a sudden deep inspiration was taken (often from laughter). The symptoms are immediate, due to obstruction by the body and to spasm, and secondary, due to the situation of the body and the changes it undergoes or induces.

Lodgement in the pharynx causes violent dyspnoea. The body can be seen or felt.

Lodgement in the Larynx.-In a severe case the patient fights madly for air; his face becomes livid and cyanotic; his veins stand out prominently; speech is impossible, though he may make noises and utter harsh cries; violent coughing begins, and then vomiting; he tries to force a finger down his throat and clutches at his neck; sweat pours from him; he feels a sense of impending dissolution, and he falls down unconscious, with incontinence of feces and urine. In a less severe case violent dyspnoea gradually departs and the patient lies exhausted, but dyspnoea and cough are liable to recur suddenly at any time because of spasm, and they may be induced by a change of position. These attacks of fierce spasmodic cough are not at first linked with expectoration, but after inflammation begins. there is a profuse and often bloody expectoration. Inflammation follows more rapidly the lodgement of a sharp or irregular body than it does that of a round or smooth body. Inflammation is apt to produce cedema of the glottis, broncho-pneumonia, or ulceration and necrosis of the larynx. 1 See C. Mansell Moullin's graphic description.

Any foreign body in the larynx may at any moment produce spasmodic dyspnoea, and it is always very liable to cause oedema of the glottis.

Lodgement in the Trachea.-The immediate symptoms of foreign bodies in the trachea depend on the shape and weight of the body, and whether it becomes fixed in the mucous membrane or moves to and fro with the air-current. A smooth heavy body falls to the bifurcation, and, if it does not enter a bronchus, moves with every breath, and by its movement causes violent laryngeal spasm, cough, and whooping inspiration without aphonia. The patient is often conscious of the movements of the foreign body, and the surgeon may detect them with the stethoscope. A foreign body in the trachea is liable to cause death by dyspnoea, or it may ascend so as to be caught in the larynx, or may even be expelled. Irregular or sharp bodies lodge in the mucous. membrane, produce inflammation, frequent cough, and expectoration, and finally lead to ulceration. Bodies which swell up from heat and moisture tend to lodge and to become fixed (seeds may sprout).

Lodgement in a Bronchus.-Foreign bodies in the bronchi usually lodge in the right bronchus. When a small lungarea is obstructed, the obstructed side shows diminished respiratory movement and murmur with occasional whistling sounds and large moist râles; percussion note is normal. When an entire lobe is obstructed, all respiratory sounds. are absent over it, and over the unobstructed lung respiration is exaggerated; the percussion note, at first resonant, becomes dull. Lodgement in a bronchus may cause bronchopneumonia, abscess, hemorrhage, and even gangrene.

Treatment. If a foreign body lodges in the pharynx, try to pull it forward; if this fails, push it back into the œsophagus. In lodgement in the larynx or below, if the symptoms are very urgent, at once perform a quick laryngotomy. If