deal of care. External manipulation may first be tried, but it is generally necessary to introduce some instrument into the nostril to push out the bones. It must be remembered that the space between the nasal process of the superior maxilla and the septum is very narrow, and therefore only a very fine instrument can be used in order to push out the bones properly; to attempt to do it with ordinary dressing forceps is quite futile. A pair of fine sinus forceps, a curved probe-director, or, still better, a fine spatula should be employed. This is introduced into each nostril alternately, and the fragments gradually pushed up into position with the assistance of the fingers applied externally. The fragments may be retained in position by packing the upper part of the nostril with very narrow strips of cyanide gauze, applied with a fine firm probe; below this the nasal plug shown in Fig. 203 is inserted, in order to keep the packing in position and allow the patient to breathe.

T

The objection to this method is that the packing is difficult to apply owing to the narrowness of the nostril; that in a short time it becomes foul, and must therefore be frequently renewed; and that this renewal is apt to be followed by recurrence of the displacement, and may cause great pain. When, therefore, the fragments will not remain in position of themselves, it is better to use some external appliance, such as a metal band round the forehead, from which two arms project furnished with pads, which can be applied, one on each side of the bridge of the nose, and tightened up so as to keep the nasal bones in position (see Fig. 204). Mason suggested a simple method of keeping up the bridge in bad cases by passing one or more hare-lip pins from side to side through the nose beneath the fragments. These pins project on each side for about half an inch, and a good firm cork is pushed over each projecting end (see Fig. 205). The two pieces of cork on each pin are then pressed together, so as to exercise lateral pressure on the nasal bones, while the pin prevents the bridge from falling back. In many ways this is a more satisfactory arrangement than the apparatus just mentioned, because, while applying lateral pressure, it prevents the bones from falling back. No apparatus need be continued for more than three or four days, for by that time so much lymph and new material will have been thrown out, that the fragments will remain in position if care be taken not to blow the nose or to disturb it in any way.

Of Complications. The treatment of the various complications of these fractures presents few features of importance. The bleeding, even when severe, can usually be checked by affusion of cold water to the face, by syringing the nostrils with ice-cold water, or by the application of a small ice-bag to the side of the nose. When the bleeding is really alarming as it may be if the nasal artery has been torn-it may be advisable to plug the nares. The plugs must be carefully introduced into the upper part of the nose and packed in place with a firm probe, taking care not to push in too large a mass at a time. They should be impregnated with adrenalin chloride (1 in 1000); and they also help to support the bridge of the nose.

If emphysema is present, no special treatment is required beyond keeping the nostril on the affected side clear by repeated syringing with warm normal salt solution; the patient should be cautioned

FIG. 205.-MASON'S METHOD OF SUPPORTING THE BRIDGE OF THE NOSE AFTER FRACTURE. The lateral pressure of the pieces of cork help to keep the nasal bones inclined at the proper angle to one another. If the cork becomes loose a figure-of-eight silk suture will keep them from slipping.

not to blow the nose. The emphysema will subside readily and give no further trouble. The treatment of epiphora will be mainly directed to careful re-position of the fragments, the nasal duct being kept open by the regular introduction of suitable probes. If there is any cerebral injury, the case must be treated on the lines laid down for fracture of the base of the skull (see p. 352), the fracture of the nasal bones being of secondary importance; nevertheless, care should be taken to remedy the deformity.

Compound fracture in this situation is not usually accompanied by serious symptoms. Healing takes place readily, septic infection seldom. gains a foothold and necrosis of the fragments very rarely occurs. When the fracture is compound through the skin, the wound should be purified in the ordinary manner, special care being taken to prevent the strong lotions from getting into the eyes. The edges of the wound should be brought together as accurately as possible with fine horse-hair sutures. Should the wound become septic, large boric fomentations should

be employed, combined with frequent douching of the nasal cavity with warm normal saline solution.

Of long-standing Deformity.-The surgeon is sometimes consulted with regard to old cases of fracture of the nose, in which there has been considerable loss of substance or marked depression of the bridge, or in which coal-dust or other material has been ground into the soft parts, leaving an unsightly or pigmented scar; the latter condition. has already been referred to on p. 446. The possibility of remedying the permanent deformities of the nasal bones frequently requires very careful consideration. At an early period the bones may be loosened at the line of fracture by introducing a narrow chisel through small incisions in the skin, and they may then be brought into position by lateral pressure, either by the hare-lip pins or by the pads on each side of the nose mentioned above. Sometimes, however, the fracture is of such long standing and consequently so firm that the deformity cannot be remedied in this way. When the bridge of the nose is much depressed, the tilting forward of the nostrils is in itself so unsightly that a more elaborate operation must be performed, similar to that employed for cases in which the bridge of the nose has been lost from disease; in some cases the subcutaneous injection of paraffin may suffice. These operations are described in connection with the plastic surgery of the face (see Chapter XLI.).

CHAPTER XXXIX.

AFFECTIONS OF THE LIPS.

WOUNDS.

THERE are only a few points of special interest in connection with wounds of the lips. Healing is rapid and satisfactory.

TREATMENT.-A most important point in closing these wounds is to see that the red line of the lip is brought into accurate position. Buried sutures cannot be used when the wound has been inflicted accidentally, on account of the soiling and consequent risk of sepsis. The sutures should be inserted with a round sewing-needle; fine horse-hair should be used for the skin, whilst catgut may be employed for the mucous membrane. It is well to suture the whole of the wound on the mucous surface with catgut. No dressing is required; the line of incision is dusted with boric acid powder, and a scab forms, under which healing takes place readily. When there has been much loss of substance of the lips, some form of plastic operation will be necessary (see Chapter XLI.).

INFLAMMATORY AFFECTIONS.

There is little of importance to say concerning these affections. Gangrene of the lips may occur, and is usually the result of cancrum oris, a disease already described (see Vol. I. p. 85), and seldom seen nowadays.

CRACKS AND FISSURES OF THE LIPS.

These rather painful affections are not uncommon in cold weather and cause great inconvenience from their constant liability to be torn open. They may also become infected, and acute inflammation or erysipelas may result.

TREATMENT.-The lips should be kept moist with glycerine jelly, and a piece of goldbeater's skin should be placed over the fissure to protect it from irritation. The fissure generally heals quickly under these circumstances.

HYPERTROPHY OF THE LIPS.

In weakly children of the tuberculous type, it is not at all uncommon to meet with considerable thickening and overgrowth of the lipsespecially the upper-with eversion of the mucous membrane. This is usually due to chronic inflammation, especially of the lymphatic vessels, following cracks and fissures of the lip. It may also follow the excoriation of the skin of the upper lip, which occurs in children suffering from chronic coryza. Although it is commonly met with in tuberculous children, there is no evidence of any actual deposit of tuberculous material.

TREATMENT.-The first point is to treat the excoriation and cracks so as to obtain healing as quickly as possible (vide supra). When the fissure is deep, and has existed for some time, it may be advisable to excise it and bring the edges together with fine catgut stitches. The general condition of the patient must also be attended to, the food should be light and nourishing, and the child should be placed in good hygienic surroundings. As regards medicines, cod-liver oil and iron are often of great value.

In some cases the thickening of the lip may be so marked and permanent that the surgeon is called upon to remedy the deformity. This is done by excising a horizontal strip of the mucous membrane and submucous tissue from the inner surface of the lip. An elliptical incision is made through the mucous membrane, enclosing a piece varying in breadth according to the amount of deformity. The upper border of the incision. should run parallel to the red line, enough of the mucous membrane being left between the two to represent the normal thickness of the lip. In depth the wound is made wedge-shaped, so that the piece excised resembles a segment of an orange, the outer surface of which corresponds to the mucous surface of the lip. The bleeding is usually slight and is readily arrested by torsion. The edges of the incision are brought together by two or three fine catgut stitches, and healing is rapid.

TUBERCULOUS AFFECTIONS.

Tuberculous ulcerations may be met with either on the mucous membrane or the skin, and may take the form of lupus or of the ordinary tuberculous ulcers.

LUPUS.

Lupus of the upper lip is usually an extension from disease of the nose or cheek. The treatment is discussed in Vol. II. p. 15.