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to side, push the blades of the forceps deeper into the socket, and extract by pulling downward,

Lower Incisors. The tooth has a root flattened laterally. Apply the forceps; pull outward, and then, by rocking the tooth inward and outward, loosen it sufficiently to allow the blades of the forceps to be forced deeper toward its root. Extract by drawing upward and slightly outward.

Lower Canine.The root is conical, hence the tooth is removed in the same manner as the upper canine, except that the pull is upward.

Lower Bicuspids. Use forceps with narrow blades, which form almost a right angle with the handle. These teeth are extracted like the upper bi- . cuspids, except that they are pulled upward.

Lower Molars.The roots are one internal and one external. Apply the forceps and force the tooth outward. Rock the tooth forward and backward, because the roots incline backward. Push the blades of the forceps deeper toward the roots, and extract by drawing upward. Protect the roof of the mouth by holding the forceps near the blades.

Extract broken roots of teeth by an elevator, having a short, thin blade, which is grooved on the inner side. The blade has a sharp-pointed or broad edge, and bends so as to make an obtuse angle with the shaft. Two are necessary, right and left. In extracting the root, make the internal plate of the alveolar process the fulcrum for the elevator.

PERFORATION OF THE ANTRUM.

Place the subject on the back, with the head hang. ing over a block. Stand on the right-hand side of the table. Extract the first or second molar tooth of the upper jaw, the rule being to choose the one most decayed.

Hold the bone-drill, or, as Fergusson recommends, an ordinary gimlet in the right hand, with the indexfinger applied along the shaft. Enter the instrument into the socket of the tooth extracted, and by boring upward and slightly inward, keeping up uniform pressure, perforate the floor of the antrum.

The index-finger, applied along the shaft, prevents the instrument from plunging through the cavity of the antrum against the floor of the orbit.

The antrum may be perforated from the canine fossa by dissecting off the tissues, the upper lip being turned upward, until the bone is cleared, and then by using a trephine or drill to bore horizontally backward.

EXCISION OF THE TONGUE.

Partial Excision.— The only partial excision which claims notice is that of a longitudinal half

of the organ.

The lingual artery of the corresponding side must be ligated in the triangle formed by the hypoglossal nerve and the tendon of the digastric muscle, as a step of the operation (see ligation of linguals).

Retain the jaws widely separated by means of a mouth-gag. Pass two stout ligatures through the front half of the tongue, one on each side of the median line. Pull the tongue forward and upward. Cut with a scalpel the mucous membrane in the median line of the under surface of the tongue from the tip to the frænum. Divide with the scissors the frænum, also the mucous membrane reflected from the under surface of the half of the organ to be removed to the floor of the mouth. Divide the mucous membrane reflected from this side to the fauces, also the underlying muscles. Pull the tongue forward and downward, and cut with a scalpel the mucous membrane, and slightly the underlying muscular tissue along the dorsum in the median line from the root to

the tip.

With the fingers separate the two halves of the tongue all the way to the hyoid bone. Tear with the fingers the attachments to the under and lateral sur faces.

Sever the part from the hyoid bone by means of scissors, blunt-pointed, and curved on the flat.

By traction on the ligature through the remaining half of the organ, the cut surface is brought into view.

Complete Excision.—Ligate the lingual arteries and perform tracheotomy as steps of the operation (see tracheotomy and ligation of linguals).

Keep the jaws separated by means of a gag. Pass a stout ligature through the anterior part of the tongue and draw, by pulling on the ligature, the tongue upward and forward.

Cut the mucous membrane on the inner surface of the symphysis menti, and separate the tissues from the bone with an elevator, until the origins of the muscles attached to the genial tubercles are exposed. Cut these tendons close to the bone.

Draw the tongue forward, and pass a ligature through each lateral glosso-epiglottidean ligament. Bring these ligatures out of the angles of the mouth and fasten them to the cheeks by plaster.

Divide with scissors the frænum and the mucous membrane at its reflection from the under surface of the tongue to the floor of the mouth, also the mucous membrane and muscular attachments to the sides of the

organ. Tear with the fingers all tissues neces. sary to free the tongue to its base.

Slip the noose of an écraseur over the tongue down to its attachment to the hyoid bone. Prevent the écraseur from slipping forward by passing hare. lip pins through the tongue in front of the noose. Begin slowly to divide the tissues in the loop of the écraseur, by making about two turns of the handle every minute.

By drawing on the ligatures passed through each lateral glosso-epiglottidean fold the stump attached to the hyoid bone may be inspected.

If removal beneath the inferior maxilla is practiced, Kocher's method is recommended (see textbooks on surgery).

BRONCHOTOMY.

Thyrotomy, Laryngotomy, Trachcotomy. Place the subject on the back with the shoulders depressed. Place a block under the neck and allow the head to hang backward. Stand on the right-hand side facing the subject.

1. Thyrotomy.-Steady the thyroid cartilage between the index-finger and thumb of the left hand. Make an incision in the median line from the hyoid bone to the cricoid cartilage through the skin and fasciæ. Divide the fibrous connection between the sterno-hyoid muscles. Separate the sides of the wound by means of retractors. Ligate, if present, the communicating branch between the two hyoid

arteries just below the hyoid bone, also that of the crico-thyroid arteries below the thyroid cartilage.

Locate with the left index-finger the notch on the superior border of the thyroid cartilage which marks the junction of its halves. Divide the thyroid cartilage from this notch downward, never deviating from the median line. Open into the larynx through the mucous membrane exactly in the median line, to avoid wounding the vocal cords. Retract the alæ of the cartilage.

In closing the wound the halves of the cartilage must be accurately joined by sutures. Provide for drainage, and stitch the integument and fascia together.

2. Laryngotomy.Locate the cricoid cartilage. The space just above this cartilage and below the thy. roid in the median line is the site of the operation.

Make an incision in the median line extending three quarters of an inch above and below the center of the crico-thyroid space. Divide the integument and fusciæ covering the crico - thyroid membrane. Retract the sides of the incision. Steady the part by means of a tenaculum hooked under the lower border of the thyroid cartilage. Pierce the membrane above the middle of the cricoid cartilage and enlarge the opening into the air - passage by lateral incisions through the membrane just above the cricoid cartilage.

Dilate the opening and insert a laryngeal tube, directing its end horizontally backward into the airpassage and then downward. If the opening does not readily admit the tube, divide the cricoid cartilage in the median line.

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