Chapter XXIX: The Larynx, Trachea, and Bronchi7

Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS:
(1) Interference with the voice: _Hoarseness_; _Aphonia_--(2)
Dysphagia--(3) Interference with respiration: _Diphtheritic
laryngitis_; _Acute oedema of the larynx_; _Intubation of the
larynx_; _Tracheotomy_; _Bilateral abductor paralysis_;
_Syphilitic affections_; _Tuberculosis_--Tumours: _Papilloma_;
_Epithelioma_; _Sarcoma_--Foreign bodies in the air-passages: _In
the pharynx_, _larynx_, _trachea_, _bronchi_.

[7] Revised by Dr. Logan Turner.

#Examination of the Larynx.#--For this purpose the examiner requires a laryngeal reflector with forehead attachment, one or two sizes of laryngeal mirror, a tongue cloth, and the means of obtaining good illumination. The source of light should be by preference placed opposite to and on the same horizontal plane as the patient's left ear. The forehead reflector is placed over the observer's right eye so that he may look through the central aperture, while at the same time he throws a good circle of light into the patient's mouth. The patient should be seated with the head thrown slightly back; the tongue is protruded and covered with the cloth, and held lightly but firmly between the finger and thumb of the left hand. A full-sized mirror, warmed so as to prevent the condensation of the breath upon it, is inserted with the reflecting surface turned downwards, and pressed gently against the soft palate so as to push that structure upwards. The handle of the instrument is carried towards the left angle of the mouth, and by slightly altering the plane of the reflecting surface of the mirror the different parts of the larynx are in turn brought into view. The movements of the vocal cords should be observed during both respiration and phonation, and for the latter purpose the patient should be directed to phonate the vowel sound "eh."

In the upper part of the mirror the epiglottis usually comes first into view: it is of a pinkish yellow colour, and presents a thin, sharply defined free margin. In front of the epiglottis are the median and lateral glosso-epiglottic folds passing forwards to the base of the tongue, and enclosing the two valleculae. Extending backwards and downwards from the lateral margins of the epiglottis are the two ary-epiglottic folds which reach the arytenoid cartilages posteriorly. Between the two layers of mucous membrane of which the ary-epiglottic folds are composed are the cartilages of Wrisberg and Santorini. In the interval between the two arytenoid cartilages is the inter-arytenoid fold of mucous membrane, which forms the upper margin of the posterior wall of the larynx. The upper aperture of the larynx is bounded by the epiglottis in front, the ary-epiglottic folds laterally, and the inter-arytenoid fold behind. In the interior of the larynx the vocal folds (true vocal cords) form the most prominent features, being conspicuous as two flat white bands, which form the boundary of the rima glottidis or glottic chink. Above each true cord, and parallel with it, the ventricular fold or false cord is evident as a pink fold of mucous membrane. Between the ventricular fold and the vocal fold on each side is a linear interval, which indicates the entrance to the ventricle of the larynx.

_Direct Laryngoscopy._--The larynx may also be examined by the direct method by means of Jackson's or Killian's spatulae. After cocainisation of the base of the tongue, the soft palate, and the posterior surface of the epiglottis, the patient is seated upon a low stool and his head supported by an assistant. The light is obtained from a small lamp in the handle of the instrument or reflected from a forehead mirror. The spatula is warmed and introduced under the guidance of the eye, its end being passed over the epiglottis, and pressure exerted so as to draw the latter structure forward. In children a general anaesthetic is required, and the examination is made with the head hanging over the end of the table. Killian's "suspension laryngoscopy" affords the best method of examining the larynx in young children.

_Tracheoscopy and Bronchoscopy._--Direct examination of the trachea and larger bronchi may be carried out in a similar way, by passing through the mouth and larynx metal tubes, after the method devised by Killian. This procedure is described as direct upper tracheoscopy and bronchoscopy. The examination may also be made through a tracheotomy wound--direct lower tracheoscopy. These procedures have proved of great service in the recognition of foreign bodies in the lower air-passages, and in their extraction; in the diagnosis of stenosis of the trachea, and of aneurysm pressing on the trachea.

CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS

The cardinal symptoms of laryngeal affections are interference with the voice and with respiration, and pain on swallowing. Laryngeal cough of a croupy or barking character may be present, and is usually associated with a lesion of the posterior wall or inter-arytenoid fold. Haemoptysis is seldom of laryngeal origin, and unless the bleeding spot is visible in the mirror, the source of the bleeding is much more likely to be in the bronchi or lungs.

#Interference with the Voice.#--_Hoarseness_ results from some affection of the vocal cords: it may be simple laryngitis, some specific cause such as tuberculosis or syphilis, or some condition which prevents the proper approximation of the cords, as in tumours and certain forms of paralysis. Huskiness of voice occurring in a middle-aged person, lasting for a considerable period, and unattended by any other local or constitutional symptom, should always arouse suspicion of malignant disease, and calls for an examination of the larynx. Should this reveal a congested condition of one vocal cord, associated with some infiltration, and should the mobility of the cord be impaired, suspicion of the malignant character of the affection is still further increased. The hoarseness in these cases is sometimes greater than the local appearances would seem to account for.

_Aphonia_, or loss of voice, sudden in origin, and sometimes transient, occurs more often in women, and is usually functional or hysterical in nature. Although the patient is unable to speak, she is quite able to cough. In these cases there is a bilateral paralysis of the adductor muscles, so that the cords do not approximate on attempted phonation; or the internal tensors may be paretic, leaving an elliptical space between the cords on attempted phonation. If the arytenoideus muscle alone is paralysed, a triangular interval is left between the cords posteriorly. There is no inflammation or other evidence of local disease.

The _treatment_ of functional aphonia should be general and local; tonics such as strychnin, iron, and arsenic should be administered; the intra-laryngeal application of electricity usually effects a sudden cure. In obstinate cases the use of the shower-bath and cold douching, the administration of chloroform, and even hypnotism may be tried.

An examination of the lungs should be made in all cases of adductor paralysis, as this functional condition may be met with in early pulmonary tuberculosis.

#Dysphagia.#--Pain on swallowing, due to causes originating in the larynx, is usually associated with ulceration of the mucous membrane covering the epiglottis, ary-epiglottic folds, or arytenoid cartilages, that is, in connection with those parts with which the food is brought into direct contact.

The most frequent causes of such ulceration are tuberculosis, syphilis, and malignant disease. The differential diagnosis is often difficult from local inspection alone. The Wasserman test, the previous history, the state of the lungs and sputum, and the results of anti-syphilitic treatment may clear it up.

The _treatment_ of dysphagia, apart from that of the disease associated with it, resolves itself into the use of local sedative applications, such as a weak cocain or eucain spray before meals, insufflations of acetate of morphin and boracic acid, and the use of a menthol spray. One of the best anaesthetic applications is orthoform powder, introduced by means of the ordinary laryngeal insufflator. Its action is more prolonged than that of any of the others, often lasting for from twenty-four to forty-eight hours.

Injection of the superior laryngeal nerve with a 60 per cent. solution of alcohol has been found satisfactory where other means have failed.

#Interference with Respiration.#--It is only necessary here to refer to such causes of interference with respiration as may call for surgical treatment.

The chief forms of _laryngitis_ to be considered in connection with the production of dyspnoea, are membranous or diphtheritic laryngitis and acute inflammatory oedema.

#Diphtheria of the larynx# is described on p. 110, Volume I.

#Acute Oedema of the Larynx.#--Oedema of the larynx may be inflammatory or non-inflammatory in origin. The former is the more common, and may arise in connection with disease of the larynx, such as tuberculosis or syphilis, or it may be secondary to acute infective conditions at the base of the tongue, or in the fauces or pharynx; more rarely it results from infective conditions of the cellular tissue or glands of the neck. The non-inflammatory form may be a local dropsy in renal or cardiac disease, may be induced by pressure on the large cervical veins, and in some cases it appears to follow the administration of potassium iodide in the treatment of laryngeal affections.

The oedema consists of an exudation into the loose submucous areolar tissue, which may be of a simple serous character or may become sero-purulent. The situations mainly involved are the glosso-epiglottic fossae between the base of the tongue and the epiglottis, the ary-epiglottic folds (Fig. 287), and the false cords. If the infective process commences in front of the epiglottis this structure becomes swollen and rigid, and often livid in colour--points which are readily discerned on examination with the mirror, or even without its aid in some cases. The patient complains of great pain on swallowing, and has the sensation of a foreign body in the throat. Should the oedema spread to the ary-epiglottic folds, either from the interior of the larynx or from the fauces and pharynx, dyspnoea becomes a prominent and grave symptom. The patient may rapidly become cyanosed, the inspirations assume a noisy, stridulous character, and great distress and imminent suffocation supervene. If laryngoscopic examination is possible, the ary-epiglottic folds may be found greatly swollen and the upper aperture of the larynx partly occluded. Digital examination may reveal the swollen condition of the parts. The urine should be examined for albumin and tube casts.

(From drawing lent by Dr. Logan Turner.)]

_Treatment._--In the milder forms, the sucking of ice, the inhalation of medicated steam, or spraying with a solution of adrenalin, and the application of poultices to the neck, may suffice to relieve the condition. Scarification of the epiglottis and ary-epiglottic folds with a knife, followed by free bleeding, may give complete relief. Diaphoretic and purgative treatment should not be neglected. If suffocation is imminent, tracheotomy or intubation is called for.

In performing #tracheotomy#, a roller pillow is placed beneath the neck to put the parts on the stretch, and an incision is carried from the lower margin of the cricoid cartilage downwards for about 2 inches. The sterno-hyoids and sterno-thyreoids are separated; the cross branch between the anterior jugular veins, and any other veins met with, secured with forceps before being divided; and the trachea exposed by dividing transversely the layer of deep fascia which passes from the cricoid to the isthmus of the thyreoid. If the isthmus cannot be pulled downwards sufficiently, it may be divided in the middle line. All active bleeding having been arrested, the larynx is steadied by inserting a sharp hook into the lower edge of the cricoid cartilage, and the trachea is opened by thrusting a short, broad-bladed knife through the exposed rings. The back of the knife should be directed downwards, and the opening in the trachea enlarged upwards sufficiently to admit the tracheotomy tube. In children it is sometimes found necessary to divide the cricoid for this purpose (_laryngo-tracheotomy_). The slit in the trachea is then opened up with a tracheal dilator, and the outer tube inserted and fixed in position with tapes. The inner tube is not fixed, so that it may be coughed out if it becomes blocked, and that it may be frequently removed and cleaned by the nurse. The tube should be discarded as soon as the patient is able to breathe by the natural channel.

_Intubation of the Larynx._--This procedure is employed as a substitute for tracheotomy, especially in children suffering from membranous and oedematous forms of laryngitis. As experience is required to carry out the manipulations successfully, and as its use is attended with certain risks which necessitate that the surgeon should be constantly within call, the operation is more adapted to hospital than to private practice. O'Dwyer's apparatus is that most generally employed. The operation consists in introducing through the glottis, by means of a specially constructed guide, a small metal or vulcanite tube furnished with a shoulder which rests against the false vocal cords. The part of the tube which passes beyond the true vocal cords is bulged to prevent it being coughed out.

In an emergency a gum-elastic catheter with a terminal aperture may be passed, as recommended by Macewen and Annandale.

#Bilateral Abductor Paralysis.#--Both recurrent nerves may be interfered with by such conditions as enlargement of the thyreoid, tumour of the oesophagus, or intra-thoracic tumour, or by injury in the course of operations for goitre. A gradually increasing inspiratory dyspnoea is developed, which at first is only noticed on exertion, when the desire for air is increased; later it becomes permanent, and even during sleep the stridor may be marked. Suffocation may become imminent. When the larynx is examined with the mirror, the vocal cords are seen to lie near each other, and on inspiration their approximation is still greater.

The _treatment_ is directed to removing the cause of pressure on the nerves. In the majority of cases tracheotomy is called for and the tube must be worn permanently.

#Syphilitic Affections of the Larynx.#--_Secondary syphilitic_ manifestations in the form of congestion of the mucous membrane, mucous patches, or condylomata, are occasionally met with, and give rise to a huskiness of the voice. These conditions usually disappear rapidly under anti-syphilitic treatment.

In _tertiary syphilis_, whether inherited or acquired, the most common lesion is a diffuse gummatous infiltration, which tends to go on to ulceration and to lead to widespread destruction of tissue. It usually attacks the epiglottis, the arytenoids, and the ary-epiglottic folds, but may spread and implicate all the structures of the larynx. Syphilitic ulcers are usually single, deep, and crateriform; the base is covered with a dirty white secretion, and the surrounding mucosa presents an angry red appearance. When the perichondrium becomes invaded, necrosis of cartilage is liable to occur.

Hoarseness, dyspnoea, and, when the epiglottis is involved, dysphagia, are the most prominent symptoms.

Cicatricial contraction leading to stenosis may ensue, and cause persistent dyspnoea.

The usual _treatment_ for tertiary syphilis is employed, but on account of the tendency of potassium iodide to increase the oedema of the larynx, this drug must at first be used with caution. Intubation or tracheotomy may be called for on account of sudden urgent dyspnoea or of increasing stenosis. The stenosis is afterwards treated by gradual dilatation with bougies, which, if a tracheotomy has been performed, may conveniently be passed from below upwards. An annular stricture causing occlusion may be excised, and the ends of the trachea sutured.

#Tuberculosis.#--The larynx is seldom the primary seat of tubercle. In the majority of cases the patient suffers from pulmonary phthisis, and the laryngeal mucous membrane is infected from the sputum. The disease may take the form of isolated nodules in the vicinity of the arytenoid cartilages, of superficial ulceration of the vocal cords and adjacent parts, or of a diffuse tuberculous infiltration of all the structures bounding the upper aperture of the larynx. The mucous membrane becomes oedematous and semi-translucent. The nodules coalesce and break down, leading to the formation of multiple superficial ulcers. The parts adjacent to the ulcers are pale in colour. Perichondritis may occur and be followed by necrosis of cartilage and the formation of abscesses in the submucous tissue of the larynx or in the cellular tissue of the neck.

The voice becomes hoarse or may be lost, there is persistent and intractable cough, and in some cases dyspnoea supervenes. When the epiglottis is involved there is pain and difficulty in swallowing.

In the presence of advanced pulmonary phthisis the treatment is chiefly palliative, but if the disease in the lungs is amenable to treatment, and the laryngeal lesion limited, the electric cautery may be used. Tracheotomy may be called for on account of urgent dyspnoea.

#Tumours.#--The commonest form of simple tumour met with in the larynx is the _papilloma_. It may occur at any age, and is comparatively common in children. It most frequently springs from the vocal cords and adjacent parts, forming a soft, pedunculated, cauliflower-like mass of a pink or red colour, which may form a fringe hanging from the edge of the cord (Fig. 288), or may spread until it nearly fills the larynx. In children, the growths are frequently multiple and show a marked tendency to recur after removal. They sometimes disappear spontaneously about puberty.

(From drawing lent by Dr. Logan Turner.)]

The most prominent symptoms are hoarseness, aphonia, and dyspnoea, which in children may be paroxysmal.

The _treatment_ consists in removing the growth by means of laryngeal forceps or the snare, under cocain and adrenalin anaesthesia. For the removal of multiple papillomata, the removal of the growths through Killian's tubes or by suspension laryngoscopy has now taken the place of the external operation in children. In a certain number of cases it has been found that the tumour disappears after the larynx has been put at rest by the operation of tracheotomy.

#Cancer.#--_Epithelioma_ of the larynx is almost always primary, and usually occurs in males between the ages of forty and seventy. It is important to distinguish between those cases in which the growth first appears in the interior of the larynx--on the vocal cords, the ventricular bands, or in the sub-glottic cavity (_intrinsic cancer_)--and those in which it attacks the epiglottis, the ary-epiglottic folds, or the posterior surface of the cricoid cartilage (_extrinsic cancer_).

_Clinical Features._--In the great majority of cases of _intrinsic_ cancer the first and for many months the only symptom is huskiness of the voice, which may go on to complete aphonia before any other symptoms manifest themselves. When the larynx is examined in an early stage, the presence of a small warty growth on the posterior part of one vocal cord, or a papillary fringe extended along the free edge of the cord, should raise the suspicion of malignancy, especially if the affected cord is congested and moves less freely than its fellow. Early diagnosis is essential in intrinsic cancer, and the absence of enlargement of lymph glands, or of foetor and cachexia, must in no way influence the surgeon against making a diagnosis of malignancy. The impaired mobility of the affected cord is an important point in determining the malignant nature of the growth.

Intrinsic cancer may spread over the upper boundaries of the larynx and become _extrinsic_, or the disease may be extrinsic from the outset.

In cases of _extrinsic_ cancer the early symptoms are much more marked, pain and difficulty in swallowing, and the secretion of frothy, blood-stained mucus being among the earliest manifestations. The cervical glands are infected early, sometimes even before there are any symptoms of laryngeal disease. Difficulty of breathing is also an early symptom on account of the growth obstructing the entrance of air. Tracheotomy may therefore be called for. In other respects the course and terminations are similar to those of intrinsic cancer.

When the growth spreads into the tissues of the neck the patient's sufferings are greatly increased. The oesophagus may be invaded with resulting dysphagia; the nerve-trunks may be pressed upon, causing intense neuralgic pains; the lymph glands become infected and break down, and the growth fungates through the skin. The general health deteriorates and death results, usually from septic pneumonia set up by the passage of food particles into the air-passages, from absorption of toxins, or from haemorrhage. The duration of this form of the disease varies from one to three years.

The _treatment_ consists in removing the growth. In early and limited forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good results; in more advanced cases the entire larynx must be removed--_complete laryngectomy_--and at the same time, or after an interval, the associated lymph glands are removed from the anterior triangle of the neck on both sides.

In cases in which excision is impracticable, the sufferings of the patient may be alleviated by performing low tracheotomy, and by feeding with the stomach tube or by nutrient enemata. In some cases the difficulty of feeding the patient may make it necessary to perform gastrostomy.

#Sarcoma# of the larynx gives rise to the same symptoms as cancer, and can seldom be diagnosed from it before operation.

#Foreign Bodies in the Air-Passages.#--Foreign bodies impacted _in the pharynx_ usually consist of unmasticated pieces of meat or large tooth-plates, and they occlude both the food and the air-passages, frequently causing sudden death. They are considered with affections of the pharynx.

The bodies most frequently impacted _in the larynx_ are small tooth-plates in the case of adults, and buttons, beads, sweets, coins, and portions of toys in children. These are drawn from the mouth into the air-passage during a sudden inspiratory effort, for example while laughing or sneezing. If the glottis is completely blocked, rapidly fatal asphyxia ensues. If the obstruction is incomplete, the patient experiences severe pain, difficulty of breathing, and a terrifying sensation of being choked. The irritation of the foreign body causes spasmodic coughing and retching, and may induce spasm of the glottis, with threatening suffocation.

Small round bodies may lodge in the upper aperture or in one of the ventricles, and give rise to hoarseness and repeated attacks of dyspnoea and spasmodic cough. Wherever the body is situated, the symptoms may suddenly become urgent from its displacement into the glottis, or from the onset of oedema. The position of the body may often be ascertained by the use of the X-rays.

_Treatment._--If the symptoms are urgent, laryngotomy, which consists in opening the larynx below the glottis by dividing the crico-thyreoid membrane, or tracheotomy must be performed at once, and an attempt made to remove the foreign body thereafter. In less severe cases in adults, the throat should be sprayed with cocain, and the larynx examined with the mirror; in children, the direct method must be employed. In both instances an attempt should be made to extract the body by the direct method. As these manipulations are liable to induce sudden spasm of the glottis, the means of performing tracheotomy must be at hand. If it is found impossible to remove the body through the mouth, laryngotomy or tracheotomy should be performed, and the body extracted through the wound, or pushed up into the pharynx and removed by this route. In the case of small bodies, a strand of gauze pushed up from the tracheotomy wound, through the larynx and out of the mouth, catches the foreign body and carries it out (Walker Downie).

The foreign bodies that are most likely to become impacted _in the trachea_ are tooth-plates with projecting hooks, and small coins. The position of the foreign body may be ascertained by the use of Killian's tracheoscope, or by means of the X-rays. If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspnoea.

Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. One of Killian's tracheal tubes may be introduced through the tracheotomy wound and the body extracted by means of suitable forceps.

_Foreign Bodies in the Bronchi._--Rounded objects, which pass through the larynx, usually drop into one or other of the bronchi, usually the right, which is the more vertical and slightly the larger. The body may act as a ball-valve, permitting the escape of air with expiration, but preventing its entrance on inspiration, with the result that the portion of lung supplied by the bronchus becomes collapsed. The physical signs of collapse of a portion or of the whole lung may be recognised on examination of the chest. In some cases the body is dislodged and driven up into the larynx, causing severe dyspnoeic attacks and spasms of coughing. The irritation caused by the foreign body in the bronchus may set up bronchitis or pneumonia, and abscess of the lung may supervene. This has frequently followed the entrance of an extracted tooth into the air-passage, and it may be a considerable time before pulmonary symptoms arise. Sometimes the tooth is ultimately coughed up and the symptoms disappear. In some cases the physical signs closely simulate those of pulmonary phthisis.

The _treatment_ consists in removing the body by the aid of Killian's or Jackson's tube passed through the mouth. If this is not successful, low tracheotomy is performed and the tube is passed through the tracheotomy opening.

INDEX

Abducens nerve, 400

Abductor paralysis, 404, 639
splint, 221

Abscess. _See_ Individual Organs and Regions

Accessory nasal sinuses. _See_ Individual Sinuses
nerve, 404

Acetabulum, fracture of, 125
tuberculous disease of, 210
wandering, 210, 227

Achillo-bursitis, 294

Acoustic nerve, 579

Acromion process, fracture of, 69

Actinomycosis. _See_ Individual Organs and Regions

Adenoids, 578

Alveolar abscess, 507
process, fracture of, 519
tumours of, 513

Ambulant splint for ankle, 189
treatment of hip disease, 222

Amputation in compound fracture, 26

Anatomy. _See_ Surgical Anatomy

Angina Ludovici, 548, 597

Ankle, deformities of, 273
diseases of, 238, 240
dislocations of, 194
fractures in region of, 186, 187
injuries in region of, 185
surgical anatomy of, 185
tuberculous disease of, 238

Ankylosis of joints. _See_ Individual Joints

Anosmia, 399, 578

Anterior poliomyelitis, 242

Aphasia, 335

Aphonia, 636

Arm, upper, injuries of, 44

Arthritis. _See also_ Individual Joints

Arthritis, septic, 34

Arthrodesis, 246

Astragalus. _See_ Talus

Athetosis, 247

Atlo-axoid disease, 440
joint, fracture-dislocation of, 430

Auditory nerve, 403

Aural polypi, 558
vertigo, 555

Auricular appendages, 560

Avulsion of scalp, 322

Balkan frame splint, 150

Basedow's disease, 614

Bell's paralysis, 401

Bennett's fracture, 116

Bezold's mastoiditis, 566

Bier's constricting bandage, 12, 26

Black eye, 370, 484

Blepharospasm, 403

Bones, atrophy of, 2
contusion of, 1
fracture of, 1
gun-shot injuries of, 27
injuries of, 1
repair of, 8
wounds of, 1

Bow-knee, 271
-leg, 271

Box splint, 182

Brachial plexus, lesions of, 597

Brachio-thoracic triangle, 470

Bradford frame, 438

Brain, abscess of, 360, 374, 376, 378, 382
localisation of, 380
adhesions, 358
cerebral irritation, 342, 346
compression of, 347
differential diagnosis of, 350
concussion of, 341, 344
contusion of, 342
cyst of, haemorrhagic, 344
decompression operations on, 396
diseases of, 373
pyogenic, 373
foreign bodies in, 350
functions of, 331
haemorrhage into, 352
hernia of, 397
injuries of, 341
mechanism of, 343
repair of, 344
irritation of, 342, 346
laceration of, 342
lesions of, 341
localisation of centres in, 336
membranes of, 328
diseases of, 372
motor area of, 330
sclerosis of, 358
sensory mechanism of, 332
softening of, 342
surgical anatomy of, 328
syphilitic gumma, 395
traumatic oedema of, 343, 352
tuberculosis of, 395
tumours of, 393
localisation of, 394
wounds of, 357

Branchial carcinoma, 601
cysts, 598
fistulae, 585

Broken back, 427

Bronchi, foreign bodies in, 644

Bronchocele. _See_ Goitre, 605

Bronchoscopy, 635

Bryant's triangle, 129

Bunion, 296

Cachexia strumipriva, 610

Calcaneus, fracture of, 193
separation of, tuberosity of, 193
spurs on, 294

Callipers, ice-tong, 165

Callus, absorption of, 10
excess of, 9
tumours of, 10
varieties of, 8

Cancrum oris, 497

Capitate bone, dislocation of, 114

Carcinoma. _See_ Cancer

Cardiospasm, 624

Carotid artery, internal, injuries of, 356
gland, tumours of, 603

Carpal bones, dislocation of, 113
fracture of, 110

Carpo-metacarpal dislocations, 115

Cauda equina, injuries of, 419

Caudal appendage, 458, 459

Cavernous sinus, phlebitis of, 386

Cellulitis. _See_ Individual Regions

Cephal-hydrocele, 321
traumatic, 390

Cephaloceles, 387

Cerebello-pontine angle, tumours of, 394

Cerebellum, abscess of, 381
tumours of, 394

Cerebral abscess, 360
apoplexy, 351
centres, 334
embolism, 351
hyperpyrexia, 348
irritation, 342, 346
localisation, 336
oedema, 352
palsies of childhood, 247
shock, 341, 344
softening, 358
tumours, 393
vomiting, 377

Cerebro-spinal fluid, 329, 339
meningitis, 378

Cerebrum. _See_ Brain

Cerumen in ear, 561

Cervical auricles, 583
caries, 440
fascia, 583
ribs, 585
sympathetic, 405, 615

Charcot's disease of hip, 228

Chauffeur's fracture, 106

Cheilotomy, 228

Chiene's test, 129

Cilio-spinal reflex, 405

Cirsoid aneurysm of scalp, 326

Clavicle, absence of, 303
dislocations of, 49
fracture of, 45

Cleft palate, 475, 477

Club-foot, 273

Club-hand, 311, 312

Coccydynia, 127, 450

Coccyx, fracture of, 127

Cock-up splint, 77

Coin-catcher, 622

Colles' fracture, 102
reversed, 106
unreduced, 106

Compound dislocation, 40

Compression of brain, 347

Compression fracture of spine, 426

Concussion of brain, 344
of spinal cord, 413

Congenital deformities, 241. _See_ Individual Regions
dislocation, 43. _See_ Individual Joints

Conus medullaris, injuries of, 419

Coracoid process, fracture of, 69
separation of epiphysis of, 70

Coronoid process, fracture of, 87

Coxa valga, 256, 261
vara, 136, 256, 257

Cranial nerves, affections of, 398. _See_ Individual Nerves

Cranium. _See_ Skull

Crepitus in fracture, 15, 30

Cricoid cartilage, fracture of, 593

Crossed-leg deformity, 224, 257

Cruciate ligaments, rupture of, 171

Cubitus valgus, 84, 308
varus, 84, 310

Cut-throat, 593

Deafness, varieties of, 553

Decompression of brain, 396

Deep sensibility, 332

Deformities of extremities, 241. _See_ Individual Regions

Dental caries, 507
ulcer of tongue, 529

Dentigerous cysts, 517

Diplacusis, 554

Dislocation. _See also_ Individual Joints and Bones
compound, 40
congenital, 43
by elongation, 96
with fracture, 40
habitual, 43, 65
old-standing, 40, 65
pathological, 43
recurrent, 43
traumatic, 36
varieties of, 37

Displacement of semilunar menisci, 168

Dorsal abscess, 444

Drop-finger, 318
wrist, 76, 311

Dugas' symptom in dislocation of shoulder, 54, 55

Dupuytren's contraction, 314
fracture, 187, 188, 196
splint, 190

Dysphagia, 623, 636

Ear, 553. _See also_ Tympanic membrane

Ear, aspergillus in, 562
boils, 562
cardinal symptoms of disease of, 554
deafness, 553, 554
deformities of, 560
discharge from, 555
earache, 554
eczema of, 562
foreign bodies in, 563
furunculosis of, 562
hearing tests, 555
inspection of, 556
middle, acute infection of, 564
chronic suppuration in, 565
inflation of, 558
noises in, 554
otorrhoea, 555
outstanding, 560
pain in, 554
physiology of, 553
polypi, 558
rupture of membrane of, 563
syringing of, 561
surgical anatomy of, 553
tumours of, 560
vertigo, 555
wax in, 561

Earache, 554

Ectropion, 483

Elbow, ankylosis of, 208
arthritis deformans of, 208
diseases of, 205
dislocations, congenital, 308
paralytic, 308
traumatic, 88, 92
examination of, 80
injuries in region of, 79
neuro-arthropathies of, 208
pyogenic diseases of, 208
sprain of, 96
surgical anatomy of, 79
tennis player's, 97
tuberculous disease of, 206

Empyema of knee, 232

Encephalitis, 376, 377

Encephalocele, 388, 389

Epicritic sensibility, 332

Epilepsy, 397
Jacksonian, 359
traumatic, 358

Epiphyses, separation of. _See_ Individual Bones

Epistaxis, 575

Epulis, 513

Ethmoidal cells, suppuration in, 577, 578

Eustachian catheter, 558

Extension by Hodgen's splint, 151, 159
by ice-tong callipers, 150, 158
by perineal band, 152
by Steinmann's apparatus, 150
vertical, 154
by weight and pulley, 220

Extra-dural abscess, 374

Eyeball, injuries of, 486

Eyelids, wounds of, 484

Face, cicatricial contraction of, 483
congenital malformations of, 474, 481
development of, 474
diseases of, 483
epithelioma of, 484
frog-, 581
injuries of, 482
rodent cancer of, 484
tumours of, 484

Facial cleft, 481
nerve, 400
paralysis, 400
spasm, 403

Facio-hypoglossal anastomosis, 403

False joint, 12

Fat embolism in fractures, 19

Femur, fracture of, in children, 135, 154
of condyles of, 162
of greater trochanter of, 139
of head of, 129
just below lesser trochanter of, 139
of lower end of, 157
of neck of, 130
of shaft of, 148
of upper end of, 129
incurvation of neck of, 257
separation of epiphyses of, 129, 139, 161

Fibula, absence of, 272
dislocation of, total, 167
fracture of, 165, 178, 183

Fingers, congenital contraction of, 313
deficiencies, 317
deformities of, 313
dislocation of, 121
drop-, 121, 318
Dupuytren's contraction of, 314
fractures of, 115
hypertrophy of, 317
injuries of, 115
mallet, 121, 318
supernumerary, 316
trigger, 318
webbed, 317

Flat-foot, 285
adolescent, 287
degrees of, 291
exercises for, 291
paralytic, 292
spasmodic, 292
static, 287
traumatic, 293
varieties of, 287, 294

Foerster's operation, 247

Foot, club-, 273
deformities of, 273
flat-, 285
hollow claw-, 284
injuries of, 185
movements of, 185
splay-, 285
surgical anatomy of, 185

Foot and mouth disease, 530

Footballer's knee, 172

Forearm, deformities of, 310
fracture of both bones of, 97
injuries of, 79
intra-uterine amputation of, 311

Fracture, 1. _See also_ Individual Bones
amputation in, 26
badly united, 10
Bennett's, 116
during birth, 3
chauffeur's, 106
clinical varieties of, 4
Colles', 102
comminuted, 6
complications of, 18
compound, 5, 24
crepitus in, 15
deformity in, 15
delayed union, 11
depressed, 5, 7
with dislocation, 40
displacement of fragments in, 7
Dupuytren's, 196
extension in, 26
fat embolism in, 19
fever in, 18
fibrous union of, 12
fissured, 5
greenstick, 5, 98
gun-shot, 27
indentation, 5
intra-uterine, 3
Jones', 194
longitudinal, 6
mal-union of, 10, 99, 183
massage in, 21
mechanism of, 14
multiple, 6
non-union, 9, 12
oblique, 6
old-standing, 87
open, 5
operation in, 24
pain in, 17
passive hyperaemia in, 12
pathological, 1
prognosis in, 19, 25
radiography in, 16
reduction of, 20
repair of, 8
retention of, 21
setting of, 20
shock in, 18
simple, 4, 8, 14, 19, 24
Smith's, 106
spiral, 6
splints in, 22
sprain-, 35
subcutaneous, 4
sub-periosteal, 6
transverse, 6
traumatic, 3
treatment of, 20, 25
un-united, 12, 78, 100, 101, 183
varieties of, 4
violence, forms of, causing, 3
X-rays in, 16

Frog-face, 581

Frontal sinus, suppuration in, 577

Gampsodactyly, 302

Genu recurvatum, 263
valgum, 264, 265
varum, 264, 271

Gingivitis, 508

Girdle-pain, 419

Glands, lymph. _See_ Lymph Glands

Globus hystericus, 624

Glomus carotica, tumours of, 603

Glossitis, 530, 533

Glosso-pharyngeal nerve, 403

Goitre, 605
adenomatous, 610
colloid, 607
cystic, 607
exophthalmic, 614
fibrous, 607
intra-thoracic, 607, 609, 613
malignant, 612
non-toxic, 605
parenchymatous, 605
retro-sternal, 607, 609, 613
sudden dyspnoea in, 608-610
thyreoidectomy for, 610
toxic, 614
vascular, 607

Gooch's splinting, 22

Graefe's symptom, 614

Graves' disease, 614

Gravitation paraplegia, 414

Greenstick fracture, 5

Gumboil, 507

Gums, affections of, 508

Gun-shot injuries. _See_ Individual Structures

Habitual dislocation, 43

Haemarthrosis, 33

Haematoma auris, 560
of periosteum, 1

Haematomyelia, 414

Haematorrachis, 414

Hallux dolorosus, 298
flexus, 298
rigidus, 298
valgus, 296
varus, 298

Hammer nose, 570
toe, 300

_Hanche a ressort_, 254

Hand, club-, 311, 312
deformities of, 310
injuries of, 102
surgical anatomy of, 102

Hare-lip, 475

Head injuries, 340
after-effects of, 358

Hearing, impairment of, 554
tests of, 555

Heel, painful affections of, 294

Hemianopia, 335

Hemi-glossitis, 530

Hernia cerebri, 397

Hiatal oesophagismus, 624

Hip, ankylosis of, 256
arthritis deformans of, 226
Charcot's disease of, 228
contractures of, 256
contusion of, 147
disease, 209
dislocations, congenital, 248
old-standing, 147
varieties of, 126, 142
examination of, 128, 211
hysterical, 229
injuries in region of, 127
loose bodies in, 229
neuro-arthropathies of, 228
osteo-chondritis deformans juvenilis, 228
paralytic deformities of, 255
Perthes' disease of, 228
pyogenic diseases of, 224
snapping, 254
sprain of, 147
surgical anatomy of, 128
Thomas' splint for, 222
tuberculous disease of, 210
abscess formation in, 217
bilateral, 224
deformities following, 223
diagnosis of, 218
dislocation in, 218
stages of, 211
treatment of, 220

Histrionic spasm, 403

Hoarseness, 635

Hodgen's splint, 151

Hollow claw-foot, 284

Homonymous hemianopia, 335

Hospital throat, 500

Humerus, fracture, of anatomical neck, 74
of condyles, 80
with dislocation of shoulder, 63
of head, 70
of lower end, 84
of shaft, 75
of surgical neck, 70
of tuberosities, 74
un-united, 78
separation of lower epiphysis of, 82, 84
of upper epiphysis of, 73

Hunch-back, 440, 444

Hydrencephalocele, 388, 389

Hydrocele of neck, 599

Hydrocephalus, 391
acute, 386, 391
chronic, 391

Hygroma of neck, 599
sacral, 459

Hyoid bone, fracture of, 593

Hyperaesthesia acustica, 554

Hyperpituitarism, 396

Hyper-thyreoidism, 609, 614

Hypoglossal nerve, 404

Hypophysis cerebri, tumours of, 396

Hypopituitarism, 396

Hysterical aphonia, 636
spine, 448
wry-neck, 592

Ice-tong callipers, 150

Iliac abscess, 445, 446

Ilium, fracture of, 126

Infantile paralysis, 242

Injuries. _See_ Individual Regions

Internal derangements of knee-joint, 168

Inter-phalangeal dislocation, 200

Intra-cranial haemorrhage, 352
in newly born, 356
syphilis, 387, 395
tuberculosis, 386
venous sinuses, injuries of, 356

Intra-uterine amputation, 311

Intubation of larynx, 639
of oesophagus, 632

Ischaemic contracture of muscles, 85, 98, 310

Ischium, fracture of, 127

Jacksonian epilepsy, 359, 394

Jaw, lower. _See_ Mandible
upper. _See_ Maxilla
_See also_ Temporo-mandibular Joint

Joints. _See also_ Individual Joints
Charcot's disease of, 228, 238
contusions of, 33
dislocations of, 36
false, 12
gun-shot injuries of, 34
injuries of, 32
sources of strength of, 32
sprains of, 35
wounds of, 34

Jones' fracture of fifth metatarsal, 194

Kernig's sign, 386

Klapp's four-footed exercises for scoliosis, 472

Knee, ankylosis of, 264
arthritis deformans of, 237
bow-, 271
Charcot's disease of, 238
cold abscess of, 234
contracture of, 264
deformities of, 236, 264
diseases of, 229
pyogenic, 237
tuberculous, 231
dislocations of, 165
congenital, 262
empyema of, 232
footballer's, 172
genu-recurvatum, 263
valgum, 265
varum, 271
hydrops of, 172
hysterical diseases of, 238
injuries in region of, 155
injuries of semilunar menisci, 167
internal derangement of, 168
knock-, 265
loose bodies in, 238
rugby, 165
rupture of cruciate ligaments of, 171
sprains of, 171
surgical anatomy of, 155
tuberculous disease of, 231
clinical types of, 231
deformities following, 236
extra-articular abscess in, 234
white swelling of, 233

Knock-knee, 265

Kocher's method of reducing dislocation of shoulder, 58

Kyphosis, 461, 462

Laryngitis, 637

Laryngoscopy, 635

Larynx, cancer of, 641
cardinal symptoms of affections of, 635
diphtheria of, 637
examination of, 634
foreign bodies in, 642
fracture of, 593
inflammation of, 637
intubation of, 639
oedema of, 637
paralysis of, 639
surgical anatomy of, 634
syphilis of, 639
tuberculosis of, 640
tumours of, 640
wounds of, 594

Laryngo-tracheotomy, 638

Lateral curvature of spine, 463
sinus. _See_ Transverse Sinus
ventricles, bursting of abscess into, 381
haemorrhage into, 342

Leg, bow-, 271
fracture of bones of, 178
congenital deficiencies of, 272
injuries of, 155
rickety deformities of, 271

Lepto-meningitis, 376

Leucokeratosis, 530

Leucoplakia, 530

Ligaments, cruciate, rupture of, 171

Lingual dermoids, 537

Lip, chancre of, 491
chronic induration of, 491
cracks of, 491
cysts of, 493
double-lip, 491
epithelioma of, 493
fistulae of, 482
hare-lip, 475
herpes of, 490
lymphangioma of, 492
macrocheilia, 492
mucous cysts of, 493
strumous, 491
syphilis of, 491
tuberculosis of, 491
tumours of, 492
ulcers of, 491

Lipoma nasi, 570

Liston's long splint, 152

Little's disease, 247, 357

Longitudinal sinus, phlebitis of, 385

Lordosis, 461

Ludwig's angina, 548, 597

Lumbar abscess, 445
puncture, 338

Lunate bone, dislocation of, 114
fracture of, 110

Luxation. _See_ Dislocation

Lymphangiomatous macroglossia, 540

Macrocheilia, 492

Macroglossia, 540

Macrostoma, 481

Madelung's deformity of wrist, 313

Malar bone. _See_ Zygomatic Bone

Malformations. _See_ Individual Regions

Mallet finger, 318

Mandible, actinomycosis of, 512
cleft of, 481
dentigerous cyst of, 517
dislocation of, 523
old-standing, 524
fixation of, 526
tumours of, 517

Manus valga, 109, 313
vara, 313

Massage in fractures, 21

Mastoid, suppuration in, 566

Maxilla, affections of, 510
fracture of, 519
tumours of, 514

Maxillary sinus, suppuration in, 577

Meninges, surgical anatomy of, 328

Meningitis, 360, 374
basal, 377
cerebro-spinal, 378
serous, 377
spinal, acute, 453
chronic, 452
tuberculous, 433
syphilitic, 387
tuberculous, 386

Meningocele, 388
spinal, 454

Meningo-encephalitis, 376

Meningo-myelocele, 454

Mercurial gingivitis, 508
glossitis, 530

Metacarpals, fracture of, 115, 116

Metatarsals, diseases of, 240
fracture of, 194

Metatarsalgia, 295

Micrencephaly, 393

Microstoma, 481

Middeldorpf's splint, 72

Middle-ear disease, cerebral abscess due to, 378

Middle meningeal haemorrhage, 352

Mid-tarsal dislocation, 199

Miller's method of reducing dislocation of shoulder, 60

Mobile semilunar meniscus, 168

Morbus coxae, 210

Morton's disease, 295

Motor areas, 330
tracts, 331

Mouth, affections of, 496
floor of, 499
roof of, 498

Mumps, 546

Musculo-spiral nerve. _See_ Radial Nerve

Myelitis, compression, 453
haemorrhagic, 453
spinal, 453
syphilitic, 453
tuberculous, 433

Myelocele, 455

Myxoedema, post-operative, 610

Nasal affections. _See_ Nose
bones, fracture of, 567
ducts, injuries of, 567

Naso-pharynx, affections of, 567
tumours of, 580

Navicular bone, dislocation of, 115
fracture of, 110, 194

Neck, actinomycosis of, 598
boils of, 598
branchial carcinoma, 160
bursal swellings in, 599
carbuncles of, 598
cellulitis of, 597
cervical auricles, 583
fascia, 583
ribs, 585
cicatricial contraction of, 592
contusion of, 592
cystic lymphangioma of, 599
cysts of, 598
blood, 599
branchial, 598
bursal, 599
dermoid, 598
fistulae of, 584, 585
hydrocele of, 599
hygroma of, 599
injuries of, 592
malformations of, 583
paraffin epithelioma of, 602
potato-like tumour of, 603
stiff, 587
surgical anatomy of, 582
thyreo-glossal cysts in, 538
tumours of, 598, 599
wounds of, 593
wry-, 587

Nelaton's line, 129

Nerve anastomosis, 246

Nerve roots, injuries of, 420

Neuralgia, trigeminal, 400

Neuro-arthropathies. _See_ Individual Joints

Neurone lesions, 334

Node, traumatic, 1

Nose, adenoids, 578
anomalies of smell, 578
artificial, 570
asthma, reflex, 578
bleeding from, 575
carcinoma of, 573
cardinal symptoms of nasal affections, 571
concretions in, 575
deformities of, 568
discharge from, 574
displacement of cartilages of, 567
emphysema of, 568
erectile swelling of, 572
examination of, 570
foreign bodies in, 574, 576
fracture of, 567
hammer, 570
lipoma nasi, 570
obstruction of, 572
ozaena, 575
polypi of, 573
potato, 570
reflex symptoms, 578
rhinitis, 575
rhinoliths, 575
rhinophyma, 570
saddle, 567, 568
sarcoma of, 580
septum of, deviations, 573
haematoma, 573
ridges, 573
spines, 573
sunken-bridge, 568
suppuration in accessory sinuses, 576
swelling of turbinated bones, 572
traumatic saddle, 567

Nystagmus, labyrinthine, 555

Oculo-motor nerve, 399

Odontoid process, fracture of, 430

Odontoma, 517

Oedema glottidis, 637

Oesophagismus, hiatal, 624

Oesophagitis, 623

Oesophagoscopy, 617

Oesophagospasm, 624

Oesophagus, carcinoma of, 629, 631
cicatricial contraction of, 628
compression of, 624
dilatation of, 625
diverticula of, 625
examination of, 616
foreign bodies in, 619, 621, 623
inflammation of, 623
intubation of, 632
paralysis of, 625
rupture of, 618
spasm of, 624
stricture of, cicatricial, 628
malignant, 629
spasmodic, 624
surgical anatomy of, 616
swallowing of corrosive substances, 618
syphilis of, 623
tuberculosis of, 623
tumours of, 629
varix of, 623
wounds of, 618
X-ray examination of, 617

Old-standing dislocations, 40. _See also_ Individual Joints

Olecranon, fracture of, 85
separation of epiphysis of, 87

Olfactory nerve, 399

Ophthalmia, sympathetic, 487

Ophthalmoplegia externa, 400

Optic nerve, 399

Orbit, aneurysms of, 490
cellulitis of, 487
contusions of, 484
emphysema of, 486
eyeball, injuries of, 486
foreign bodies in, 485
fractures of, 485
injuries of, 484
tumours of, 487
wounds of, 485

Os magnum. _See_ Capitate Bone

Osteo-chondritis deformans juvenilis, 228

Os trigonum tarsi, 193

Otitis media, 564

Otorrhoea, 555

Ozaena, 575

Pachymeningitis, 374, 433

Palate, affections of, 498
cleft, 477

Palmar fascia, Dupuytren's contraction of, 314

Panophthalmitis, 487

Paracusis of Willis, 554

Paralysis, abductor, 404, 639
Bell's, 401
conjugate, 335
crossed, 334
facial, 400
infantile, 242
spastic, 247
of sterno-mastoid, 404
of tongue, 542
of trapezius, 404

Paraplegia dolorosa, 448
gravitation, 414
spastic, 451

Para-thyreoid glands, 604

Parosmia, 578

Parotid, carcinoma of, 552
duct, affections of, 544
fistula, 544
inflammation of, 545
injuries of, 543
mixed tumours of, 549
recurrent enlargement of, 547
sarcoma of, 552
surgical anatomy of, 543
tuberculosis of, 549
tumours of, 549

Parotitis, 545, 547

Patella, absence of, 262
dislocation of, 177
congenital, 262
floating, 171, 229
fracture of, 173
injuries of, 173

Patheticus nerve, 400

Pathological dislocation, 43
fracture, 1

Pelvis, fractures of, 122
injuries of, 122

Periodontitis, 507

Peri-oesophagitis, 623

Periosteum, haematoma of, 1

Peri-tonsillitis, 501

Perthes' disease, 228

Pes arcuatus, 273, 284
calcaneo-valgus, 273, 282, 284
calcaneo-varus, 273, 282, 284
calcaneus, 273, 282
cavus, 273, 282, 283, 284
equinus, 273, 280
excavatus, 284
planus, 285, 287
transverso-planus, 294
valgus, 273, 285, 287
varus, 280

Phalanges of fingers, injuries of, 119, 121
of toes, injuries of, 194, 200

Pharyngeal dimple, 626

Pharyngitis, varieties of, 500

Pharynx, affections of, 500, 619
foreign bodies in, 619, 642
tumours of, 504

Phlebitis. _See_ Individual Vessels

Phosphorus necrosis of jaw, 510

Pigeon-toe, 298

Pituitary body, tumours of, 396

Plaster-of-Paris splints, 23

Pneumatocele capitis, 326

Pneumogastric nerve, 403

Poliomyelitis, anterior, 242

Politzer's inflation of middle ear, 558

Polydactylism, 303, 316

Polypi. _See_ Individual Organs

Poroplastic felt, 23

Post-anal dimple, 459

Posterior nerve roots, resection of, 247

Post-nasal obstruction, 578

Pott's disease of spine, 431
fracture, 186
with inversion, 191
puffy tumour, 375, 406

Premaxillary bone, 474

Protopathic sensibility, 332

Pseudarthrosis, 12

Psoas abscess, 445

Pubes, fracture of, 123

Pulpitis, 507

Pyorrhoea alveolaris, 509

Quinsy, 501

Radial nerve, implicated in fracture of humerus, 76

Radio-carpal joint, dislocation of, 112

Radio-ulnar joint, inferior, dislocation of, 112
superior, synostosis of, 310

Radius, absence of, 310
avulsion of tubercle of, 88
dislocation of, 94
fracture of lower end, 102
of shaft, 100
of tubercle, 88
of upper end, 88
separation of epiphyses, 88, 109, 110
subluxation of, 96

Railway spine, 422

Ranula, 549

Recurrent dislocation, 43

Reduction of dislocations. _See_ Individual Joints

Retro-pharyngeal abscess, 441, 442, 505

Rhinitis, 575

Rhinoliths, 575

Rhinophyma, 570

Rhinoscopy, 570, 571

Rib hump, 466

Ribs, cervical, 585

Round shoulders, 462

Rugby knee, 165

Sacral hygroma, 459

Sacro-coccygeal fistulae, 459
sinuses, 459
tumours, 459

Sacro-iliac joint, tuberculosis of, 446

Sacrum, fracture of, 127

Saddle nose, 567, 568

Salivary calculi, 545
fistulae, 544
glands. _See_ Parotid, Submaxillary, Sublingual
Mikulicz's disease of, 547
recurrent enlargement of, 547
surgical anatomy of, 543
tuberculosis of, 548
tumours of, 549

Scalp, abscess of, 323
air-containing swellings of, 326
aneurysms of, 326
avulsion of, 322
cellulitis of, 322, 406
cirsoid aneurysm of, 326
contusion of, 320
cysts of, 323
dangerous area of, 321
diseases of, 323
emphysema of, 326
erysipelas of, 323
haematoma of, 320, 366
infective conditions of, 323
injuries of, 320
lupus of, 323
pneumatocele of, 326
surgical anatomy of, 319
tumours of, 324
wounds of, 321
complications of, 322

Scaphoid. _See_ Navicular

Scapula, congenital elevation of, 303
displacements of, 303, 306
fracture of, 67
separation of epiphyses of, 69, 70
winged, 306

Schlatter's disease, 165

Scissors-leg deformity, 224, 257

Scoliosis, of adolescents, 465
congenital, 465
exercises for, 472
habitual, 465
paralytic, 464
postural, 465
rickety, 464
static, 463

Sculler's sprain, 97

Semilunar menisci of knee, injuries of, 167

Sensation, varieties of, 332

Separation of bony processes, 6
of epiphyses. _See_ Individual Bones

Shock, cerebral, 341, 344

Shoulder, ankylosis of, 204
arthritis deformans of, 203
contusion of, 66
diseases of, 201
deformities of, paralytic, 308
dislocation of, with fracture of humerus, 63
dislocation of, 52
congenital, 306
old-standing, 65
paralytic, 308
recurrent or habitual, 65
varieties, 53
examination of, 44
injuries of, 44
loose bodies in, 204
neuro-arthropathies of, 203
pyogenic diseases of, 203
sprain of, 66
Sprengel's, 303
surgical anatomy of, 44
tuberculosis of, 201

Sigmoid sinus, phlebitis of, 384

Sinus phlebitis, 383
thrombosis, 360

Skull, contusion of, 361
diseases of, 406
fracture of, 361
base, 367
anterior fossa, 369
middle fossa, 370
posterior fossa, 371
comminuted, 364
compound infected, 382
by _contre-coup_, 362
depressed, 364
fissured, 363
gutter, 364
indentation, 364
pond, 364
punctured, 364
vault, 361
injuries of, 360
necrosis of, 406, 407
osteomyelitis of, 406
periostitis of, 406
surgical anatomy of, 328
syphilis of, 407
tuberculosis of, 407
tumours of, 407

Smell, anomalies of, 399, 578

Smith's fracture of radius, 106

Smoker's patch on tongue, 532

Snapping hip, 254

Sore throat, varieties of, 500

Spastic paralysis, 247
paraplegia, 451

Speech centres, 335

Sphenoidal cells, suppuration in, 578

Spina bifida, 453
occulta, 457

Spinal accessory nerve, 404

Spinal cord, concussion of, 413
diseases of, 431
functions of, 331, 412
haemorrhage into, 413
injuries of, 413
at different levels, 416
localisation of, lesions in, 410, 412
membranes of, 412
partial lesions of, 420
in Pott's disease, 433
reflex centres in, 412
segments of, 412
surgical anatomy of, 411
total transverse lesions of, 415
tuberculosis of, 433
tumours of, 450
haemorrhage, 413

Spine, railway, 422

Splay-foot, 285

Splints, 22
abduction; for hip, 221
frame, for arm, 72
ambulant, for ankle, 189
Balkan frame, 150
box, 182
Bradford frame, 438
"cock-up," 77
for Colles' fracture, 106
Dupuytren's, 190
Hodgen's, 151
Liston's long, 152
Middeldorpf's, 72
Syme's stirrup, 190
Taylor's, for hip, 222
Thomas', arm, 72
double, 439
hip, 222
knee, 149, 159, 235
wheel-barrow, 439

Spondylitis, traumatic, 427

Sprains of joints, 35
fracture, 35, 171
sculler's, 97

Sprengel's shoulder, 303

Status lymphaticus, 602

Steinmann's apparatus, 150

Stenson's duct, 543

Sterno-mastoid, haematoma of, 588

Stomatitis, varieties of, 496

Subclavicular dislocation of shoulder, 62

Sub-conjunctival ecchymosis, 369

Sub-coracoid dislocation of shoulder, 54

Subdural abscess, 376

Sub-glenoid dislocation of shoulder, 62

Subgluteal abscess, 446

Sublingual gland, inflammation of, 548
ranula of, 549
surgical anatomy of, 543
tumours of, 552

Submaxillary gland, calculi of, 545
inflammation of, 548
peri-adenitis of, 548
recurrent enlargement of, 547
surgical anatomy of, 543
tuberculosis of, 549
tumours of, 552

Subspinous dislocation of shoulder, 62

Sub-taloid dislocation, 198

Superior sagittal sinus, phlebitis of, 385

Supernumerary fingers, 316
toes, 303

Surgical anatomy, of ankle, 185
of brain, 328
of ear, 553
of elbow, 79
of forearm, 79
of foot, 185
of hip, 128
of knee, 155
of meninges, 328
of neck, 582
of oesophagus, 616
of parotid gland, 543
of salivary glands, 543
of scalp, 319, 328
of shoulder, 44
of sublingual gland, 543
of submaxillary gland, 543
of thymus gland, 582
of thyreoid gland, 604
of tongue, 528
of tympanic membrane, 557
of vertebral column, 411
of wrist, 102

Swallowing, difficulty in, 623, 636
pain in, 623, 636

Syme's stirrup splint, 190

Symonds' tube, 632

Symphysis pubis, separation of, 122

Syndactylism, 303, 317

Synovitis, septic, 34

Syphilis. _See_ Individual Organs

Syringo-myelocele, 455

Tail-like appendage, 458, 459

Talipes equino-varus. _See also_ Pes
acquired, 279
congenital, 274

Talus, dislocation of, 196
fracture of, 192

Tarso-metatarsal dislocation, 200

Tarsus, diseases of, 240
dislocations of, 196
fractures of, 192
tuberculosis of, 240

Taste, anomalies of, 578

Taylor's splint for hip, 222

Temporal abscess, 380

Temporo-mandibular joint,
arthritis of, 525
arthritis deformans of, 525
dislocation of, 523
fixation of, 525
internal derangements of, 524
suppuration in, 525
tuberculosis of, 525

Tendons, lengthening of, 248
transplantation of, 245

Tennis elbow, 97

Tetany, 610

Thomas' flexion test for hip disease, 215
splints, 72, 149, 159, 222, 235, 439

Thoracic duct, 597

Throat, hospital, 500

Thrush, 496

Thumb, dislocation of, 119
fracture of, 116
stave of, 116

Thymic asthma, 603

Thymus death, 603
gland, affections of, 602
surgical anatomy of, 582
stenosis, 602

Thyreo-glossal cysts, 538, 583, 599
fistulae, 538, 583
tumours, 538

Thyreoid cartilage, fracture of, 593
gland. _See also_ Goitre
accessory, 604
adenoma of, 610
carcinoma of, 281
goitre, 605. _See also_ Goitre
inflammation of, 605
malignant, 612
physiological hyperaemia of, 604
sarcoma of, 281
surgical anatomy of, 604
syphilis of, 605
tuberculosis of, 605

Thyreoidectomy, 610

Thyreoidism, acute, 610

Thyreoiditis, 605

Thyreotoxicosis, 614

Tibia, absence of, 272
fracture of, 183
upper end of, 162
head of, 162
separation of lower epiphysis of, 192
upper epiphysis of, 165
tuberosity, avulsion of, 165
and fibula, fracture of, 178

Tibio-fibular articulation, inferior, dislocation of, 196
superior, dislocation of, 167

Tinnitus aurium, 554

Toes, clawing of, 280
deformities of, 296
dislocation of, 200
fracture of phalanges of, 194
hammer-, 300
hypertrophy of, 302
pigeon-, 298
supernumerary, 303
webbing of, 303

Tongue,
absence of, 540
atrophy of, 540
bifid, 540
cancer of, 534
inoperable, 537
cysts, 537
dental ulcer of, 529
foot and mouth disease, 530
foreign bodies in, 529
glossitis, 530
gumma of, 533
hemi-glossitis, 530
inflammatory affections of, 530
leucokeratosis, 530
leucoplakia, 530
macroglossia, 540
malformations of, 540
mucous patches on, 533
nervous affections of, 540
neuralgia of, 540
paralysis of, 542
sarcoma of, 536
sclerosing glossitis, 533
smoker's parch, 532
spasm of, 542
surgical anatomy of, 528
syphilis of, 533
-tie, 540
tuberculosis of, 532
tumours of, 534, 537
ulcers of, 532, 536
wounds of, 529

Tonsil, calculi of, 503
hypertrophy of, 502
infective conditions of, 500
inflammation of, 500
Luschka's, 579
naso-pharyngeal, 579
quinsy, 501
syphilis of, 503
tuberculosis of, 503
tumours of, 504

Tonsillitis, varieties of, 500

Tooth, wisdom, impaction of, 508

Torn semilunar meniscus, 170

Torticollis, 587. _See_ Wry-neck

Trachea, foreign bodies in, 643
fracture of, 593
scabbard, 608
thymus stenosis of, 602
wounds of, 595

Tracheoscopy, 635

Tracheotomy, 638

Transplantation of tendons, 245

Transverse sinus, phlebitis of, 384
tarsal dislocation, 199

Trapezius, paralysis of, 404

Traumatic apoplexy, 355
cephal-hydrocele, 321, 390
epilepsy, 358
insanity, 360
neurasthenia, 345, 358
node, 1
oedema of brain, 352
spondylitis, 427

Trendelenburg's test, 252

Trigeminal nerve, 400
neuralgia, 400

Trigger finger, 318

Trochlear nerve, 400

Tuberculosis. _See_ Individual Organs

Tumours. _See_ Individual Organs

Tympanic antrum, suppuration in, 566
membrane, lesions of, 557
perforation of, 557
rupture of, 557, 563
surgical anatomy of, 557

Typhoid spine, 448

Ulna, deficiency of, 311
dislocation of, 94
fracture of upper end, 85
lower end, 110
shaft, 100
separation of epiphysis of, 87, 110

Uvula, bifid, 477
elongation of, 499

Vagus nerve, 403

Valsalva's method of inflating ear, 558

Venous sinuses, intra-cranial injuries of, 356

Ventricles, lateral, bursting of abscess into, 381
haemorrhage into, 342

Vertebral column, actinomycosis of, 448
arthritis deformans of, 449
blastomycosis of, 448
compression fracture of, 426
congenital deformities of, 458
deviations of, 461
diseases of, 431
dislocations of, 424, 427, 428
fracture-dislocation of, 427
fractures of, 425, 426, 427
hydatid cysts of, 448
hysterical affections of, 448
injuries of, 423
kyphosis, 461, 462
lateral curvature of, 463
lordosis, 461
malignant disease of, 447
osteomyelitis of, 431, 448
Pott's disease of, 431
scoliosis, 463
sprains of, 423
surgical anatomy of, 411
syphilis of, 447
tuberculous disease of, 431
tumours of, 447
twists of, 423
typhoid, 448
wounds of, 430

Vertigo, 555

Visual centres, 335

Volkmann's ischaemic contracture, 85, 98, 310
supra-malleolar deformity, 273

Wandering acetabulum, 210, 227

Wax in ear, 561

Webbed fingers, 317
toes, 303

Wens, 324

White swelling of knee, 233

Winged scapula, 306

Wisdom tooth, impaction of, 508

Wounds. _See_ Individual Regions and Organs

Wrist, diseases of, 208
dislocation of, 111, 112
congenital, 313
drop-, 311
injuries of, 102
Madelung's deformity of, 313
sprain of, 115
surgical anatomy of, 102
tuberculous disease of, 208, 209

Wry-neck, 587
acute, 587
hysterical, 592
permanent, 588
rheumatic, 587
spasmodic, 591
transient, 587

Xerostomia, 547

X-rays in fracture, 16

Zygomatic bone, fracture of, 519