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hours with a soft catheter, which is kept strictly aseptic. Take every precaution to prevent bed-sores. Some surgeons advocate reduction of the deformity by extension and counter-extension, and by the application of a firmly-fitting but removable jacket with the suspension collar (as used in Pott's disease). The head of the bed is raised and the collar is fastened to it. Every day extend gently from the shoulders in dorsolumbar fracture, and from the chin and occiput in cervical fractures. Extension may be maintained permanently until cure. White says laminectomy should be performed for fracture or for dislocation when there is obvious depression of the vertebral arches; in all cases of pressure upon the cauda equina; when there are characteristic symptoms of spinal hemorrhage; and in some cases where rapid degeneration becomes manifest. Surgeons, as a rule, agree that operation will be useless when there are complete persistent anesthesia and entire loss of reflexes, because these symptoms indicate that total division of the cord has taken place. It is useless to operate for fracture-dislocation of the atlas or axis. In ordinary cases treat by extension for six or eight weeks, and then operate if the case is not improving. In hemorrhagic cases, or cases with marked depression of the arches, operate early. If signs of degeneration begin within six or eight weeks, operate at once. "In compound fractures, in injuries of the lamina and spinous processes without a complete crush of the cord, when symptoms are due to hemorrhage, when pachymeningitis arises, if the cauda equina is compressed, operate" (Thorburn).

Operations on the Spine.-Operations for Spina Bifida.-Mayo Robson maintains' that operation is not demanded when the sac is of small size and is well protected by sound integument; that operation is improper when a large portion of the column is fissured, or when paraplegia or hydrocephalus exists; that operation is only advisable in meningocele, in cases where integument is thin and translucent, in cases where the cord is flattened out, or the nerves are fused. Robson has closed the osseous defect by transplanting periosteum.

Instruments Required.-Scalpels, dissecting- and hemostatic forceps, scissors, rongeur forceps, dural separator, Hagedorn needles and needle-holder, silk, silkworm-gut or catgut.

Operation.-Surround the sac by elliptical incisions. Find the neck of the sac, and if it contains no visible nerves ligate 1 Annals of Surgery, vol. xxii., No. 1.

it and cut off the protrusion. Push the stump into the canal. Freshen the bone-margins and spring a piece of celluloid beneath them to close the gap (Park). Suture over the stump with small sutures of catgut.'

Treves's Operation for Vertebral Caries (page 483).

Laminectomy.-The instruments required in laminectomy are dissecting-, rat-toothed, and hemostatic forceps; scalpels; bone-cutting forceps; rongeur forceps; a dry dissector; a periosteum - elevator; sequestrum - forceps; small scissors, straight and curved on the flat; a chisel and mallet; retractors; blunt hooks; a probe; tenaculum-forceps; a spoon-curet; a sand-pillow; fine needles, curved and straight, large needles, and a needle-holder.

In the operation of laminectomy the patient lies prone and a sand-pillow is placed under the lower ribs. Make an incision down the vertebral spines, the middle of the incision corresponding to the seat of fracture. The sides of the spinous process and the lamina are cleared. The periosteum is incised in the angle between the laminæ and spines, and it is lifted away from the arch. The spinous processes are cut off with forceps close to their bases, the laminæ are removed on each side with the rongeur, and the dura is exposed. In some cases the fragments will be found on exposing the vertebra, 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 silkwormgut, and dress antiseptically.2

Puncture of the spinal meninges, or lumbar puncture, was devised by Quincke, and has been carefully tried by many surgeons (Fürbringer, Naunyn, and others). It is employed as a means of diminishing cerebral pressure in hydrocephalus, cerebral tumor, uremia, and tubercular meningitis. It has proved of little therapeutic value. In some cases the examination of the fluid has been of diagnostic value. Stadelmann has reported 37 cases in which tubercle bacilli were found in the fluid.3 Turbidity of the fluid indicates the existence of meningitis. The back is sterilized; the

A full consideration of the various plans of operating will be found in an article by Marcy, in Annals of Surgery, March, 1895.

See J. W. White's description in the Annals of Surgery, July, 1889. * Berliner klinische Wochenschrift, July 8, 1895.

patient may lie prone, with a pillow under the belly, or may sit in a chair, with the body bent forward; no anesthetic is required. A Pravaz syringe is employed, and the point is inserted at the under surface of a spinous process. In some cases but a few drops of fluid will be obtained, in other cases many ounces can be removed.

XXV. 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 lodgement.

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 anesthesia is required. Some foreign bodies require to be pushed back into the nasopharynx. Occasionally expulsion may be effected by inserting a rubber tube into the unblocked nostril and telling the patient to blow forcibly through the tube. 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 Highmore (Maxillary Antrum).-The source of this disease may be inflammation of the nose or periostitis around the roots of the teeth. In some cases the opening into the nose is patent; in other cases it is partly or completely blocked. Caries and necrosis may arise. The symptoms are pain, edematous swelling of the face, and thinning of the bone so that it may crepitate under pressure. When pus has formed certain positions of the head will cause a purulent flow from the nose, and if a speculum is inserted pus may be seen as it flows into the nose. The opening of the maxillary antrum into the nose is at the summit of the cavity; hence the antrum drains when the head is inverted. The ethmoidal cells and frontal sinus drain best when the patient is upright. Wipe the interior of the nose and place the patient with his head between his knees. If the nostril fills with pus, it comes from the antrum (Cobb). In severe cases the jaw expands, the eye protrudes, and great tenderness of the alveolus exists. Percussion exhibits a dull note. In making a diagnosis it is well to take the patient into a dark room, insert an electric light into

the mouth and note the diminution of light-transmission on the diseased side as contrasted with the sound side Transillumination may be easily practised by the use of a cautery electrode, protected by a small glass vial. Any cautery battery may be employed (plan suggested by Ohls). Exploratory puncture will settle a doubtful diagnosis. This may be by way of the lower meatus, the canine fossa, or the alveolar process.1

Treatment.-Before pus forms, order the use of hot fomentations, and remove any diseased teeth. When pus has formed evacuate it at once. Before performing a severe operation try the effect of opening into the antrum from the nose, by means of Krause's trocar, followed by insufflation of iodoform. If this procedure fails, other means may be employed. 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 peroxid 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. In severe cases make a free incision through the canine fossa by means of a chisel.

Distention and Abscess of the Frontal Sinus.— The usual cause is an injury which may long antedate the symptoms. This injury causes or leads to blocking of the infundibulum; secretion accumulates and distends the sinus; and in some cases pus forms. In many cases the fluid slowly accumulates, and it requires years to produce marked symptoms. In other cases infection takes place, and the symptoms are positive and violent. If the outlet into the nose is not permanently blocked, the fluid may discharge itself from time to time. In the chronic cases there is rarely much pain. The chief sign is a swelling of the inner or upper part of the orbit, which swelling progressively increases in size and displaces the eye. If at any time acute symptoms supervene, there will be pulsatile pain, discoloration, and tenderness.

Treatment. In some cases it is possible to pass a trocar upward from the nose into the sinus, and so drain and irrigate. In most cases an incision should be made through the

1 Cobb, in Boston Med. and Surg. Jour., May 7, 1896.

soft parts, and the sinus opened by a trephine or chisel. After the sinus has been opened it must be curetted, the opening into the meatus should be restored and enlarged, and a drainage-tube is to be passed from the forehead incision into the nostril. Some surgeons open the sinus by making an osteoplastic flap.

2. DISEASES AND INJURIES OF THE LARYNX AND TRACHEA.

Edema of the Larynx (Edema of the Glottis).-The causes of edema of the larynx are-acute laryngitis; chronic diseases, such as tuberculosis, malignant disease, 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, and the inhalation of irritating vapors, such as those of ammonia and sulphur. The symptoms are sudden and rapidly increasing dyspnea, respiratory stridor, huskiness of the voice, and finally aphonia. The swollen epiglottis may be felt with the finger and may be seen with a mirror.

Treatment. In cases in which edema of the larynx is 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 cricothyroid or thyrohyoid 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 silver wire, catgut, or kangaroo-tendon, and the superficial parts with silkworm-gut, dress antiseptically, and place a bandage around the head and chest so as to

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