Chapter XXXVII (2)

All sorts and descriptions of foreign bodies may enter the ear. Young children have a tendency to introduce all kinds of bodies into the ear, as into the nose, and sometimes intrude them to such a distance that their removal is made difficult. Living insects make their way into the meatus auditorius and even deposit their larvæ, which may subsequently go through their developmental phases and fill the passage-way with young insects. Among the inanimate materials which children introduce are small buttons, pebbles, beans, peas, beads, etc. Such a foreign body may not be at once discovered, and some of those which easily undergo decomposition, like fresh vegetable substances, may not be detected until they have set up trouble by decomposition. Therefore it may be hours or days before its presence is recognized. Sometimes it may be easily seen, again it may be concealed. When the auricle is drawn upward and backward the external meatus is somewhat straightened, and bodies within it are more easily made visible, especially by reflected light. Therefore the head mirror is usually required for their detection and removal. The substance may be one which is easily seized and withdrawn, after certain turning or shifting motions have been attempted, or it may be impacted so as to offer considerable difficulties. It should never be pushed farther in, for injury might thus be done to the membrana tympani, and the effort should be to remove it with the least possible damage to the lining of the canal. So essential is it to have the head kept perfectly still during these maneuvers that it will be advisable, with young children, to administer an anesthetic. Instances occasionally occur which necessitate incision and liberation of the auricle, with its deflection forward, and the consequent more complete exposure of the auditory canal. Forceps of various fashions may be used, or occasionally a blunt hook may be made with a probe, which may be used to advantage.

Of living foreign bodies information can be obtained more promptly, as the annoyance caused by their movements will at once disturb the patient.

Relief has often been promptly afforded by filling the meatus with water or glycerin as warm as can be borne, by which the insect is killed, after which it may be removed by irrigation or by forceps, assisted by good illumination.

That which is essentially a foreign body may be produced by an _accumulation of cerumen_ in wax-like form within the auditory canal. Neglectful patients sometimes allow this to accumulate until it constitutes not only a source of irritation but an obstacle to hearing. Its removal is not ordinarily accompanied by difficulty, but requires patience and often considerable effort, not only with instruments, but with irrigation, especially with an alkaline solution, by which the waxy substance is softened.

A phenomenon noted in many of these cases, where instrumentation has to be practised within the vicinity of the middle ear, is coughing or sneezing, sometimes to a degree which interferes with the work to be done. This is a reflex to be explained through connection with the pneumogastric nerve.

THE EXTERNAL AUDITORY CANAL.

In the fibrocartilaginous as well as in the more richly cellular portions of this passage-way small phlegmonous processes frequently occur. They give rise to an amount of suffering, and even of sympathetic reaction, disproportionate to the extent of the difficulty. They are called furuncles, or boils, sometimes occurring singly, often in groups. A commencing process of this kind may be cut short by the use of an ointment of 1 to 2 per cent. yellow sulphate of mercury, but after the furuncle is well developed it is best treated by free incision, which can be made with the freezing spray, and without much pain to the patient.

More extensive phlegmonous destruction, assuming even carbuncular form, is occasionally met with in this region. There will be more or less necrosis of tissue in such cases, which will require removal, usually with the sharp spoon. These cases are not without their danger, since the veins connect so freely with the interior of the cranium.

_Hyperostosis_ and _exostosis_ produce either a narrowing of the auditory canal or its complete obstruction, and sometimes even the formation of an osseous tumor of considerable size. A thickening and even new formation of bone may be the result of the chronic irritative processes which frequently occur in the middle ear, but many of these conditions occur in the newborn, in whom they are to be regarded as congenital excesses and in whom they frequently cause permanent impairment or loss of hearing. Some of the osteomas in this region are of bone-like hardness, their density being sufficient to dull or even to break the finest tempered steel instruments.

A small exostosis may be removed with the ordinary instruments of the surgeon or the dental engine, but the larger and more dense growths offer formidable difficulties for the operator and uncertain results for the patient. When growths of this kind attain considerable size they should not be attacked through the natural passages, but the auricle should be separated and pushed forward and the auditory canal opened.

THE MIDDLE EAR.

The middle ear has for its external boundary the membrana tympani, which, for clinical purposes, constitutes a limit beyond which the general surgeon should not trespass, the structures within being those within the field of the aural surgeon. Nevertheless the student of surgery should realize that the membrane of the drum may be ruptured in consequence of a blow upon the external ear, or perhaps by the sudden condensation of air produced by explosions, etc. It may, moreover, be lacerated in consequence of various injuries to the head, basal fractures, etc., even those involving the opposite side of the head; it may also be injured by foreign bodies, introduced usually from without and through the canal. While this membrane has normally an opening by which air pressure is equalized on either side, this seems to play but a small part in the liability to or exemption from injury such as just described. The membrane has its own blood supply, which can become congested to a degree permitting considerable escape of blood after laceration. It does not follow that bleeding from the ear is necessarily an indication of basal fracture, after injuries of the head, unless the hemorrhage is continuous and considerable, in which case it may be stated that the injury must be deeper and more extensive than one of the membrane alone. If, however, cerebrospinal fluid can be detected as escaping with and diluting the blood, or escaping independently, then the diagnosis of basal fracture may be regarded as certain.

After such injuries as lead to hemorrhages from the ear the external auditory canal, should be irrigated and protected against infection by light tamponing, etc.

It is the writer’s opinion that the general surgeon should abstain from operative intervention in the ordinary diseases of the middle ear, save in the presence of symptoms which accompany mastoiditis, acute infections of the sinuses, or even of the brain itself. When it comes to an extensive operation, such as is often required in such instances, including not merely opening of the mastoid antrum and cells, but exposing the dura and judging of the condition of the sinus, with perhaps the simultaneous ligation of the jugular in the neck and washing out of the intervening portion, then these are measures requiring such surgical judgment and operative skill that it would seem that the general surgeon should be peculiarly equipped for this task. But the ordinary office operations should be left to those who make a specialty of these diseases.

When the cavity of the tympanum is involved in a suppurative condition, with caries of the surrounding bone and extension into the spongy tissue of the adjoining mastoid, this abscess cavity should be cleaned out. Therefore the more radical operations of the aurist, by which the membrana tympani is destroyed, the ossicles of the ear removed, etc., are but applications of broad surgical principles to a limited region of the body, but made justifiable by their results. Moreover, in a more chronic type of cases, where the tympanum is filled by redundant granulation tissue and by polypoid formations, which are producing more or less circumscribed caries or necrotic processes in the bone, by which bony partitions between the cranial cavity and the ear proper are gradually thinned or lost, and by which encroachment on the intracranial sinuses with all its dangers is incurred, they are still to be subjected to the same general radical methods of treatment, no matter whether it be carried out by a specialist or a general operator.

THE ACCESSORY CRANIOFACIAL SINUSES.

While these cranial cavities are connected with the respiratory tract there are, nevertheless, good topographical and physiological reasons for considering their lesions in this place. There is free venous communication between each of them and the cranial cavity, and free lymphatic communication as well from at least three of them. Infection, therefore, may and often does travel from the smaller to the greater cavity, and thrombophlebitis, brain abscess, or purulent meningitis may be the ultimate result of apparently trifling infection of one of the sinuses.

They are four in number--the _frontal_, the _ethmoidal_, the _sphenoidal_, and the _maxillary_, or antrum of Highmore. They are all connected with the nasal cavity, and all lined with the same Schneiderian membrane, which affords a continuous pathway of infection. At least two of them are cellular in character, much resembling the mastoid cells. Their means of communication with the nasal cavity are small, and often obstructed by catarrhal swelling and inspissated discharge. If thus plugged their retained contents may undergo decomposition and intensify the trouble. It has been shown that the effect of inward currents of air through the nostrils is to suck out from these sinuses more or less of their secretion. In this way perhaps may be accounted for the strings of tenacious mucopus which slowly make their way out of especially the anterior sinus openings. Some surgeons believe that if one sinus is affected all the others on that side of the head are more or less involved; while this may be true in many cases, and is easily explained on anatomical grounds, it is not strictly true of all instances, least of all in cases of chronic empyema of the antrum, which often long remains simple and uncomplicated.

Surgical lesions within the accessory sinuses result from infective processes, proceed often to suppuration, often, too, with caries of the surrounding spongy bone as well. These conditions may result from the ordinary acute catarrhs, or follow the more specific fevers, like influenza and the exanthems, and frequently follow diphtheria. Traumatic causes may also conspire to produce the same effect. In the maxillary sinus disease is often due to extension upward from carious teeth. In syphilitic and tuberculous patients these affections will partake to a greater or less degree of the specific nature of these diseases.

_Symptoms_ differ according to location and are often obscure enough to make diagnosis difficult. Perhaps the most prominent symptom is _pain_, either deep-seated, vague, or disquieting, located in the neighborhood of the diseased sinus; or intense and neuralgic in character, radiating from the source of the trouble. Its severity is proportionate to the acuteness of the case. When the frontal and maxillary sinuses are involved there occur external swelling and tenderness. If the sinus openings be patulous there will be more or less purulent discharge into the nasal cavity, that which comes down from the upper sinuses appearing beneath the middle turbinate body. Transillumination by means of a small electric light, passed into the nostril, will demonstrate an opacity in the region of the affected sinus which does not appear on the healthy side. The condition is frequently associated with nasal polypi, small or large; while granulations in time spring up within these cavities and may even escape therefrom as these become filled. The general clinical picture is one of nasal obstruction, with more or less constant discharge, sometimes mucopurulent, sometimes offensive, which perhaps may be favored by certain positions of the head, this being especially true of the maxillary antrum. Along with these features go a degree of headache, of local pain, and even of mild or severe febrile disturbances, proportionate to the severity of the lesions which produce them.

When the anterior ethmoid cells are involved pain is usually referred to the temples rather than the forehead, though both may suffer alike.

_Treatment_ should be based upon the fact that we have affected and infected cavities whose interiors are diseased, and whose outlets are blocked. The more free and thorough the drainage and the cleansing which can be given, the more prompt the results. In all well-marked cases, then, radical treatment is indicated. The ordinary treatment by sprays, inhalations, etc., is useless, as the source of the trouble is not reached.

Special treatment for each sinus will now be considered.

_Frontal Sinus._--Most of the symptoms of affection of the frontal sinus are objective, and there is frequently external swelling, with tenderness and edema. For its relief intranasal methods will often suffice. In almost all cases we may expect to find hypertrophic conditions within the nose. When empyema exists there is often a deviated septum. It is impossible to avoid the conclusion that there is a strong relation between hypertrophic lesions and sinus retention. The difficulty may arise from many causes, most of which lead to sneezing, coughing, and hacking, by which the mucous membrane of the nasopharynx is both thickened, loosened, and predisposed to polypoid changes. The irregularities thus produced harbor more germs than usual and their effect is, in a measure, proportionate to their numbers. For the examination of the upper part of the nasal cavity Killian’s speculum is of great help.

The frontal sinus differs very much in shape and size, not only in different individuals but on opposite sides of the same individual. It may be rudimentary upon one side and large upon the other. It is usually more capacious in those individuals who have prominent foreheads and resonant voices. Here, as elsewhere, it will usually be found that the most radical operation is the best, although one endeavors naturally to preserve cosmetic features of the nose, so far as he can, without sacrificing the patient’s interests. The nasopharyngeal duct is so often connected with the ethmoidal cells, as well as the frontal, that the former may be easily affected when the frontal sinus is diseased.

In case of sinus disease, especially when the frontal sinus is involved, it is better to encourage patients to snuff materials back into the throat rather than to forcibly blow the nose or expectorate them, as the latter would tend to force into the sinus that which it would be better to have aspirated out of it.

The frontal sinuses may be attacked from within the nose or externally. It is perhaps the least open to mild and conservative treatment, as it is the most difficult of access by non-operative methods. The anterior ethmoid cells are usually connected with it and infection rarely spares one part to involve the other alone. Therefore if it be necessary to operate on the frontal sinus the anterior and upper cells should be exposed at the same time. Thus operations which have for their object continuous drainage have usually as an objection the necessity for wearing the drainage tube for months. After opening the sinus from without the nasal duct may be enlarged to any size and desired degree, and a tube inserted which shall afford ample drainage downward. This may be covered with a flap and allowed to remain for a number of weeks. Nevertheless it is a foreign body which has to be subsequently removed from the nose. Killian’s method is doubtless the best for most cases, as the most anterior of the ethmoid cells, and those which extend over the orbits, cannot be easily reached through the nose, and if disease involve the posterior ethmoid cells its extension to the sphenoid may be expected. The operation includes an incision from the temporal end of the shaved eyebrow, along its curve to the side of the nose, and down to the middle of the nasal processes. The periosteum is divided along a line a little higher, and again in the centre of the frontal process, the intent being to so remove it that a bony bridge may be left after removal of the anterior lower wall of the sinus. The first periosteal incision should correspond to the upper border of this bridge, either above or below it. The sinus is opened at first with a chisel, afterward with bone forceps or surgical engine. It is then completely scraped out, leaving the supra-orbital ridge for a bridge. Its floor is resected along with the frontal process of the superior maxilla. Through this opening the anterior and middle ethmoid cells may be reached and cleaned out to the middle turbinate. The ethmoid cells may then be attacked, the sphenoidal cells inspected, and also attacked if necessary. The opening into the nose should be made free, and a flap should be formed from the nasal mucoperiosteum, so that there may remain a permanent opening of sufficient size. This method may be modified to suit various needs. After doing all the work necessary the external wound is closed, with a tube for drainage, while the formation of the bridge above alluded to prevents much of the sinking in of the anterior wall of the sinus, which would otherwise occur. If the little pulley over the superior oblique muscle has been interfered with in the operation or loosened from its attachment there will be at least temporary and perhaps permanent diplopia. This should be carefully avoided. There is also danger of injury to the contents of the orbit. For some time after the operation there will be some drooping of the upper lid. Nevertheless the results are usually satisfactory. After the operation the patient should be permitted to lie upon the healthy side and be forbidden to blow his nose; he should rather attempt to aspirate the fluid from the wound. If necessary both sinuses can be attacked at the same time and after the same fashion, the septum being removed.

Here as with the other sinuses the test of the efficacy of the treatment will be furnished by relief of the headache, pressure, and pain. Should carious or necrotic bone be exposed, or should there be indications of malignancy, much more radical surgery would be indicated.

_The Ethmoidal and Sphenoidal Cells._--For the exposure of these, especially the latter, it is necessary to make room for work. This would be true even in normal cases, and is still more so when the parts are hypertrophied and the passage-way is obstructed. It is necessary at least to remove all deviated portions of the nasal septum, and to clear away not only all hypertrophies of the turbinates, but to remove more or less of these bones. With a free passage-way it is possible to expose the opening of the sphenoidal cells, whose anterior wall may then be broken down, after which granulations may be removed with an appropriate small spoon, or the purulent contents cleaned out with swabs.

In dealing with the ethmoidal cells by intranasal methods it is necessary to break down the slight compartments between them, one after another, because of the fact that they all constitute foci of disease. An opening at least 2 Cm. in length will usually be required, and can be comfortably made, under suitable illumination, if all obstructions have been removed; after this a probe is gently passed upward and alongside of the nasal septum until it rests against the ethmoid, then passed backward until it meets the posterior wall, which will be in the immediate neighborhood of the sphenoidal opening, through which, by gentle manipulation, it may be passed. At this point the presence of polyps or a greatly thickened mucosa may be detected by palpation with the finger within the nasopharynx, while should pus be removed by the end of the probe it would indicate empyema of this cavity.

In all these accessory nasal sinus examinations and operations the greatest aid will be afforded by cocaine solution, which has the double advantage of not merely abolishing sensation, but of contracting and rendering anemic the mucous membranes, and thus to a certain extent shrinking them. When necessary for this latter purpose, or for the control of hemorrhage, adrenalin may be added to the cocaine. For all these purposes a spray of a mild solution may be first used, for its general benumbing effect, after which it would be advisable to use a strong solution, even saturated, very sparingly, applying it by the aid of illumination just to the area where the effect is desired, and not allowing it to come in contact with other parts of the nasal cavity; this is done to avoid unpleasant symptoms from cocaine absorption. Another benefit obtained from the use of cocaine is in thus abolishing sensation to an extent which does away with reflex vasomotor symptoms, shock, etc. Therefore even when a general anesthetic is used it will be well to use at least a small amount of it for this latter purpose.

The question of instruments and of methods will depend much on the equipment of the operator and his expertness in the necessary technique.

_The Maxillary Antrum of Highmore._--This is the largest of the accessory sinuses, the most easily approached, and the one whose disturbance is most quickly and easily appreciated. It may be infected by continuity, along the Schneiderian membrane which lines it, or by extension upward of disease from carious teeth, as well as after a variety of injuries involving its integrity. So long as its opening into the nose be not plugged it will, when involved in catarrhal or suppurative inflammation, discharge into the latter a characteristic fluid, which is especially likely to escape when the head is held downward and to the opposite side. Any statement of this fact, coupled with evidences of local inflammation, should enable an easy recognition of antral disease. In more chronic cases it becomes blocked by thickening of its membrane, the production of granulations or of polypi, which sometimes completely fill it. When thus plugged and filled there is a tendency to protrusion of its anterior outer wall and floor, while the overlying cheek may become somewhat edematous, the parts at the same time being tender. The pain from a diseased antrum will often induce the patient to go to the dentist for extraction of a molar tooth, which, however, affords little relief.

The relief for chronic antral disease is surgical, as in the case of the other sinuses. Opening the antrum through a tooth socket would seem judicious only when a diseased tooth is the cause of the lesion. It is useful only for such otherwise uncomplicated cases. The argument usually used in its favor is that it affords better drainage. This, however, is not the case, since the position assumed by the head for the greater part of the time does not locate such an opening in the most dependent part of the cavity. Moreover, the discharge is not always fluid, nor does it flow freely; on the contrary it is often thick, and so adherent to the wall or roof of the cavity that it takes a strong irrigating stream or swab to dislodge it. If the antrum is to be opened through the mouth it would seem more surgical to open it widely, cleanse it, and then either drain it or close it again. Other things being equal, the best method is that which permits of both examination and subsequent treatment. Jansen’s method is frequently most serviceable. It includes careful cleansing of the teeth, with disinfection of the mouth, and walling off the area to be exposed by gauze strips in order to prevent hemorrhage into the throat. An incision is made through the anterior mucoperiosteum, beneath the floor of the antrum, from the first incisor to the first molar. Its edges are then separated and the entire front wall of the antrum removed. Through such an opening its interior can be carefully inspected and cleansed. Should it seem desirable to go farther the inner wall may be removed by forceps, and through this opening the ethmoid cells can be seen and curetted up to the insertion of the middle turbinate. Then the sphenoid surface can be inspected and the lower portion of the sphenoid cells resected. Finally a good-sized counteropening is made inward, onto the floor of the nose, the antrum is loosely packed, the ends of the gauze extending into the nose, and the mucoperiosteal wound closed, in order to secure primary union. All bone edges should be made smooth and non-irritating; the sphenoidal cells should not be packed, but left open for subsequent treatment.

In the presence of bone disease, malignant growth, etc., it may not be possible to shut off the mouth again from the antral cavity. In such cases the packing may be made more snug and the granulation process will have to be substituted for sutures.

Special flaps or plastic methods should be devised for special cases, as, for instance, the formation of a mucoperiosteal flap from the outer side of the antral wall and its union posteriorly within the cavity of the antrum with another made from the antral floor. By turning the latter in the necessary direction a line of suture may be made through the mouth. Any such cavity, long diseased, will call for a radical method of attack and opening, which latter can be maintained to permit of subsequent treatment, as an early closure would sometimes be undesirable. Antral cavities thus left more or less open should be treated with cleansing sprays or applications, and with such stimulating applications as silver nitrate in various strengths of solution, or similar antiseptic stimulants.

THE CRANIAL NERVES.

While most of the affections of the nerves are considered to be non-operative, and to belong rather to the internist than to the surgeon, there are, nevertheless, some nerve lesions which are only to be relieved by surgical intervention. These may be divided into: (1) _Wounds and injuries._ (2) _Morbid conditions_, such as (_a_) _neuralgia_, and (_b_) _muscle spasm_.

WOUNDS OF THE NERVES.

Wounds of nerves have been considered in the chapter on Wounds, and the possibility of nerve regeneration and repair therein discussed. In every division of a nerve trunk of importance or size the nerve ends should be trimmed and reunited by a suture, passed either through the sheaths or through the nerve itself. The ends should be brought together securely and the tension should not be too great. If this be promptly done the best of results may be expected. This is equally true of cranial and peripheral nerves. Clinical experience has long since established the necessity of this procedure after all such injuries, and _nerve suture_, or _neurorrhaphy_, is now a standard operation. Later there was added to this measure the analogous one of _nerve grafting_, and it has been found that nerves can be juggled with just as can tendons, as described in the section on Tendon Suture. Indeed the methods of nerve suture and _nerve grafting_ are strikingly similar to those employed with tendons, where can be made either end-to-end junction, lateral implantation, or a more properly termed _grafting_, a trimmed end of one nerve being inserted into another. In the arm, when the ulnar nerve has been caught in callus and completely destroyed, both the upper and lower portions may be grafted into one of the adjoining nerves, _e. g._, the median; this procedure seems to reëstablish communication and serve the double purpose, in a manner corresponding to duplex or quadruplex telegraphy over one wire. Nerves which have been divided and entangled in scars may be disengaged, their ends trimmed off and approximated, success being proportionate to the length of time during which nerve degeneration may have been taking place.

Another operation is practised on nerves, solely for the relief of painful or disturbing symptoms, _i. e._, _neurectomy_. In cases of intractable and hopeless neuralgia, where other measures fail, sensory or complex nerve trunks are divided, a portion of the continuity being resected. This operation is practised more often upon the trifacial nerve than upon all others. It is generally successful, but in those cases where pain is due to some central lesion it is often palliative rather than curative. In the case of the trifacial nerve the operator endeavors to be as radical as possible in its practice, and to remove the Gasserian ganglion rather than portions of any of its branches.

The neuralgia for which these operations are performed may be due either to central or constitutional causes, as well as to local irritations, compressions, or degenerations. The term neuralgia itself is so vague and covers such widely differing changes that nothing which can be said in this place would clear up the problems of its pathology; consequently attention will be directed here solely to its surgical relief in connection with the various nerve trunks which are usually attacked.

One other operation is practised upon nerves for the relief of pain and spasmodic affections--namely, _nerve stretching_, or nerve _elongation_. This is practised more often upon the sciatic than upon any other nerve, but has been done for the relief of choreic spasm of the arm and shoulder, by exposing and stretching the various cords of the brachial plexus, for the relief of spasmodic torticollis, and in various other places. Nussbaum was the first to note that obstinate intercostal neuralgia was relieved by accidental stretching of an intercostal nerve, and introduced the procedure.

Various incisions for reaching different branches of the trifacial nerve: _a_, supra-orbital; _b_, external nasal; _c_, Bruns’ incision; _d_, inf. dent. at mental foramen; _e_, internal nasal; _f_, infra-orbital; _g_, Carnochan’s incision. (Marion.)]

Operations upon nerves, then, include _suture_, _grafting_, _stretching_, _division_, and _resection_. After any operation upon a nerve trunk the parts pertaining to it should be placed in a position of rest; and, furthermore, such position as will prevent stretching and favor relaxation of the sutured trunk should be maintained. The writer is credited with the first primary suture of the sciatic nerve, which was done immediately after its accidental division, during the course of an extensive operation. Recovery was prompt and complete. The limb was immobilized in the extended position and physiological rest thus maintained.

Nerves can be stretched, it has been found, to one-twentieth of their length. Nerve trunks have much more strength than has been generally appreciated. The sciatic trunk of a full-grown individual will bear a stress of more than eighty pounds, while even six pounds’ pull are necessary to tear the supra-orbital nerve. The benefit which follows nerve elongation is ascribed to the improvement in its nutrition produced by the damage done to its substance, and the consequently enhanced blood supply, as well as to the severing of adhesions between the sheath and its surroundings and between the nerve bundles within the sheath.

The operation of nerve stretching consists simply in exposing the nerve at a site of election, detaching it from its surroundings, and then hooking either the finger or some smaller instrument beneath it and pulling firmly, yet gently, in both directions; in the case of the sciatic, for instance, the entire limb should be lifted from the table, and even this does not entail upon the nerve trunk anywhere near a breaking force.

The _cranial nerves_ are sought, found, and treated as follows, in their respective cases:

The _supra-orbital nerve_ is attacked at its exit from the supra-orbital notch, which can usually be felt, or foramen, when such exists, either by a straight incision made directly over it, where it can be felt, or by a curved incision through the region of the eyebrow, which should have been shaved for the purpose, the resulting scar being hidden by the hair as it grows again.

The _infra-orbital nerve_ is similarly treated at the infra-orbital foramen, where it lies under the levator labii superioris. It may be exposed by either a curved incision, parallel to the orbital margin, or by a vertical incision, which will leave a more disfiguring scar.

The _second branch of the fifth nerve_ may be attacked from the front by Chavasse’s modification of Carnochan’s original method, consisting of a T-shaped incision from one corner of the eye to the other, the vertical branch extending from its middle well down to the mouth. After the infra-orbital nerve is identified it is secured with a piece of silk. The anterior wall of the antrum is then removed, the cavity opened, and a small trephine applied to its posterior wall. The nerve, being exposed in its canal or groove, is divided anteriorly, pulled down into the cavity by means of a ligature previously applied to it, and now made to serve as a guide into the sphenomaxillary fossa. Here it may be followed directly into its connection with Meckel’s ganglion, which may also be extirpated. The nerve trunk is forcibly pulled out of the foramen rotundum, through which it escapes from the Gasserian ganglion.

Horsley does not open the antrum but lifts the orbital contents, including the periosteum, follows the nerve along the canal by means of sharp-pointed bone forceps, and thus follows it up to the foramen rotundum, where it is evulsed as above. (See Fig. 399.)

Luecke years ago devised a method of lateral approach, attacking the ganglion and the nerve from the temporal region. An incision is made from the external angle of the orbit straight downward in the direction of the molar teeth, where it is met by another extending from the middle root of the zygoma, downward and forward. Through these incisions the zygoma is exposed and divided. Thus an osteoplastic flap is formed which is laid up over the temporal region, the divided piece of bone being raised with the overlying skin and not detached. This exposes the temporal and zygomatic fossæ. The temporal muscle is then drawn backward with a hook, the fatty tissue which fills these fossæ cleaned out, and the nerve sought for in the sphenomaxillary fossa, where both it and Meckel’s ganglion may be extirpated. The flap is then turned down and fastened in place (Fig. 400).

Branches of the inferior maxillary nerve which most concern the surgeon: _a_, auriculo-temporal; _b_, inf. dental; _c_, buccal. (Marion.)]

Exposure of Meckel’s and the Gasserian ganglia by temporary resection of the zygoma; Luecke’s method. (Marion.)]

The _inferior dental, or third division of the fifth nerve_, may be reached in several ways: Its terminal portion where it escapes at the mental foramen; its upper portion by an incision two inches along the lower border of the jaw and above the angle, the masseter muscle being separated from the jaw, and the ascending ramus opened with a ³⁄₄-inch trephine at a point 1¹⁄₄ inches above the angle, its upper edge ¹⁄₄ inch below the sigmoid notch. The nerve is here exposed before it enters the canal. The lingual nerve may also be found resting upon the internal pterygoid muscle. A ligature tied around each nerve, for traction purposes, permits easy tracing of their trunks to the foramen ovale, where, after vigorous stretching, they are divided. They should then be traced downward and at least one inch of their trunks removed.

=The Gasserian Ganglion.=--When all three branches of the trifiacial nerve are involved in painful _tic_, or when operation has already been practised upon one or more of them and the tic has recurred, it becomes necessary to attack the Gasserian ganglion itself.[45] This may be approached by either one of two methods. Both are difficult and serious, having a mortality of from 15 to 20 per cent. As Cushing has pointed out, however, its mortality rate is scarcely as great as the death rate by suicide in neuralgic cases of this kind. The attack from below was first carefully worked out by Rose and then by Andrews, and is begun in much the same way as the operation for the removal of Meckel’s ganglion by resection of the zygoma, described above. A flap is laid up, larger and wider, including the zygoma, with the most complete possible exposure of the zygomatic fossa. The coronoid process is drilled in two places, divided between the openings, which are to be used for subsequent suture, and the temporal muscle pushed upward and forward, out of the way, with the upper fragment. The foramen ovale is then identified by following into it the inferior maxillary nerve, the base of the skull being cleaned away in that neighborhood, and a small trephine opening made between it and the foramen rotundum, connecting these two openings by a much larger one. Through this opening the ganglion is exposed and destroyed piecemeal or extracted as completely as possible. The operation is exceedingly difficult, and hemorrhage, especially from the middle meningeal artery at the foramen spinosum, maybe so troublesome as to make it impracticable unless the carotid be tied. I have preferred in doing this operation to make preliminary ligation of the common carotid, which facilitates the balance of the procedure. The exposure by this method, however, is not as satisfactory as by that next to be described.

[45] _Osmic Acid and Other Treatment of Trigeminal Neuralgia._--While
it hardly pertains to operative surgery, it may be worth while to say
that it seems to me that no case of trifacial neuralgia should be
subjected to radical operation until at least two or three remedies
have been given a fair trial. One of these is _castor oil_ its use
being based upon the theory that such neuralgia is of toxic origin
and that a prolonged evacuant treatment should benefit it. This
would mean the administration of two or three good-sized doses of
castor oil every day for a period of two to three weeks. It is not
such a drastic remedy, thus given, as would appear, for after the
oil has once thoroughly produced its laxative effect it ceases to
distress, but serves as a very effective eliminant. The second remedy
is _gelsemium_, the best preparation being the tincture of the green
root. It seems to exercise a selective affinity for the trifacial
nerve. It should be given in large doses, pushed to the physiological
limit, _i. e._, until the patient begins to see everything in yellow
colors. Its effect on the heart must also be guarded. Fifteen drops
of the green tincture given every two hours, and for a few days, will
usually suffice to thoroughly test its efficacy.

_Osmic acid_ is used only for _intraneural injection_, its efficiency
now being under trial. Ten to twelve drops of a 2 per cent., freshly
prepared aqueous solution are directly injected into the nerve trunk
after its exposure. Murphy has been its particular advocate, and
has reported relief of pain in a number of cases thus treated. It
seems to depend for its effect upon two factors--the destruction of
nerve filaments and their substitution by connective tissue. All the
nerve branches that can be exposed should be injected; the palatine
and lingual through the mouth; the intra-orbital and supra-orbital
by incisions upon the face; orbicular-branches, as well, should be
injected, if possible. Most of those who have used it advise also
to inject a few drops into the foramina of exit, around the trunks,
which are thus infiltrated with the solution. The procedure is
painful and usually requires a general anesthetic, but it seems to
be free from danger. While the treatment has been successful in some
cases it has been equally disappointing in others, and the method
will scarcely supplant the more radical method of ganglion exsection.

Hartley and Krause, about the same time and independently, devised a method of attacking the ganglion, after raising an osteoplastic flap from the side of the skull, which affords a better exposure and a more satisfactory method.

Within reason the larger the osteoplastic flap the easier the balance of the operation. Whether it be square or horseshoe in shape, whether it be made by chisel, by Gigli saw, or by surgical engine, matters little. In fact experience has shown that the conservation of the bone is not a matter of serious import, and there is no good reason why there should be any hesitancy to remove the bone should the formation of such an osteal flap present too many difficulties. After the dura is completely exposed it is to be separated from the base of the skull until the foramen spinosum and middle meningeal artery are reached. It is better to do this quickly and with the finger than slowly with instruments. After this separation the brain with its dural covering is lifted by a spatula or retractor, so as to afford a good view of the region of the ganglion. It will be necessary to double ligate the middle meningeal artery unless preference has been given to make a preliminary temporary or permanent ligation of the carotid. Should this artery have been injured in raising the flap it should be secured before going any farther, either by plugging the opening or canal with gauze or with antiseptic wax (Fig. 401).

The upper surface of the ganglion is adherent to the dura, and these adhesions should be separated. The second and third branches should be identified and divided near their exit. The first branch is in too close relation with the cavernous sinus to justify much interference. The ganglion itself is then seized, after complete isolation, with forceps and evulsed, with as much of its longer and shorter roots as possible. Hemorrhage is checked by adrenalin or by pressure with gauze, as may be required. If gauze be used for the purpose it may also be utilized for drainage. The brain is restored to position and the flap sutured in its proper place.

Before doing either of these operations I should prefer to place the patient within the Crile pneumatic suit and then tilt the body to an angle of at least 45 degrees, thus prompting emptying of the cranial and cervical veins by gravity, while at the same time blood pressure is maintained by the pneumatic pressure (see p. 180).

Abbe has endeavored to lessen the shock of the operation by not formally tearing out the ganglion, but by taking out a section of the nerve trunks between it and their foramen of exit, and then interposing a piece of thin, sterile, rubber tissue, inserting it in such a way that it shall effectually prevent regeneration of nerve trunks across the interval, this rubber being intended to remain and become encapsulated. This method of Abbe seems to have made operative attack upon the Gasserian ganglion less formidable and less dangerous. It remains to be seen whether it is permanently as effective as more complete extirpation.

=The Lingual Nerve.=--In some cases of cancer of the tongue there is such intense pain that not only has the lingual artery been tied but the lingual nerve been stretched or exsected. It can ordinarily be reached where it lies on the floor of the mouth beneath the mucous membrane, at the fold between it and the tongue, where it can be felt if the tongue be forcibly stretched. Through a small incision a blunt hook may be passed and the nerve thus secured. Close to the first lower molar the nerve lies in the tongue near the surface, where it can also be found.

=The Seventh or Facial Nerve.=--This nerve has sometimes to be stretched for spasmodic affections. When the desire is simply to reach its trunk it may be sought through an incision behind the ear, by which the posterior border of the parotid is exposed, the sternocleidal insertion identified, the nerve lying in the interval between these two landmarks. A more easy method of reaching it would probably be by an incision in front of the ear just before its main branch divides as it enters the parotid gland. If necessary this may be followed backward until the main trunk is reached.

Intracranial exsection of Gasserian ganglion; dura open, brain lifted up. Hartley-Krause method. (Marion.)]

Relations of the facial and spinal accessory nerves: _a_, carotid; _b_, int. jug.; _c_, facial nerve; _d_, transv. proc. atlas; _e_, spinal acces.; _f_, stern. mast. muscle. (Marion.)]

=Neuro-anastomosis for Facial Palsy.=--In view of the hopelessness of facial paralysis, when resulting from destructive injuries to the nerve trunk, the introduction of anastomotic methods has marked a very distinct advance. Ballance, in 1895, was the first to apply neuro-anastomotic methods to the facial nerve. He attached the facial to the spinal accessory. His own experience, as well as that of half-a-dozen later operators, proved that nerve regeneration is possible, but that in this particular instance voluntary movements of the face were often accompanied by distressing and unsightly associated movements of the shoulder, and _vice versa_. Hence, Taylor and others suggested the use of the hypoglossal instead of the spinal accessory, the former being a purely motor nerve running near the facial, intimately associated with it in function, and arising by nuclei, which are equally closely associated in the cranial centres. The operation is indicated in all cases of paralysis caused by lesion of the nucleus within the brain, or the nerve trunk at the base of the brain, or along its course. It is justifiable in Bell’s palsy, when there is complete reaction of degeneration in the facial nerve after several months of treatment (Fig. 402).

The steps of the operation are practically as follows: Incision is made along the anterior margin of the mastoid and the sternomastoid muscle, and the parotid gland is retracted forward and the posterior belly of the digastric is exposed. It should then be pulled downward and backward and divided if necessary. The styloid process is identified, and the facial nerve which emerges from the stylomastoid foramen near its base is then sought and isolated. It should be separated as high as possible and divided close to its exit, so that one-half inch of its free trunk may be secured before it enters the gland. Two fine silk sutures are then passed, one on either side, through the peripheral end of its sheath and tied, the ends remaining long, to be subsequently used. This nerve end should be trimmed to a wedge shape. Next the transverse process of the atlas is identified and the deep cervical fascia divided. This will expose the internal jugular, which should be separated and held out of the way. There will now be seen the spinal accessory nerve, which runs obliquely downward and outward, sometimes in front of and sometimes behind the jugular (Fig. 403). When the vein is held forward and the fascia well retracted both the hypoglossal (Fig. 404) and the pneumogastric nerves are seen, with the internal carotid to their inner sides. The former may be identified either by the electric current, which will cause contractions in the muscles supplied by it, or it may be followed down to where it turns forward around the occipital artery and gives off the descendens noni. Here it should be separated until its trunk is sufficiently free, so that the facial stump can be inserted into it without tension. The nerve being elevated by a hook a slit is made in it, about ³⁄₄ inch long. Into this the wedge-shaped end of the facial trunk is introduced, and held there by utilizing the sutures which have already been passed through its sheath. When the nerve is thus firmly held in the cleft, with its end turned toward the direction of nerve supply, a little cargile membrane may be wrapped around the junction and the wound closed.[46]

[46] Taylor and Clark, New York Medical Record, February 27, 1904, p.
321.

Nerve regeneration has been known to follow this procedure in a number of cases, and it has given encouraging results. Considerable time, however, is required, and the patients should be warned that results are not to be quickly expected.

Exposure required for anastomosis of facial and spinal accessory nerves: _a_, facial nerve; _b_, sp. acces.; _c_, int. jug.; _d_, digastric muscle; _e_, atlas, trans. proc. (Marion.)]

Exposure required for anastomosis of facial and hypoglossal nerves: _a_, facial nerve; _b_, sternomastoid; _c_, digastric; _d_, parotid; _e_, hypoglossal. (Marion.)]

=The Spinal Accessory Nerve.=--The principal reason for attack upon this nerve is spasmodic torticollis, or _wryneck_. It is exposed through an incision along the anterior border of the sternocleidomastoid muscle, extending two inches downward from the ear. The nerve is found a little above the level of the hyoid bone; or, again, it may be found by an incision along the outer border of the muscle, opposite its centre, just above which it will be detected (Fig. 405).

=The Deep Posterior Cervical Plexus.=--When operation upon the spinal accessory has failed to relieve long-standing and serious spasmodic torticollis, Keen has suggested to divide the first, second, and third cervical nerves. The operation is difficult and not always successful; still it is worth trying. A transverse incision is made below the level of the lobe of the ear, the trapezius being divided and dissected up until the great occipital nerve is found. It is followed after the necessary division of the complexus until its origin from the posterior division is reached. The suboccipital or first cervical nerve, which lies in the triangle close to the occiput that is formed by the two oblique muscles and the posterior rectus, is excised. The exterior branch of the posterior division is found lower down, and should be divided close to the bifurcation of the main nerve (Fig. 406).

Exposure of the spinal accessory nerve alone: _a_, digastric; _b_, jugular veins; _c_, sternomastoid muscle; _d_, spinal accessory. (Marion.)]

Incisions through which the various nerves in the neck may be sought: _a_, facial; _b_, facial and hypoglossal; _c_, facial and sp. acces.; _d_, spinal accessory; _e_, cervical plexus; _f_, brachial plexus. (Marion.)]

=The Cervical Sympathetic.=--The cervical sympathetic is a most complicated nerve trunk, furnishing fibers of various functions to the skin, and to the deeper parts fibers which are vasomotor, vaso-inhibitory, pilomotor, and secretory in function. It supplies the various glands, the upper viscera, the heart and bloodvessels, and connects with nerves below, which supply even the genital organs and the non-striped muscles of the body. The upper part has a very important oculopupillary function, as it supplies the dilator pupillæ, the non-striped part of the elevator of the upper lid, and the orbital muscle of Müller, _i. e._, a small bundle of non-striped muscle which lies behind the globe and projects across the sphenomaxillary fissure at the back of the orbit. (By contraction of this muscle the eye may be pushed forward.) It also supplies the submaxillary gland, the cutaneous bloodvessels, and the sweat glands of the head and neck. The pupil dilating fibers arise in the medulla, run backward in the lateral columns of the cord to the ciliospinal centre, emerge through the anterior roots of the first and second dorsal segments, and enter the inferior cervical ganglion, thence passing upward through the sympathetic trunk to the orbit. Therefore ocular and other symptoms are produced not only by lesions of the external trunk, but also by lesions within the cord at the level of the upper dorsal segments. These nerves may be injured anywhere in the neck, or compressed by inflammatory deposits or new-growths, or even by cicatricial tissue at the apex of a tuberculous lung. Many cases of phthisis show inequality of the pupils. One nerve may be injured in operations on the neck, the result being slight drooping of the lid and flushing of the face, as well as excessive perspiration on the injured side; the corresponding pupil being smaller than the other because of paralysis of the dilators, but contracting to light, as the third cranial nerve which supplies its sphincter is unaffected. The eye will then sink back somewhat, owing to paralysis of Müller’s muscle, and thus permit a nearer closure of the lids. These oculopupillary symptoms are pathognomonic of paralysis of the cervical sympathetic. Cocaine will not dilate a pupil whose dilator has thus been paralyzed. The area of skin supplied with sweat fibers by the cervical sympathetic includes the corresponding side of the head, neck, shoulder, and upper part of the trunk (Fig. 407).

When the cervical sympathetic is unduly stimulated we have dilatation of the pupil, exophthalmos, widening of the palpebral aperture, delayed descent of the upper lid when the patient looks downward, all of which can be imitated or produced by dropping into the eye a solution of cocaine, which stimulates the nerve.[47]

[47] Stewart, Some Affections of the Cervical Sympathetic, The
Practitioner, February, 1905.

The surgical sympathetic is attacked surgically for three widely variant conditions: _epilepsy_, _glaucoma_, and _exophthalmic goitre_--the first, because of its vasomotor control of the vascular supply of the brain; the second, because of the relation of the nerve to the orbital circulation and nutrition; and third, because of its relations to the thyroid and the heart. In the latter case it is especially desirable to remove the lower cervical ganglion and the first dorsal, if it can be reached, although the procedure here is exceedingly difficult.

The tachycardia of Graves’ disease is due apparently to irritation of the accelerator nerves of the heart, which come from the sympathetic, or else to paralysis of the regulator (pneumogastric) supply. The former spring from the lower part of the cervical cord and the upper dorsal segments, and pass to the third cervical ganglia and to the first dorsal, terminating in the cardiac plexus.