of a feather and Parker's solution. A steam spray atomizer may very often be used with advantage.

Quick laryngotomy must never be attempted upon a child under thirteen years of age, because of the small size of the cricothyroid space before this age (Treves.) In view of the difficulty of introducing a tube and of wearing it so near the vocal cords, laryngotomy should not be performed for croup, diphtheria, or for any condition in which a tube must be long worn. An incision an inch and a quarter long is made in the middle line, from above the lower edge of the thyroid cartilage to below the lower border of the cricoid. Divide the skin, superficial fascia, and deep fascia, separate the cricothyroid and sternothyroid muscles, divide the deep layer of fascia, and cut the cricothyroid membrane horizontally just above the cricoid cartilage. The tube must be shorter than is the tracheotomytube. An operation which opens vertically the cricothyroid membrane, the cricoid cartilage, and the upper rings of the trachea is called "laryngotracheotomy."

Intubation of the Larynx (O'Dwyer's Operation).The instruments required in this operation are a mouth-gag, an instrument to hold the tube and introduce it, an instrument for extracting the tube, and a graduated scale. The collar of the tube has a perforation through which a piece of silk is fastened to draw out the tube. The child is wrapped in a sheet to secure the limbs, is seated in a nurse's lap, and its head is held by an assistant. The jaws are to be opened and held apart by the self-retaining mouth-gag. The surgeon sits in front of the patient, wraps the index finger of his left hand with a piece of rubber plaster, and passes it into the child's mouth until his finger touches the epiglottis. He introduces the holder and tube (observing if the silk is free) along the surface of the tongue until the obturator touches the epiglottis; raises the epiglottis with the left index finger, and passes the tube into the larynx; places the left index finger against the tube, and withdraws the holder with the right hand. The silken thread is tied to the ear, and the nurse is directed to employ the thread to remove the obturator if it becomes obstructed or is coughed up. The tube is removed in two or three days; if breathing is easy, it is not reintroduced, but if dyspnea recurs, it is replaced for two or three days more. If, in introducing the tube, a mass of false membrane is pushed before it into the trachea, breathing ceases, and, if the mass is not at once coughed up, tracheotomy must be performed. Wharton feeds these

patients on semi-solids rather than upon liquids (mush, soft eggs, and corn-starch), and if trouble occurs in swallowing these articles, he feeds by the rectum or by means of a tube.

4. DISEASES AND INJURIES OF THE CHEST, PLEURA, AND LUNGS.

Pleuritic effusion may arise from foreign bodies, from injury by fragments of a broken rib, from tumors, and from inflammation of the lung, but most usually from pleuritis. Inflammatory effusion is nearly always unilateral (except in tubercular pleurisy, but even this form is one-sided at the start).

The signs of pleuritic effusion are-dulness on percussion over the effusion, this dulness, when the patient is erect, being at the lower part of the chest and ascending higher posteriorly than anteriorly (alteration of position alters the situation of the dulness); the intercostal spaces are widened and the intercostal depressions are obliterated; no breathsounds can be detected in the area of flatness when the collection of fluid is large, but in small effusions deeply situated the breath-sounds are often audible; the percussion-note above the liquid is hyper-resonant or tympanitic, and is often associated, at the edge of the liquid, with a friction-sound; posteriorly, high up and near the spine, there are bronchial respiration and bronchophony (DaCosta). In these cases pain disappears with the advent of effusion, dyspnea comes on, and the patient lies upon the diseased side. Cough and fever always exist. In serous effusions the diagnosis may be confirmed by the introduction of an asepticized aspiratingneedle.

The treatment in this stage is to discontinue arterial sedatives and to stimulate if the circulation calls for it. The exudation is removed by salines, by compound jalap powder, or by elaterium. If these means fail, if the effusion is excessive, or if it is producing dyspnea, at once aspirate. If pus forms, drain by operation.

Empyema is a collection of pus in the pleural cavity. It may begin suddenly, but rarely does so. Among the causes of empyema are those of serous effusion. Empyema is due

to infection of the pleura. The pneumococcus is the causative organism in many of the cases which follow pneumonia. This organism lives but a short time, and an empyema due to pneumococci may possibly be absorbed (Stephen Paget).

Most cases of empyema are due to streptococci and staphylococci. These organisms may appear in an empyema induced originally by pneumococci (Stephen Paget). In empyema developing during or after typhoid fever the typhoid bacillus may be discovered. In putrid empyema various bacteria are found. Bouchard thinks acute empyema has a special organism. The bacilli of tuberculosis are present in tubercular empyema. Empyema may be due to a wound or contusion, an attack of pneumonia, tubercular pleurisy, phthisis, typhoid fever, infection of a serous effusion, caries of a rib, specific fevers, peritonitis, malignant disease of the pleura, or gangrene of the lung. The signs are in reality those of pleurisy with effusion, viz., dulness on percussion, absent breath-sounds, bulging of the intercostal spaces, and sometimes edema of the skin of the chest. The symptoms are irregular fever, sweats, chills, dyspnea, pallor, and sometimes cough. There is marked leukocytosis. The fingers may become clubbed. An empyema of the left side may pulsate. A neglected empyema may break into the lungs, esophagus, or pericardium, or may point in the lumbar region. Empyema may cause death by compression of the heart and lung, pulmonary embolism, pericarditis, peritonitis, cerebral embolism, cerebral abscess, septicemia (Stephen Paget), or exhaustion.

The treatment is aspiration, incision and drainage, or thoracoplasty (see pages 608-610).

Contusions and Wounds of the Chest.-The symptoms of contusions of the chest are pain and soreness, and, as a consequence, abdominal respiration and decubitus upon the back inclining to the injured side. In severe contusions the viscera may be injured. The treatment is by strapping the chest as for fractured ribs (Pl. 5, Fig. 13). Non-penetrating wounds of the chest are not especially grave, and are treated according to general rules, the chest being immobilized. Penetrating wounds are very grave injuries. Visceral injury may be inflicted. Emphysema is apt to occur. Profuse hemoptysis suggests a wound of the lung. amining chest-wounds feel with a finger, not with a probe. In wounds of the pleura cleanse, stitch the pleura with catgut or fine silk, suture the skin, dress with gauze, and immobilize the chest. Wounds of the lung demand absolute rest. If the bleeding is slight, do not operate; but if bleeding threatens life, resect a rib to reach the lung, and arrest hemorrhage. Hemorrhage of the lung may in some cases be arrested by the ligature, in some cases by packing a small

In ex

wound with gauze, in some cases by the suture ligature. In a violent secondary hemorrhage following a gunshot-wound of the lung the author packed the entire pleural cavity with sterile gauze to obtain a base of support, and arrested the bleeding by carrying iodoform gauze directly against the oozing surface. After arresting hemorrhage in hemothorax, turn out the clots and employ drainage. If emphysema of the chest-walls is moderate, strapping or a bandage will control it; if it is great, make multiple punctures and then apply pressure. In hernia of the lung try to restore the protrusion, but if restoration is impossible or if gangrene seems highly probable, ligate the base of the protrusion with silk and cut away the mass. If foreign bodies in the thorax can be felt, remove them; if they cannot be felt, do not conduct a prolonged search, but leave them to Nature.

Abscess of the lung may follow ordinary pneumonia. It is apt to follow aspiration pneumonia. Osler tells us that it may arise by the aspiration of septic particles after "wounds of the neck, operations upon the throat," and suppurative lesions of the nose, larynx, or ear. Cancer of the esophagus may be a cause, so may perforation of the lung by an abscess, wound of the lung, impaction of a foreign body in the lung, suppuration about a focus of tubercle or metastatic abscess." Symptoms.-The physical signs of a large cavity are found, and there is profuse and offensive expectoration, the expectorated matter containing portions of lung-tissue. Pyemic abscesses are hard to diagnosticate.

The treatment is purely surgical (Pneumotomy). Make an incision over the cavity. Resect a portion of one or more ribs. Expose the pleura. If the two layers of the pleura are not adherent, suture them together and wait two days. If they are adherent, proceed at once. Search for the abscess with an aspirator. When the cavity is found, open into it with the cautery and insert a drainage-tube.

Gangrene of the Lung.-This term means the putrefaction of a devitalized portion of pulmonary tissue. It may follow pneumonia, or may be due to diabetes, to embolism of the pulmonary artery, bronchiectasis, tuberculosis, or malig

nant disease.

Symptoms. The symptoms of a cavity exist plus the expectoration of horribly offensive sputum, which contains fragments of lung-tissue and often altered blood; there is some fever, and great exhaustion. The great fetor of the

1 Annals of Surgery, Jan., 1898.

2 See Osler's Practice of Medicine.

discharge is characteristic, and is much more intense than the fetor of abscess.

The treatment is to operate as for pulmonary abscess. Tubercular Cavity in the Lung.-Surgical Treatment. For the past decade surgical thought has been actively directed toward placing on a scientific footing operations for pulmonary phthisis. The matter is still in a transition stage, and operations at present have but a very limited field of application, although Sonnenberg and others have reported cures. Mosler, a number of years ago, attempted to treat cavities by introducing a trocar into the cavity and injecting permanganate of potassium solution through the cannula. Patients were not benefited by this procedure. Hillier tried injection of corrosive sublimate into the lung-parenchyma, but the effect of the injections was disastrous. When the strength of the patient is well preserved and the pulmonary lesion is circumscribed and slowly progressive it may be justifiable to perform an operation, open the cavity, and treat it directly (pneumotomy). Fowler says it is not justifiable to operate if the disease has come "to a standstill." The same surgeon states that the only accessible region is bounded above by the clavicle, to the inner side by the manubrium, to the outer side by the lesser pectoral muscle, and below by the second rib.1

Manclaise says that pneumotomy is only justifiable in circumscribed tubercular cavities without peripheral infiltration and in pulmonary abscesses. Bronchiectatic cavities are usually multiple; they are excessively difficult to locate, and treatment by pneumotomy should not be attempted. In the treatment of pulmonary tuberculosis resection of the diseased area has been proposed (pneumectomy). Tuffier successfully performed this operation. Surgeons, as a rule, do not believe in pneumectomy. Reclus voices the general opinion when he says the operation is not required if the area of disease is very limited, as such a condition is frequently curable by medical means, and it does no good if the area of disease is extensive.3

Paracentesis Thoracis.-Aspiration will very rarely cure empyema. It will occasionally cure a small encysted empyema or a pneumococcus empyema in a child. Its chief use is in diagnosis, or as a temporary measure when dyspnea is severe

1 See the very full and thoughtful article of George Ryerson Fowler on "The Surgery of Intrathoracic Tuberculosis,” Annals of Surg., Nov., 1896. 2 La Tribune médicale, Sept. 21, 1893.

Revue de Chirurgie, Nov. 11, 1895.