Manual of Surgery Volume II Part 49

[Ill.u.s.tration: FIG. 228.--Scoliosis with primary curve in Thoracic Region.]

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 p.u.b.erty, 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 s.p.a.ces on the side of the convexity. To relieve the muscles of the back she is inclined to lounge in easy and ungainly att.i.tudes.

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 s.p.a.ce 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 b.r.e.a.s.t.s are asymmetrical, and the right nipple is on a higher level than the left.

[Ill.u.s.tration: FIG. 229.--Scoliosis showing rotation of bodies of vertebrae, and widening of intercostal s.p.a.ces on side of convexity.]

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 att.i.tudes; 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 att.i.tudes. 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 a.s.sume awkward att.i.tudes 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 100-110 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 should be used. In weakly girls approaching the period of p.u.b.erty, 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 gla.s.ses. 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 a.s.sume the correct posture; on opening the eyes, the faulty att.i.tude 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 ma.s.sage 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.

_a.s.sume 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 b.a.l.l.s of toes. 7. _Keynote position_: rise on to b.a.l.l.s 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" att.i.tude, 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 ma.s.sage are useful adjuvants to the exercises.

[Ill.u.s.tration: FIG. 230.--Diagram of att.i.tudes in Klapp's four-footed exercises for Scoliosis.]

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 att.i.tude; 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.

[Ill.u.s.tration: FIG. 231.--Head of human embryo about 29 days old, showing the division of the lower part of the mesial frontal process into the two globular processes, the intervention of the nasal clefts between the mesial and lateral nasal processes, and the approximation of the maxillary and lateral nasal processes, which, however, are separated by the nasal-orbital cleft. (After His.)]

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 a.s.sociated 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 a.s.sociated with cleft palate.

#Lateral hare-lip# is much more common. It is due to imperfect fusion of the globular process with the l.a.b.i.al 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 pa.s.ses 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).

[Ill.u.s.tration: FIG. 232.--Simple Hare-lip.]

[Ill.u.s.tration: FIG. 233.--Unilateral Hare-lip with Cleft Alveolus.]

When the hare-lip is _bilateral_, the two clefts may be unequal, one forming a simple notch in the lip, the other pa.s.sing 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.

[Ill.u.s.tration: FIG. 234.--Double Hare-lip in a girl aet. 17.]

[Ill.u.s.tration: FIG. 235.--Double Hare-lip with Projection of Os Incisivum, in an infant before first dent.i.tion.]

#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 pa.s.ses 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).