INJURIES OF THE EYEBALL AND ADNEXA IN GENERAL.

This topic has already been considered. It seems advisable, however, to summarize some of the results of such injuries in order to call attention to their dangers and methods of treatment. Burns of the orbital regions, for instance, are liable to cause not only opacity of the cornea following ulceration, but adhesions between the conjunctival surfaces and the palpebral margins. The term symblepharon is applied to those lesions where the lids are more or less fixed upon the globe and their motility partly or completely impaired. When the edges alone of the lids have grown together the condition is known as ankyloblepharon. Both of these conditions are the result of adhesion of granulating surfaces and of cicatricial contraction, and should be avoided.

By a concussion of the orbital region, and especially of the eyeball, all sorts of injuries may be inflicted, from those involving the cornea to deep lesions which leave little or no superficial evidences, but cause partial or complete blindness. Detachment of the retina, for instance, is one of the possibilities of such conditions. Intra-ocular hemorrhages or dislocation of the lens, with traumatic cataract, may also occur.

The sclerotic may be ruptured with or without the presence of a foreign body, in which case the contents of the eye may have partially or completely escaped. An eye which has collapsed from these causes offers an almost hopeless field for the general or special surgeon, and little can be done, save possibly for cosmetic purposes. There is danger of sympathetic ophthalmia, and it may be a question whether evisceration, i. e., completion of the evacuation, may not be the wiser course.

Perforating wounds, even when inflicted by minute bodies, have dangers of their own, including the possibilities of infection. The interior mechanism of the eye is so easily disturbed, and its transparent media so easily clouded, by the results of accident or hemorrhage, that even apparently trivial injuries may be followed by disturbances of vision.

Treatment.

—The general principles of treatment of all such injuries should include, first, the removal of every detectable foreign body, followed by the application of cold, and the use of antiseptic eye-washes, which, however, must not be used too strong lest they irritate. Saturated boric-acid solution is perhaps as strong as anything which is permitted, while even this may occasionally require dilution. In addition to this the use of atropine solution is always indicated. It has the double effect of soothing and allaying pain and of dilating the iris into a narrow ring. With such measures as these it may be possible to save vision; at all events it will limit reaction and prevent harm.

DISTURBANCES OF INNERVATION.

The nerves which supply the eye and its adnexa may undergo injury, either within the orbit or within the cranium, or in their course from one to the other. The paralyses may be caused by syphilis, by intracranial tumors, or by injury. A careful study of the areas and nerves involved will sometimes lend considerable help in diagnosis, both in traumatic and pathological cases. Thus diplopia, or double vision, may be caused by paralysis of the external rectus on one side, by which its antagonistic internal rectus is permitted to swerve the eye too much to the inner side and away from the normal axis of vision required for single sight. When there is complete paralysis of the third nerve there may be drooping of the eyelid, called ptosis, with impaired motion of the eye, upward, inward, or downward. The eye will roll outward because the external rectus is supplied by the sixth nerve. There will also be dilatation of the pupil, with loss of accommodation. When the upper lid is raised there is also double vision. This third-nerve paralysis, however, is not always complete, and diplopia may result only when the eye is directed in a certain way. When the sixth nerve is paralyzed the eye is rolled inward, and again there is diplopia. When the fourth nerve is paralyzed the eye is but slightly displaced upward and inward. When the sympathetic nerve is involved there will be protrusion of the globe with dilatation of the pupil. This will be accompanied by flushing of the face.

MUSCULAR AND ACCOMMODATIVE DEFECTS.

Detection of errors of accommodation is practically a specialty within a specialty, while the various forms of strabismus, or deviation of the eyes from their normal axes, depend largely upon regulation of accommodative errors.

REGION OF THE EXTERNAL AND MIDDLE EAR.

The region of the ear is subject to congenital malformations, deviations, and defects, which include anomalous shapes of the auricle, malpositions of the organ, defects in the cartilaginous structure with resulting deformity, and congenital excesses or redundancies by which there are made to appear supernumerary auricles or portions thereof. These latter have been described by Sutton and treated in his work on Comparative Pathology. They bear relation as well to the branchial clefts, and are of great interest from a phylogenetic point of view. Some of these defects result from absolute arrest or excess of development, others from injury during intra-uterine life; some are accentuated by lack of care during the early months of infancy. The most common deformity of the ear is that by which it is made unduly prominent and deflected outward or forward, the cartilage being thick and abnormally curved. Such overlapping or overprominent ears can be made to assume their proper position on the side of the head by the excision of an elliptical piece, either of skin or of skin and cartilage, at the point of junction of the ear and the scalp. The amount to be removed should be proportionate to the desired effect. The parts may be brought together by sutures, and the auricle should then be bound upon the head.

Fig. 395 illustrates a common form of defect, inherently of the cartilage and of the overlying skin. This is but one illustration of many, two cases being rarely found exactly alike. Not infrequently these arrests of development include the structures of the middle ear as well. The auditory meatus may be entirely covered and concealed, or may be absent, having failed to develop.

Supernumerary auricles are usually found as small tags of skin and cartilage in front of or below the ear. They are easily removed and leave no disfiguring scar.

The external ear is also exposed to injury, which it frequently receives in the way of contusions and lacerations. It is occasionally detached. The ordinary wounds of these parts require only the conventional treatment, while it may be possible, by replacement and approximation of a completely detached portion, to see it re-adhere. This happened to the writer after his horse had completely bitten a piece out of the ear of his groom. Here, as with detached finger-tips, cleanliness is necessary, and the parts must be kept warm and protected after dressing. The cartilage of the ear is covered by a perichondrium which corresponds to the periosteum. Beneath it, or beneath the skin alone, blood may be extravasated as the result of contusions. When such collections fail to promptly resorb they should be incised and the contained blood released. Such lesions are referred to as traumatic othematomas.

A peculiar lesion of this general character occurs occasionally in the insane. If due to injury the latter is but trifling. It makes a conspicuous tumor, involving usually the lower end of the auricle, and is known as the othematoma of the insane. It is scarcely amenable to surgery, nor does it often need it, but it constitutes a disfigurement which is not only easily apparent, but diagnostic as to the cerebral or mental condition.

The ear is the site of many neoplasms, both innocent and malignant. Small papillomas are common, while fibrous tumors are likely to develop, especially about the fibrocartilaginous lower end of the auricle, where the ear has been pierced for ear-rings. Keloid tumors, of still more conspicuously fibrous nature, are common about the ear, especially among negroes. All innocent tumors may be excised, through incisions which should be so planned as to leave a minimum of disfigurement. (See Fig. 397.)

Of the malignant tumors epithelioma is perhaps the most frequent. It pursues a course here similar to that which characterizes it elsewhere, save that the dense structures of the cartilaginous ear yield but slowly to its encroachment. The form known as “rodent ulcer” is slower here than elsewhere. Fig. 396 illustrates a case under the writer’s care, showing complete destruction of the external ear by a growth of this kind, which had attained a degree and extent that did not permit of successful treatment, and which eventually proved fatal. When growths of this character have not progressed too far they should be radically removed, the question of cosmetic effect being secondary to that of their eradication. By a well-planned plastic operation much can be done to atone for disfigurement resulting from radical operation.

FOREIGN BODIES IN THE EAR.

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.

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).