CHAPTER XXXVII
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THE ORBIT AND ITS ADNEXA; THE EXTERNAL AUDITORY APPARATUS; THE ACCESSORY SINUSES; THE CRANIAL AND CERVICAL NERVES; THE ORBITAL CONTENTS AND ADNEXA.
INJURIES OF THE ORBIT.
_Intra-orbital hemorrhage_ is not uncommon after injuries to the head. It may result from rupture of orbital vessels proper or by escape of blood from within the cranium, either outside or beneath the dural prolongation which constitutes the sheath of the optic nerve. When extensive it may produce a pulsating tumor, and this may, in time, become practically a traumatic aneurysm. After basal fractures blood frequently will escape forward so as to appear beneath the conjunctiva. Collections of blood in the orbit may also interfere with the return circulation in such a way as to lead to extensive chemosis of the conjunctiva or edema of the lids and orbital contents. Pressure may cause temporary disturbance of vision. Should there be absolute blindness it may be inferred that there has been injury to some part of the optic tract. Protrusion of the globe is an indication of the degree and amount of extra-ocular hemorrhage, which may be very pronounced. When visual symptoms are bilateral, while external evidences are confined to one orbital region, it may be assumed that there has been intracranial disturbance as well, with laceration along the optic tract. Such immediate damage will in time be followed by the ordinary symptoms of neuroretinitis and atrophy.
The more external the injury the more quickly will it yield to ice-cold applications. There are times when incisions for relief of tension may be desirable. An extensive clot in the orbit which seriously displaces the eyeball, and which does not quickly absorb, should be evacuated by an incision, either directly through the lid or beneath the lid and outside of the globe.
_Penetrating injuries_, like gunshot wounds, are usually easy of recognition. If vision be instantly and completely lost the harm done to the optic nerve or the globe will probably prove irreparable. Foreign bodies penetrate from various directions, and sometimes to such a depth that they are difficult to find. I have seen a large chip of wood completely lost within the orbit, and such bodies may enter either from outside or from within the nasal cavities. A foreign body will nearly always limit the motility of the globe and usually displace it. If its presence can be ascertained or revealed before operation it should be sought and removed at the expense of almost any and every other indication. If its presence be suspected it may be sought for, even though a skiagram fail to reveal it. When the usefulness of the eye is destroyed it will be advisable in such case to remove it in the progress of this search.
Aside from the traumatic hematomas above mentioned extravasation occurs, due to constitutional or vascular disease, as atheroma, especially when coupled with violent straining efforts. Subconjunctival effusion and exophthalmos, with limitation of motion, will be unfailing expressions of such damage. _Orbital aneurysms_, spontaneous or traumatic, are occasionally seen. They will cause a more or less pulsating exophthalmos, while, in some instances, a bruit may be detected with the stethoscope. Cases may be imagined where it would be suitable to cut away the external wall of the orbit and expose such a tumor. Ordinarily, however, ligature of the internal or common carotid will be required. _Angiomas_ occur also in the orbit, producing exophthalmos, usually without pulsation. Such tumors will prove compressible and the globe may be gently pressed backward into the orbit to immediately protrude again when pressure is removed. These lesions will prove very difficult, usually impossible of treatment, and no general rule can be made therefor.
_Orbital cellulitis_, _i. e._, infection of the cellular and other tissues in the orbit, may occur, either from without or from within, but usually in connection with some traumatism. Sometimes this involves first the cornea or the structures of the globe; at other times infection is by a more direct method, through the conjunctival sac or the orbital coverings. It varies in intensity between extreme limits. It may even be bilateral. While cases occasionally undergo resolution it usually terminates by formation of abscess. It is met with in the infectious fevers, in facial erysipelas, by extension upward of infection from diseased teeth, after primary infection of the ethmoidal or sphenoidal sinuses, or by extension from external phlegmons. There will be edema of the lids, usually with chemosis, fixation and protrusion of the eyeball, commonly with divergence. In proportion to the severity of the lesion there will be present septic symptoms, with deep-seated pain and headache. Vision is disturbed in proportion to the pressure upon the nerve and globe, as well as the involvement of the ocular structures proper. When the disease is begun within the eye it will usually terminate by a combination of panophthalmitis with orbital abscess.
=Treatment.=--The application of the compound ichthyol or Credé’s silver ointment, with ice, preceded perhaps by the use of leeches, will be suitable local treatment unless the presence of pus be distinctly made out or until tension threaten serious harm. In either of these events, however, free incisions are required at points of greatest tension, the knife being so directed as to avoid the globe. These incisions should be free and sufficiently deep. Should there be accompanying panophthalmitis the eyeball itself should be freely incised through its anterior aspect and its contents completely evacuated. Such emptying of the contents of the sclerotic is called _evisceration of the globe_. While theoretically indicated, experience has shown that it is a disastrous practice to enucleate the eye at such a time; _evisceration first and enucleation later_, should it prove desirable.
TUMORS OF THE ORBIT.
The orbit is the site of many primary tumors which originate within its proper tissues as well as those which encroach upon it from neighboring cavities or from the face. Prognosis is better in the former than in the latter, but unfavorable in all malignant cases.
Of the primary _cystic tumors_ there may be nearly all the known varieties, including those of parasitic origin. The pseudocysts of the cranial cavity sometimes project into the orbit, forming _orbital encepholacele_. _Dermoid cysts_ are not at all uncommon. Around the bursæ of the orbital muscles exudation cysts occur, while the retention cysts, including the cholesteatomas, are not infrequent. The true dermoid cysts may contain all the ordinary epithelial products, just as in any other part of the body. _Parasitic cysts_ include the echinococcus and the cysticercus, the latter being rare, while the former may extend into the frontal sinus or cranial cavity. It produces almost constant ciliary neuralgia. _Vascular tumors_ of all types are found in the orbit and the various expressions of telangiectasia of the lids and orbit are often seen. These are always of congenital origin. Of the more simple types of mesoblastic tumors the osteomas are perhaps as common as any. These assume all the types described in the chapter on Tumors, and are of all degrees of hardness. _Sarcoma_ and osteosarcoma, originating within the orbit, are unfortunately too common. Naturally they spread to and involve all the adjoining structures. True _endothelioma_ is rarely recognized as such until after removal and microscopic examination. _Epithelioma_ commencing upon the surface of the eye, or about the skin and spreading inward, is also quite common.
Exophthalmos is an expression of intra-orbital tension common to all forms, while by the extent of protrusion and its direction the site of the tumor may to some extent be determined. Other disturbances of position, with limitation of motion and consequent diplopia, are further expressions of pressure and dislocation. Ptosis, or drooping of the upper lid, is a feature of tumors which proceed from the upper part of the orbit. The vascular tumors, as already mentioned, produce more or less pulsation. Ocular tension is usually increased, and when circulation and enervation have been seriously affected necrosis and even perforation of the cornea may occur. Pain is a variable feature, but is sometimes pronounced. An exploring needle may be passed into a tumor which seems to be cystic, but it should be done with every precaution, both against infection and injury to the eye.
_Tumors of the optic nerve_ proper originate more often in its sheath than in its true neural tissue. They may occur at any point, but usually within the orbit. These tumors are usually of the sarcomatous, gliomatous, or endotheliomatous type. Cystic changes are not infrequent; they occur usually in the young. All of these tumors will involve the optic nerve in such a way as to produce signs easily recognizable with the ophthalmoscope, such as optic neuritis and nerve atrophy. Moreover, they affect or completely destroy vision. They are not so painful as most of the other intra-orbital tumors, and, while causing a direct forward protrusion of the eye, affect its motility less than other forms. Nevertheless they grow with great rapidity and evince destructive tendencies. In theory the treatment for all tumors of the orbit is complete extirpation, while the malignant tumors require emptying of the orbital contents. Benign tumors and cysts are usually successfully treated by this method. Of most malignant tumors it may be said that the prognosis is unfavorable. The lymphatic and vascular connections are so free, and extension into surrounding cavities so easy, that recurrence takes place in the larger proportion of cases. Too often by the time a patient is willing to sacrifice the eye and the orbital contents it is too late to effect a radical cure.
EXOPHTHALMOS.
The term _exophthalmos_ simply implies protrusion of the eyeball beneath and even between the lids. Usually it is in a downward and outward direction. In some cases the displacement is accompanied by an easily recognizable pulsation, and occasionally by a bruit or audible sound. The latter instances are spoken of as pulsating exophthalmos. They are connected in most cases with vascular tumors or intra-orbital aneurysms, although sometimes the aneurysm may be primarily intracranial. For instance, arteriovenous aneurysms, by communication of the internal carotid artery with the cavernous sinus, will produce pulsating exophthalmos. Whatever be its cause exophthalmos is an expression of pressure from behind. This is true even of the ocular symptoms accompanying Graves’ disease or exophthalmic goitre, only here the protrusion is permitted by general fulness of the vessels and undue vascularity of the orbital tissues.
In proportion to the amount of projection there will be swelling and edema of the upper lid, the skin being more or less shiny and the veins distended. In extreme cases the lids are everted and the conjunctiva extremely chemotic, while by exposure of the cornea it becomes vascular, infected, and often necrotic. Should it be possible to replace the globe by pressure it will protrude so soon as pressure is removed. In vascular cases a bruit may be heard and pulsation detected with the finger. Audible sounds are lost by making firm compression on the common carotid of the same side, and return instantly when this pressure is removed. By the ophthalmoscope both arterial and even venous pulsation may be perceived at the fundus. Vision is only slightly affected by a well-marked protrusion, especially when the latter has occurred slowly. The pulsating forms will frequently give subjective symptoms of sound and sense, _e. g._, vertigo.
A history of injury, coupled with external evidences, may give a clue to some of these cases as an indication of traumatic aneurysm or communicating vascular tumor. Soft and vascular tumors, without history of injury, are usually malignant, this being true also of multiple growths.
=Treatment.=--The treatment of exophthalmos should depend entirely on its nature. When due to arteriovenous aneurysms, or to the consequences of injury alone, a ligation of the common or of the internal carotid will give the best result. When compression of the carotid gives temporary relief to at least some of the features of the case its permanent ligation is indicated. Bilateral exophthalmos implies a more serious condition, especially in Graves’ disease. When thyroid symptoms are prominent a thyroidectomy is indicated. When the thyroid
## participates but slightly such a case may be treated by excision of the
cervical sympathetic on both sides.
INTRA-OCULAR TUMORS.
These tumors may assume most of the known types and may spring from practically all of the tissues of the eye.
From the _iris_ there may develop _cysts_ of traumatic or even of congenital origin. In the former such a foreign body as an eyelash may be found, having entered through an external wound of the cornea. Vascular tumors are occasionally met with, many of which are full of pigment, while melanomas, with a minimum of vascular structure, are also observed. The actively malignant tumors of the iris usually assume the sarcomatous or endotheliomatous type, and when melanotic assume an exceedingly rapid and serious phase and course. In the iris, also, tuberculous or syphilitic granulomas are occasionally encountered.
In the _choroid_ are seen expressions of tuberculosis, especially the more acute, as a complication of tuberculous meningitis. The most common malignant tumor here is sarcoma of the melanotic variety. Of the _retina_, glioma is the most common as well as the most malignant tumor, occurring usually in the young. All of these tumors when malignant spread from their primary site to the adjoining tissues. When extremely malignant they kill too quickly to show many metastatic expressions. At other times they will appear in other parts of the body.
All intra-ocular tumors tend to impair, and the malignant to quickly destroy vision. Tension is increased and the natural contour of the globe may be lost. Fixation to and involvement of the surrounding orbital tissues depend in some measure on the rapidity of growth and its location. They occur sooner or later in malignant cases.
A malignant growth of any part of the globe calls for enucleation of the eye, as well as removal of the orbital contents. When the orbital tissues are thus involved it is too late to secure more than temporary benefit. If the eyelids are involved they should also be sacrificed and the orbital opening covered by some plastic procedure.
PANOPHTHALMITIS.
The term _panophthalmitis_ implies a phlegmonous process involving the entire contents of the sclerotic, by which the eye is destroyed. It is usually traumatic in origin, but may occur as an extension of infection from ulcer and abscess of the cornea, or from thrombotic or metastatic processes. Its course is usually rapidly destructive, while it is accompanied by more or less orbital cellulitis. These signs, therefore, are not confined to the orbit proper, for the lids become edematous, the conjunctiva chemotic, and there is more or less purulent discharge from the entire conjunctival sac, which will escape beneath the lids. If the cornea is at first clear it rapidly becomes cloudy, and to the signs of intra-orbital mischief are added all those above described under the heading of intra-orbital cellulitis. The sclerotic is an unyielding membrane; hence pain in these cases is usually intense, while septic features are added according to the nature of the cause. When the lesion has begun in the cornea it usually ruptures early and the ocular contents may escape in this way.
=Treatment.=--Panophthalmitis is dangerous to life as well as to the eye when not promptly treated. The same rule prevails here as well as elsewhere in the presence of pus. Prompt evacuation offers the greatest safety and relief. _Evacuation of the entire contents_ of the eye through a free incision and by means of a sharp spoon, with antiseptic irrigation, affords the only safe measure in these cases.
As previously remarked, the general consensus of opinion among oculists and surgeons is that, under these circumstances, enucleation should never be done, the danger being that of a purulent meningitis or thrombosis by extension backward along the sheath of the optic nerve.
SYMPATHETIC OPHTHALMITIS.
This, too, is a matter of interest common to the eye specialist and the general surgeon. The term refers to lesions of one eye which follow sooner or later upon injuries or infections of the other. These expressions of so-called sympathy occur in irritative or inflammatory lesions. The former are more or less neurotic and include pain, often referred to the region beyond the orbit, photophobia, blepharospasm, too free lacrymation, and various subjective phenomena of impaired vision. These features will be accompanied by more or less tenderness of the globe, with ciliary neuralgia and injection. These may subside under treatment, but will recur when the eye is again used.
Contrasted with these lesions is another form whose features are most pronounced along the uveal tract, though the retina may also suffer. Its subjective features are those of _uveitis_, to which are added actual exudates in various parts of the globe, some of which may be seen with the ophthalmoscope, with intra-ocular tension, which reduces the anterior chamber, and with partial or complete loss of sight that may end in total atrophy. In some instances these lesions occur rapidly; in others the course of the disease is chronic.
The oculopathologists have striven hard to explain these phenomena. Most of them believe in the continuity of the subdural or subvaginal sheath of the nerve from one orbit around into the other, and believe that the germs passed along this subway. Involvement of the yet unaffected eye may follow the entrance of foreign bodies, occurrence of traumatisms, punctures, existence of corneal lesions as minute ulcers, constant irritation of the presence of an artificial eye upon the stump, the performance of some of the common operations upon the globe, and even the much less frequent conditions of pathological changes in the choroid, the ciliary body, the optic nerve, or the existence of intra-ocular tumors. A recognition of the possibilities in these cases will lead to more radical treatment of the lesions which may produce them. Even a minute foreign body should be promptly removed and an ulcer of the cornea should not be regarded as a trifling lesion. Under all circumstances the surgeon, as well as the general practitioner, should be alert to the possibilities of these lesions, quick to recognize the symptoms, and prompt in urging the only satisfactory relief. It will be seen that the earliest suggestive features are those of involvement of the uveal tract.
=Treatment.=--There is usually but one efficient method of treatment for these cases, and this consists of _removal of the injured_ or _diseased other eye_, more particularly if it be more or less already impaired by the consequences of the original lesion. The exceptions to this statement occur in the event of well-marked sympathetic inflammation, as it may be possible that there will be better vision in the originally injured eye than in that secondarily infected; but so long as it is a matter of simple sympathetic irritation enucleation is the proper course. While this is extremely radical there is no satisfactory substitute for it. The only excuse for delay should be threatening phlegmonous processes by which communication posteriorly might be afforded. Bull has laid down the following indications for enucleation of the first eye before the outbreak of sympathetic inflammation in the other eye:
1. When the wound is in the ciliary region, and so extensive as to greatly damage or entirely destroy vision;
2. When the wound is in the ciliary region, and is already accompanied by iritis and cyclitis;
3. When the eye contains a foreign body, and attempts at its removal have proved futile;
4. When the eye is atrophied or shrunken and tender on pressure, or is continually irritated.
ENUCLEATION OF THE GLOBE OF THE EYE.
The conditions which justify enucleation of the eye have been pointed out. For the operation, which is usually done under general anesthesia, the lids should be widely separated with the ordinary eye speculum or by suitable retractors. A circular incision is then made through the conjunctiva, around the margin of the cornea. This is carried down to the sclerotic at a little distance from the corneal margin, by which Ténon’s capsule is opened; then a strabismus hook is inserted in each direction and the tendon of each muscle raised upon it and divided close to its insertion. By pressure upon the surrounding tissues the eye is now made to protrude. Should the globe have been already collapsed it should be drawn forward with forceps, one blade of which may be thrust within it. After thus firmly withdrawing it a blunt-pointed, curved scissors is passed behind and around it, the blades being made to open in such a way as when closed to divide the optic nerve at a little distance from the globe. After this enucleation by pressure is easy, and any further tissues requiring division may be readily cut. The principal source of hemorrhage is the artery extending through the nerve, but this is readily controlled by pressure.
Should there have been any inflammatory or septic condition about the orbit or the conjunctival sac the parts should be cleansed with hydrogen peroxide or other antiseptic. Sutures are seldom required. A compress should be applied outside the eyelids, removing it sufficiently often to be certain there is no retention of fluid or blood.
Recovery is usually rapid. Granulation tissue sometimes forms at the bottom of the conjunctival sac and becomes exuberant. In this case it should be removed with scissors and cauterized, after which it rarely recurs.
SYPHILITIC AFFECTIONS OF THE EYE AND THE ORBIT.
As already described, many expressions of the various stages of syphilis pertain to the eye. Thus there may be _chancre_ upon the eyelid or conjunctiva, or ulceration of the same; syphilitic iritis as a secondary expression; syphilitic retinitis, neuroretinitis, choroiditis, as tertiary lesions; and the formation of gummas in the later stages of the disease, and in almost any imaginable locality, especially the uveal tract. _Syphilitic tumors_ are seen upon the iris more often than anywhere else within the eye. Outside of the globe and within the orbit the ordinary expressions of syphilitic periostitis and of gummatous tumors occur. These constitute also the more common intra-orbital expressions of this disease.
The _symptoms_ of syphilitic lesions in this location do not vary from similar lesions elsewhere, save so far as they involve special tissues or disturb the special sense of sight. The _prognosis_ in nearly all of them is relatively good if suitable and active _treatment_ be promptly instituted. It is, however, too much to expect that annular destruction of areas of the retina or choroid can be completely repaired.
CATARACT.
Cataract is a subject of primary interest to the general surgeon only so far as it pertains to the consequences of injury to the orbital region. The term implies opacity of the lens or of its capsule, or both, which may be partial or complete. Its pathognomonic feature is slow and progressive failure of vision. Examination by direct as well as bilateral illumination will show the opacity to be located behind the iris. Everyone should be able to recognize it; its excision should be relegated to the trained specialist, since it is one of the most delicate special operations.
GLAUCOMA.
The term _glaucoma_ implies a collection of more or less variable pathological conditions within the eyeball which lead to increased intra-ocular tension. Because of this increased pressure, with its disturbance of circulation and the peculiar coloration often given to the cornea or the pupil, the disease has received this name. Among its symptoms are pupillary changes, including both size and mobility of the iris; turbidity of the cornea, as well as the fluid humors of the eye; pain, corneal anesthesia, impairment or final loss of vision, engorgement of the visible vessels of the globe, and a peculiar cupping or excavation of the optic disk. Unless checked by operative intervention the course of the disease is steadily toward blindness. It varies in acuteness, the favorable cases being the acute ones, in which early operation can be practised. It admits of no other treatment.
=Treatment.=--The operation almost universally practised by the oculist is either iridectomy or sclerotomy. The condition is briefly mentioned in this place for the double reason that the student may be made aware that the condition may follow certain injuries to the eyeball or the head, and that the more chronic forms have been successfully treated by _excision of the cervical sympathetic_, on one side or both, the operation being based upon anatomical and physiological facts pertaining to the distribution and function of those sympathetic fibers which pass to the orbit from the cervical trunk. The operation is described in the section on the Cranial and Cervical Nerves.
AFFECTIONS OF THE IRIS AND THE CILIARY BODY.
These lesions are frequently the result of blows and of penetrating injuries, as well as of syphilis. Moreover, motility of the iris is so essential to the normal function of the eye that where it may possibly be effected the surgeon should protect against those adhesions between the iris and the lens or cornea, which are very likely to occur, by instillation of a sufficiently strong solution of atropine, a ¹⁄₂ to 1 per cent. solution being usually sufficient for this purpose. These adhesions are referred to as _synechiæ_, and are anterior when the iris becomes affixed to the cornea, or posterior when affixed to the lens. They occur easily after minute punctures of the cornea, the result being a limited mobility or a dislocation of the pupil, along with opacity of the cornea, all of which work to the detriment of vision.
The iris is so visible that the mechanism of an exudate on or in it can be observed almost from beginning to end when it occurs in the form of iritis. Occasionally an exudate will merge into an actual collection of pus which will gradually fill up the anterior chamber, and which is then spoken of as _hypopyon_. Under the most favorable circumstances a disappearance of this pus by absorption may be noted. It may prove destructive or may necessitate evacuation.
The iris and the ciliary body are intimately connected, and inflammation beginning in one point may easily spread to and involve other tissues. These structures with the choroid constitute the so-called _uveal tract_, and when they participate in inflammation it is called _uveitis_.
The _symptoms of iritis_ consist of pain, lacrymation, photophobia, which is often intense; increasing turbidity of the aqueous humor, as well as of the cornea, by which vision is impaired; visible discoloration; irregularity and sluggishness in movements of the iris, and circumcorneal injection. A congestion which assumes an annular form about the cornea and does not involve the conjunctival sac indicates trouble in the ciliary region, while a true conjunctivitis is limited only by the extent of the membrane itself.
Iritis due to syphilis, whether assuming the plastic or the gummatous form, requires the most active antisyphilitic medication, in addition to local treatment. The non-specific and traumatic forms need absolute rest in a dark room, with cold applications about the eye and the free use of atropine, to completely dilate the pupil and prevent the formation of synechiæ.
THE CORNEA.
The cornea being the most exposed part of the eyeball will be frequently subjected to minor or serious injury in connection with violence to the orbital region. It is an exceedingly sensitive membrane, whose reflex excitability is heightened by the presence of a small foreign body, this accident being one of frequent occurrence. It is a lesson in neurophysiology to watch the relatively local and general disturbances which the presence of a minute speck of foreign material embedded in the cornea may cause. Every extraneous body should be removed at once, the procedure being now facilitated by the local use of cocaine, for any abrasion or serious injury of the cornea occurring in surgical cases offers a possible source of infection to the deeper ocular structures. Careful attention should be given to the use of antiseptics of suitable strength in the conjunctival sac, whenever this region is involved. This statement cannot be made too positive. There is danger both to the cornea and to the iris in perforating ulcer or traumatism of the cornea, and there is as much occasion for the use of atropine in these instances as in those pertaining to the iris proper. To the protrusion of the cornea, which is produced by weakening of its structure and tension from within, is given the name _staphyloma_. It is frequently combined with adhesions of the iris and dislocation of the pupil. It constitutes not only a cosmetic disfigurement, but a serious impediment to vision.
[Illustration: PLATE XLV
FIG. 1
Lacrymal Fistula on the Right Side; Ectasia of the Lacrymal Sac on the Left; Bilateral Epicanthus. (Haab.)
FIG. 2
Dacrocystitis. (Haab.)]
THE CONJUNCTIVAL SAC.
The mucous membrane lining the conjunctival sac is perhaps the most exposed to irritation and even infection of all mucous surfaces. It is not strange then that conjunctivitis is the most common of all eye affections. Whether irritated by constant exposure to dust and dirt, or raw and cold winds, or by the heat of a blast furnace, by the dazzling brilliancy of electric lights, or contact with bacteria, it displays a surprising degree of accommodation and resistance. It has peculiar susceptibilities, particularly to the germs of _gonorrhea_ and _diphtheria_. To these it is peculiarly sensitive, and under their influence it may quickly succumb. The harm done in either of these conditions is by no means limited to the conjunctiva, but may extend in such a way as to eventually cause loss of vision.
Nowhere else may the phenomenon of hyperemia be so easily studied as by watching the ocular conjunctiva for a few moments after the occurrence of irritation. The rapidity with which the vessels dilate and become visible, the occurrence of the consequent redness and swelling, and the reflex phenomena attending it become appreciable within a short time. In the chronic conditions the tissues become thickened and less mobile. A chronic conjunctivitis is the constant condition in certain laborers whose eyes are exposed in their occupation.
A peculiar granulomatous condition of the conjunctiva, especially the palpebral, is that known as _trachoma_, which appears to be due to a specific form of infection that leads to exudation, organization and thickening, intensified in punctate areas, and giving the surface the appearance of an ordinary granulation. This condition has assumed such importance as to be sufficient for the exclusion of aliens and immigrants.
The milder conditions of acute or subacute conjunctivitis subside under cold applications and mild antiseptic and astringent eye-washes or collyria. These should be frequently instilled, beneath the lid whenever this area is involved as a complication of injuries to the head or face. In acute cases of the infectious type, such as the gonorrheal or diphtheritic, atropine should be used locally, so that the iris may be drawn out of harm’s way and the pupil left free should resolution and recovery ensue. Individuals suffering from either gonorrhea or diphtheria should be cautioned and protected from possibility of conjunctival infection. The eyes of the newborn are not infrequently infected during the process of parturition. The parturient canal of women suspected of having an infectious lesion of this kind should be cleansed before the passage of the fetal head, and in all suspicious cases instant and constant attention should be given to the eyes of the newborn infant.
THE LACRYMAL TRACT.
The _lacrymal gland_, though situated in the anterior and upper part of the orbit, and beneath the upper lid, where it is ordinarily well protected, is nevertheless liable to both acute infections and chronic irritations. When acutely inflamed it usually goes on to abscess formation. We have then acute _dacryo-adenitis_, which will produce the ordinary symptoms of phlegmon, with the added ocular features of vascularity and chemosis of the conjunctiva and more or less edema and immobility of the upper lid. Displacement of the eyeball may be produced by great inflammatory swelling. These abscesses tend to discharge either through the skin near the external angle or sometimes through the conjunctiva. While in the former case a scar results, it nevertheless is a preferable point either for spontaneous opening or for incision. If the case be seen in time it will be advisable to make this incision early and so limit destruction. (See Plate XLV, Fig. 1.)
The lacrymal gland suffers occasionally in instances of constitutional syphilis, undergoing chronic and obstinate enlargement. It may also be the site of tumors either non-malignant, usually adenoma, or cancerous, most instances of the latter being expressions of extension.
The _tear passages_ proper are composed of the canaliculi, the lacrymal sac, and the duct. These are altered, occasionally, in their relations, or absent, as the result of congenital defects. The passages proper frequently become obstructed, as the result of any chronic irritation which produces thickening of the conjunctiva, and in many laborers and others who are exposed to dust, dirt, or cold winds there will be a more or less constant stillicidium or overflow of tears. In some of these cases it is sufficient to slit up one or both canaliculi with a fine probe-pointed bistoury.
DACRYOCYSTITIS.
The _lacrymal sac_ proper is frequently the site of both acute and chronic disease, known as _dacryocystitis_, which is the result of infection spreading from the conjunctival sac, rarely from the nose, or the exaggeration of conjunctival thickenings, like those mentioned above. The first symptoms are overflow of tears, accompanied by swelling or enlargement in the region of the sac. By pressure upon this a mixture of water, mucus, and sometimes pus may be expressed. As the disease goes on the fluid becomes purulent. If the sac, by pressure, can be emptied into the nose the nasal duct may be regarded as patulous and the treatment is simplified. If not there is stricture, usually at the upper end of the duct, which requires division and dilatation. The more chronic forms of trouble in this region are frequently intensified into acute phlegmonous lesions which, if neglected, will lead to spontaneous perforation and the formation of a _lacrymal fistula_ at a point below the inner angle of the eye. (See Plate XLV, Fig. 2.)
=Treatment.=--The treatment should consist of exposure of the sac by incision of the canaliculi and its irrigation by means of a syringe and antiseptic fluid. Unless this fluid passes easily into the nose the stricture should be divided and Bowman’s probes passed, the principle of treatment being the same as that in treating urethral stricture. This part of the treatment should be referred to an oculist.
In acute dacryocystitis with suppuration the sac along the natural passages should be opened. When a diagnosis of an acute lesion of this kind is made nothing but the most radical treatment is advisable.
THE LIDS.
Congenital deformities of mild degree are not infrequent about the eyelids.
EPICANTHIS.
Epicanthis is a term implying folds of redundant skin extending from the internal end of each eyebrow to the inner canthus and over the lacrymal sac. It varies much in degree, is a more or less hereditary feature in certain families, and is not infrequently associated with other defects. The palpebral fissure varies in length in different individuals, giving a longer or shorter window through which the eye proper shall appear. Sometimes the fissure is much too short and requires division or extension, which is easily made by incision at the outer angle.
COLOBOMA.
Coloboma is a term applied to various lesions of the eyelid, the iris, and the choroid, implying a defect in structure, which, in the eyelid, leaves a V-shaped deficiency, corresponding to harelip, whose edges may be brought together by a simple operation.
STYE; HORDEOLUM.
The eyelids are subject to certain painful or disfiguring lesions, which frequently come under the notice of the general surgeon. Of these the most common is _stye_, or _hordeolum_. This is a phlegmon of one of the minute glands along the margin of the lid, which has become infected and violently reacted. It forms a miniature furuncle, often associated with conjunctivitis, and giving a disproportionate reaction. So soon as the presence of pus can be detected a puncture should be made and the contained drop of pus exvacuated. Threatening suppuration may sometimes be aborted by local use of 1 or 2 per cent. mercurial (yellow) oxide ointment.
CHALAZION.
A somewhat similar but non-inflammatory cystic distention of one of the Meibomian glands, which pursues a slow and painless course, is called _chalazion_. It presents rather beneath the mucous surface, but is often visible through the skin. Its contents are mucoid or dermoid. When it attains troublesome dimensions it should be exposed through a small incision, usually external, and thoroughly extirpated.
XANTHELASMA.
Small, elevated areas of dirty-yellow color are met with in the skin about the eyelids, more often near the inner angle. Such a lesion is called _xanthelasma_, the lesion being a fatty metamorphosis of a portion of the skin structure. While harmless, it is amenable to excision for cosmetic effect.
Any of the ordinary tumors which affect similar tissues elsewhere may be seen about the eyelids. The more common are the vascular tumors, especially small nevi. Epithelioma occasionally commences along the palpebral margin, but is more often an extension from neighboring tissues.
BLEPHARITIS.
The margins of the lids are frequently involved in a mildly infectious inflammatory condition called _blepharitis_, in which nearly all the structures participate; when the borders alone are involved it is referred to as _blepharitis marginalis_. The condition is largely due to dirt, and to irritation in which the Meibomian ducts seem to share. It is accompanied by chronic conjunctivitis. The condition is seen more often in the ill-nourished, the rickety, and the tuberculous. The best local treatment consists in the use of an ointment of yellow oxide or yellow sulphate of mercury. The former may be used in 2 per cent. strength, and the latter not stronger than 1 per cent. This should be applied along the lid margins at night, and thoroughly rubbed in. A commencing phlegmon and stye may be aborted by one of these preparations.
TRICHIASIS.
Another very annoying complication, and usually the sequel of the condition already mentioned, is _trichiasis_, or turning inward of the eyelashes. Chronic irritation and cicatricial contraction on the inner aspect of the eyelids, or a chronic blepharospasm, which may be the result of corneal infections, serve to draw the lids inward, especially with the margins of the hair follicles, so that the eye-winkers grow toward the ocular surfaces, which they constantly irritate. The result is a vicious circle, each morbid condition intensifying the other. In time there is produced a condition of _entropion_, which is to be remedied only by operation. It is not sufficient to treat trichiasis by epilation, as the hairs will grow again and continuously cause trouble. The cause should be removed and the effect treated.
ENTROPION.
By this term is meant a condition of inversion of the margin of one or both lids, by which the external surface is brought into actual contact with the surface of the eyeball. It is a chronic condition brought about through the action of several contributing causes. Any condition of the cornea or deeper portion of the eye which leads to photophobia and spasmodic closure of the eyelids will produce in time hypertrophy of the orbicularis, with corresponding strengthening of the muscle and exaggeration of its activity. Chronic blepharospasm will thus in time lead to a mild degree of entropion, while any affection of the inner palpebral surfaces which leads to cicatricial contraction will still more intensify it. So soon as trichiasis or irritation by the eyelashes is added to what has gone before, every feature is exaggerated and the cornea is made to lie practically in contact with the skin surface of the eyelid. A further consequence is corneal disease, often with ulceration and opacity, with even worse structural changes.
The condition is really a serious one and is to be treated not alone by operation upon the lid, but care should be given to all the contributing features. So far as the lid condition alone is concerned, I have found the operation suggested by Hotz the most satisfactory of any, at least in average cases. An incision is made from one end of the lid to the other, along the distal border of the tarsal cartilage, and down to it. Through this a bundle of those orbicularis fibers which run parallel with the incision is dissected away. In extreme cases the tarsal cartilage, which is incurved as the result of the old condition, may be either incised or a strip excised from its structure. Sutures are then inserted which include not only the borders of the skin incision, but the exposed border of the tarsus and the tarsoörbital fascia. By applying the central suture first, and then one on either side, it will usually be found that as the sutures are tightened the edge of the lid is drawn outward and the desired effect obtained.
The large number of operative methods which have been suggested for the cure of entropion bespeak the variety of causes which may produce it and the many devices to which different ingenious ophthalmic surgeons have resorted.
[Illustration: FIG. 390
Arlt’s operation for ectropion. (Arlt.)]
ECTROPION.
This condition is the reverse of entropion, and implies eversion of the margin, or of a considerable portion of a lid, with consequent exposure of its conjunctival surface, which undergoes changes in consequence of which it becomes thickened, contracted, and irritated. Ectropion may possibly be produced by violent orbicular spasm, especially in children, the lids being so tightly shut as to be everted. Ordinarily it is the result of external lesions which produce cicatricial contraction, like burns, or of chronic ulcerative lesions along the palpebral border, such as are met with in tuberculous and syphilitic disease. The lower lid is much more frequently involved than the upper.
For the relief of ectropion plastic operations are practised, usually on the lower lid. The milder cases require a V-shaped incision, its apex downward, with free dissection of the integument up or near to the margin of the lid, by which it is released from the scar tissue which has bound it down. Fig. 390 illustrates the general principle of such an operation. The lower portion of the V-shaped defect is then brought together with sutures, the triangular flap being fastened in a position much higher than that in which it originally rested.
All of these operations upon the eyelids are included under the term _blepharoplasty_, of which the above is the most simple. When necessary new flaps may be raised from the temporal region, from the forehead or from the cheek, as may be required, and turned into place, their pedicles being so planned as to carry a sufficient blood supply for nourishment of the same. If this supply be properly provided these operations are practically always successful. It is necessary only to make the transplanted flap at least one-third larger than appears to be necessary, judging from mere size of the defect, for experience shows the necessity of allowing at least one-third for primary and cicatricial shrinkage. A _heteroplastic_ operation is occasionally performed for this purpose, by which the flap of skin is detached from an entirely different part of the body, or from the body of another individual. Skin thus transplanted should be prepared by removal of all of the fat upon its raw surfaces, skin alone being desired and not other tissue. Figs. 391, 392, 393 and 394 illustrate blepharoplastic operations of various types, which may be modified or made more extensive. These are but a few of the various plastic devices, and are intended to serve merely as suggestions or examples rather than methods to which one is limited.
[Illustration: FIG. 391
Richet’s operation for ectropion. (Arlt.)]
[Illustration: FIG. 392
Fricke’s method of blepharoplasty. (Arlt.)]
[Illustration: FIG. 393
Dieffenbach’s method of blepharoplasty. (Arlt.)]
[Illustration: FIG. 394
Arlt’s method when a portion of the eyelid is to be sacrificed. (Arlt.)]
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.
[Illustration: FIG. 395
Developmental defect of external ear. (Broome.)]
_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.
[Illustration: FIG. 396
Complete destruction of auricle by rodent ulcer. (Buffalo Clinic.)]
[Illustration: FIG. 397
Congenital lymphangioma of ear. (Lexer.)]
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.
[Illustration: FIG. 398
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).
[Illustration: FIG. 399
Branches of the inferior maxillary nerve which most concern the surgeon: _a_, auriculo-temporal; _b_, inf. dental; _c_, buccal. (Marion.)]
[Illustration: FIG. 400
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.
[Illustration: FIG. 401
Intracranial exsection of Gasserian ganglion; dura open, brain lifted up. Hartley-Krause method. (Marion.)]
[Illustration: FIG. 402
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.
[Illustration: FIG. 403
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.)]
[Illustration: FIG. 404
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).
[Illustration: FIG. 405
Exposure of the spinal accessory nerve alone: _a_, digastric; _b_, jugular veins; _c_, sternomastoid muscle; _d_, spinal accessory. (Marion.)]
[Illustration: FIG. 406
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.
The operation described below is practically that advised by Jonnesco, more or less modified by other operators, and may be varied to some extent to meet the exigencies of particular cases. Thus whether it shall be done through one or two incisions will depend on the will of the operator. It is made about as follows: A long incision is made along the posterior border of the sternomastoid. The latter may be either retracted forward or its fibers separated, in order that the fascia on its inner side may be reached and separated from the deeper muscles. This fascia should be divided as high as the base of the skull. The upper ganglion of the cervical sympathetic lies on the inner side of the anterior tubercle of the transverse process of the second and third vertebral processes, resting upon the muscles covered by this fascia. The ganglion, being recognized by its shape, and the sympathetic trunk being thus identified, the nerve should be divided and made free, as high as possible and just beneath the base of the skull. (See Fig. 408.)
[Illustration: FIG. 407
Diagram to illustrate the relations of the cervical sympathetic and the mechanism of the various disturbances following lesions of its trunk. (Stewart.)]
The lower end is to be exposed by continuation of the first incision, or by another beginning 1 Cm. above the clavicle and extending along the posterior border of the sternomastoid for 4 or 5 Cm. The platysma should be entered and the tissues separated upward until the fingers can meet in a channel thus made by connection with the upper incision. The tissues should also be loosened downward until a point has been reached behind the clavicle. They then should be widely retracted and the inferior thyroid artery sought. The middle cervical ganglion is found inside of its curve. Occasionally this ganglion is replaced by a plexus, or the main trunk may pass behind the artery. At this level it is to be seized and its upper divided end pulled down and out through this opening. The nerve trunk should then be followed downward. The artery should be freed from any plexus of sympathetic fibers around it, all of which should be destroyed, and especially those fibers which constitute the middle cardiac nerve, which pass to the inner side. The main trunk is to be drawn down beneath the artery and then followed downward and outward to the lower ganglion, where it lies behind the clavicle, on the neck of the first rib, between the scalenus anticus and the longus colli. The ganglion and the trunk should be separated from the efferent and afferent branches which connect with it, as well as from the vertebral artery; being thus made free it is again drawn outward. Here one should divide especially the cardiac branches which form the lower cardiac nerve, as well as the vertebral branches which have so much to do with controlling the supply through the vertebral artery. The ganglion, after being identified, should be finally removed. The nerve should be traced still farther down to the first thoracic ganglion, which has much to do with supplying the heart, and this also should be separated and destroyed (Fig. 409).
[Illustration: FIG. 408
Sympathectomy. Exposure and removal of middle and upper ganglia. (Marion.)]
[Illustration: FIG. 409
Sympathectomy. Seizure and removal of inferior ganglion. (Marion.)]
It is rarely necessary to provide for drainage after the operation, unless the retraction and laceration of tissues have been very great. My own preference is to make one long incision along the posterior border of the sternomastoid, by which the dissection is facilitated and the operation made less complicated and difficult. When done for glaucoma on one side it will be sufficient to attack one nerve, but when for epilepsy or for exophthalmic goitre the operation should be bilateral. When for epilepsy or glaucoma it is not so necessary to remove the lower cervical ganglion; this is indicated rather in those cases where it is desirable to control the accelerator nerves to the heart. The operation has given good results in all three affections named, yet it is one of considerable difficulty. It would be made extremely difficult by the presence of a large goitre, and in such case it would probably be better to extirpate the thyroid rather than to attack the nerve. (See Glaucoma, Epilepsy, and Exophthalmic Goitre.)
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