Manual of Surgery Volume II Part 50

[Ill.u.s.tration: FIG. 236.--Asymmetrical Cleft Palate extending through alveolar process on left side.]

_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 tw.a.n.g, 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 a.s.sured. 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 pa.s.ses 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 pa.s.sing 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 a.s.sociated 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 st.i.tches, 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 st.i.tches.

_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.

[Ill.u.s.tration: FIG. 237.--Ill.u.s.trating the deformities caused by Lupus Vulgaris, which dated from adolescence.

(Mr. D. M. Greig's case.)]

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 a.s.sociated 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 ca.n.a.liculus 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 ca.n.a.liculi.

_Contusion_ of the eyelids and circ.u.m-orbital region--the ordinary "black eye"--is a.s.sociated 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 ma.s.sage 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 Rontgen 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 sh.e.l.l, and they not only endanger the eyeball, but are liable to be a.s.sociated 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 circ.u.m-orbital and sub-conjunctival ecchymosis, and sometimes is a.s.sociated 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 p.r.o.ne 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 pa.s.s 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.