_Brain abscess connected with middle-ear disease_ will usually be

found in the temporosphenoidal lobe, but occasionally occurs beneath

the tentorium, in the cerebellum. Many of these cases are connected

with self-evident indications of purulent otitis media and mastoid

disease, and operation for the latter has often to be combined with the

recognition of and suitable treatment for brain abscess. The surgical

treatment of mastoid disease will be discussed in separate paragraphs

and under a separate heading. Whenever there is any reason to suspect

the existence of pus within the cranium the operator should expose the

dura by opening above the mastoid; or his operation may already have

taken him as far as the sigmoid sinus, in which case, with the dental

engine or with other bone-cutting instruments, he may much enlarge the

field of operation and thus make access both to the sinus and to the

brain itself. An extradural collection of pus may be found within the

sinus or above it. Drops of pus may escape as the operator cleans away

or even presses apart the granulations. He has often to decide upon

further exploration, either to open the sinus expecting to find it

filled with disintegrated blood clot and products of decomposition, or

to open the dura proper, expose the cortex, and perhaps explore here

with the aspirating needle for pus located more deeply. In those cases

where evidences of brain abscess are more pronounced, and those of

mastoiditis less so, the lateral region of the skull may be exposed

and the cranium opened with a trephine before working downward and

exposing the mastoid region. In not a few instances both operations are

combined and the area of bone to be cut away is relatively large. Thus

complete _tympanic eventration_, with removal of much of the mastoid,

may be combined with trephining and opening of a brain abscess, or

opening of the sinus, in which latter there may be found such a

condition as to make it advisable to ligate the common jugular low in

the neck, and irrigate from the sinus to the location of the ligature,

where the vein is laid open, or even to pass a small swab upon the

end of a flexible probe. Nothing can more predispose to typical

pyemia than a breaking-down clot within a sinus or vein involved in

thrombophlebitis.

_Temporosphenoidal abscess_ will often be indicated by the escape of

pus through the dura, above the roof of the tympanum. Although such an

abscess might be evacuated by enlarging the tympanic approach to it, it

would ordinarily be much better to open the skull above the ear, and

thus make free access and provision for drainage. In any part of such

an operation when the dura has once been exposed its appearance should

be carefully noted. The coarse of the pial vessels can usually be

traced through it. Therefore when it is sufficiently opaque to prevent

any appreciation of conditions beneath, or sufficiently distended, it

may be opened.

When cerebellar abscess is suspected the trephine should be applied

about midway between the tip of the mastoid and the external occipital

protuberance (inion), _i. e._, one inch beneath Reed’s base-line and

one and a half inches back of the mastoid. The instrument should here

be used with care, as the occipital bone is of irregular and variable

thinness. In a brain abscess which can be freely opened gauze packing

will be found serviceable, even though its use necessitates the

employment of secondary sutures or perhaps leaving the wound open in

order to permit of its removal.

Localizing symptoms are only occasional in connection with cerebral

abscess, because the majority of these lesions are located without

the motor area. Pupillary alterations are indefinite. As an abscess

enlarges the size of the pupil may increase. Infective thrombosis

rarely affects the pupils, save that when located in the cavernous

sinus it may produce ptosis. In _temporosphenoidal abscess_ pain is

usually localized in or near the ear upon the same side. As the motor

area becomes involved there is a gradual development of localizing

phenomena, referred to the opposite side. _Facial paralysis_ is

common in advanced destructive lesions in the mastoid and tympanum.

When produced by cortical lesion it is rarely so pronounced as when

by direct paralysis of the nerve. In _frontal abscess_ there are

few localizing phenomena. Abscess in the _parietal region_ is most

commonly of traumatic origin, and is to be suspected in accordance with

external surface markings. _Occipital abscess_ is exceedingly rare,

and cerebellar abscess furnishes few localizing symptoms. Its most

prominent clinical features are retraction of the head and neck; slow,

feeble pulse and respiration; subnormal temperature; violent yawning;

rigidity of the masseters; slow speech; optic neuritis; vertigo and

vomiting. If accompanied by thrombosis there is pain upon pressure in

the upper part of the neck. In all of these cases _when abscess is

near the surface there is more or less leptomeningitis_, which becomes

diffuse at once when the abscess bursts. If meningitis be present we

have high temperature without marked remissions, rapid pulse, and

general irritability, rapidity of pulse indicating predominance of

leptomeningitis over encephalitis, since the more marked the latter

the slower the pulse. As distinguished from sinus thrombosis we have

in the latter high temperature with marked remission, rapid and weak

pulse, frequent chills, profuse sweats, and often symptoms of pulmonary

infarct or diarrhea, with cervical and submastoid tenderness and

involvement along the jugular vein upon the affected side. _If all

three conditions be associated the symptoms of thrombosis usually

prevail_, although there may be retraction of the head due to basilar

meningitis. As between tumor and abscess we have in the former absence

of explanation of infection, slow progress of symptoms, more definite

localizing phenomena, progressive involvement of nerves, pronounced

optic neuritis, absence of chill, and alternating periods of mitigation

of symptoms. Temperature and pulse afford little help, save that

subnormal temperature points rather to abscess.

=Prognosis.=--From every direction come statements that the tendency

of cerebral abscess is invariably toward fatality. No matter what the

cause, unless relief be promptly afforded, death is the sure result. Of

the acute cases those not promptly operated usually die within a few

weeks. The more chronic or prolonged cases rarely come under surgical

treatment; most of those which do are the result of disease in or about

the middle ear. Were it possible to early diagnosticate formation of

these abscesses prognosis would be much more favorable. When seen

before necessarily fatal complications have arisen, in instances where

the position can be reasonably well determined, surgical attack is

likely to give good results. After proper evacuation even complete

mental and bodily recovery is possible. Anchoring of the brain by

adhesions may leave a train of disquieting symptoms, which, however,

are not so bad as fatality. Abscesses may remain for a long time

encysted, and yet be a fruitful source of danger. Multiple abscesses

may complicate both the diagnosis and the treatment and produce a

condition beyond help.

The operative treatment of these cases will be discussed by itself.

B. =Sinus Thrombosis.=--The sinuses are predisposed to thrombosis

by virtue of their size, inflexibility, shape, and the fact that

they are not emptied during respiration, all of which tend to retard

blood flow. If to these be added defect in the blood supply, then

everything predisposes toward _marasmic thrombosis_. This occurs

much less frequently than the infective form, is mostly confined to

the longitudinal sinus, is noted mainly at the two extremes of life,

and is often seen in cases of death following exhausting diarrhea in

children. In the _marasmic form_ the clots are dense, firm, stratified,

and non-adherent; they rarely occupy the whole caliber. In old cases

the clots may be tunnelled sufficiently to permit reëstablishment

of circulation. Their principal evil consequences are edema of the

frontal lobes and serosanguineous effusion into the ventricles or

orbits--in the latter case producing exophthalmos. Sometimes epistaxis

is produced. Strabismus, tremor, muscle rigidity, or contractures are

more often seen conjoined, especially in children, with convulsions,

sometimes unilateral, and choked disk.

=Diagnosis.=--The diagnosis in adults is difficult, but in children,

when convulsions occur after exhausting illness, with the signs just

noted, marasmic thrombosis may ordinarily be diagnosticated.

_Infective thrombosis_, the other variety, is due exclusively to the

invasion of pyogenic organisms. It is observed mostly in the basal

sinuses; its origin is local, and it is always secondary to some

external infection. Its most frequent cause is middle-ear disease;

consequently the sigmoid sinus is the one most often involved. It may

follow carbuncle, erysipelas, or cellulitis of the external parts, or

nasal ulceration, as well as dental caries, suppuration of the tonsils,

etc. Infection may be propagated by tissue continuity, or through the

circulation.

=Symptoms.=--Infective thrombosis presents few distinctive symptoms.

Local ischemia, perversion of function, extracranial edema are too

vague. Headache is nearly always constant and vomiting is frequent;

temperature runs high, with marked remissions; the pulse is small

and rapid, and remains so even under an anesthetic. _Chills_ are

frequent, of the pyemic type, and are followed by copious sweats.

Should pulmonary infarct occur there will be typical thoracic signs,

although at first physical examination may give negative results.

Later, however, we get prune-juice expectoration, putrid sputum, etc.

Cerebral function is disturbed late rather than early. The duration of

the disease ordinarily is from two to four weeks. Should _meningitis_

complicate the case there is more violent headache, persistent high

temperature, great excitement, muscle spasm, strabismus, delirium, and

coma; if the sigmoid sinus be involved there is usually retraction of

the head. Should leptomeningitis extend down the spine, complaint of

girdle pains will be made.

=Differential Diagnosis.=--The two conditions which are most likely to

be confused with sinus thrombosis are meningitis and brain abscess.

In _thrombosis_ there are pain and tenderness over the mastoid,

extending down the neck. Fever is high, pulse rapid, respiration not

affected, rigidity not usually present. Chills are frequently followed

by profuse perspiration. The general picture is one of sepsis and the

typhoid state. There are no special eye symptoms. Death is finally

due to pyemic processes. In _meningitis_ pain is an early, constant,

and severe symptom. Headache is frontal or general, fever is not

characteristic, pulse is rapid until the accumulation of pus causes

slowness by pressure, breathing is short and rapid, and finally of the

Cheyne-Stokes variety. Rigidity of the neck and back, with retraction

of the head, is nearly always present, with spasmodic contractions or

convulsions about the neck. Chills are not so pronounced, vomiting is

almost invariably of the projectile type, optic neuritis is frequent,

and the intellect is early impaired. In _brain abscess_ pain is at

first localized and severe, extending and becoming excruciating. This

increases on pressure, and does not disappear until relief is obtained

or the patient becomes unconscious. Temperature is normal or subnormal

until the abscess ruptures. The pulse is slow, as in compression from

other causes; breathing is slow and stertorous. Rigidity and vomiting

are like those of meningitis. Eye symptoms are almost always present,

photophobia at first, later inequality of pupils, with dilatation on

the affected side, optic neuritis and irregular movements of the eye

and lids. Drowsiness, dizziness, and impaired intellect are features

when the abscess is in the cerebellum. Death occurs in coma unless the

case be complicated by meningitis.

We may also have _exophthalmos_ on one side or both, with conjunctival

injection, edema of the lids, and disturbances of vision, due to

thrombosis of the cavernous sinus and stasis in the ophthalmic vein.

In thrombosis of one transverse sinus only the internal jugular on

that side will carry less blood. So long as that on the other side is

free it will take that which cannot pass through the obstructed one.

Consequently the jugular on the other side will carry more. But if

the contained clot extend so far that direct communication with the

internal jugular is interfered with then the internal jugular of the

affected side will be almost empty, while the external of the same side

will be the more distended. When the eye is protruded and the frontal

vein distended it is evident that the cavernous sinus on that side is

involved. If the superficial veins of the scalp be distended it is

the superior longitudinal sinus which is at fault. When the veins of

the mastoid region are involved, we may locate the thrombus in the

transverse sinus; when there are no localizing symptoms, it can only be

said in a general way that thrombosis has occurred.

=Prognosis.=--Prognosis is always unfavorable, though recovery is not

impossible. The therapeutics are in the main prophylactic. By actual

physiological rest the possibility of pulmonary complications can be

diminished. The treatment, aside from this, is purely operative, and

will be discussed elsewhere.

C. =Sinus Phlebitis.=--This may be the result--

(_a_) Of thrombosis; or,

(_b_) The continuation of suppurative processes from neighboring

tissues.

=Symptoms.=--The symptoms are seldom diagnostic. Sinus phlebitis

is often accompanied by meningitis, even encephalitis. The first

symptom is usually severe headache, often localized, made worse by

pressure. Anorexia with early mental disturbance and often delirium

follows, with vomiting, restlessness, and mania, changing to stupor

and coma. _Rigidity_ or spasm of _cervical muscles_, or of those of

the extremities, followed by paralyses, is often seen. Evidences of

_irritation of special nerves_, particularly the oculomotor or the

vagus, are not rare. When pyemic symptoms occur they are vague and are

most conspicuous in the lungs and liver. Taken in conjunction with

aggravating brain symptoms they make prognosis unfavorable.

Symptoms will in large measure depend upon the sinus most involved.

They are characteristic if this be the _cavernous_ sinus. There are

disturbances in the eye on the same side, congestion of orbital veins,

pain and photophobia, and, later, cloudiness of the cornea and edema

with exophthalmos. Finally the pupil becomes paralyzed and dilated, the

cornea loses its polish, the upper lid cannot be raised, and, if the

case persists, the cornea ulcerates. Along with these local evidences

there will be complaint of frontal pain, usually with paralysis of

the hypoglossal nerve and consequent thickness of speech. When the

_transverse_ sinus is involved there are, first, vagus irritation,

then paralysis with paralytic sequences in the muscles of the jaw, the

tongue, palate, pharynx, etc. Diaphragmatic motions are interfered with

and the character of the respiration altered. As the trouble extends to

the internal jugular we have further paralysis of accompanying nerves,

especially of the hypoglossal. As the irritation extends down the vein

there will be tenderness, rigidity, and often swelling. The local signs

and symptoms vary obviously as the lesion extends from one sinus to

the other, for when one cavernous sinus is involved the trouble nearly

always extends to the other, and local symptoms are repeated upon the

opposite side.

D. =Meningitis.=--The dura has a duplicate anatomical character. Its

outer surface, having the structure of periosteum, functionates as

such; its inner surface, being lined with endothelium, partakes of the

nature of a true serous membrane. When the former texture is mainly

at fault we have pachymeningitis externa, or endocranitis, which is

rarely a primary, but usually a propagated lesion met with after injury

or external infection. It may lead to infiltration with purulent

products, and, if speedy exit for pus be not provided, to involvement

of the pia within. _Extradural suppuration_ without external injury

is very rare, but should there have been a subdural hemorrhage with

external lesion the blood clot may become infected and break down.

_Pachymeningitis externa_ is most common after chronic lesions of

the cranial bones--_i. e._, caries and necrosis. _Symptoms_ are not

characteristic and often not distinguishable. When chronic there will

be local tenderness, evidence of the presence of pus, with focal

symptoms.

=Treatment.=--The treatment is always surgical, save possibly in

certain cases due to syphilis, where delay may be justifiable for the

purpose of testing the action of antispecific drugs.

=Pachymeningitis Interna.=--Pachymeningitis interna is often confounded

with chronic hydrocephalus. It is frequently the occasion of a firm,

membranous exudate upon the internal surface of the dura, which forms

in time a new membrane rich in small and extremely friable vessels,

from which hemorrhages easily occur, thus giving rise to the condition

of pachymeningitis hæmorrhagica. Trifling hemorrhages will produce

little or no disturbance; when of greater extent they may give rise to

localizing brain symptoms. These extravasations may absorb or undergo

fluidification--_i. e._, produce localized or cystic collections of

fluid. The condition sometimes occurs after other acute infections,

especially pneumonia, pleurisy, typhoid, whooping-cough, etc. Recovery

is possible, but usually at the expense of adhesions, which lead to

subsequent complications.

The _symptoms of pachymeningitis hæmorrhagica_ are headache, which

will increase in intensity with every new escape of blood, usually

localized in the vertex, with more or less paralysis following each new

extravasation. The final result may be atrophy. Absence of disturbance

in the cranial nerves points to lesions in the convexity rather than

basal or ventricular. In chronic cases there is optic neuritis, and

toward the end coma, usually coming on slowly. Dennis has recommended

trephining under these circumstances, and has practised it with great

benefit.

=Treatment.=--The treatment should be in a large degree surgical, for

little short of eradication will bring about the desired result.

=Leptomeningitis.=--This term refers to inflammation (_i. e._,

infection) of the pia mater, in whose texture we encounter tissue

quite different from that composing the dura, and in which, when

inflamed, distinction as between the arachnoid and pia has disappeared.

_Leptomeningitis suppurativa_ is an exceedingly common expression of

intracranial infection, and may result not merely by extension, but as

a primary infection. When begun it spreads rapidly, the fluid contained

within the meningeal cavities, mixed with pyogenic agents, helping to

disseminate the active agents to the ultimate limits of the membranous

involvement. Consequently basilar meningitis usually extends down the

spinal canal. Next to injury the most frequent cause is _middle-ear

disease_, with its infectious complications and extensions. Next to

this come sinus phlebitis and endocranitis. Infection from the teeth

and the nasal cavity may occur. It is also known to result from

panophthalmitis: in traumatic cases, when primary, it sets in early,

even from four to thirty-six hours after injury. So rich is the pia in

loose connective tissue that even from the outset the inflammation may

assume the phlegmonous type. The cerebrospinal fluid, as well as that

of the ventricles, becomes cloudy, contains numerous flocculi, and is

often blood-stained.

=Symptoms.=--When the disease is limited to the vertex and follows

several days after injury it usually begins with chills and malaise,

with increasing temperature; after which the symptoms assume the

pyemic type, distinguished from true pyemia by their comparatively

early onset. The pulse becomes frequent, first full and then small;

patients are disturbed, restless, or uncontrollable, and complain of

headache, moan, grate the teeth, become delirious, with glistening

eyes and congested face. After a while delirium subsides into stupor

and restlessness into insensibility. The pupils contract and remain

inactive to light. Paralyses and cramps are not infrequent. _Traumatic

basilar leptomeningitis_ occurs often with fracture of the base.

Signs and symptoms are less distinctive here; paralyses occur more

easily and are less distinctive, save those which involve the special

cranial nerves. When _ptosis_ occurs with dilatation of the pupils and

glossopharyngeal paralysis we should be quick to suspect extension of

the process along the brain. Cramp or stiffness of cervical muscles

mean the same thing, and are signs of grave import which may be

considered pathognomonic. Albuminuria is frequent, with marked increase

of phosphates in the urine.

_In the non-traumatic cases the symptoms of leptomeningitis are

those of increasing brain pressure and temperature._ The disease

usually commences with headache followed by vertigo, hyperesthesia,

restlessness, delirium, insomnia followed by somnolence, muscle spasm,

paralyses, coma, and death. If the disease extends from the middle ear

there is frequently facial paralysis before the meningeal symptoms

appear.

The type of fever is one of gradual increase, though before death

temperature often falls even below the normal. Pathognomonic fever

should not be mistaken for the elevation of temperature which often

accompanies absorption of intracranial hemorrhages. In these latter

cases temperature may mount to 39° C., but if rising higher than this

meningeal complications should be suspected.

=Diagnosis.=--The diagnosis as between sinus phlebitis and

leptomeningitis depends principally upon the existence of pyemic

symptoms. When the latter are entirely wanting we may at least say that

the predominating symptoms of sinus phlebitis are absent.

=Prognosis.=--The prognosis is unsatisfactory. Many cases end in

forty-eight hours; others may live for two weeks or more.

=Treatment.=--Treatment seems almost futile, though one should

endeavor by energetic purgation, venesection, etc., to do what he can.

The only prospect or hope comes from the possibility of relieving

the compression from effusion of purulent fluid, and of irrigating

and draining what is now an enlarged abscess cavity. Since we do

not hesitate to open and wash out other serous cavities when thus

affected--_e. g._, peritoneum, pericardium, joints, pleura--we should

no longer hesitate to open the dura and wash out the subdural space,

even though this necessitate more than one trephine opening. The

measure was suggested by S. W. Gross, in 1873, when he reported cases

thus treated with success, and has since been practised by other

surgeons, among them by Souchon, who has advised multiple puncture with

the small drill and irrigation and disinfection through numerous small

openings. Of 11 cases collected by Gross more than twenty-five years

ago, 45 per cent. recovered.

E. =Encephalitis.=--The etiology of this condition is practically

that of leptomeningitis. It may proceed from sinus phlebitis or from

the veins emptying into the sinus, infection travelling backward

rather than forward. In many cases the primary infection occurs from

without, as in gunshot fractures. It is also transmitted along the

lymphatic channels, since I have operated on abscess in the frontal

lobe following intranasal operation. It assumes practically always the

suppurative type, and may run either an acute or a chronic course. When

acute the lesion is usually limited in area, and the result is an acute

abscess with irregular boundaries. It may be distinguished from uremic

coma by examination of the blood (leukocytosis) as well as that of the

urine.

OPERATIVE TREATMENT OF INTRACRANIAL SUPPURATIONS.

In dealing with pus the surgeon can never follow a safer rule than

to go according to this dictum: _i. e._, that pus left alone is a

greater source of danger than the surgeon’s knife judiciously used.

Consequently _ubi pus, ibi evacua_, applies to intracranial collections

as well as others. For its detection and evacuation operations are now

regarded as not merely justifiable, but indicated whenever there is

presumption of its presence. Discussion now hinges entirely upon the

wisdom of exploration when absolutely no diagnosis can be made. Save

where an opening already exists, trephining is a necessary preliminary.

Among other _indications_ is _spontaneous escape of pus_ through a

previous opening or any of the natural outlets of the cranium, with

or without localizing phenomena. _Further indications_ are those

pertaining to the bone--_i. e._, loosening of pericranium; or to the

scalp--_i. e._, edema, puffy tumor, etc.; and certain other indications

are those of a more general character, chills and pyrexia. When the

dura is exposed much can be determined by the existing brain tension,

it being now well established that brain pulsation is often intensified

by the presence of pus beneath the dura. The most feasible method for

detection of subdural or deep collections is the use of the aspirating

needle--a method now generally in vogue and everywhere accepted.

MASTOID DISEASE AND THE MASTOID OPERATION.

In all cases of infection and suppuration of the middle ear the

adjoining portions of the cellular structure of the mastoid undoubtedly

participate. Fortunately morbid activity is usually so limited that

the clinical evidences of what is called _mastoiditis_ occur in a

relatively small proportion of cases, but otitis media purulenta is so

common that mastoiditis is consequently a complication of sufficient

frequency, and occasionally of such severity, that it is as likely

to come under the supervision of the general surgeon as that of the

specialist. Moreover, the region affected is such common ground, as it

were, between the broad field of the former and the restricted field of

the latter that it seems to me that every general surgeon or student of

general surgery should be familiar with the condition and its surgical

treatment.

Several of the specific germs, of diseases like pneumonia, la grippe,

etc., are known to set up acute mischief within the tympanum as well

as the commonly known pyogenic organisms. They have easy access to the

middle ear through the Eustachian tube, as well as by the deeper blood

and lymph channels. The nasopharynx is never free from the presence of

organisms, while the specific fevers, like scarlatina, and notably such

infections as diphtheria, predispose to germ activity in the region

into which the inner end of the Eustachian tube opens. The Schneiderian

membrane, which is practically continuous from the ethmoid cells to

the membrana tympani, affords easy travelling, and in all directions,

for infecting organisms. The violence of reaction will depend upon two

uncertain and indeterminable factors, the virulence of the organism and

the susceptibility of the patient. To what extent the mastoid cells

and antrum, around an infected tympanum, shall participate may be, to

a considerable degree, a matter of their anatomical arrangement. When,

however, they do participate to any great extent the fact is made known

by symptoms of unmistakable character. These constitute the added

features of what is known as _mastoiditis_.

The cavity in the mastoid known as the _mastoid antrum_, no matter

what may be the arrangement of the other cells, is always present, and

in the presence of deep disease the antrum should be first opened. In

close proximity to the antrum are cavities like the sigmoid sinus,

the horizontal semicircular canal, the facial canal, and the interior

of the cranium. While opening the antrum care should be taken to

avoid encroachment upon the other cavities or structures, except in

those instances where there is evidence of intracranial mischief, in

which case it may be desirous to expose the sinus wall, or even a

considerable area of brain surface. The mastoid prominence varies in

different individuals, extending outward to accommodate the sigmoid

groove for the lateral sinus.

According to the intensity of the process the pathological condition

of the mastoid may vary between an empyema of its cavities, an

osteomyelitis of its osseous structure, or osteoperiostitis of its

external surface. Nevertheless all three of these may be combined in

the same case.

=Symptoms.=--The symptoms of mastoiditis are _pain_, referred to the

mastoid, as well as to the region around it, although when pressure is

not made by retained pus pain may not be intense; local tenderness is

present in nearly all cases, and will depend upon the proximity of the

trouble to the surface. This tenderness is evoked by gentle pressure,

which will sometimes produce pitting, or by tapping lightly with the

finger. When the trouble is superficial there will often be _edema_,

with all the local evidences of suppuration. In addition to this there

will be coincident symptoms of _disease of the middle ear_, with

discharge, earache, etc., and frequently edema or actual phlegmon of

the auditory canal.

The different directions in which destructive processes may extend, and

their consequences, are as follows: (_a_) Externally, with well-marked

local evidences of the proximity of pus; (_b_) anteriorly into the

meatus, with phlegmonous appearances in that canal; (_c_) upward,

through the roof of the tympanum or the antrum, with disastrous

cerebral symptoms or extradural abscess; (_d_) inward, toward the

sinus, with consequent thrombophlebitis, extradural abscess, and

perhaps cerebellar abscess; (_e_) downward, and away from the mastoid,

with phlegmon deep in the neck.

The first appearance of symptoms of any of these complications should

awaken apprehension and demand scrupulous attention. Any collection of

pus along the auditory canal should be promptly incised, and the first

indication of mastoid tenderness or inflammation should cause a prompt

application of leeches, followed by antiseptic irrigations. In this way

it may be possible to avert serious symptoms, provided these measures

be instituted early.

But with either the access of local symptoms indicating the presence

of pus, or of more general symptoms, elevation of temperature,

acceleration of pulse, headache, or anything else suggestive of dural

irritation or cerebral complication, no time should be lost in making

free and radical operation. The _mastoid operation_, so called, is

then demanded in these cases. When thus indicated the first objective

point should be the _antrum_. In order to reach this the customary

incision of many writers, back of and parallel to the posterior convex

border of the ear, is insufficient and uncertain. The antrum lies

within what Macewen has described as the _suprameatal triangle_, and

is to be regarded as the key to the situation. It is necessary to

recognize the posterior zygomatic root, which projects behind and

above the ear, as well as the tip of the mastoid process, and then

to make a perpendicular linear incision, about a quarter of an inch

behind the posterior border of the external osseous meatus, extending

from this posterior root down to or nearly to the mastoid tip. The

surgeon should cut down directly upon the bone, without dissecting or

scratching his way through the different tissue layers. The posterior

auricular attachments are thus fully exposed, and should be reflected

forward, so that the posterior aspect of the external meatus is fully

exposed. After thus exposing the bone the surgeon notes the position

of the superior meatal triangle, which is formed by the posterior

zygomatic root, the upper posterior segment of the external osseous

meatus, and an imaginary line uniting these two, extending from the

most posterior portion of the osseous meatus to the zygomatic root.

Within this triangle the mastoid antrum may be entered, its depth being

proportionate to the depth of the middle ear from the surface. So long

as care is exercised the sigmoid groove will not be injured. The depth

at which it lies from the surface varies. It is more superficial in

children, while in adults with chronic ostitis of the region it may

have a thick covering. When opened it should be thoroughly cleansed,

for it may contain not only pus but granulation tissue or masses

of cholesterin. After cleansing the antrum the passage between it

and the middle ear should be noted, as well as the position of the

facial canal, which traverses its inner side obliquely from without

inward as it passes into the inner wall and roof of the tympanum. It

is recognizable by a ridge of harder osseous tissue. If changes have

occurred in the surrounding bone it may not be recognized. If the

operator keeps to the upper and outer part of the antrum he will avoid

the nerve. Any injury to it will produce facial twitching. The bony

canal may be eroded by granulations, so that the nerve itself may be

exposed when the antrum is being cleansed.

The _mastoid cells_ lie posteriorly and below this antrum, and should

be exposed, when cleaning out their morbid contents, by removing the

external mastoid wall. In this part of the operation the _sigmoid

groove_ should not be forgotten, as it may have been disintegrated by

granulations which have extended into the fossa and separated the dura

from the bone. When granulations have thus formed there is usually more

or less thrombosis of the sigmoid sinus in addition to the localized

pachymeningitis.

The instruments which may be employed during this work are a matter

of choice. It can be done with the ordinary bone instruments of the

general surgeon, which should, however, include gouges and curettes of

small size as well as delicate chisels and mallet. A dental or surgical

engine is advisable, which will serve admirably and for the desired

purpose. Just what instrument should be used and how manipulated will

depend upon the more or less pneumatic (_i. e._, cellular) character of

the bone. Some mastoids are richly cellular. Pus or granulation tissue

should be followed wherever it may lead.

When both mastoid cells and tympanum participate in the morbid process,

and are practically filled with pus, debris, or granulations, there

may then be added to the operation those features which entitle it

to be called _tympanomastoid exenteration_, as devised by Schwartze,

Zaufal, Stacke, and others, and frequently described under their names.

It is an extension of the measures already described, and results in

converting the mastoid cells and antrum, the tympanic cavity, and the

auditory canal into one common cavity. Not only is the bony barrier

between the antrum and the tympanum removed, but the ossicles as well.

This leaves a large cavity, which should be partially closed and

lined by granulation and cicatricial tissue, epithelial lining being

furnished so far as it may extend from the exterior.

The operation may be begun practically as already described, the

incisions being more extensive and the auricle more freely detached,

so as to be reflected forward. There need be no particular effort to

save the periosteum over the area of the attack, although there is no

objection to reflecting it with the softer tissues. Some operators

prefer to detach the cartilaginous meatus and the ear from its osseous

insertion and to shift them all farther forward. The antrum and the

mastoid cells having been exposed, opened, and cleaned out, the

surgeon next passes forward and upward to the external wall of the

epitympanum, and the dividing barrier of bone between the tympanum and

the mastoid. This cavity being uncovered, the incus, if present, may

be lifted out of its position, or all of the ossicles removed in as

gentle a manner as circumstances will permit. All the bony prominences

and partitions between the tip of the mastoid and the anterior wall of

the tympanum are then smoothed off with a curette, or surgical engine,

while granulation tissue is followed in to any recesses which may be

occupied by it, or along any of the cranial outlets which it may be

seen to traverse. One gives the greatest care to avoidance of injury to

the horizontal semicircular canal, to the aqueduct of Fallopius, or to

inadvertent puncture of the sigmoid groove. The Fallopian aqueduct, or

canal, lies in the ridge between the mastoid and the meatus, along the

floor of the aditus, and it should be spared in the process of cutting

away the bone.

If the membranous portion of the meatus has been split, as advised by

some operators, its margins may be brought together with chromic gut.

At all events the auricle should be brought back into place after the

cleansing is finished, where it should be fastened and retained by

sutures as well as by the dressings. Should there be insufficient skin

to cover the opening thus made, slide a flap, or even cover the exposed

raw area with a skin graft. The former will usually be the better

plan. The cavity left after such closure should be packed with gauze,

on which balsam of Peru should be used. This may be left for two or

three days, after which a daily dressing, with irrigation or suitable

cleansing, will suffice.

Most of the mechanism of the middle ear is apparently destroyed, but

loss of hearing is not complete.

CEPHALOCELE.

The term _cephalocele_ is applied to tumor of the endocranium,

presenting through defects in the cranial bones, of essentially

congenital origin, and containing more or less of intracranial

contents. It comprises--

A. _Meningocele_, which means a tumor consisting of a membranous

protrusion and containing cerebrospinal fluid; and,

B. _Encephalocele_, referring to tumors which contain also more or less

of actual brain substance.

[Illustration: FIG. 380

Occipital cephalocele.]

Such tumors of non-traumatic origin can only be explained by the

existence of congenital defects which permit the escape of that which

the normal bone retains within normal limits. In most instances the

defect is in the middle line, at either one or the other extremity of

the skull. In some instances the arches of the atlas, or even of other

cervical vertebræ, are lacking. The most common cephaloceles are the

occipital, which are known as inferior when below the occipital spine,

or superior when above it. Those appearing anteriorly are known as

sincipital, and are met with most often at the root of the nose, where

they may communicate with the orbit or the nasal cavity. Other and

irregular forms are laterally or unsymmetrically located (Figs. 380,

381 and 382).

_Cephaloceles_ have an elastic feeling, many of them an exquisite

fluctuation. Sometimes by touch alone we recognize both their fluid

and solid contents. A meningocele with thin walls is _translucent_. By

pressure they can be _reduced in size_, such pressure usually producing

brain symptoms, often paralysis or convulsions. Many children thus

affected cannot lie upon the tumor without becoming restless. When the

patients cry or make violent straining efforts it becomes larger and

its covering more vascular, while during quiet sleep it is usually

reduced in size or tension.

[Illustration: FIG. 381

Sincipital meningocele.]

A large proportion of patients with these congenital defects die

shortly after birth. The tumor, when large, may be ruptured during

delivery. Occasionally the sac ruptures spontaneously, which accident

is usually followed by purulent meningitis from infection, though it

may possibly lead to spontaneous recovery. The principal danger is the

liability to such accident.

[Illustration: FIG. 382

Sincipital hydrencephalocele; two views. (All of these from the Buffalo

Clinic.)]

The _encephaloceles_ are divided into the _cenencephaloceles_,

containing solid brain substance, and _hydrencephaloceles_, consisting

of the protrusion of a dilated brain cavity--_i. e._, a thin area of

brain enclosing fluid communicating with one of the ventricles. Most of

the large tumors pertain to the latter class. The more brain material

such a tumor contains the more it pulsates, especially if the patient

cry or strain; the smaller, too, is the skull--_i. e._, the greater the

tendency toward microcephalus.

_Congenital cysts_ of brain and membranes, in a measure traumatic, are

classified by Rawling, as follows:

1. According to situation: (_a_) within the calvarium, subosteal,

subdural, subarachnoid or intracerebral; (_b_) projecting through an

opening in the skull, with or without ventricular communication.

2. According to origin, _i. e._, whether they arise from blood clot or

other causes.

3. According to contents, whether they contain clear fluid, altered

clot, or brain substance.

Cysts of this character are to be differentiated from the cephaloceles

already considered because there is about most of them the element

of traumatism, although this may have been intra-uterine or produced

during parturition. Those which are associated with premature

synostosis and microcephaly, with hydrocephalus, with marked deformity,

or situated below the external occipital protuberance, are generally

considered inoperable, while those considered operable consist of

limited protrusions without any of the above defects. This practically

excludes the greater proportion of these cases from operation, which is

always dangerous. Nevertheless if success is to be achieved the risks

should be taken. Osteoplastic methods of closing cranial openings may

be perhaps of value in rare cases, although in the young the skull is

too thin to furnish an external table which can of itself be detached.

In inoperable cysts of this kind, with a tendency to increase, while

the rest of the brain lags behind in the rate of growth, the edges of

the opening become everted, and operation is thus made more difficult

and less desirable.

=Treatment.=--Treatment should, first of all, be protective, by

a shield of some device held in place by a suitable bandage or

dressing. _Compression_, with or without puncture, has given at times

satisfactory results, but not much should be expected from any method

or combination. Most of the cases are such that extirpation would seem

applicable, but the impossibility of absolute asepsis in young infants

and the liability to fatal shock preclude many of these attempts. In

some instances ligature of a meningocele has been successfully applied.

_Operation_ may be attempted in young children in selected cases.

Plastic operations may be resorted to, or plastic maneuvers combined

with extirpation. It may be possible by the insertion of a celluloid

plate to atone for a small defect in the skull after extirpation of a

tumor of this kind. I have successfully practised this method in spina

bifida.

HYDROCEPHALUS.

This term is applied to abnormal collections of cerebrospinal fluid

within the cranial cavity. We speak of--

A. _Hydrocephalus ventriculorum_ or _internus_, when the fluid is

confined to the dilated ventricles of the brain; or of--

B. _Hydrocephalus meningeus_ or _externus_, when the fluid collects

between the brain and the dura.

The former condition is much the more common. The cause of

hydrocephalus in the young is essentially congenital, and inseparable

from imperfect development within the cranium. The forms are

occasionally combined. At the time of commencing trouble the skull may

be of natural size, but yields to the accumulation of fluid within

until it attains relatively enormous dimensions. Most children thus

affected die early, some shortly after birth. It is most common in

rachitic children. Hydrocephalus developing in the adult is the result

almost solely of atrophy of the brain. _Pachymeningitis interna_ (see

p. 572) may also produce subdural exudate leading to _hydrocephalus

externus_. Encapsulated collections of cerebrospinal fluid due to

pachymeningitis interna are known as _hygromas_ of the dura. A

_ventricular_ form of hydrocephalus may also result from meningitis and

tuberculous disease. The condition is essentially chronic, the fluid

collecting in the dilated lateral ventricles, though the third or forth

are sometimes also distended: 4000 Cc. of cerebrospinal fluid have been

found in more than one instance. As the result of the presence of the

fluid there is _atrophy of brain_, with _arrest of development_, to

such an extent even that the hemispheres are changed into great sacs,

being merely spread out upon the outer wall of cystic cavities; all the

surface markings are lost, and gray and white substances are scarcely

to be differentiated.

In the cranium itself the bones of the vertex separate, and instead of

sutures there is a tightly stretched membrane. There is also congenital

or acquired _aplasia_--_i. e._, absolute defect of bone between the

dura and pericranium. All these changes give to hydrocephalic heads

a distinctive appearance. Other developmental defects--hare-lip,

club-foot, etc.--are common in these patients. Many infants thus

affected die during delivery unless skilful help is at hand. The

resulting disproportion between the enlarged head and the small face

is most distinctive. Children in this condition suffer from disturbed

digestion, are emaciated, with rachitic curvatures of the long bones;

special senses are seldom developed perfectly; strabismus and nystagmus

are frequent, while cramps and stupor are by no means infrequent.

=Prognosis.=--While spontaneous recovery is possible, as already

stated, the tendency is always toward fatality.

=Treatment.=--Treatment by compression of the enlarging skull, with

elastic bandages or their equivalent, is an abandoned method since

compression which can be effective is too great to be tolerated.

Treatment by mere aspiration is also useless. Tapping is an old

operation long discontinued, recently revived, but again proved

disappointing. The establishment of _permanent drainage_ is a more

recent suggestion. It depends upon the demonstration of the fact

that the tension of the cerebrospinal fluid and of the blood in the

cerebellar veins is the same, and that intracranial pressure forces

fluid into the veins and away from the skull. Thus subdural or

_autodrainage_ was suggested. Sutherland and Cheyne, in 1898, were

the first to operate in this manner. They opened the dura near the

lower angle of the anterior fontanelle, through the opening carried a

strand of catgut into the ventricle, and passed the outer end beneath

the dura; but the method again proved disappointing. Mikulicz passed

a gold tube into the right ventricle, leaving its outer end in the

subcutaneous tissues about 5 Cm. from the middle line. After being

three weeks in this position it ceased to drain, and was then inserted

into the other ventricle. The child died, unbenefited, in six weeks.

In another case he used a glass-wool drain, making it subdural rather

than subcutaneous. This case seemed to be benefited. Senn has modified

the method by making a large pocket in the subcutaneous tissues of

the cervical region, inserting one end of a rubber tube into it and

carrying the other into the ventricle between the temporal and frontal

bones. Even this proved disappointing. I have twice tried conducting

fluid by a small rubber tube from the ventricle into the cellular

tissue in the neck, passing the tube beneath the skin by suitably

curved forceps. This method, however, showed no advantage over the

others mentioned above. Taylor has endeavored to make a permanent

fistula between the ventricles and the subdural space by passing

chromicized catgut into the ventricle and letting it drain into the

latter. His results, however, were not encouraging, in spite of the

plausibility of the theory upon which they were based. Drainage through

the spinal canal into the abdominal cavity has also been practised by

a very few surgeons. The ingenuity and theory of the method are most

attractive, though but very few little patients are in condition to

bear the abdominal section which is necessitated for the purpose.[43]

[43] In March, 1906, Cushing informed me that his present routine

in effecting such drainage was to make a laminectomy and expose the

spinal canal from the rear, then to do a laparotomy, and, exposing

the bodies of the vertebræ, pass through from in front backward a

silver tube, whose end should reach into the spinal canal, draining

it into the abdominal cavity, the posterior wound being always snugly

closed. The spinal canal is thus exposed in order to ensure the

accurate performance of the other part of the operation.

Permanent drainage, then, has been a most disappointing procedure,

although there need be no hesitation in tapping the lateral ventricles

when there is indication for it. This can easily be done at any time by

an opening about 3 Cm. behind the external auditory meatus and the same

distance above the base-line of the skull. By directing the puncturing

instrument to a point on the opposite side, 6 Cm. above the meatus,

the lateral ventricle will be entered. (This same general direction

will serve for opening an abscess in the temporosphenoidal lobe.) The

best results in hydrocephalus seem to have been obtained by _lumbar

puncture_, as first suggested by Quincke, the method being the same as

that now in general use for intraspinal cocainization. As directions

for entering the spinal canal with the aspirating instrument would

be identical with those mentioned in the chapter on Anesthesia, when

describing intraspinal cocainization, the reader is referred to that

section for further direction (p. 208). The only case of well-marked

hydrocephalus which I have ever apparently cured was one repeatedly

tapped in this fashion, a considerable amount of fluid being withdrawn

at each little operation.

SURGICAL TREATMENT OF DEFECTS OF INTRACRANIAL DEVELOPMENT.

There are numerous causes which produce _imbecility_ and _kindred

conditions_ in the young. Some are in effect congenital, some are

postnatal. Within the past few years a number of these cases have

been subjected to surgical operation, in many instances with more or

less success. Mental defect may occur from injuries at the period of

birth--mainly hemorrhages, more commonly cortical, though sometimes

deep. In either case the clots thus formed frequently undergo cystic

alterations. The term _porencephalon_ is modern, and applied to changes

comprising disappearance of real nerve tissue with partial substitution

by connective tissue, often with other degenerations, the result being

atrophic alterations which apparently permit of no remedy. In a case of

true porencephalon the outlook for operation is not at all encouraging,

nor is it in any cases which are accompanied or caused by a genuine

arrest of cerebral development. On the other hand, when the mental

condition can be ascribed to the result of injuries, to hemorrhages, to

meningeal irritation, to premature ossification, or too early closure

of the fontanelles, or when it is accompanied by evidence of meningeal

irritation or symptoms which point to a definite area of the brain as

being the site of the principal disturbance, operation as a _legitimate

experiment_ may be conscientiously suggested and performed.

[Illustration: FIG. 383

Lines of removal of bone as practised by the author, by Lannelongue,

and by others.]

[Illustration: FIG. 384

Defective cerebral development. (Buffalo Clinic.)]

The _operation_ is usually described as _craniotomy_ or _craniectomy_,

and is apt to be successful in many cases of microcephaly combined with

idiocy. An _acquired form_ will give a better prognosis than will the

_congenital condition_. The danger of the operation is often great, and

especially so since it is called for in puny, ill-nourished, and badly

cared-for children. To be successful it ought to be _extensive_. It

should vary in character and degree--from simple division of the skull

along the middle line, from near the root of the nose to the occiput on

one or both sides, to the formation of large bone flaps by cutting away

a wide groove of bone so as to relieve pressure upon the hemispheres.

Fig. 383 presents the various ways of performing the operation.

It can usually be made bloodless, or nearly so, by an elastic

tourniquet around the skull. The incision in the skin should not

correspond to the groove in the bone, but should overlap it some

little distance. For my own part I prefer to do most of these

operations in two sittings. I would advise, as a rule, to prepare the

scalp carefully for operation, to divide the skin along the proposed

line, separate it from the pericranium and check all oozing; then,

after opening the skull with the trephine, to cut away with proper

forceps (rongeur) along the desired line, or, if provided with it, to

remove the bone by some surgical engine or revolving saw operated by

electricity. The strip of bone thus removed should be at least half

an inch wide, and the overlying periosteum should be removed with it,

as only in this way can the undesirably rapid regeneration of bone be

prevented. By this means the dura is exposed, but not opened. In some

cases this will be sufficient.

In many others, however, it will be insufficient; and, could this be

foreseen, it would be well to combine the above measures in one as a

first operation, and then, a few days later, to open the dura as the

second procedure--this, however, only on the discovery by careful

inspection that the wound is absolutely free from possibility of

infection. Could infection be prevented, this is certainly the safer

procedure, since in weak, puny young children to make a long scalp

incision, to remove a long strip of bone, and then to widely open the

dura is more than can safely be done in the majority of instances.

It should have been carefully explained to those interested in the case

that improvement will in all probability be extremely slow, and that

little or nothing is to be expected at first, even if prompt recovery

from the operation ensue. Neither would I advise any one to perform the

operation unless parents are willing to assume all risks and abide by

the results.

SURGICAL TREATMENT OF EPILEPSY AND THE PSYCHOSES.

Operations for relief of _epilepsy_ seem to date back even to the

prehistoric era, and were for centuries done as a purely empirical

measure; later, to have been practised with more or less plausible

reason; then to have fallen into discredit for long periods of time,

with occasional revivals of the practice, until within the past

twenty-five years the operation has been again revived upon its merits

and upon the recognition of more or less accurate indications.

Operations of this character are based upon two fundamental facts:

the first, the widespread experience that after various operations

epileptic patients have been benefited; and, second, that a certain

proportion of these cases, especially those of traumatic origin, are

characterized by a localized and definite aura, and by a systematic and

practically invariable order of muscle involvement, according, it would

seem, to some fixed law, and pointing definitely to a certain area of

the brain from which apparently the irritation arises and spreads. This

form of epileptic seizure is that generally known as the _Jacksonian_,

and is that in which operation is most often of real service. The

statements of patients regarding these phenomena should never be

accepted; only those made by a trained observer (nurse or physician)

are reliable.

_In spasms of the Jacksonian type_ there is a _certain order of

progression_ which is scarcely ever violated. Thus, irritation

beginning in the leg centre can hardly reach the face centre without

traversing that of the arm. It is possible also to have sensory

equivalents for _Jacksonian_ attacks, as when they commence with

peculiar sounds indicating irritation in the centre of hearing, or

with optical phenomena, or with disturbances of smell or taste, the

former indicating occipital irritation, the latter irritation in the

temporosphenoidal region.

The surgeon will often be consulted as to the wisdom of operation

in the presence of this condition. In brief, and in a general way,

the following statements may be made: It is necessary, first of all,

to establish a traumatic origin, and epilepsy which has preceded a

severe head injury can in no sense be ascribed to it. If it can be

clearly established that it has followed injury, and if a distinct

scar--especially a scar which is adherent--or depression can be

discovered, or any area which is always irritable and which seems

epileptogenic when irritated; or if, again, by close study of the case

it can be determined that the aura and the initial muscle symptoms

arise always in the same part--as, for instance, a finger, thumb, foot,

etc.--and proceed according to a constant program--then it may be said

that operation is not merely justifiable, but advisable. On the other

hand, when neither distinct scar nor history of localizing phenomena

can be obtained operation should rarely be attempted.

Again, in epilepsy of the non-traumatic type, operation may be advised

when it assumes the distinctly _Jacksonian_ form--_i. e._, when

everything points to irritation proceeding from a localized portion

of the brain. In the absence of Jacksonian symptoms operation is even

more of an experiment than in the traumatic form. Such cases should

be studied a long time on their merits before a decision is made to

trephine.

The _operation_ itself is directed to excision of irritable scars,

to exposure of the dura at the point of opening, to the detection

and suitable treatment of depressed fragments, dural adhesions,

tumors, foreign bodies, etc. It is essential in every case that it be

represented to those interested that the operation itself removes the

_cause_, but _cannot_ be, _per se_, expected to _complete the cure_,

especially in cases of long standing, and that the final cure must

depend in large measure upon the avoidance of subsequent irritation,

upon the establishment of perfect habits of diet and excretion, which

are often perverted, and perhaps upon the long-continued administration

of drugs, of which the bromides are those most constantly given. The

reader need not be reminded that _old cases are the least favorable_,

and that recent cases are the most so for operation, and that the

longer the diseased condition has existed the harder it will be to cure

by any method.

Besides these direct operative attacks it has been suggested by

Alexander to tie the vertebral arteries (now practically abandoned)

and by Jonnesco to excise the superior and middle cervical sympathetic

ganglia. This seems to me particularly indicated in those cases where

a convulsion can be aborted by prompt administration (by inhalation)

of amyl nitrite as soon as the preliminary aura is recognized. The

operation is described in the chapter on Surgery of the Cranial and

Cervical Nerves. Many encouraging results of this treatment have been

reported.

_I believe thoroughly in operating in selected cases._ I am

equally confident that indiscriminate operation must lead only

to disappointment and to occasional disaster. In the presence of

long-standing lesions, like bone depressions, cystic degeneration of

old clots, etc., the brain may have been so long pressed upon as to

have become atrophied.

The whole subject of the modern surgical treatment of epilepsy is

inseparable from the topic of prompt and efficient treatment of all

head injuries. Were the indications in these always met at the time

of the accident we should have a much smaller proportion of cases of

traumatic epilepsy.

Inasmuch as one object of many of these operations is to break up

adhesions between the dura and the pia, there is generally anxiety

to know the result after such operations as to whether they do not

speedily form anew. There is always this theoretical danger, and it

is my custom in such cases to insert beneath the dura, at the point

where such adhesions have been divided or torn, a piece of delicate

gold-foil, duly sterilized, in order that it may separate these

surfaces and prevent the recurrence of the old condition. Foil used

for this purpose is harmless, and I have numerous patients in whom it

has been used, apparently without producing the slightest disturbance.

(Foils of silver or aluminum answer as well or better.)

_Mental and psychic disturbances after head injuries_ have been

long known and the suggestion to operate upon the skull in cases of

so-called _traumatic insanity_ is not new. In a general way it may be

said that whenever distinct mania follows a recognized lesion of the

vertex of the skull, and fails to subside within a reasonable time and

under proper treatment, there are the best of reasons for raising the

scalp, trephining, and exploring as to the deeper conditions. Patients

might be released from asylums who have long been inmates had this

measure been practised at the beginning of their mental alienation.

The same measure will give relief in certain cases of _cephalalgia_,

or headache, where the pain is always ascribed to a particular region,

and especially when there is tenderness over this region. These

operations are, of course, _empirical_, yet, as the result of altered

nutrition and allayed irritation, relief follows in a fair proportion

of instances.

INTRACRANIAL TUMORS.

Until within recent years these were regarded as having interest mainly

for the pathologist and clinician, but as essentially hopeless so far

as surgical help is concerned. Recent discoveries in the field of

cerebral localization and recent experience with extensive openings

into the cranium have shown, however, that a small proportion of

intracranial tumors are of such a character and so located as to make

them amenable to surgical relief. These tumors occur with about equal

frequency in childhood and adult life. In the order of frequency they

stand about as follows: Tuberculous gumma, glioma, sarcoma, cysts,

carcinoma, and syphilitic gumma, with a small proportion of fibroma,

etc.

Of 100 cases of brain tumor selected at random not more than 5 to 7

per cent. are so placed as to justify surgical attack. In as many

more, at least, the tumors are so located as to justify opening the

cranium for mere relief of pressure without any notion or endeavor to

attack the tumor itself. _Before opening the cranium_ diagnosis should

be made as carefully as possible--first, as to _location_; second, as

to whether _cortical_ or _subcortical_; third, as to the _number of

tumors present_; fourth, as to their _general character_. Location is

determined in the main by study of pain complained of, by watching

patients during convulsive seizures, by determining the extent of local

or general paralysis, by careful history which shall reveal the method

and rate of extension of these symptoms, and by the study of the optic

disks, of vision, and by noting the presence or absence of stupor,

nausea, coma, slow pulse, or other compression symptoms.

=Symptoms.=--A brief epitome of the principal features attending cases

of brain tumor will include:

1. _Pain and headache_, rarely localized with much accuracy; the former

sometimes increased by percussion or pressure, occasionally periodical

and usually intense. The location of the pain sometimes corresponds

with that of the tumor.

2. _Vomiting_, usually without pain or nausea, and often projectile. I

have repeatedly seen obstinate constipation in brain-tumor cases which

has gone almost to a degree of acute obstruction, and which has caused

serious error in diagnosis.

3. _Vertigo_, independent of indigestion or the condition of the

stomach or bowels. It is most frequent in cerebellar tumors, but occurs

in about 50 per cent. of all cases. It is sometimes quite severe.

4. _Eye symptoms_ such as optic neuritis, choked disk, usually double,

indicating pressure, but telling little or nothing as to the location

of the tumor causing blindness. Ophthalmoplegias are of little value by

themselves as symptoms. Hemianopsia, when homonymous, usually indicates

a lesion of the cuneus of the same side, the blind half, according to

the patient, indicating the side.

5. _Localizing symptoms_ which may be due to the destruction of

brain tissue or to indirect pressure. Those of importance comprise

paralysis or spasms, indicating involvement of the motor area; sensory

aphasia, indicating trouble in Broca’s area, ataxia or staggering,

due to cerebellar lesions; loss of sense of position, sometimes seen

in lesions of the parietal regions; anesthesia, which is rare unless

the internal capsule is involved. Other symptoms are: word-deafness,

which indicates a lesion of the posterior part of the first temporal

convolution; agraphia, indicating deep lesions under Broca’s speech

centre, and alexia, usually produced by lesions of the lower left

parietal lobe. Tumors in the sensory zone affect vision and speech, and

reveal themselves by irritative symptoms. For instance, a patient with

verbal deafness and marked hemiplegia probably has tumor involving the

left superior or dorsotemporal gyrus, which, as it grows, would involve

loss of muscle sense and anesthesia on the opposite side of the body.

A patient with headache, vomiting, choked disk, stupor, increasing

hemianesthesia, lateral hemianopsia, without spasm or hemiplegia,

probably has a tumor in the white substance of the occipital lobe. If

hemianopsia alone be present there is almost always a tumor upon the

inner aspect of the occipital lobe, on the side opposite to the dark

half-fields, which by downward growth may cause cerebellar symptoms.

Psychic and mental disturbances are present in many cases, but not in

all; most frequently in frontal lesions. They are met with in about

one-third of the cerebellar tumors and two-thirds of the temporal

tumors; they assume the epileptic type, with hallucination, mania,

or sometimes convulsions of Jacksonian type, the latter, of course,

indicating lesions of the motor area.

6. Finally there are frequent _constitutional_ disturbances, including

anomalies of thirst and appetite, and disturbances of heart and

respiration. In two or three instances the writer has seen such

serious obstruction of the bowel as to lead to mistake in diagnosis,

the obstruction in each case being finally fatal, but apparently not

justifying operation.

The above symptoms pertain to the brain tumors in general. When it

comes to tumors of the cerebellum these constitute, in a measure, a

class by themselves. Those which are operable comprise tumors located

in one lateral lobe, or invading the vermis or middle lobe, or those

found at the junction point of the cerebellum, medulla, and pons,

those first mentioned being by far the more favorable for attack. It

is not relatively difficult to decide upon the presence of a tumor in

the cerebellum, but to minutely locate it is extremely difficult. In

addition to the symptoms already rehearsed above the following features

may be mentioned: Headache is often intense, sometimes agonizing.

While usually referred to the back of the head it is occasionally

frontal. Nausea and vomiting are generally present, at least for

a time. Sometimes they subside to recur later. Optic neuritis and

choking of the disk occur earlier and oftener than in other tumors.

Blindness sometimes comes on promptly. Vertigo, as in other brain

tumors, is commonly due to irritation of those branches of the fifth

nerve which supply the inner surface of the dura, this irritation

being reflected to the bulbar nuclei of the fifth, and thence to the

nuclei of the pneumogastric. This is partly true of those growths

which are in relation with the dura, though sometimes it is true of

tumors which make pressure at the base of the brain. It is important to

distinguish, if possible, between mere vertigo and cerebellar ataxia.

The more directly focal symptoms are: nystagmus, which may be present

when the eyes are quiet or only when they are in use; paralysis, when

the pyramidal tracts are involved; muscle weakness, seen more often in

the legs, which is nearly always a cerebellar symptom; and sometimes

a peculiar posture of the head, where the spinal column becomes

concaved toward the affected side, the face looking almost backward.

Incoördination is a common indication; in about four-fifths of the

cases patients stagger in their gait.

To determine whether a given tumor is an irritative or destructive

lesion special study should be made of the spastic or non-spastic

condition of the limbs, and note to which side the eyes are turned.

Tonic spasms and contractures are rare in cerebellar tumors. A tremor

of the head and upper part of the body is not infrequent, and muscle

sense is rarely lost.

Between cerebellar tumors and those of the parietal region the chief

diagnostic points are muscular and cutaneous sensibility in the

former, with nystagmus and peculiar and extreme vertigo. From frontal

growths they may sometimes be differentiated by the clearness of

the mental processes and the absence of those symptoms which point

especially to involvement of the temporocortical region, _e. g._,

aphasia. In cerebellar tumors convulsions, one-sided or general, are

not infrequent, and incontinence of urine and feces is often noted.

The convulsions are accompanied by subjective sensations and noises,

vertigo, and by sudden blindness, with loss of consciousness, while

such tonic spasms as occur are generally of the extensor type, and last

from one to ten minutes.

_Basal tumors_ of the cerebrum produce a collection of symptoms which

sometimes are significant. Owing to their location they involve the

functions of several of the special nerves. In tumors in the _anterior

fossa_ there is involvement of the optic, the oculomotor, and the

first branch of the fifth. In tumors of the _pituitary body_ there is

involvement of the optic, the chiasm, the oculomotor, and the first

branch of the fifth, as well as the abducens. In tumors resting on

the _middle fossa_ and situated above the dura the oculomotor, the

patheticus, and the chiasm are involved. If situated beneath the dura

there is paralysis of the three ocular nerves and also the fifth nerve.

In tumors of the _posterior fossa_ there is involvement of the facial,

the trigeminus, the auditory, the glossopharyngeal, the vagus, the

accessorius, and the abducens.

=Neurofibroma of the Acoustic Nerve.=--Fränkel and Hunt have recently

shown that basal tumors spring from the acoustic nerve, which are

essentially _neurofibromas_. They have their site upon the nerve at the

point where it merges from the junction of the pons and the medulla; in

other words, where the function of the nerve is more or less disturbed,

and the patient thereby made to complain of deafness, tinnitus, and

vertigo. They slowly displace surrounding tissues. They vary in size

from a cherry to that of a robin’s egg, are loosely attached, and when

exposed easily enucleated. Their general symptoms are those common to

all brain tumors, but focal symptoms may include ataxia, paralyses

(especially of the fifth, sixth, and seventh nerves), inequality of the

pupils, and loss of coördinate movements of the eyes; these symptoms

are in addition to those of the auditory already mentioned.

Access to these tumors is a serious matter. It should be undertaken

in two stages: the first including a large lateral exposure, with or

without an osteoplastic flap, comprising the lower portion of the

squamous, a part of the occipital, and perhaps even the posterior

aspect of the mastoid. Drainage will be required for a few hours as in

other similar operations.

As to _depth_ and _number_ the former may only be learned by studying

the nature and location of the signal symptoms, the presence and order

of appearance of the same, presence or absence of headache, and local

changes in temperature. Tumors occurring in tuberculous individuals are

probably _multiple_. When different centres or systems are involved

multiple lesions are usually present.

It has been held that the three cardinal symptoms of brain tumor

are _optic neuritis_, _headache_, and _vomiting_; and while each of

these is significant, and all of them are corroborative, they are not

necessarily present nor does their absence exclude possibility of

tumor. _Other signs indicating the presence of tumor, it is a mistake

to wait for the development of these three._ The most distinctive

feature of intracranial neoplasms is the _progressive character_ of

such symptoms as are present.

There is but one form of brain tumor which is amenable to internal

treatment--namely, _syphilitic gumma_; and in case of doubt it may be

justifiable to keep the patient actively under the influence of iodides

for a reasonable length of time. This, however, need never be prolonged

beyond six weeks, after which time, should no improvement occur,

operation should not be delayed.

=Operation.=--Brain tumors are operated for two purposes: First, for

relief of pain and other distressing symptoms in incurable cases;

second, for radical cure. Operation is justifiable in any case when

pressure symptoms become severe, particularly so when pain is localized

to a reasonable extent. Choking of the optic disks is not infrequently

relieved and threatened disability postponed. The complete operation

consists in the _exposure_ of the tumor and in its _removal_.

The osteoplastic method should be used in exposing the tumor, by which

a bone flap is raised, along with the overlying scalp, from which it

is not detached. The centre of this flap is supposed to be calculated

to overlie the centre of the deep lesion which it is proposed to

attack. In many instances the operation should be divided into two

distinct procedures, the first consisting in removal of the bone and

exposure of the dura; this exposure should be ample, including the

whole lateral region if necessary, as Horsley has shown; the second, a

week or two later, comprising the balance of that which is to be done.

But comparatively little shock attends removal of the tumor in the

second stage of such a divided operation. After removal of the growth

its cavity is best packed with a gauze tampon, after prompt ligation

of all bleeding vessels within the field of operation, although it is

usually required merely on account of venous oozing, as it is often

possible to cut to the depth of an inch in the brain without a single

artery spurting except those in the pin. The tampon is of value if

allowed to remain for forty-eight hours, as preventing filling of the

cavity with clot or excessive bleeding during the vomiting which may

follow the administration of the anesthetic. The vasoconstricting

properties of adrenalin may prove of great service here; it should be

used in the standard 1 to 1000 solution, diluted 1 to 3. I have no

hesitation in spraying this upon the brain or in saturating tampons

with it, which may be left _in situ_ so long as necessary. A number of

the old-fashioned small serrefines, properly sterilized, can also be

resorted to, if needed, for securing vessels, which may not be easily

tied. They can be left in place along with the tampon and all may be

removed together.

Next to the danger from hemorrhage is that of rapid edema of the

brain, which may result from increased tension in the arteries or

through venous stasis, which later produces lymph stasis, by which

fluid collection in the tissues is still further facilitated. Another

reason for using tampons is to prevent such relaxation of veins as may

predispose to this edema. In most respects the operations for removal

of brain tumors differ slightly from those whose general principles

are elsewhere mentioned in this work. I am greatly in favor of using

secondary sutures (_i. e._, those tied with bow-knots), which may

be loosened on the second or third day, permitting the raising of

the flap, removal of tampon, etc., and I employ them largely after

all sorts of operations upon the cranium. If we desire to prevent

any attempt at union of wound margins we may employ the green silk

protective introduced by Lister, which should have been previously

carefully sterilized by boiling.

The _operative treatment of cerebellar tumors_ is made doubly

difficult by their protected position and the large sinuses with

which this part of the brain is surrounded. The cavity is restricted

in size, intradural tension is greater than above the tentorium, and

there is no room for easy displacement or retraction of parts. The

occipital bone varies much in thickness and at points is somewhat

thin. Operation which is begun either as an exploration or with a

fixed purpose may prove palliative, even should the original purpose

fail of accomplishment, as relief may be afforded by reducing tension,

such relief consisting perhaps in freedom from headache, vomiting, and

vertigo. Incision should extend from the tip of the mastoid process, a

little above the superior curved line, to beyond the median line, with

a vertical median incision by which a flap sufficiently large may be

reflected downward. It is best to reflect the periosteum with the other

soft tissues in order to expose the bone. The bone should be bitten

away with forceps or removed with a reliable engine as rapidly as

possible, hemorrhage being controlled with Horsley’s wax.

The operation may be divided into two stages, confining the first stage

to the exposure of the cerebellar surface, or the operator may attempt

all at one time.

The second stage consists in raising a dural flap, by which the

cerebellar surface is exposed for inspection. It will protrude promptly

through the opening, so that, with the finger, it may be possible to

detect a tumor by the sense of touch. If no tumor appear on or near the

surface deeper exploration should be made, with the aid of a retractor

and by removal of a portion of the cerebellar hemisphere. This may

require further exposure of the lateral region of the skull. Tumors

situated deeply or at the junction of the cerebellum and pons require

all the room that can be afforded from the outside, and are better

approached from the lateral region than from above or below. It is

comforting to realize what considerable portions of the cerebellum can

be removed without serious or extensive disturbance, but as the medulla

and pons are approached there is need of great care. The opening may

be extended across the middle line, and either the lateral or the

longitudinal sinus, or both, may be doubly ligated and divided. The

tentorium may also be divided nearly to the petrous portion, after the

lateral sinus has been thus divided, and so better access given to the

deep location.

These remarks apply especially to operations for tumors of the

cerebellum. The other features of such operative attack are those

common to brain tumors in any location.

In all operations for brain tumor, but particularly for cerebellar

tumor, it will prove of the greatest advantage to have the operating

table so inclined that the patient’s head will be three or four feet

above his heels. In this position the veins are drained by gravity,

and the operation is complicated by but little venous oozing. _Crile’s

pneumatic suit_, or at least the lower part of it, should be worn, and

an assistant should watch and report on the blood pressure. These two

precautions permit such an operation to be conducted with an ease and

safety hitherto unknown.[44]

[44] New York Medical Journal, February 11 and 18, 1905.

Cushing, dealing especially with a group of brain tumors in which

radical procedures are impossible, where nevertheless relief from

symptoms would prove a therapeutic desideratum, has proposed to afford

this by removal of a portion of their bony covering, in order to allow

a part of the brain to protrude, and thus provide a means of relief for

the constantly increasing pressure. The incomplete union of the bones

in _infancy_ permits something of this kind to occur through natural

causes, but after fusion of the elements of the cranial vault it is

no longer possible, save in those rare cases where an opening results

from the process of slow pressure absorption, which comes only when the

tumor is in actual contact with the bone.

It would be mechanically ideal if, during adult life, a dislocation

of cranial sutures could be produced similar to that observed in very

small children. The dangers of such operation are many, among them

being the possible injury to the functions of that portion of the

cortex which protrudes through the opening thus made, by which, for

example, preëxisting paralyses might be aggravated. For this reason it

is preferable to establish the hernia over some “silent” or unimportant

part of the cortex and to avoid making it unnecessarily large. Cushing,

after various trials, recommends to make the bone defect under the

temporal muscle, which not only affords a certain degree of protection,

but exposes an area where few important motor centres are involved. He

has reported several cases, with gratifying results, with a minimum of

undesirable sequels.

Obviously in tumors below the tentorium the opening would best be made

in the suboccipital region. Nevertheless, Cushing believes that even

here the final result would be no more effectual than were the defect

placed elsewhere.

Beck has called attention to the value of the temporal fascia as a

substitute for the other firm coverings, by which the brain should be

left enclosed after exposure, and when these latter are not available.

For the purpose he would fold over a flap made from the temporal muscle

and the adjoining periosteum in such a manner that fascia originally

external should now be placed deeply and in contact with the cortex.

[Illustration: PLATE XLIV

FIG. 1

Topographical Anatomy of Cortex. Localization of Functions. (Ziehen.)

FIG. 2

Topographical Anatomy of Inner Surface of Right Hemisphere.

Localization of Functions. (Ziehen.)]

OPERATIONS UPON THE CRANIUM.

The _fissure of Rolando_ is the anatomical landmark whose position it

is important to determine with reference to a number of modern surgical

procedures, for around it cluster most of the motor areas or centres.

It commences at the middle line about 56 per cent. of the distance

backward from the glabella (root of the nose) to the inion (occipital

protuberance), and, passing downward and forward, makes with the middle

line an angle of 67 to 69 degrees. For most purposes it begins half

an inch back of a point midway between the glabella and inion. It may

be easily found by _Chiene’s method_, which consists in folding a

square piece of paper diagonally and folding this again; after which

it is three-quarters unfolded, the acute angle then representing

67¹⁄₂ degrees. If this be properly applied to the skull, one edge of

its surface can be made to fall directly over the Rolandic fissure.

The fissure may also be located by a simple instrument known as the

cyrtometer--a gauged metal strip having a sliding arm upon it, which,

when the long strip is placed over the longitudinal sinus (_i. e._,

the middle line of the skull), can be made to fall directly over the

fissure. While neither of these methods is invariably and minutely

exact, either of them is sufficiently accurate for all practical

purposes.

The _fissure of Sylvius_ may be indicated by a line drawn from a point

3 Cm. behind the external angular process to a point 2 Cm. below the

most prominent part of the parietal eminence. The short and ascending

limb of this fissure is of relatively small importance in this

connection.

_Reid’s base-line_, so called, is a line drawn from the inferior margin

of the orbit backward through the centre of the external auditory

meatus. It is a line often alluded to in cranial topography. The

colored plate (see Plate XLIV) will indicate with reliable accuracy

the relations of the motor centres to each other and to the principal

fissures and convolutions. It pertains merely to the left hemisphere

of the brain, in whose third frontal convolution is placed Broca’s

centre for speech, the corresponding area upon the right side having no

exactly corresponding function. The centre for vision, it will be seen,

is located in the cuneus, the most basal portions of the hemispheres

being the seat of the special senses of taste, smell, and hearing.

=Operation.=--The word _trephine_ is at present used both as a noun and

as a verb, the older term _trepan_ being now wellnigh discarded. The

instrument consists of a section of a tube, one of whose extremities

is arranged with sharply cut saw teeth, the whole provided with a

grip or handle, which revolves in a plane parallel to that in which

the saw teeth cut. The best instrument is that arranged in a slightly

conical manner, so that it may less easily burst through the skull

and do harm to parts within. The trephine proper is manipulated by

the hand. A variety of substitutes have resulted from applications of

human ingenuity to the problem of opening the cranial bones. Some of

these are operated by foot or hand power, with reduplicated mechanisms,

and others by electricity. The more complicated the mechanism the

more likely it is to get out of order, and there are but few of these

substitutes which give anything like lasting satisfaction.

The operation of trephining is made to include any method by which an

opening is made in the uninjured cranium or by which an opening already

existing is enlarged and made to subserve the surgeon’s purpose. Aside

from the saws already alluded to, there are in use a variety of cutting

bone forceps, rongeurs of various device, and a variety of chisels,

which are to be used in connection with the mallet or hammer. In order

to use any of the latter instruments to advantage the first attack

should be made with a trephine of reasonable size, say 2 to 3 Cm. in

diameter, after which forceps, chisel, or saw may be used. Straight

saws also are of occasional usefulness. I do not favor the use of the

chisel and mallet, feeling that the concussions resulting from blows

of the hammer add to the shock of the operation. The common trephine

is provided with a centre pin, which can be withdrawn after a shallow

groove has been cut. To prevent slipping of the centre pin the point to

which it is to be applied should be marked by cutting a nick with the

point of a chisel.

The _Gigli saw_ should be in every surgeon’s outfit. It consists of a

piece of steel wire having a thread cut around and along it by a die,

by which it is made as effective as a series of saw teeth. Two small

trephine openings are made, and it is then passed into one and out

of the other, the dura protected by depressing it, and the wire then

handled as though it were a chain saw. It can thus be made to cut its

way quickly through the bones of the skull.

Other aids in mechanical procedures are revolving small saws and the

surgical engine.

[Illustration: FIG. 385

The Powell electric saw cutting a “trap-door” in the skull.

(Illustrating the operation upon a cadaver.)]

In the absence of a wound a flap of scalp is raised before applying

the instrument. This flap is ordinarily of horseshoe shape, and should

be made with its convexity pointing toward the occiput, as drainage is

best afforded later by this arrangement. The old crucial incisions are

now wellnigh abandoned. The pericranium is detached, after incision,

with the periosteum elevator, and it should be turned up with its

overlying scalp without completely separating it. The scalp flap can

be held out of the way by temporarily sewing it to some other part of

the scalp, every portion of which should be previously shaved closely

and thoroughly scrubbed. The operator has his choice--to seize vessels

as they bleed or to make the operation in large degree bloodless by

applying an elastic tourniquet tightly around the scalp above the

eyebrows and beneath the occiput, the ears preventing it from sliding.

If the tourniquet be used the vessels will often bleed in an annoying

way after the wound is closed. If the operation be performed for

fracture of the skull, should there be an opening already made by the

depression of fragments, it may not be necessary to use the trephine,

but with suitable bone forceps fragments may be removed or detached.

In this case, however, there are often sharp points of bone which

will require removal by cutting bone forceps, for the surgeon should

leave the margin of the bone opening comfortably round and smooth.

Should there be no opening into which the point of an elevator or of

bone forceps can be inserted, then one should be made; it is for this

purpose that the trephine is mainly used in cases of fracture of the

skull. It should now be applied upon a firm and undetached surface of

bone, one which will bear the pressure necessary in the process of

perforation. As used for this purpose it should be so applied that at

least two-thirds of the circle cut by its teeth will be upon unbroken

skull; the remaining segment of the circle may be over the fractured

area. After it has begun to cut a distinct groove the centre pin should

be withdrawn and the instrument maintained in its position during its

work by a firm and steady hand, which will force it evenly through the

bone and not exercise undue pressure. As the diploë is perforated the

bone-dust becomes soft and bloody and the resistance is diminished. As

the instrument sinks deeper the operator should frequently intermit its

use, and determine his position by means of the irrigator and of the

probe or other instrument. The nearer the inner surface is approached

the more caution must be exercised, remembering that the bone is

likely to be of unequal thickness. When the skull has been completely

perforated at one or two points around the little circle the operator

should introduce the point of an elevator and pry up the disk of bone,

or by rocking the handle of the trephine he may be able to remove the

button with that instrument. When the operation is performed in the

ideal manner the dura is scarcely touched, certainly not raggedly

injured by the teeth of the instrument (Figs. 386, 387 and 388).

[Illustration: FIG. 386

Construction of an osteoplastic flap; bone is exposed; first openings

are made with a hand trephine or burr. (Marion.)]

[Illustration: FIG. 387

Division of bone by use of hammer and chisel. (Marion.)]

Before opening the dura every loose particle of bone and every splinter

should be removed, depressed fragments should be picked out, and those

which are semidetached should be raised to their proper level. Through

the opening thus made the dura is carefully examined; extradural

collections of blood are recognized instantly, while some idea as to

the amount of intracranial tension may be secured, even through a small

opening. Absence of pulsation means probably the presence of cyst,

tumor, or abscess deeper. Edema of the membranes usually subsides

after nicking or opening them. A yellowish discoloration of the dura

often indicates the existence of a tumor beneath. Nothing abnormal

being discovered outside of the dura, should brain tension be great

or should the dura be discolored, as by blood beneath, the membrane

should be opened, by a triangular or horseshoe flap, and the subdural

condition accurately estimated. In some cases of meningeal hemorrhage

clots will be ejected with some force the instant the dura is opened.

In other cases of intracranial pressure, either from tumor or from

intraventricular hemorrhage, the brain will instantly protrude to such

an extent as to make its reposition difficult or even impossible.

Horsley’s dural separator is exceedingly useful, both outside and

inside the dura, for detecting and separating adhesions, and as a

retractor.

Incisions in the dura should be made, so far as possible, parallel with

its vessels rather than across them. When accessible, dural vessels can

always be secured and tied. Vessels of the pia can also be picked up

and secured with fine catgut ligatures. When the brain tissue itself is

diseased it should be carefully excised. The cortex itself is not so

vascular as to afford much trouble. Upon any portion of the membranes

or cerebral surface a sterilized solution of adrenalin can be sprayed

or applied without hesitation. In all deliberate operations sinuses

are avoided. When exposed or when necessary to attack them they may

be ligated and divided, or may be packed with tampons of sterilized

gauze, or may be seized with serrefines or light hemostatic forceps,

which may be left for a day or two included within the dressings.

Any of the exposed motor areas or centres can be stimulated, when

desired, if the patient be not too deeply anesthetized, by the faradic

current of mild degree, applied to surfaces which have not been bathed

with antiseptics, nor long exposed to the vapor of the anesthetic,

through a double brain electrode made for the purpose, or by sterilized

probes connected with the battery.

Buttons of bone or chips of the skull may be replaced after suture of

the dura, when desired, though this is seldom advisable. When fragments

are thus to be replaced they should be placed in warm sterile salt

solution at once after removal, and kept warm. When a button is thus

put back the periosteum may be sewed over it with buried catgut sutures.

The dura should be stitched with fine catgut as closely as possible. I

have often placed beneath the dural opening a piece of gold, silver, or

aluminum-foil, carefully sterilized, with a view to preventing dense

adhesions between the dura and the membrane or cortex beneath. I have

never known it to do harm.

[Illustration: FIG. 388

Exposure of cortex or of cerebellum after division of dura. (Marion.)]

[Illustration: FIG. 389

Osteoplastic resection after Wagner. (Chipault.)]

Drains and drainage are to be avoided when possible, and should be

removed early, except in cases of abscess. They may be made of catgut,

horse-hair, gauze, rubber, or even of glass, like those short ones

which Kocher inserts after extensive operations, their outer ends

flanged to prevent their slipping beyond control.

_Opening the skull_, or, in general terms, _trephining_, is at present

_resorted to for the following purposes_:

1. _For relief of compression_--

(_a_) By depressed bone, as in comminuted or gunshot fracture;

(_b_) By removal of clot or ligation of vessels;

(_c_) By evacuation of pus, either from the meningeal cavity or from

a deeper abscess;

(_d_) By the removal of serous effusions, either extraventricular or

intraventricular.

2. _For removal of foreign bodies._

3. _For relief of intracranial irritation_--_e. g._, epilepsy, the

psychoses, etc.

4. _For removal of tumors._

5. _To compensate for defective development._

6. _For exploratory or purely empirical reasons_, including the making

of “relief openings” for relief of pain, etc.

Aside from the ordinary methods of trephining as applied for common

conditions, modern surgery comprises the resort to essentially new

methods for raising areas of skull of considerable size and then

restoring them to their previous position. These are ordinarily spoken

of as _osteoplastic resections_, and have added very materially to the

art and resources of the surgeon. These consist, in a general way, of

the formation of a window, as it were, in the vertex or lateral region

of the skull by outlining a quadrangular or horseshoe flap of scalp,

which is detached only for a slight distance around the incision,

after which, by use of the revolving saw or by chisel and mallet, a

groove is cut through the bone running parallel with the margin of the

scalp-flap, but perhaps a centimeter within it. After this bone area is

completely cut through on three sides it is then sprung up or elevated

in such a way as to be broken across the base of the bone-flap. It

is not at all detached nor separated from the scalp, and so when

subsequently lowered into position retains its vitality by virtue of

its vascular connections.

When some particular measure seems indicated in order to atone for

a large defect in bone it has become quite customary to insert some

_artificial substitute_, mainly either _celluloid_ or a thin aluminum

plate, previously absolutely sterilized and cut at the time into such

shape as may be called for, but a trifle larger than the real defect,

being let in or sprung in, as it were, either completely beneath the

bone or into the bony opening, so as not to be easily detached or slip

out of the way. By this _heteroplastic_ method most admirable results

have been achieved. I have used celluloid for this purpose in the

spinal column also, closing with it the defect which remained after the

extirpation of the sac of a spina bifida. It is rarely _necessary_ to

resort to this practice in the skull, as dense fibrous tissue in due

time firmly protects the endocranial contents from external harm (Figs.

386, 387, 388 and 389).

CHAPTER XXXVII.

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.