Manual of Surgery Volume II Part 51

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 pa.s.sed 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 a.s.sociated 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, dematous, 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.

[Ill.u.s.tration: FIG. 238.--Sarcoma of Orbit, causing exophthalmos and downward displacement of the eye, and projecting in temporal region.]

[Ill.u.s.tration: FIG. 239.--Sarcoma of Eyelid in a child.

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

_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.

[Ill.u.s.tration: FIG. 240.--Dermoid Cyst at outer angle of orbital margin.]

_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 dema, 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 sc.r.a.pe it with a sharp spoon.

_Chronic Induration of the Lips (Strumous Lip)._--A chronic dematous 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 a.s.sociated 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 l.a.b.i.al 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 quant.i.ty 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.

[Ill.u.s.tration: FIG. 241.--Macrocheilia.

(From a photograph lent by Sir H. J. Stiles.)]

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 h.o.r.n.y 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.

[Ill.u.s.tration: FIG. 242.--Squamous Epithelioma of Lower Lip in a man aet. 55.

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

[Ill.u.s.tration: FIG. 243.--Advanced Epithelioma of Lower Lip.]

[Ill.u.s.tration: FIG. 244.--Recurrent Epithelioma in Glands of Neck adherent to mandible.]

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 s.e.xes, 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

Stomat.i.tis--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

#Stomat.i.tis.#--The term stomat.i.tis is applied to any inflammation of the buccal mucous membrane. The _catarrhal_ form is often a.s.sociated 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 stomat.i.tis, is met with in infants during the period of teething, and is due to the _odium 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.