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. This fact was proved by Henry Morris.

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 very drunk). In vomiting during or after the administration of an anesthetic, or in the vomiting of drunkards, the vomited matter may find its way into the larynx or lungs. There is great danger of this accident in an operation upon a patient with intestinal obstruction who has stercoraceous vomiting. 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 dyspnea. 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 dyspnea gradually departs and the patient lies exhausted; but dyspnea 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 edema of the glottis, bronchopneumonia, or ulceration and necrosis of the larynx. Any foreign body in the larynx 1 See Moullin's graphic description in his Treatise on Surgery.

may at any moment produce spasmodic dyspnea, and it is always very liable to cause edema of the glottis. The body if bony or metallic can be detected by the X-rays.

Lodgement in the Trachea.-The immediate symptoms of a foreign body 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 tracheal 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. The foreign body may be found with the Röntgen rays. A foreign body in the trachea is liable to cause death by dyspnea, 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; the 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 over the obstructed area is at first resonant, but becomes dull. The X-rays will enable the surgeon to detect some foreign bodies in a bronchus. 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 esoph agus. In lodgement in the larynx or below, if the symptoms are very urgent, at once perform a quick laryngotomy. If the symptoms are not so urgent, get a complete history of the accident and find out the nature of the foreign body. Be sure a foreign body is retained in the respiratory tract, and determine what its situation may be. Often a laryngologist can remove a foreign body from the larynx by means of forceps, a mirror and lamp being used for illumination. The fauces and upper portion of the larynx should have cocain applied to them to lessen pain and spasm. If the surgeon fails in

extraction by forceps, and laryngotomy has been performed, continue the search through the opening in the cricothyroid membrane; if laryngotomy has not been performed, let it be done in the form known as thyrotomy (a vertical incision between the alæ of the thyroid cartilage, and the separation of these ale to permit of exploration). After a thyrotomy suture the perichondrium with catgut. If the foreign body is in the trachea or in a bronchus, perform tracheotomy: this prevents suffocation from laryngeal spasm or edema. The foreign body may be expelled; if it is not expelled, search the trachea and bronchi with Gross's forceps, with probes, with hooks, or with the finger. If the foreign body cannot be found, put the patient to bed, and maintain a moist atmosphere in the room. As a rule, when the foreign body is not found insert a tube. If the foreign body be extracted do not insert a tube (unless edema of the glottis exists or is likely to come on), do not suture the wound, but cover it with moist gauze and let it heal by granulation. Morphin and sedative cough-mixtures are given. Gross says that even when a foreign body has long been retained an operation should be performed so long as the air-passages are not seriously diseased. What shall be done when a foreign body is lodged in a bronchus and we are unable to extract it through a tracheotomy wound? Truc said if "the patient is in danger of death" go through the chest-wall and attempt to remove the body. He said this with a full knowledge of the difficulty of locating the body. This difficulty has been partly overcome by the X-rays, and it seems more certainly our duty now to pursue this plan than it was a short time ago. Some surgeons advocate incision from behind. It is possible to reach the bronchus, but many surgeons believe that advances in technique will be necessary before we can hope to save a patient by opening a bronchus and removing a foreign body. Paget disbelieves in any direct incision.

3. OPERATIONS ON THE LARYNX AND TRACHEA.

Tracheotomy.-The instruments required in this operation are the scalpel, dissecting-forceps, a dry dissector, hemostatic forceps, scissors, a tenaculum, aneurysm-needle, tubes, tapes, Paquelin cautery, needles, needle-holder, a mouth-gag, tongue-forceps, foreign-body forceps, retractors, and, if membrane is present, feathers and a solution of bicar1 See Stephen Paget's Surgery of the Air-passages.

bonate of sodium. In a formal operation give chloroform, but in an emergency case this cannot be done. The patient may be placed supine with a sand-pillow under the neck and with the head thrown over the end of the table. If a child, Liston used to wrap it up to the neck in a sheet to prevent movements of the limbs, would seat himself on a chair, place the child upon the nurse's lap, and take its head between his knees. If bleeding is profuse when the surgeon is ready to open the trachea, place the patient in the Trendelenburg position with the neck extended. The head must be exactly in the middle line, and extended (in an adult this gives two and three-quarters inches of trachea above the manubrium; in a child of ten, two and a quarter inches; in a child of six, about two inches). The operator stands to the right side when the patient is supine. The trachea may be opened above or below the isthmus of the thyroid gland. The isthmus in an adult usually lies over the second and third rings (Fig. 184). The isthmus in a child usually lies

over the first ring or even over the space between the cricoid cartilage and the first ring. The high operation is always performed except in cases where it is desired to search for a foreign body in a bronchus.

High Tracheotomy.-This operation is preferred because in this region the muscles are distinctly separated (Fig. 185), the main vessels of the neck and the inferior thyroid vessels are not encountered, the anterior jugular veins are small and have very few transverse branches, and the trachea

is near the surface (Treves). Accurately locate the cricoid and thyroid cartilages. An incision is begun at the upper border of the cricoid cartilage, and is carried down precisely in the middle line for about one and a half inches. Treves advises the operator to steady the skin of the neck with the fingers of the left hand and to cut with the unsupported right hand (if the hand be supported, the respirations will interfere with the operation). Incise the skin, the superficial fascia, and the anterior layer of the cervical fascia, separate the sternohyoid and sternothyroid muscles, and divide the fascia over the trachea. This fascia is attached above to the cricoid cartilage, and it divides below into two layers to invest the thyroid body and its isthmus. If veins are in the line of the incision, push them aside, but do not stop to apply a double ligature. Even if bleeding is profuse, as soon as the trachea is opened and air enters freely into the lungs venous congestion is relieved and bleeding is apt to cease. If hemorrhage be violent and the veins are not at once caught by forceps, it may be well to place the patient in the Trendelenburg position. Before opening the trachea push the isthmus of the thyroid gland down; if it cannot be pushed down sufficiently, make a transverse incision through the fascia at the upper border of the cricoid cartilage, and lift the fascia, and the isthmus with it, off the trachea (Bose's method). Insert a tenaculum into the cricoid cartilage in order to steady the tube. Turn the back of the knife toward the sternum, hold a finger on the blade to prevent too deep a cut being made, plunge the knife, like a trocar, into the mid-line of the trachea above the isthmus, and divide two or three rings from below upward. Do not remove the hook until the operation is completed. If a foreign body is present, try to remove it; if success attends the effort, no tube need be worn, but if the body is not found, use a tube. In croup or in diphtheria remove membrane (by means of a feather and a solution of bicarbonate of sodium 3ij, glycerin 3j, water 3x-Parker) and insert a tube. Grasp an edge of the cut with the dissecting-forceps, include the mucous membrane in the bite, bring the head erect, introduce the tube, and remove the tenaculum. Secure the tube by tapes, and suture the wound below the tube. Remove the tube at the first moment consistent with safety. In croup or diphtheria put a screen around the bed; have the air moist by steam; remove the inner tube and clean every two or three hours at first; clean the outer tube, and the larynx and trachea whenever required, by means