Secondary cancer is a common disease, particularly in cases of advanced scirrhus of the breast. It leads to extensive softening of the bodies of the vertebrae, so that they yield under the weight of the body, as in Pott's disease. Clinically it is associated with severe pain in the region of the vertebrae affected, and along the course of the nerves emerging in the neighbourhood. If paralysis occurs from the cancerous bodies pressing upon the cord (paraplegia dolorosa), it is of rapid development, often becoming complete in a few hours. When the cervical cord is compressed all four limbs are paralysed, and from interference with respiration, the condition is fatal within a few days.

Actinomycosis, Blastomycosis, and Hydatid Cysts also occur in the vertebrae, and are difficult to diagnose from tuberculous disease.

Typhoid Spine.—An acute infective condition of the vertebrae, intervertebral discs, and spinal ligaments occasionally occurs during convalescence from typhoid fever. The lumbar region is most frequently affected, and the X-rays reveal inflammatory changes in the bones, disappearance of the discs, and, in the later stages, deposits of new bone leading to synostosis of adjacent vertebrae. The onset, which may be gradual or sudden, is attended with intense pain, and tenderness over the affected vertebrae. The temperature is raised, and other signs of an acute infective process are present. In a few cases there are symptoms of involvement of the membranes and cord. With prolonged rest and immobilisation of the spine the inflammation usually subsides, but sometimes it goes on to suppuration.

Hysterical Spine.—This term is applied to a functional affection of the spine occasionally met with in neurotic females between the ages of seventeen and thirty, and liable to be mistaken for Pott's disease. The patient complains of pain in some part of the spine—usually the cervico-thoracic or thoracico-lumbar region—and there is marked hyperaesthesia on making even gentle pressure over the spinous processes. As the patients are usually thin, the pressure of the corset is apt to redden the skin over the more prominent vertebrae, and give rise to an appearance which at first sight may be mistaken for a projection. The general condition of the patient, the freedom of movement of the vertebral column, and the entire absence of rigidity, are sufficient to exclude tuberculosis. The condition is treated on the same lines as other hysterical affections.

Acute osteomyelitis of the vertebrae is a rare affection, and is met with in young subjects. It attacks the more mobile portions of the spine—cervical and lumbar—and may begin either in the bodies or in the arches. It is attended with extreme sensitiveness on movement, severe localised pain in the region of the vertebrae attacked, and a marked degree of fever. Pus usually forms rapidly, but, being deeply placed, is not easily recognised unless it points towards the surface. The infection is liable to spread to the meninges of the cord and give rise to meningitis, particularly when the disease begins in the arches. A milder form occurs, in which the main incidence is on the periosteum; the symptoms are less severe, it does not tend to suppurate, and is usually recovered from. The treatment consists in applying extension to the spine and in opening any abscess that may be detected. The suppurative form usually proves fatal, and, indeed, is often only diagnosed on post-mortem examination.

Arthritis Deformans.—This disease usually begins between the ages of thirty-five and forty, and attacks men who follow some laborious occupation which involves exposure to cold and wet. It is met with, however, in women who lead a sedentary life. There is sometimes a recent history of gonorrhoea, rheumatism, or other toxic disease, and occasionally the condition follows upon injury. The discs disappear, osteophytic outgrowths develop at the margins of the bodies and in connection with the transverse processes, and bridge across the space between neighbouring vertebrae (Fig. 218). The articulations between the ribs and the vertebrae show similar changes, and the ligaments of the several joints tend to undergo ossification, so that the bones are fused together.



In the early stage the patient complains of pain and stiffness in the back; later the spine becomes rigid, and gradually develops a kyphotic curve, sometimes accompanied by lateral deviation. In some cases, the curvature of the spine assumes an extreme type, the shoulders are rounded, and the head depressed, the face approximating the sternum, so that to see an object such as a picture on a wall, the patient must turn his back to it. The chest is flattened and restricted in its movements, with the result that respiration is embarrassed and becomes almost entirely abdominal. The muscles of the back, shoulders, and hips undergo atrophy, and may exhibit tremors, and the deep reflexes become exaggerated. The nerves are liable to be pressed upon as they pass through the intervertebral foramina, and this gives rise to pain and other disturbances of sensation in their area of distribution. These pains may simulate those associated with renal or gastro-intestinal affections.

The disease may simulate tuberculous caries or malignant disease. The changes in the bones are demonstrated by the use of the X-rays.

The treatment is carried out on general principles (Volume I., p. 530), but it is seldom possible to do more than arrest the progress of the disease.

Coccydynia is the name applied to a condition in which the patient experiences severe pain in the region of the coccyx on sitting or walking, and during defecation. The pathology is uncertain. In some cases there is a definite history of injury, such as a kick or blow, causing fracture of the coccyx, or dislocation of the sacro-coccygeal joint. These lesions have also been produced during labour. In other cases the pain appears to be neuralgic in character, and is referable to the fifth sacral and the coccygeal nerves, or to the terminal branches of the sacral plexus distributed in this region. The affection is almost entirely confined to females, and the patients are usually of a neurotic type. On rectal examination the coccyx is exceedingly tender, and it is sometimes found to be less movable than normal, and unduly arched forward. When medicinal treatment fails to give relief, the coccyx may be excised.

Tumours of the Spinal Cord and Membranes.—Tumours may develop in the substance of the cord (intra-medullary), in the membranes (meningeal), or in the tissues between the dura and the bone (extra-dural); or the cord may be pressed upon by a tumour originating in the vertebrae. It is seldom possible to diagnose the nature of a tumour before operation, and it is often difficult to determine in which of the above situations it has originated.

Tumours growing in the substance of the cord are nearly as common as extra-medullary growths, and as the growth is usually sarcoma, glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldom capable of being removed by operation.

The great majority of meningeal tumours are primary sarcomas, and in about 25 per cent. of cases they are multiple. Hydatid cysts and fibromas are also met with in this situation, and they too may be multiple.

Extra-dural growths are comparatively rare. The forms usually met with are sarcoma and lipoma.

These extra-medullary tumours seldom infiltrate the cord; they simply compress it, and should be subjected to operative treatment before secondary changes are produced in the cord.

The symptoms vary according as the tumour presses on the nerve roots, on one half, or on both halves of the cord. Pressure on nerve roots is a characteristic sign in extra-medullary growths. It gives rise to pain, which, according to the level of the tumour, passes round the trunk (girdle-pain), or shoots along the nerve-trunks of the upper or lower limbs.

When the cord is pressed upon, intense neuralgic pain related to the segment first involved is one of the earliest symptoms, particularly in extra-medullary tumours. The pain is at first unilateral, but later becomes bilateral—a point of importance in diagnosis. The painful areas are anaesthetic, but the anaesthesia does not always reach to the level of the lesion. There may be a zone of hyperaesthesia at the upper limit of the anaesthesia, or in the area corresponding to the roots on which the tumour is situated, but there is never diffuse hyperaesthesia (V. Horsley). In intra-medullary tumours the pain is less severe, it is rarely an initial symptom, and is seldom referable to individual nerve roots.

The next symptom to appear is motor paresis, followed by complete paralysis, and later by contracture of the paralysed muscles—spastic paraplegia. In intra-medullary tumours the paraplegia is usually less complete than in those that are extra-medullary. When only one lateral half of the cord is pressed upon, the motor paralysis and loss of ordinary sensation are on the same side as the tumour, and the loss of the sense of pain and of the temperature sense is on the opposite side. Retention of urine accompanies the onset of paralysis, and later gives place to incontinence. The rectum becomes paralysed, and cystitis and pressure sores develop.

Anti-syphilitic treatment should be employed in the first instance to exclude the possibility of the lesion being of the nature of a gumma. Radical operative treatment is contra-indicated in intra-medullary and in metastatic growths, but decompressive measures may be employed for the relief of pain. In meningeal and extra-dural tumours, however, in view of the hopeless prognosis if the condition is allowed to take its course, an attempt may be made to remove the tumour by operation. It is to be borne in mind that the lesion may be two or three segments higher than the complete anaesthesia would appear to indicate; the vertebral canal, therefore, should be opened about four inches above the level of the anaesthesia.

When the tumour is not removable, the patient's suffering may sometimes be alleviated by resecting the posterior roots of the nerves emerging in the vicinity of the lesion.

Chronic Spinal Meningitis.—Victor Horsley (1909) described by this name a condition which gives rise to symptoms closely simulating those of a tumour of the cord. He believes it to consist in a pachymeningitis combined with a certain degree of sclero-gliosis of the periphery of the cord. The theca is greatly distended over a variable extent of the cord; the cerebro-spinal fluid is increased in quantity and is under considerable tension; and the cord itself presents a shrunken appearance. Sometimes there is thickening of the arachno-pia and matting of the nerve roots. The condition appears to begin in the lower part of the cord, and to spread up, usually as far as the mid-thoracic region. There is frequently a history of syphilis, sometimes of recent gonorrhoea, but in some cases no cause can be assigned for the lesion.

Clinical Features.—This affection is almost always met with in adults, and the earliest symptoms are pain and weakness in the legs, and sometimes a slight kyphotic projection of the spinous processes. The loss of power, which is sometimes attended with spasticity, usually manifests itself in one leg first, and later affects the other; it is progressive, and ultimately ends in complete paraplegia. The pain is not confined to the region supplied by any one nerve root, but affects a diffuse area, and the patient complains also of a sensation of tightness in the limbs. There is never absolute anaesthesia, but there is relative anaesthesia for all forms of sensation, which extends as a rule as far as the sixth or eighth thoracic root.

There are no vaso-motor phenomena, and no tendency to the formation of pressure sores. Sometimes the patient complains of pain in the spine, but this is not aggravated by movement.

Treatment.—The treatment recommended by Horsley consists in performing laminectomy, opening the theca, and washing it out with 1 in 1000 mercurial lotion. After the wound has healed, mercurial inunction over the spine is employed to hasten the absorption of inflammatory products. The administration of anti-syphilitic drugs has not proved beneficial.

Acute Spinal Meningitis.—The spinal membranes may become implicated by direct spread in cases of acute intra-cranial lepto-meningitis, or they may be infected from without—for example, in gun-shot injuries or in cases of spina bifida.

When the infection spreads from the cranial cavity, the cerebral symptoms dominate the clinical picture, but evidence of involvement of the membranes of the cord may be present in the form of rigidity of the cervical muscles with retraction of the neck; deep-seated pain in the back, shooting round the body (girdle-pain) and down the limbs; painful cramp-like spasms in the muscles of the back and limbs, with increased reflex excitability, sometimes so marked as to simulate the spasms of tetanus.

When the theca of the cord is directly infected the spinal symptoms predominate at first, but as the condition progresses it involves the cerebral membranes, and symptoms of acute general lepto-meningitis ensue.

Once the condition has started little can be done to arrest its progress, but the symptoms may be relieved by repeated lumbar puncture.

Spinal Myelitis.—The term "myelitis" is applied to certain changes which occur in the spinal cord as a result, for example, of haemorrhage into its substance (haemorrhagic myelitis); or of pressure exerted on it by fragments of bone, blood-clot, tuberculous material, or new growths (compression myelitis).

In another group of cases myelitis is a result of the action of organisms or their toxins. Syphilis is a common cause, but the condition may follow on infections with ordinary pyogenic cocci, pneumococci, the influenza bacillus or the bacillus coli.

In addition to the use of anti-syphilitic remedies, or of sera directed to neutralise the toxins of the causative organism, attention must be directed to the bladder, and steps taken to prevent cystitis and the formation of bed-sores.

CONGENITAL DEFORMITIES OF THE SPINE

Spina Bifida.—Spina bifida is a congenital defect in certain of the vertebral arches, which permits of a protrusion of the contents of the vertebral canal. It is due to an arrest of development, whereby the closure of the primary medullary groove and the ingrowth of the mesoblast to form the spines and laminae fail to take place. The cleft may implicate only the spinous processes, but as a rule the laminae also are deficient. The defect usually extends over several vertebrae (Fig. 219). While the protrusion varies much in size, there is no constant ratio between the dimensions of the swelling and the extent of the defect in the neural arches.



The condition is comparatively common, being met with in about one out of every thousand births. It is most frequent in the lumbar and sacral regions (Fig. 219), but occurs also in the cervical (Fig. 220) and thoracic regions. It is not uncommon to find spina bifida associated with other congenital deformities such as hydrocephalus, club-foot, and extroversion of the bladder.



Varieties.—Four varieties are usually described according to the character of the protrusion. They are analogous, to a certain extent, to the varieties of cephalocele (p. 387). (1) Spinal meningocele, in which only the membranes, filled with cerebro-spinal fluid, are protruded. (2) Meningo-myelocele, the form most commonly met with clinically, in which the cord and some of the spinal nerves are protruded, and spread out over the inner aspect of the sac (Figs. 219, 220). (3) Syringo-myelocele, in which there is a dilatation of the central canal in the protruded part of the cord. In these three forms the protrusion may be covered by healthy skin, or by a thin, smooth, translucent membrane through which the contents are visible. Frequently this thin covering sloughs or ulcerates, and permits the cerebro-spinal fluid to drain away. (4) In the myelocele, this skin, as well as the vertebral arches and membranes, is absent, and the cord lies exposed on the surface. This form is comparatively common, but as the infants are either dead born or die within a few days of birth, it seldom comes under the notice of the surgeon.

Clinical Features.—The presence of a swelling in the middle line of the back, which has existed since birth, and which contains fluid and increases in size and tenseness when the child cries, renders the diagnosis of spina bifida easy. The defect in the bone may be seen in skiagrams. The swelling is usually sessile, but may be pedunculated; it is usually possible to palpate the edges of the gap in the bones. It may be reduced in size by making gentle pressure over it, and in young children this may cause a bulging of the fontanelles. This test, however, must be employed with caution, as it is liable to induce convulsions. A meningocele, as it contains no nerve elements, may be translucent. In a meningo-myelocele the shadows of the cord and nerves stretched out in the sac may be recognised. The presence of the cord is sometimes indicated by a median furrow, and after withdrawal of some of the fluid the cord can sometimes be palpated. It is, however, often difficult to distinguish between a meningocele and meningo-myelocele.



Sometimes there are no nervous disturbances, and this is especially the case when the defect is in the lower lumbar and sacral regions below the termination of the cord. In most cases, however, there are paralytic symptoms referable to the lower extremities, the bladder, and the rectum, and there may also be trophic disturbances in the parts below. Paralytic symptoms may be absent during infancy, and develop during childhood or adolescence.

Prognosis.—Comparatively few children born with spina bifida survive longer than four or five years. The great majority die within a few weeks of birth, death being due to the escape of cerebro-spinal fluid, or to spinal meningitis following on infection. The condition in some cases remains stationary for years, but spontaneous disappearance is rare.

Treatment.—The more severe forms of spina bifida only call for palliative treatment, which consists in protecting the protrusion against infection and applying a sterilised dressing and a supporting bandage. A meningocele may be tapped with a fine needle passed through healthy skin, and the empty sac compressed by a pad of wool and an elastic bandage.

Operative treatment is seldom to be recommended in a young child unless it is otherwise viable and the swelling is increasing rapidly and threatening to burst, and there is reason to believe that the paralysis is due to pressure. The immediate results of operation are usually satisfactory, but in a large proportion of cases the child subsequently develops hydrocephalus, from which it ultimately succumbs. The hope of improvement in the motor symptoms after operation depends on the site of the spina bifida; above the twelfth thoracic vertebra there is no prospect of improvement; below this level, inasmuch as it is the tip of the conus or the cauda equina that is involved, there may be regeneration of nerve fibres and return of power in the lower extremities, and control of the sphincters may be regained. Murphy has practised resection of cicatricial or atrophied portions of the cauda, with end-to-end suture.

The term spina bifida occulta is applied to a condition in which there is no protrusion of the contents of the vertebral canal, although the vertebral arches are deficient. The skin over the gap is often puckered and adherent, and is frequently covered with a growth of coarse hair.

A mass of fat may project towards the surface, and when situated in the lumbo-sacral region may suggest a caudal appendage or tail (Fig. 222).



The clinical importance of spina bifida occulta lies in the fact that it is sometimes associated with congenital club-foot, and with nerve symptoms, in the form of sensory, motor, and trophic disturbances referable to the lower limbs, such as perforating ulcer, and to the sphincters. These nerve symptoms usually result from the presence of a tough cord composed of connective tissue, fat, and muscle, stretching from the skin through the vertebral canal to the lower end of the spinal cord. As this strand of tissue does not grow in proportion with the body, in the course of years it drags the cord against the lower border of the membrana reuniens, which closes in the vertebral canal posteriorly. These symptoms may be relieved by the removal of this strand of tissue from the gap in the vertebral arches, or by incising the membrana reuniens.

Congenital Sacro-coccygeal Tumours—Teratoma.—Many varieties of congenital tumours are met with in the region of the sacrum and coccyx. The majority are developed in relation to the communication which exists in the embryo between the neural canal and the alimentary tract—the post-anal gut or neurenteric canal. Some are evidently of bigerminal origin, and contain parts of organs, such as limbs, partly or wholly formed, nerves, parts of eyes, mammary, renal, and other tissues.

Among other tumours met with in this region may be mentioned: the congenital lipoma—a small, rounded, fatty tumour which often suggests a caudal appendage (Fig. 222); the sacral hygroma, which forms a sessile cystic tumour growing over the back of the sacrum, and is believed to be a meningocele which has become cut off in utero by the continued growth of the vertebral arch; dermoids, sarcoma, and lymphangioma.



The treatment consists in removing the tumour, as from its situation it is exposed to injury, and this is liable to be followed by infection. From the position of the wound, and the fact that many of these tumours extend into the hollow of the sacrum and therefore necessitate an extensive dissection, there is considerable risk from infection, especially in young children. The risk is increased when the tumour communicates with the vertebral canal.

Congenital Sacro-coccygeal Sinuses and Fistulae.—The post-anal dimple, a shallow depression frequently observed over the tip of the coccyx, may be due to traction exerted on the skin at this spot by the remains of the neurenteric canal, or by the caudal ligament of Luschka. Sometimes the integument is retracted to such an extent that one or more sinuses are formed, lined with skin which is furnished with hairs, sweat, and sebaceous glands. The bursting of a dermoid, or its being incised in mistake for an abscess, may result in the formation of such a sinus, which fails to heal and may persist for years.

In some cases the depression communicates with the vertebral canal, constituting a complete sacro-coccygeal fistula, which may be lined with cylindrical or ciliated epithelium.

From the accumulation of secretions and subsequent infection, these conditions may be associated with a persistent offensive discharge, and they are liable to be mistaken for ano-rectal fistulae. They are best dealt with by complete excision, and as primary union cannot be expected, the wound should be treated by the open method.



CHAPTER XVIII

DEVIATIONS OF THE VERTEBRAL COLUMN

LORDOSIS—KYPHOSIS—SCOLIOSIS

Three main deviations of the vertebral column are described: Lordosis, in which it is unduly arched forwards; Kyphosis, in which it is unduly arched backwards; and Scoliosis or lateral deviations, in which the spine deviates to one side of the middle line.

Lordosis or anterior curvature of the spine with the convexity forwards, is chiefly met with in the lumbar region as an exaggeration of the natural curvature. A minor degree of lordosis sometimes occurs as a peculiarity in the conformation of the individual and may be present in several members of the same family; also in street-hawkers and others who carry weights suspended in front of them; in very obese persons; in those who suffer from large abdominal tumours, such as fibroids; and in pregnant women. In its more marked and typical forms it is met with as a compensatory deviation when the pelvis is tilted forwards in association with flexion of one or of both hip-joints. Illustrations of this association are found in congenital dislocation of the hip, particularly when this is bilateral, in tuberculous disease of the hip when recovery has occurred with ankylosis in the flexed position, and in Charcot's disease of the hip. The resuming of the erect position with tilting of the pelvis from flexion at the hip is necessarily attended by an exaggeration of the forward curvature of the lumbar spine. Its relationship to the erect posture is readily demonstrated by noting its partial or complete disappearance when the patient is sitting and the tilting of the pelvis is thus eliminated.

Lordosis elsewhere than in the lumbar segment is met with as a compensatory deviation to kyphotic or backward curvature of the spine: in Fig. 211, for example, a kyphotic projection in the mid-thoracic region has led to a lordosis in the cervico-thoracic segment above, and in the thoracico-lumbar segment below, the forward curve being again a necessary outcome of the resuming of the erect posture. The absence of a compensatory lordosis in such a condition would warrant the inference that the patient had been bed-ridden.

Kyphosis or posterior curvature of the spine with the convexity backwards, is met with at all periods of life, and results from a wide range of conditions.

In infancy it is a common result of general debility. The child need not appear to be badly nourished, it may even be fat and look well, but there is a want of muscular vigour such as should enable it to hold itself erect in the sitting posture. It is to be noted that a considerable degree of kyphosis may exist without interference with the normal outlook in the erect posture, and, therefore, the question of compensatory curvature does not arise. In the adolescent a degree of kyphosis in the cervico-thoracic region is common, and is spoken of as "round shoulders"; it is largely a matter of habit that requires correction by the governess or nurse. Among agricultural labourers and gardeners after middle life, and in the aged, this type of curvature is of common occurrence and is evidently associated with their occupation. An exaggerated form of the same cervico-thoracic kyphosis is met with in patients suffering from progressive muscular atrophy, poliomyelitis, osteitis deformans of Paget, acromegaly, and many allied conditions in which either the muscular or the mental vigour is deficient, and the patient adopts the cervico-thoracic kyphosis as the attitude of rest.

Another type of diffuse kyphosis without compensatory curvature is met with in arthritis deformans, in which the kyphosis is associated with the disappearance of the intervertebral discs and ankylosis of the vertebral bodies by bridges of new bone in the position of the anterior common ligament.

Partial or localised kyphosis, on the other hand, is the result of organic changes in the bodies of the vertebrae of the segment of spine affected. It is most often met with in Pott's disease in which the extent of the curve depends on the number of bodies affected, and its degree on the amount of destruction that the bodies have undergone. With the resumption of the erect posture, and in order that the eyes should look directly forwards, a compensatory lordosis is acquired above and below the segment that is the seat of kyphosis (Fig. 211). A similar but less marked type of kyphosis may follow upon compression fracture of the spine—in the condition known as traumatic spondylitis; and as a result of other lesions, such as osteomalacia, or malignant disease, in which the bodies undergo softening and yield, so that the spinous processes project posteriorly.

SCOLIOSIS

Scoliosis or lateral curvature is by far the commonest and most important deviation of the spine. The student will obtain a clearer conception of the nature of this deformity if we consider in the first place those types for which an obvious explanation is available.

Static scoliosis, for example, when one leg is shorter than the other, the pelvis is tilted down on the short side, the thoracico-lumbar spine deviates laterally to the normal side, and to restore the equilibrium of the trunk the cervico-thoracic spine deviates again in the opposite direction. The causes of one leg being shorter than the other are numerous and varied; they include such conditions as unilateral congenital dislocation of the hip, fractures united with overriding of the fragments, diseases of the joints, e.g., hip disease, or of the bones, especially such as interfere with the function of ossifying junctions; and acquired deformities such as unilateral flat-foot, knock-knee, or bow-leg. Clinically, this type of scoliosis is identified by observing that when the patient sits down the deviation of the spine disappears; it is relieved or got rid of by raising the sole and the heel of the boot on the short side, and, if required, by inserting an "elevator" inside the boot.

When there is shortening of the muscles on one side of the trunk there develops a lateral curvature of the spine with its convexity to the normal side; a good example of this is afforded in cases of infantile hemiplegia (Fig. 224) in which the deviation affects the entire column: a localised form is seen in congenital wry-neck, in which the convexity of the cervico-dorsal curve is on the side of the normal sterno-mastoid with a compensatory deviation to the opposite side in the spine below (Fig. 272). Unilateral paralysis of muscles acting on the trunk may also cause a lateral deviation of the spine, as is well seen in paralysis of the trapezius, which results in a cervical scoliosis with the convexity to the non-paralysed side.



Asymmetry of the thorax, such as may follow on empyema with defective expansion of the lung, causes a lateral deviation of the dorsal spine with the convexity towards the normal side.

Attitudes adopted to relieve pain, such as that caused by sciatica, sacro-iliac or hip disease, in which the weight of the body is transferred to the normal side, cause a scoliosis similar to that due to irregularity in the length of the lower extremities, and is similarly made to disappear when the patient sits upon a flat surface.

Malformation or disease of the vertebrae themselves is a well recognised cause of scoliosis; the best known, as it may be also the most severe and the most intractable, is that due to rickets, under which heading it has already been described (Fig. 225). In a few cases a rudimentary wedge-shaped vertebra has been revealed by the X-rays.



In all of these forms or types of scoliosis the primary cause must be searched for and when found is made the first object of treatment; the treatment of the scoliosis as such is on the same lines as in the postural variety that now falls to be described.

Habitual or Postural Scoliosis.—These names have been given to the type of scoliosis that develops in young girls and for which there is no mechanical explanation.

It is most frequently met with in rapidly growing girls of poor physique who are overworked at school or lessons, or on commencing an apprenticeship for which they are physically unfit. In some cases there is nasal obstruction from adenoids, in others the development and free play of the chest are interfered with by tight and ill-fitting garments; in all of them the muscular system is weak and the muscles of the trunk do not take their proper share in maintaining the erect posture. The most important determining factor would appear to be the habitual or repeated assumption of faulty attitudes, partly from carelessness, largely from fatigue, in order to relieve the feeling of tiredness in the back. So far as is known, the condition does not occur in communities living under aboriginal conditions. In some cases there is a hereditary tendency to scoliosis; we have seen it, for example, in a father and his daughters.

The excessive use of one arm in the carrying of weights, the habit of resting on one leg more than the other, or the assumption of a faulty attitude in writing or in playing the piano or violin, doubtless, determine the seat and direction of the curvature, and, when it has once commenced, tend to aggravate and to perpetuate it.

It is probable that the greater frequency of the primary curvature towards the right is associated with the more general use of the right hand and arm, although primary curvatures towards the left are not confined to left-handed persons.

Morbid Anatomy.—The original deviation or "primary curve" is usually in the thoracic region, and has its convexity directed towards the right side. To re-establish the equilibrium of the column, "secondary" or "compensatory" curves, with their convexities to the left, develop in the regions above and below the primary curve. It has been proved experimentally that lateral deviation of the spine is inevitably accompanied by rotation of the vertebrae around a vertical axis, in such a way that their bodies look towards the convexity of the curve, while their spines, laminae, and articular processes are directed towards the concavity (Fig. 226).



As the deformity increases, the individual vertebrae are distorted, the bodies becoming wedge-shaped from side to side, the base of the wedge looking towards the convexity of the curve, while the narrow end looks towards the concavity (Fig. 228). As the spine, laminae, and articular processes also undergo alterations in shape, a line uniting the tips of the spinous processes does not furnish an accurate index of the degree of lateral deviation but minimises it considerably. The muscles and ligaments are altered in length in accordance with the changes in the shape and position of the bones.

In the thoracic region, the ribs necessarily accompany the transverse processes, so that on the side of the convexity they form an undue prominence behind—the "rib-hump" (Fig. 227), while on the side of the concavity the chest is flattened and the ribs crowded together so that the intercostal spaces are diminished or even obliterated. The converse—flattening on the side of the concavity—is seen on the front of the chest.



The general shape of the thorax is altered: on the side of the convexity it is longer and narrower than normal and its capacity diminished, while on the side of the concavity it is shorter and broader and its capacity is increased.

The viscera are distorted and displaced in accordance with the altered shape of the thoracic and abdominal cavities. The twisting of the spine causes the patient to lose in stature, and the limbs appear to be disproportionately long. In advanced cases the pelvis becomes obliquely contracted—a deformity known as the scoliotic pelvis.



In spite of the marked deformity the spinal cord is never compressed.

Clinical features.—The development of scoliosis is always slow and insidious. As a rule, attention is first attracted to the deformity about the age of puberty, but in most cases it has existed for a considerable time before it is observed. The patient—usually a girl, although it also occurs in boys—is easily fatigued, has difficulty in keeping herself erect, and often complains of pain in the back and shoulders and along the intercostal spaces on the side of the convexity. To relieve the muscles of the back she is inclined to lounge in easy and ungainly attitudes.

The most common form of scoliosis met with in adolescents is a primary thoracic curvature with its convexity to the right (Fig. 227), and with more or less marked compensatory curves towards the left in the lumbar and cervical regions. The thoracic spines lie towards the right of the middle line. On account of the prominence of the ribs, the right scapula is projected backwards, and its inferior angle is on a higher level and farther from the middle line than that of the left scapula. The right shoulder seems higher than the left, and is popularly said to be "growing out"—a point which is often first observed by the dressmaker. The right side of the back is unduly prominent, while the left side is flattened. A deep sulcus forms in the left flank below the costal margin, and the space between the arm and the chest wall—the "brachio-thoracic triangle"—on the left side is much more marked than on the right; and the left iliac crest usually projects upwards and backwards. As seen from the front, the right side of the chest is flattened, while the left side is abnormally prominent, the breasts are asymmetrical, and the right nipple is on a higher level than the left.



In aggravated cases, the patient may suffer from shortness of breath on exertion, and the respiratory difficulty may react on the heart, causing dilatation of the right side, palpitation, and precordial pain.

Sometimes, and particularly in males, the primary curvature is in the lumbar region, and the convexity is to the left. The deviation of the lumbar vertebrae produces a prominence in the left flank which masks the outline of the iliac crest on that side, while the right flank shows a deep furrow and the right half of the pelvis is unduly prominent. There is a slight compensatory curve to the right in the thoracic region, and the right side of the chest projects backwards. The brachio-thoracic triangle is much more marked on the right than on the left side.

Diagnosis of Adolescent Scoliosis.—In many cases the patient is brought to the surgeon on account of pain and weakness in the back before any distinct deviation has developed, and, unless a careful examination is made, the real cause of the symptoms is liable to be overlooked.

The patient should be stripped and examined in a good light in various attitudes; for example, standing in an easy position, standing as straight as she can, and sitting on a flat stool. She should also be asked to read from a book and to write, in order to exhibit her usual attitudes. In early cases, an inequality in the level of the angles of the scapulae is often the only physical sign to be detected. It should also be observed whether the line of the spines is altered when the patient hangs from a horizontal bar or trapeze. Any backward projection of the ribs on one side is rendered more obvious if the patient folds the arms across the chest and bends well forward, while the surgeon looks along the back from behind.

Pott's disease may be excluded by the absence of rigidity. Any mechanical cause of deviation of the spine, such, for example, as inequality in the length of the limbs or contraction of the chest after empyema, must be sought for. Scoliosis that depends upon inequality in the length of the limbs or tilting of the pelvis, disappears on sitting.

Treatment.—The treatment of postural scoliosis implies a comprehensive programme, including attention to the general health, habits, and exercises out of doors and in the gymnasium, clothing, etc., all requiring supervision over a period of months, or even of years. The object of the treatment is to correct the deformity before the position has become fixed by rotation of the vertebrae and alteration in their shape. The child must not be allowed to assume awkward attitudes while reading, writing, or playing the piano; she must sit on a low chair, the seat of which slopes slightly downwards and backwards, and the back rest of which reaches as high as the shoulders, and is at an angle of 100 deg.-110 deg. with the seat. The feet should rest on a sloping stool, and when the child is reading or writing, a desk sloping at an angle of 45 deg. should be used. In weakly girls approaching the period of puberty, special care should be taken to avoid compression of the trunk by tight corsets. Adenoids or other sources of respiratory obstruction must be removed; and if the patient is myopic she should be provided with suitable glasses. Standing should be avoided, as there is a great tendency to throw the weight on to one leg; but walking, running, and other exercises which bring both sides of the body into action equally are permitted under supervision. Horse-riding is a suitable form of exercise, but girls must ride astride; cycling is not to be recommended.

In mild cases—that is, those in which the curvature is obliterated when the patient is suspended—the prophylactic measures above mentioned must be rigidly enforced, and gymnastic exercises should be prescribed. The exercises should not be commenced, however, until, after a period of rest in bed, all pain and feeling of tiredness in the back have disappeared.

In cases in which the curvature is not affected by suspension, the deformity is usually permanent, but by suitable exercises it may be prevented from becoming worse, and the patient may be educated to disguise it to a considerable extent. Training is also directed towards regaining the muscular sense; with the eyes shut before a mirror, the child should endeavour to assume the correct posture; on opening the eyes, the faulty attitude is seen and corrected. Forcible correction by means of successive plaster jackets, applied in the flexed position, somewhat on the lines employed by Calot in Pott's disease, has yielded results which may be described as encouraging. Only in very advanced cases should the patient be allowed to wear a supporting jacket; such appliances have no curative effect, and can only be expected to relieve symptoms.

* * * * *

Exercises for Lateral Curvature.—The particular exercises given must be carefully selected to meet the indications present in each case, the movements prescribed being designed to strengthen the weak muscles and ligaments, to increase the mobility of the spine as a whole, and to correct the deviation that exists. The exercises should be taken twice daily, preferably in the morning and afternoon, and after each spell the patient should rest for an hour, lying flat on the back. During the exercises the breathing should be carefully regulated, and at the end of each movement one or two deep breaths should be taken. Each movement should be carried out slowly, the number of times it is repeated varying from four to twelve or more, according to the nature of the exercise and the strength of the patient. The exercises should be stopped if the patient feels fatigued. Hot-air baths and massage are useful adjuvants to all forms of exercise.

Special Exercises for Thoracic Curvature with convexity to right.—1. Stand with arms by side; palms directed forward; shoulders braced back. This is referred to as the "best standing position" or original position. 2. Slowly raise arms from sides until level with shoulders, with palms directed forward; carry left arm straight upward—"the keynote position." Then slowly lower left arm to level of shoulder; lower both arms into original position. 3. Assume keynote position: slowly bend body forwards at hips until stooping position is reached, with legs kept quite straight, head bent slightly backwards, and eyes directed forward. Gradually return to keynote and original positions. 4. Keynote position: slowly bend whole spine to right; resume keynote and original positions. 5. Keynote position: turn body forward sideways. 6. Keynote position: rise on to balls of toes. 7. Keynote position: rise on to balls of toes; bend knees; back to original position in reverse order. 8. Patient suspended from bar or rings, the left end of the bar or left ring being three inches higher than the right. (a) Draw right knee upwards and forwards against resistance. (b) Draw legs apart against resistance. (c) Draw legs together against resistance. 9. Patient lying on back. (a) Bend right knee- and hip-joints against resistance. (b) Extend right knee and hip against resistance. (c) Rotate right hip against resistance. 10. Patient lying on face with pillow under chest; slowly raise arms to keynote position. While limbs are firmly held by a nurse, raise the body backwards and to the right. 11. Same position: make swimming movements. 12. Patient astride a narrow table or chair, without a back. (a) Repeat exercises 3, 4, 5, and 11. (b) Bend body forwards, backwards; and rotate to right and left against slight resistance made by nurse grasping patient's shoulders.

Klapp's "four-footed" Exercises.—Rudolf Klapp has devised a series of exercises designed to strengthen the muscles and ligaments of the spine, and to increase the mobility of the column. To take the weight of the body off the spine, and to render both ends of the column mobile, these exercises are carried out in the "all-fours" attitude, the patient crawling in imitation of a quadruped, that is, in such a way that the hand and knee of one side are approximated, while those of the other side are separated; in other words, the hand and knee of one side should not move forward simultaneously (Fig. 230). With each step the spine is curved laterally, the concavity of the curve being towards the side on which the hand and knee are approximated. The exercises, for a case of dorsal curvature with the convexity to the right, for example, are graduated as follows: (1) The child crawls in a straight line till he has acquired the "quadruped gait"; (2) with each step forward the head is inclined towards the side on which the hand and knee are approximated; (3) at each step the hand and knee which are wide apart are brought over and cross the limbs on the other side; (4) to open out the concave left side, he crawls in a circle towards the right. The exercises are practised morning and afternoon for from fifteen to sixty minutes at a time. If there is a marked double curve, it is best neutralised by imitating the "pacing" action of a quadruped, i.e., the limbs of the same side moving forward together. The hands, knees, and toes should be protected by suitable gloves and leather pads. Hot-air baths and massage are useful adjuvants to the exercises.



Abbott has introduced a method of treatment applicable to cases in which the deformity has become permanent. Under general anaesthesia, the patient being slung in a bracket-frame with the spine flexed, the curvature is over-corrected and a plaster-case is then applied to maintain the attitude; the plaster-case is renewed at intervals of two or three months.



CHAPTER XIX

THE FACE, ORBIT, AND LIPS

FACE—Congenital malformations: Hare-lip and cleft palate; Macrostoma; Microstoma; Facial cleft; Mandibular cleft—Injuries of soft parts: Wounds; Burns—Bacterial diseases: Boils; Anthrax; Glanders, etc.; Lupus; Syphilis. Tumours: Epithelioma. ORBIT—Injuries: Contusion; Wounds; Fractures—Injuries of eyeball—Orbital cellulitis—Tumours. LIPS—Cracks; Chronic induration; Tuberculous ulcers; Syphilitic lesions—Tumours: Naevi; Lymphangioma; Cysts; Epithelioma.

THE FACE

CONGENITAL MALFORMATIONS.—The description of the various congenital malformations of the face will be simplified by a brief consideration of its development.

Development.—About the middle of the first month of intra-uterine life the prosencephalon bends acutely forward over the end of the notochord and sends out from its base a series of processes, which ultimately blend to form the face (Fig. 231). These processes surround a stellate depression, the primitive buccal cavity or stomatodaeum, from which the mouth and nasal cavities are developed. The buccal cavity is bounded above by the fronto-nasal process, which is divided by a fissure—the nasal cleft or olfactory pit—into a lateral nasal process, and a mesial nasal process, at the outer angle of which a spheroidal elevation appears—the globular process.



From the mesial nasal and globular processes the septum of the nose, the mesial segment of the premaxillary bone, and the middle portion of the upper lip are developed; while the lateral nasal process forms the roof of the nasal cavity, the ala nasi and adjacent portion of the cheek, and the lateral segment of the os incisivum or premaxillary bone. Each segment of the os incisivum carries one of the incisor teeth, and each of the mesial segments may contain in addition an accessory tooth. The nasal cleft ultimately becomes the anterior nares.

The primitive buccal cavity is bounded below by the mandibular arch, which contains Meckel's cartilage, and from which are developed the mandible, the lower lip, and the floor of the mouth.

From the lateral and back part of the mandibular arch springs the maxillary process, which grows upwards and blends with the lateral nasal process across the naso-orbital cleft—the deeper portion of which persists as the nasal duct. From the maxillary process are developed the cheeks, certain of the facial bones, the lateral portions of the upper lip, the soft and hard palate (with the exception of the os incisivum). The development of the face is completed about the end of the second month of intra-uterine life.

HARE-LIP AND CLEFT PALATE

Hare-lip is a congenital notch or fissure in the substance of the upper lip, and cleft palate a congenital defect in the roof of the mouth. Either of these conditions may exist alone, but they occur so frequently in combination that it is convenient to consider them together.

In hare-lip the cleft may be median or lateral, and it may or may not be associated with a cleft in the palate. The resemblance to the Y-shaped cleft in the upper lip of the hare, suggested by the name, is in most cases only superficial.

Median hare-lip is extremely rare. It occurs in two forms: one in which there is a simple cleft in the middle of the lip, the result of non-union of the two globular processes; another in which there is a wide gap due to entire absence of the parts developed from the mesial nasal process—the central portion of the lip, the mesial segment of the os incisivum, and the septum of the nose. The second form is usually associated with cleft palate.

Lateral hare-lip is much more common. It is due to imperfect fusion of the globular process with the labial plates of the maxillary process. There may be a cleft only on one side of the lip, or the condition may be bilateral. In some cases the cleft merely extends into the soft parts of the lip—simple hare-lip (Fig. 232) forming a notch with rounded margins on which the red edge of the lip shows almost to the apex. In other cases the cleft passes into the alveolus of the jaw—alveolar hare-lip—partly or completely separating the mesial and lateral segments of the premaxillary bone (Fig. 233). These cases are usually combined with cleft palate (Fig. 236).



When the hare-lip is bilateral, the two clefts may be unequal, one forming a simple notch in the lip, the other passing into the nostril. In most cases, however, both clefts are complete, and the mesial portion of the lip is entirely separated from the lateral portions. The central portion or prolabium is usually smaller than normal, and is closely adherent to the os incisivum. This bone may retain its normal position in line with the alveolar processes of the maxilla (Fig. 234), or it may be tilted forward so that the incisor teeth, when present, project beyond the level of the prolabium (Fig. 235). In aggravated cases, the os incisivum and prolabium are adherent to the end of the nose. In these cases there is a Y-shaped cleft in the palate.



Cleft Palate.—It has already been mentioned that the palate is formed by the blending of the two palatal plates of the maxillary processes with the four segments of the os incisivum, derived from the nasal processes. The foramen incisivum (anterior palatine foramen) marks the point at which these elements of the palate unite. The process of fusion begins in front and spreads backwards, the two halves of the uvula being the last part to unite.

As development may be arrested at any point, several varieties of cleft palate are met with. The uvula, for example, may be bifid, or the cleft may extend throughout the soft palate. In more severe cases, it extends into the hard palate as far forward as the foramen incisivum. In these varieties the whole cleft is mesial. In still more aggravated cases, the cleft passes farther forward, deviating to one or to both sides in the fissures between the mesial and lateral segments of the os incisivum or between the lateral segments and the maxillae. These cases are combined with double hare-lip.

The cleft varies considerably in width. It may be so wide that the imperfectly developed nasal septum is seen between its edges, and gives to the cleft the appearance of being double, or the septum is adherent to one edge of the palate—usually the right—and the cleft appears to be to the left of the middle line. In most cases the roof of the mouth is unduly arched, and is narrower than normal (Fig. 236).



Clinical Features.—Single hare-lip is about twice as common on the left as on the right side, and it occurs more frequently in boys than in girls. In a considerable proportion of cases there is a well-marked hereditary tendency to these deformities, and they frequently occur in several members of a family.

The nose is characteristically broad and flattened, the ala being bound down to the alveolar margin of the maxilla by fibrous tissue. The margins of the cleft in the lip are also attached to the alveolus by firm reflections of the mucous membrane. The orbicularis oris and other muscles of expression about the mouth being defective, the deformity is exaggerated when the child cries or laughs. In simple hare-lip the child may have difficulty in sucking, but this can usually be overcome by some mechanical contrivance to occlude the cleft.

When the hare-lip is double and combined with cleft palate, the child is unable to suck, and food introduced into the mouth tends to regurgitate through the nose. The nutrition can only be maintained by having recourse to spoon-feeding, and in feeding the child it is necessary to throw the head well back and to introduce the food directly into the back of the pharynx. Many of these infants are of such low vitality, however, that in spite of the most careful feeding they emaciate and die.

In those who survive, the voice has a peculiar nasal twang, as in phonation the air is expelled through the nose instead of through the mouth, and the articulation, especially of certain consonants, is very indistinct. Taste and smell are deficient. The constant exposure of the nasal and pharyngeal mucous membrane renders it liable to catarrhal inflammation and granular pharyngitis.

Treatment.—The only means of correcting these deformities is by operation, and, speaking generally, it may be said that the earlier the operation is performed the better, provided the general condition of the child is equal to the strain. In simple hare-lip the best time is between the sixth and the twelfth weeks. When cleft palate coexists with hare-lip, the lip should be operated on first, as the closure of the lip often exerts a beneficial influence on the cleft in the palate, causing it to become narrower.

Considerable difference of opinion exists as to when the cleft in the palate should be dealt with. Some surgeons, notably Arbuthnot Lane, recommend that it should be done in early infancy, as soon as the viability of the child is assured. We agree with R. W. Murray, James Berry, and others in preferring to wait until the child is between two and a half and three years old. It should not be delayed longer, because, even if the cleft in the palate is repaired, the nasal character of the voice persists, as the patient cannot overcome the habit of expelling the air through the nose.

Before the operation is undertaken, the child must be got into the best possible condition; and arrangements must be made for its constant supervision by a competent nurse. Success depends largely on the avoidance of infective complications, and on absence of tension between the rawed surfaces that are brought into apposition. More than one operation is sometimes required to effect complete closure of the cleft.

Voice Training.—The treatment of cleft palate does not cease with a successful operation; the importance of voice training must be explained to the parents. The child must be taught, in speaking, to send the stream of air through the mouth, instead of through the nose. If the soft palate is not sufficiently large and mobile to shut off the mouth from the nasal cavity, little improvement in speaking can be looked for.

In adolescents and adults, if the cleft is wide and the soft tissues of the palate are thin and atrophied, better physiological results may be obtained by the use of an artificial obturator or velum. With the aid of the dentist a plate of vulcanite or gold is fitted to the teeth and kept in position by suction.

Other Congenital Deformities of the Face.—Macrostoma is an abnormal enlargement of the mouth in its transverse diameter, due to imperfect fusion of the maxillary and mandibular processes.

Microstoma is due to excessive fusion of the maxillary and mandibular processes. In some cases the buccal orifice is so small as only to admit a probe.

Facial cleft is due to non-closure of the fissure between the nasal and maxillary processes. It passes upwards through the lip and cheek to the lateral angular process of the frontal bone.

Mandibular cleft occurs in the middle line of the lower lip, and may extend to, or even beyond, the chin; it is due to non-union of the two lateral halves of the mandibular arch.

These various deformities are treated by plastic operations carried out on the same principles as for hare-lip.

Fistulae of the Lower Lip.—Two small openings, about the size of a pin's head, are occasionally met with on the free border of the lower lip, near the middle line. On passing a probe, each is found to lead into a narrow cul-de-sac, which runs for about an inch laterally and backwards under the mucous membrane. Watery, saliva-like fluid exudes through the openings. These fistulae frequently occur in several members of the same family, and are usually associated with hare-lip. The treatment consists in dissecting them out.

Injuries of the Soft Parts of the Face.—Owing to its free blood supply, the skin of the face has great vitality, and even when severely lacerated it not only survives, but shows such resistance to bacterial infection that primary union frequently takes place. In plastic operations, also, even extensive flaps seldom become infected, and they heal so rapidly that the sutures can be removed in two or three days.

In incised wounds the bleeding is usually free at first, but unless one of the larger arteries, such as the external maxillary (facial) or temporal, is injured, it soon ceases. Paralysis of the muscles of expression may follow if the facial nerve is injured; and loss of sensation may result from injury to the supra-orbital or infra-orbital nerves. If the parotid gland is implicated, saliva may escape from the wound, but it usually ceases in a few days; if the duct is involved, a persistent salivary fistula may form.

Punctured wounds may perforate the orbit, the cranial cavity, or the maxillary sinus, and be followed by infective complications, particularly if the point of the instrument breaks off and is left in the wound.

Contused and lacerated wounds result from explosions and injuries by firearms, and foreign bodies, such as particles of stone or coal, or grains of gunpowder and small shot, may lodge in the tissues. Every effort should be made to remove such foreign bodies, as if left embedded they cause unsightly pigmentation of the skin. Ligatures are seldom necessary for the arrest of haemorrhage unless the larger branches are injured, as the bleeding from smaller twigs is arrested by the sutures. The edges of the wound are approximated by means of Michel's clips, or by a series of interrupted horse-hair stitches, and for this purpose a fine Hagedorn needle is to be preferred, as it leaves less mark than the ordinary bayonet-shaped needle. If the mucous membrane of the mouth or of the eyelid is implicated, its edges should be approximated by a separate row of catgut stitches.

Cicatricial contraction after severe burns may lead to marked deformities of the eyelids (ectropion), mouth, and nose. When the burn has implicated the neck, the chin may be drawn towards the chest, and the movements of the lower jaw and head seriously impeded.

Bacterial Disease.—Boils, carbuncles, and anthrax pustules frequently occur on the face, and when situated near the middle line, and particularly on the upper lip, are liable to give rise to general infection and to intra-cranial complications which may prove fatal. The primary infection of glanders and of actinomycosis may also occur on the face.

The various forms of tuberculous lupus are met with more frequently on the face than in any other situation (Fig. 237). Tuberculous disease of the facial bones, particularly of the lateral half of the orbital margin at the junction of the zygomatic (malar) bone with the maxilla, is not uncommon in children.



The primary lesion of syphilis, and the various forms of secondary and tertiary syphilides, may simulate tuberculous lupus, cancer, and other ulcerative conditions.

Tumours.—The simple tumours met with on the face include sebaceous and dermoid cysts, naevus, plexiform neuroma and adenoma; the malignant forms include the squamous epithelioma, and rodent, paraffin, and melanotic cancers.

Epithelioma occurs most frequently in men beyond the age of forty. The affection usually begins at the margin of the lip, the edge of the nostril, or the angle of the eye. There is generally a history of prolonged or repeated irritation, or the condition may develop in connection with a scar, a wart, a cutaneous horn, or an ulcerating sebaceous cyst. It may begin as a hard nodule, or as a papillary growth which breaks down on the surface, leaving a deep ulcer with a characteristically indurated base—the crateriform ulcer. The neighbouring lymph glands are infected early, but metastases to other organs are not common. The treatment consists in excising the growth and the associated lymph glands as early and as freely as possible. When excision is impracticable, benefit may be derived from the use of radium or of the X-rays.

The face is the commonest seat of rodent cancer (Volume I., p. 395).

THE ORBIT

Injuries.—Wounds of the eyelids are liable to be complicated by damage to the lachrymal apparatus, leading to stenosis of the canaliculus and persistent watering of the eye. If the wall of the lachrymal sac or nasal duct is torn, the patient should be warned not to blow his nose for some days lest air be forced into the tissues and produce emphysema. In suturing wounds of the lids care must be taken to secure accurate apposition at the free margins, and to avoid constricting the canaliculi.

Contusion of the eyelids and circum-orbital region—the ordinary "black eye"—is associated with extravasation of blood into the loose cellular tissue of these parts, and is followed within a few hours of the injury by marked ecchymosis. The lids may swell to such an extent that the eye is completely closed. In some cases the impinging object lacerates the vessels of the conjunctiva and produces a sub-conjunctival ecchymosis, which may be situated under the palpebral conjunctiva of the lower lid, or close to the corneal margin on the front of the globe. The blood effused under the conjunctiva remains bright red as it is aerated from the atmospheric air. The characteristic play of colours which attends the disappearance of effused blood is observed within a week or ten days of the injury.

Firm pressure applied by means of a pad of cotton wadding and an elastic bandage, if employed early, may limit the effusion of blood; and massage is useful in hastening its absorption.

A black eye is to be distinguished from the effusion which sometimes follows such injuries as fracture of the anterior fossa of the skull, fracture of the orbital ridges, or a bruise of the frontal region of the scalp, chiefly by the facts that in the former the discoloration comes on within a very short time of the injury, the swelling appears simultaneously in both lids, and the sub-conjunctival ecchymosis, when present, is coeval with the ecchymosis of the lids. In fractures of the orbital plate and bruises of the forehead, on the other hand, the ecchymosis does not appear in the eyelids for several days, and that under the conjunctiva is usually disposed on the globe as a triangular patch towards the lateral canthus.

Wounds of the orbit result from the introduction of pointed objects, such as knitting pins, pencils, or fencing foils, or from chips of stone or metal, or small shot. They are attended with considerable extravasation of blood, which may be diffused throughout the cellular tissue of the orbit, or may form a defined haematoma. In either case the eyeball is protruded, and the cornea is exposed to irritation and may become inflamed and ulcerated. The optic nerve may be lacerated, and complete and permanent loss of vision result. Sometimes the ocular muscles and nerves are damaged, and deviation of the eye or loss of motion in one or other direction results. The globe itself may be injured. Foreign bodies lodged in the orbit, so long as they are aseptic, may give rise to little or no disturbance, and are liable to be overlooked. The Roentgen rays are useful in determining the presence and position of a foreign body.

Infective complications are liable to follow injuries by bullets or fragments of shell, and they not only endanger the eyeball, but are liable to be associated with suppurative conditions in the adjacent air sinuses—frontal, maxillary, and ethmoidal—or in the cranial cavity. In purifying wounds of the orbit, and in extracting foreign bodies, great care is necessary to avoid injury of the eyeball or of its muscles or nerves.

Fracture of the margin of the orbit results from a direct blow, and is followed by circum-orbital and sub-conjunctival ecchymosis, and sometimes is associated with paralysis of the optic nerve, or of the other ocular nerves. Implication of the frontal sinus may be followed by emphysema of the orbit and lids, and if there is infection by suppurative complications.

The roof of the orbit is implicated in many fractures of the anterior fossa of the skull produced by indirect violence. It is also liable to be fractured by pointed instruments thrust through the orbit, in which case intra-cranial complications are prone to ensue, and these in a large proportion of cases prove fatal. When the medial wall is fractured and the nasal fossa opened into, epistaxis and emphysema of the orbit are constant symptoms. Sub-conjunctival ecchymosis, and some degree of exophthalmos, are almost always present. Treatment is directed towards the complications. When the nasal fossae or the air sinuses are opened into, the patient should be warned against blowing his nose, as this is liable to induce or increase emphysema of the orbit or lids.

Injuries of the Eyeball.—These injuries may be divided into two groups—(1) those in which the globe is contused without its outer coat being ruptured, and (2) those in which the outer coat is ruptured.

In cases belonging to the first group, while the sclerotic coat and cornea remain intact, the iris may be partly torn from its ciliary origin, and the blood effused collects in the lower portion of the anterior chamber; or the pupillary margin of the iris may be ruptured at several points, causing apparent dilatation of the pupil. The lens may be partly or completely dislocated, and in the latter case it may pass forward into the anterior chamber or backward into the vitreous. Among other injuries resulting from contusion of the eye may be mentioned haemorrhage into the vitreous, rupture of the choroid, and detachment of the retina.

Injuries in which the outer coat of the eyeball is ruptured may be further subdivided into two groups according to whether or not a foreign body is lodged in the globe.

Rupture of the outer coat, especially when it results from a punctured wound, adds greatly to the risk of the injury, by opening up a path through which infective material may enter the globe, and this risk is materially increased when a foreign body is retained in the cavity of the eyeball.

When the globe is burst by a blow with a blunt object, the sclerotic usually gives way, and as the rupture takes place from within outward, there is less risk of infection than in punctured wounds. The lens may be extruded through the wound, and the iris prolapsed. If the rupture is large, the conjunctiva torn, and the globe collapsed from loss of vitreous, the eye should be removed without delay. If sight is not entirely lost and there is no marked collapse of the globe, an attempt should be made to save the eye.

Wounds produced by stabs or punctures are liable to be followed by infective complications ending in panophthalmitis. When this is threatened, removal of the eye is indicated, not only because the affected eye is destroyed beyond hope of recovery, but to avoid the risk of "sympathetic ophthalmia" affecting the other eye.

Orbital Cellulitis.—Infection of the cellular tissue of the orbit by pyogenic bacteria is specially liable to follow punctured wounds and compound fractures, if a foreign body has lodged in the orbital cavity. It may also result from the spread of a suppurative process from the globe of the eye, the conjunctiva, or the nasal fossae or their accessory air sinuses. Both orbits may be affected simultaneously.

Clinical Features.—The disease is ushered in by rigors, high temperature, and severe pain, which radiates all over the affected side of the head. There is exophthalmos and fixation of the globe, with redness, swelling and tenderness of the eyelids, and congestion and ecchymosis of the conjunctiva. The pupil is usually dilated, the cornea becomes opaque and may ulcerate, and there is photophobia and sometimes diplopia. Suppuration usually ensues, and the pus burrows in every direction, and may ultimately point through the eyelids or conjunctiva. Sometimes the infection spreads to the meninges, and to the ophthalmic vein, and the phlebitis may then extend to the cavernous sinus. The eyeball may be infected and destructive panophthalmitis result. The prognosis therefore is always grave.

The treatment consists in making one or more incisions into the cellular tissue for the purpose of removing the pus and establishing drainage. A narrow bistoury is passed in parallel to the wall of the orbit, care being taken to avoid injuring the globe. When possible, the incision should be made through the reflection of the conjunctiva, but in some cases efficient drainage can only be established by incising through the lid. When the eye is destroyed by panophthalmitis, the propriety of eviscerating or enucleating it will have to be considered.

Tumours of the Orbit.—Tumours may originate in the orbit or may invade it by spreading from adjacent cavities. Those which originate in the orbit may be solid or cystic. Of the solid tumours the glioma and the sarcoma are the most common, and when they originate in the pigmented structures of the globe they present the characters of melanotic growths. Primary carcinoma begins in the lachrymal gland. Osteoma—usually the ivory variety—may originate in the wall of the orbit, or may spread from the adjacent sinuses.

Clinical Features.—In children, the tumour is usually a glioma, and it is frequently bilateral. It generally occurs before the age of four, is associated with increased intra-ocular tension, protrusion of the eyeball, and dilatation of the pupil, and soon produces blindness. The tumour fungates and bleeds, and rapidly invades adjacent structures and spreads along the optic nerve to the brain. It is highly malignant, and recurrence usually takes place, even when the tumour is removed early.

In adults melanotic sarcoma is most common. It occurs between the ages of forty and sixty, and is almost always unilateral; and while it shows little tendency to invade the brain, the adjacent lymph glands are early infected, and death usually results from dissemination.

In all varieties of intra-orbital tumour exophthalmos is a prominent feature (Figs. 238, 239), and when the protrusion of the eyeball is marked the lids become swollen, oedematous, and dusky. The eye is seldom pushed directly forward except when the tumour is growing in the optic nerve or its sheath. When the tumour is solid, the eye cannot be pressed back into the orbit, but in cystic tumours it may to some extent. The movements of the eyeball are restricted in a varying degree, and ptosis often results from paralysis of the levator palpebrae superioris. In almost all cases there is also more or less visual disturbance. The cornea being unduly exposed is liable to become inflamed, or even ulcerated. Pain is a variable symptom; when present, it usually radiates along the branches of the first and second divisions of the trigeminal nerve. Tenderness on pressure is not always present. It is comparatively uncommon for a tumour of the orbit to invade the globe directly.



Treatment.—When practicable, removal of the tumour is the only method of treatment, and in malignant tumours it is often necessary to sacrifice the eye to ensure complete removal. When the tumour has invaded the orbit secondarily, its removal may be impossible, but it may be necessary to remove the eye for the relief of pain.

The orbital dermoid usually occurs at the lateral end of the supra-orbital ridge (Fig. 240). A less common situation is the anterior part of the orbit, near the nasal wall, and this variety, from its position and from the fact that it is usually met with in children, is liable to be confused with orbital meningocele or encephalocele. Treatment consists in its removal by careful dissection, and this can usually be done under local anaesthesia.



Orbital aneurysms have already been described, Volume I., p. 317.

THE LIPS

Herpes of the lips, due to a mild staphylococcal infection, is common in delicate children and in the early stages of pneumonia. A crop of vesicles forms and, after bursting, these leave dry scabs.

A more severe staphylococcal infection may give rise to a carbuncular swelling with great oedema, and lead to infective phlebitis of the facial vein and general septicaemia. Excision of the focus is indicated.

The lip is sometimes the seat of the malignant pustule of anthrax.

Painful cracks and fissures are frequently met with in the middle line of the lip and at the angle of the mouth in young subjects. They usually develop during frosty weather, and as they are constantly being torn open by the movements of the mouth, they are difficult to heal. If local applications fail, it may be necessary to cocainise the fissure and scrape it with a sharp spoon.

Chronic Induration of the Lips (Strumous Lip).—A chronic oedematous infiltration, probably of the nature of a lymphangitis, sometimes affects the submucous tissue of the lips of delicate children. It is most common on the upper lip, and may be associated with a fissure or with chronic coryza. The lip is everted, and its mucous membrane unduly prominent. The cervical glands are frequently enlarged.

The treatment consists in removing the cause and in improving the general condition. In cases of long standing it may be necessary to remove from the inner aspect of the lip a horizontal strip of tissue having the shape of a segment of an orange.

The term "double lip" is applied to a condition occasionally met with in young men, in which there is a hypertrophy of the labial glands in the mucous membrane of the upper lip. It is of slow growth, and forms an elongated swelling on each side of the frenum, covering the teeth, and projecting the lip. It is shotty to the feel, and the only complaint is of disfigurement. The treatment consists in excising the redundant fold of mucous membrane, including the enlarged mucous glands.

Tuberculous disease may occur in the form of lupus or of ulcers. The ulcers generally occur in patients suffering from advanced pulmonary or laryngeal phthisis. They are usually superficial, may be single or multiple, and are exceedingly painful.

Syphilitic Lesions.—The upper lip is the most frequent seat of extra-genital chancre. The chancre of the lip begins on the mucous surface as a small crack or blister, which becomes the seat of a rounded, indurated swelling, about a quarter of an inch in diameter. The surface is smooth, of a greyish colour, and exudes a small quantity of sero-purulent fluid. The lip is swollen and everted, and there is a considerable area of induration around. The submental and submaxillary lymph glands on one or on both sides soon become enlarged, and may reach the size of a pigeon's egg. At first they are firm, but they may subsequently soften and become painful. In some cases the sore is much less characteristic, resembling an ordinary crack or fissure, and its true nature is only revealed when the secondary manifestations of syphilis appear.

Mucous patches and superficial ulcers are frequently met with on the mucous surface of the lips and at the angles of the mouth during the secondary stage of syphilis. In the inherited form of the disease deep cracks and fissures form, and often leave characteristic scars which radiate from the angles of the mouth.

Gummatous lesions occur on the lips, and are liable to be mistaken for epithelioma.

Tumours.—Naevi are not uncommon on the lips. When confined to the mucous surface they may be dissected out, but when they invade the skin they are best treated by electrolysis.

Lymphangioma.—The term macrocheilia is applied to a congenital hypertrophy of the lip (Fig. 241), which is probably of the nature of a lymphangioma (Middeldorpf). One or both lips may be affected. The lip is protruded, the mucous membrane everted, and, when the lower lip is implicated, it becomes pendulous and is liable to ulcerate. The substance of the lip is uniformly firm and rigid, so that it moves in one piece, and sucking, mastication, and phonation are interfered with.



The treatment consists in removing a wedge-shaped portion of the swelling on the same lines as for "strumous lip," or in employing electrolysis.

Mucous cysts occur as small rounded tumours, projecting from the inner surface of the lip. They are of a bluish colour, and contain a glairy fluid. They are treated by removal of the cyst wall, together with the overlying portion of mucous membrane.

Epithelioma of the lip is of the squamous-celled variety, and is met with either as a fungating wart-like projection, or as an indurated ulcer. It almost exclusively occurs on the lower lip of men over forty years of age. The growth begins about midway between the middle line and the angle of the mouth, either as a horny epidermal thickening, or as a warty excrescence, which bleeds readily and soon ulcerates. The affection is said to be especially common in those who smoke short clay pipes, and it is a suggestive fact that, while epithelioma of the lip is rare in women, the majority of those who do suffer are smokers.

The ulceration spreads along the lip, chiefly towards the angle of the mouth, and downwards towards the chin, and the substance of the lip becomes swollen and indurated (Figs. 242, 243). The edges are characteristically raised and hard, and the raw surface is extremely painful, especially when irritated by hot food or fluids. The growth is liable to spread to the mucous membrane and gum, and to invade the mandible. The disease spreads early to the submental and submaxillary glands, which are best felt with one finger inside the mouth, under the tongue, and another outside, behind the mandible. The infected glands tend to become fixed to the bone, and while at first extremely hard, so much so that they simulate a bony tumour of the jaw, they later soften, liquefy, and fungate (Fig. 244). Metastasis to internal organs is rare. Unless removed by operation, the disease usually proves fatal in from three to three and a half years.



The treatment consists in early and free removal of the affected portion of lip and of all the lymphatic connections in the submaxillary region and neck. Recurrence in the scar is rare; it is nearly always located in the glands.

The operation of cleaning out the glands below the mandible on both sides in men who are advanced in years is not free from risk to life, especially from respiratory complications which may or may not be traceable to the anaesthetic.

In inoperable cases benefit may follow the use of the X-rays, or of radium.

Epithelioma of the upper lip is less common. It occurs with equal frequency in the two sexes, progresses more slowly, and is, on the whole, less malignant. It sometimes appears to be due to contact infection from the lower lip. It is treated on the same lines as cancer of the lower lip.



CHAPTER XX

THE MOUTH, FAUCES, AND PHARYNX

Stomatitis—Roof of mouth: Abscess; Gumma; Tuberculous disease; Tumours—Elongation of uvula—Epithelioma of floor of mouth—Tonsillitis: Varieties—Hypertrophy of tonsils—Calculus—Syphilis and Tuberculosis—Tumours—Retro-pharyngeal abscess.

THE MOUTH

Stomatitis.—The term stomatitis is applied to any inflammation of the buccal mucous membrane. The catarrhal form is often associated with the presence of carious teeth or an infected wound; the mucous membrane is hyperaemic and swollen, and exudes an excessive amount of viscid mucous secretion, and the epithelium desquamates in patches, leaving small superficial erosions or ulcers, which are very sensitive. The aphthous form, met with in unhealthy, underfed children, is characterised by the occurrence of patches of fibrinous exudate into the superficial layers of the mucous membrane; the epithelium is shed, leaving a series of whitish spots surrounded by a red hyperaemic zone, which may become confluent and form small ulcers. The condition known as thrush, which closely resembles aphthous stomatitis, is met with in infants during the period of teething, and is due to the oidium albicans, a fungus met with in sour milk. The spots, which are most numerous on the lips, tongue, and throat, have the appearance of curdled milk.

The treatment of these forms consists in improving the general condition of the patient, and in employing a mouth-wash, such as peroxide of hydrogen, Condy's fluid, chlorate of potash, or boro-glyceride. The superficial ulcers may be touched with silver nitrate or with a 1 per cent. solution of chromic acid.

Ulcerative stomatitis is frequently met with in debilitated subjects with decayed teeth, and is specially liable to occur during the course of acute febrile diseases in which sordes accumulate about the teeth and gums. It also occurs in syphilitic subjects while under treatment by mercury—mercurial stomatitis. Some patients show a special susceptibility to mercury, and one of the first signs of intolerance of the drug is some degree of stomatitis, which may ensue after a comparatively small quantity has been administered. It begins in the gums, which become swollen and spongy, growing on to the teeth and into the interstices. The gums assume a bluish-red colour and bleed readily, and the teeth may become loose and fall out. The tongue may share in the swelling—mercurial glossitis. There is also profuse salivation, and the breath has a characteristically offensive odour. In severe cases the alveolar margin of the jaw undergoes necrosis. A similar condition occurs in lead and in phosphorus poisoning, and in patients suffering from scurvy.

The treatment consists in removing the cause, and in employing antiseptic and astringent mouth-washes. The internal administration of chlorate of potash is also indicated, as this drug is excreted in the saliva. Loose teeth should not be removed as they become fixed again when the stomatitis subsides.

Gangrenous stomatitis, or cancrum oris (Fig. 245), has already been described (Volume I., p. 102).



Roof of the Mouth.—Suppuration in the muco-periosteum of the palate is usually secondary to suppuration at the root of a carious tooth. It may also arise in excoriations caused by an ill-fitting tooth-plate, or from the impaction of a foreign body, such as a fish or game bone, in the mucous membrane. The inflammation begins close to the alveolus, and may spread back along the palate. The muco-periosteum becomes swollen, red, and exceedingly tender, and, as pus forms, is raised from the bone, forming a prominent, firm, elongated swelling, which on bursting or being incised gives exit to foul-smelling pus.

The syphilitic gumma, which begins as a rounded indolent swelling, is usually situated in the middle line near the posterior edge of the hard palate. The swelling gradually softens and ulcerates, and a sequestrum may separate and leave a perforation in the palate (Fig. 246). The treatment consists in employing the usual remedies for tertiary syphilis. If the perforation persists and causes trouble by allowing food to pass into the nose, or by giving a nasal tone to the voice, it may be closed by an operation on the same principle as that performed for cleft palate, or an obturator may be fitted to occlude the opening.



Tuberculous disease is chiefly met with in the form of lupus which has spread from the nose or lips, and it may lead to widespread destruction of the soft tissues, or even to perforation of the bony palate.

Mucous cysts, dermoids, adenomas, lipomas, and fibromas are occasionally met with. Papillomatous thickening of the mucous membrane sometimes occurs in association with leucoplakia. It resists anti-syphilitic treatment, but yields to scraping with the sharp spoon. Endotheliomas, or mixed tumours, similar to those met with in the parotid gland, also occur in young subjects, and grow in the submucous tissue of the soft palate, usually to one side of the middle line. In their early stages they are of slow growth, and give rise to no inconvenience save from their size, are easily removed, and show no tendency to recur. Later, they grow more rapidly, tend to infiltrate their surroundings and to assume malignant characters, so that complete removal becomes difficult or impossible.

Epithelioma may originate in the hard palate as a result of local irritation, or may spread from adjacent parts. When it is confined to the palate it is treated by removal of the palatal and alveolar portions of the maxilla.

Elongation of the uvula is usually due to a chronic inflammatory engorgement combined with glandular hypertrophy of the mucous membrane. It often occurs in children, and is associated with a constant hacking cough, which is usually worst when the patient is lying down. By tickling the back of the tongue and pharynx it may induce vomiting after meals. The treatment consists in snipping off the redundant portion with scissors.

Epithelioma of the floor of the mouth frequently originates in the mucous membrane between the frenum of the tongue and the inner aspect of the gum. It develops insidiously, grows slowly, and gradually spreads to the mandible and to the substance of the tongue, tacking it down so that it cannot be protruded. The glands are early involved, and their enlargement not infrequently first draws attention to the condition. It is to be regarded as a particularly unfavourable site, as local recurrence is frequent. For the complete removal of the disease it is necessary to excise the tissues in the floor of the mouth, and a variable portion of the tongue and mandible, and to clear out the glands and fat from the submaxillary and submental regions.