watching the ocular conjunctiva for a few moments after the occurrence
of irritation. The rapidity with which the vessels dilate and become
visible, the occurrence of the consequent redness and swelling, and the
reflex phenomena attending it become appreciable within a short time.
In the chronic conditions the tissues become thickened and less mobile.
A chronic conjunctivitis is the constant condition in certain laborers
whose eyes are exposed in their occupation.
A peculiar granulomatous condition of the conjunctiva, especially the
palpebral, is that known as _trachoma_, which appears to be due to a
specific form of infection that leads to exudation, organization and
thickening, intensified in punctate areas, and giving the surface the
appearance of an ordinary granulation. This condition has assumed
such importance as to be sufficient for the exclusion of aliens and
immigrants.
The milder conditions of acute or subacute conjunctivitis subside
under cold applications and mild antiseptic and astringent eye-washes
or collyria. These should be frequently instilled, beneath the lid
whenever this area is involved as a complication of injuries to the
head or face. In acute cases of the infectious type, such as the
gonorrheal or diphtheritic, atropine should be used locally, so that
the iris may be drawn out of harm’s way and the pupil left free
should resolution and recovery ensue. Individuals suffering from
either gonorrhea or diphtheria should be cautioned and protected from
possibility of conjunctival infection. The eyes of the newborn are not
infrequently infected during the process of parturition. The parturient
canal of women suspected of having an infectious lesion of this kind
should be cleansed before the passage of the fetal head, and in all
suspicious cases instant and constant attention should be given to the
eyes of the newborn infant.
THE LACRYMAL TRACT.
The _lacrymal gland_, though situated in the anterior and upper part
of the orbit, and beneath the upper lid, where it is ordinarily well
protected, is nevertheless liable to both acute infections and chronic
irritations. When acutely inflamed it usually goes on to abscess
formation. We have then acute _dacryo-adenitis_, which will produce
the ordinary symptoms of phlegmon, with the added ocular features of
vascularity and chemosis of the conjunctiva and more or less edema
and immobility of the upper lid. Displacement of the eyeball may be
produced by great inflammatory swelling. These abscesses tend to
discharge either through the skin near the external angle or sometimes
through the conjunctiva. While in the former case a scar results, it
nevertheless is a preferable point either for spontaneous opening or
for incision. If the case be seen in time it will be advisable to make
this incision early and so limit destruction. (See Plate XLV, Fig. 1.)
The lacrymal gland suffers occasionally in instances of constitutional
syphilis, undergoing chronic and obstinate enlargement. It may also be
the site of tumors either non-malignant, usually adenoma, or cancerous,
most instances of the latter being expressions of extension.
The _tear passages_ proper are composed of the canaliculi, the lacrymal
sac, and the duct. These are altered, occasionally, in their relations,
or absent, as the result of congenital defects. The passages proper
frequently become obstructed, as the result of any chronic irritation
which produces thickening of the conjunctiva, and in many laborers
and others who are exposed to dust, dirt, or cold winds there will be
a more or less constant stillicidium or overflow of tears. In some of
these cases it is sufficient to slit up one or both canaliculi with a
fine probe-pointed bistoury.
DACRYOCYSTITIS.
The _lacrymal sac_ proper is frequently the site of both acute and
chronic disease, known as _dacryocystitis_, which is the result of
infection spreading from the conjunctival sac, rarely from the nose,
or the exaggeration of conjunctival thickenings, like those mentioned
above. The first symptoms are overflow of tears, accompanied by
swelling or enlargement in the region of the sac. By pressure upon this
a mixture of water, mucus, and sometimes pus may be expressed. As the
disease goes on the fluid becomes purulent. If the sac, by pressure,
can be emptied into the nose the nasal duct may be regarded as patulous
and the treatment is simplified. If not there is stricture, usually at
the upper end of the duct, which requires division and dilatation. The
more chronic forms of trouble in this region are frequently intensified
into acute phlegmonous lesions which, if neglected, will lead to
spontaneous perforation and the formation of a _lacrymal fistula_ at a
point below the inner angle of the eye. (See Plate XLV, Fig. 2.)
=Treatment.=--The treatment should consist of exposure of the sac by
incision of the canaliculi and its irrigation by means of a syringe and
antiseptic fluid. Unless this fluid passes easily into the nose the
stricture should be divided and Bowman’s probes passed, the principle
of treatment being the same as that in treating urethral stricture.
This part of the treatment should be referred to an oculist.
In acute dacryocystitis with suppuration the sac along the natural
passages should be opened. When a diagnosis of an acute lesion of this
kind is made nothing but the most radical treatment is advisable.
THE LIDS.
Congenital deformities of mild degree are not infrequent about the
eyelids.
EPICANTHIS.
Epicanthis is a term implying folds of redundant skin extending from
the internal end of each eyebrow to the inner canthus and over the
lacrymal sac. It varies much in degree, is a more or less hereditary
feature in certain families, and is not infrequently associated with
other defects. The palpebral fissure varies in length in different
individuals, giving a longer or shorter window through which the eye
proper shall appear. Sometimes the fissure is much too short and
requires division or extension, which is easily made by incision at the
outer angle.
COLOBOMA.
Coloboma is a term applied to various lesions of the eyelid, the iris,
and the choroid, implying a defect in structure, which, in the eyelid,
leaves a V-shaped deficiency, corresponding to harelip, whose edges may
be brought together by a simple operation.
STYE; HORDEOLUM.
The eyelids are subject to certain painful or disfiguring lesions,
which frequently come under the notice of the general surgeon. Of these
the most common is _stye_, or _hordeolum_. This is a phlegmon of one
of the minute glands along the margin of the lid, which has become
infected and violently reacted. It forms a miniature furuncle, often
associated with conjunctivitis, and giving a disproportionate reaction.
So soon as the presence of pus can be detected a puncture should be
made and the contained drop of pus exvacuated. Threatening suppuration
may sometimes be aborted by local use of 1 or 2 per cent. mercurial
(yellow) oxide ointment.
CHALAZION.
A somewhat similar but non-inflammatory cystic distention of one of
the Meibomian glands, which pursues a slow and painless course, is
called _chalazion_. It presents rather beneath the mucous surface, but
is often visible through the skin. Its contents are mucoid or dermoid.
When it attains troublesome dimensions it should be exposed through a
small incision, usually external, and thoroughly extirpated.
XANTHELASMA.
Small, elevated areas of dirty-yellow color are met with in the skin
about the eyelids, more often near the inner angle. Such a lesion
is called _xanthelasma_, the lesion being a fatty metamorphosis of
a portion of the skin structure. While harmless, it is amenable to
excision for cosmetic effect.
Any of the ordinary tumors which affect similar tissues elsewhere may
be seen about the eyelids. The more common are the vascular tumors,
especially small nevi. Epithelioma occasionally commences along the
palpebral margin, but is more often an extension from neighboring
tissues.
BLEPHARITIS.
The margins of the lids are frequently involved in a mildly infectious
inflammatory condition called _blepharitis_, in which nearly all the
structures participate; when the borders alone are involved it is
referred to as _blepharitis marginalis_. The condition is largely due
to dirt, and to irritation in which the Meibomian ducts seem to share.
It is accompanied by chronic conjunctivitis. The condition is seen
more often in the ill-nourished, the rickety, and the tuberculous.
The best local treatment consists in the use of an ointment of yellow
oxide or yellow sulphate of mercury. The former may be used in 2 per
cent. strength, and the latter not stronger than 1 per cent. This
should be applied along the lid margins at night, and thoroughly rubbed
in. A commencing phlegmon and stye may be aborted by one of these
preparations.
TRICHIASIS.
Another very annoying complication, and usually the sequel of the
condition already mentioned, is _trichiasis_, or turning inward of the
eyelashes. Chronic irritation and cicatricial contraction on the inner
aspect of the eyelids, or a chronic blepharospasm, which may be the
result of corneal infections, serve to draw the lids inward, especially
with the margins of the hair follicles, so that the eye-winkers grow
toward the ocular surfaces, which they constantly irritate. The result
is a vicious circle, each morbid condition intensifying the other.
In time there is produced a condition of _entropion_, which is to be
remedied only by operation. It is not sufficient to treat trichiasis by
epilation, as the hairs will grow again and continuously cause trouble.
The cause should be removed and the effect treated.
ENTROPION.
By this term is meant a condition of inversion of the margin of one or
both lids, by which the external surface is brought into actual contact
with the surface of the eyeball. It is a chronic condition brought
about through the action of several contributing causes. Any condition
of the cornea or deeper portion of the eye which leads to photophobia
and spasmodic closure of the eyelids will produce in time hypertrophy
of the orbicularis, with corresponding strengthening of the muscle and
exaggeration of its activity. Chronic blepharospasm will thus in time
lead to a mild degree of entropion, while any affection of the inner
palpebral surfaces which leads to cicatricial contraction will still
more intensify it. So soon as trichiasis or irritation by the eyelashes
is added to what has gone before, every feature is exaggerated and the
cornea is made to lie practically in contact with the skin surface
of the eyelid. A further consequence is corneal disease, often with
ulceration and opacity, with even worse structural changes.
The condition is really a serious one and is to be treated not alone
by operation upon the lid, but care should be given to all the
contributing features. So far as the lid condition alone is concerned,
I have found the operation suggested by Hotz the most satisfactory of
any, at least in average cases. An incision is made from one end of the
lid to the other, along the distal border of the tarsal cartilage, and
down to it. Through this a bundle of those orbicularis fibers which
run parallel with the incision is dissected away. In extreme cases the
tarsal cartilage, which is incurved as the result of the old condition,
may be either incised or a strip excised from its structure. Sutures
are then inserted which include not only the borders of the skin
incision, but the exposed border of the tarsus and the tarsoörbital
fascia. By applying the central suture first, and then one on either
side, it will usually be found that as the sutures are tightened the
edge of the lid is drawn outward and the desired effect obtained.
The large number of operative methods which have been suggested for the
cure of entropion bespeak the variety of causes which may produce it
and the many devices to which different ingenious ophthalmic surgeons
have resorted.
[Illustration: FIG. 390
Arlt’s operation for ectropion. (Arlt.)]
ECTROPION.
This condition is the reverse of entropion, and implies eversion of the
margin, or of a considerable portion of a lid, with consequent exposure
of its conjunctival surface, which undergoes changes in consequence
of which it becomes thickened, contracted, and irritated. Ectropion
may possibly be produced by violent orbicular spasm, especially in
children, the lids being so tightly shut as to be everted. Ordinarily
it is the result of external lesions which produce cicatricial
contraction, like burns, or of chronic ulcerative lesions along the
palpebral border, such as are met with in tuberculous and syphilitic
disease. The lower lid is much more frequently involved than the upper.
For the relief of ectropion plastic operations are practised, usually
on the lower lid. The milder cases require a V-shaped incision, its
apex downward, with free dissection of the integument up or near to the
margin of the lid, by which it is released from the scar tissue which
has bound it down. Fig. 390 illustrates the general principle of such
an operation. The lower portion of the V-shaped defect is then brought
together with sutures, the triangular flap being fastened in a position
much higher than that in which it originally rested.
All of these operations upon the eyelids are included under the term
_blepharoplasty_, of which the above is the most simple. When necessary
new flaps may be raised from the temporal region, from the forehead
or from the cheek, as may be required, and turned into place, their
pedicles being so planned as to carry a sufficient blood supply for
nourishment of the same. If this supply be properly provided these
operations are practically always successful. It is necessary only to
make the transplanted flap at least one-third larger than appears to
be necessary, judging from mere size of the defect, for experience
shows the necessity of allowing at least one-third for primary and
cicatricial shrinkage. A _heteroplastic_ operation is occasionally
performed for this purpose, by which the flap of skin is detached from
an entirely different part of the body, or from the body of another
individual. Skin thus transplanted should be prepared by removal of
all of the fat upon its raw surfaces, skin alone being desired and not
other tissue. Figs. 391, 392, 393 and 394 illustrate blepharoplastic
operations of various types, which may be modified or made more
extensive. These are but a few of the various plastic devices, and are
intended to serve merely as suggestions or examples rather than methods
to which one is limited.
[Illustration: FIG. 391
Richet’s operation for ectropion. (Arlt.)]
[Illustration: FIG. 392
Fricke’s method of blepharoplasty. (Arlt.)]
[Illustration: FIG. 393
Dieffenbach’s method of blepharoplasty. (Arlt.)]
[Illustration: FIG. 394
Arlt’s method when a portion of the eyelid is to be sacrificed. (Arlt.)]
INJURIES OF THE EYEBALL AND ADNEXA IN GENERAL.
This topic has already been considered. It seems advisable, however,
to summarize some of the results of such injuries in order to call
attention to their dangers and methods of treatment. Burns of the
orbital regions, for instance, are liable to cause not only opacity of
the cornea following ulceration, but adhesions between the conjunctival
surfaces and the palpebral margins. The term _symblepharon_ is
applied to those lesions where the lids are more or less fixed upon
the globe and their motility partly or completely impaired. When the
edges alone of the lids have grown together the condition is known as
_ankyloblepharon_. Both of these conditions are the result of adhesion
of granulating surfaces and of cicatricial contraction, and should be
avoided.
By a concussion of the orbital region, and especially of the eyeball,
all sorts of injuries may be inflicted, from those involving the cornea
to deep lesions which leave little or no superficial evidences, but
cause partial or complete blindness. _Detachment of the retina_, for
instance, is one of the possibilities of such conditions. _Intra-ocular
hemorrhages_ or _dislocation of the lens_, with traumatic cataract, may
also occur.
The _sclerotic_ may be ruptured with or without the presence of a
foreign body, in which case the contents of the eye may have partially
or completely escaped. An eye which has collapsed from these causes
offers an almost hopeless field for the general or special surgeon,
and little can be done, save possibly for cosmetic purposes. There is
danger of sympathetic ophthalmia, and it may be a question whether
evisceration, _i. e._, completion of the evacuation, may not be the
wiser course.
Perforating wounds, even when inflicted by minute bodies, have dangers
of their own, including the possibilities of infection. The interior
mechanism of the eye is so easily disturbed, and its transparent media
so easily clouded, by the results of accident or hemorrhage, that even
apparently trivial injuries may be followed by disturbances of vision.
=Treatment.=--The general principles of treatment of all such injuries
should include, first, the removal of every detectable foreign body,
followed by the application of cold, and the use of antiseptic
eye-washes, which, however, must not be used too strong lest they
irritate. Saturated boric-acid solution is perhaps as strong as
anything which is permitted, while even this may occasionally require
dilution. In addition to this the use of atropine solution is always
indicated. It has the double effect of soothing and allaying pain and
of dilating the iris into a narrow ring. With such measures as these it
may be possible to save vision; at all events it will limit reaction
and prevent harm.
DISTURBANCES OF INNERVATION.
The nerves which supply the eye and its adnexa may undergo injury,
either within the orbit or within the cranium, or in their course
from one to the other. The _paralyses_ may be caused by syphilis, by
intracranial tumors, or by injury. A careful study of the areas and
nerves involved will sometimes lend considerable help in diagnosis,
both in traumatic and pathological cases. Thus diplopia, or double
vision, may be caused by paralysis of the external rectus on one side,
by which its antagonistic internal rectus is permitted to swerve the
eye too much to the inner side and away from the normal axis of vision
required for single sight. When there is complete paralysis of the
third nerve there may be drooping of the eyelid, called _ptosis_,
with impaired motion of the eye, upward, inward, or downward. The
eye will roll outward because the external rectus is supplied by the
sixth nerve. There will also be dilatation of the pupil, with loss
of accommodation. When the upper lid is raised there is also double
vision. This third-nerve paralysis, however, is not always complete,
and diplopia may result only when the eye is directed in a certain way.
When the sixth nerve is paralyzed the eye is rolled inward, and again
there is diplopia. When the fourth nerve is paralyzed the eye is but
slightly displaced upward and inward. When the sympathetic nerve is
involved there will be protrusion of the globe with dilatation of the
pupil. This will be accompanied by flushing of the face.
MUSCULAR AND ACCOMMODATIVE DEFECTS.
Detection of errors of accommodation is practically a specialty within
a specialty, while the various forms of strabismus, or deviation of
the eyes from their normal axes, depend largely upon regulation of
accommodative errors.
REGION OF THE EXTERNAL AND MIDDLE EAR.
The region of the ear is subject to _congenital malformations_,
deviations, and defects, which include anomalous shapes of the auricle,
malpositions of the organ, defects in the cartilaginous structure
with resulting deformity, and congenital excesses or redundancies
by which there are made to appear supernumerary auricles or portions
thereof. These latter have been described by Sutton and treated in his
work on _Comparative Pathology_. They bear relation as well to the
branchial clefts, and are of great interest from a phylogenetic point
of view. Some of these defects result from absolute arrest or excess
of development, others from injury during intra-uterine life; some are
accentuated by lack of care during the early months of infancy. The
most common deformity of the ear is that by which it is made unduly
prominent and deflected outward or forward, the cartilage being thick
and abnormally curved. Such _overlapping_ or _overprominent ears_ can
be made to assume their proper position on the side of the head by
the excision of an elliptical piece, either of skin or of skin and
cartilage, at the point of junction of the ear and the scalp. The
amount to be removed should be proportionate to the desired effect. The
parts may be brought together by sutures, and the auricle should then
be bound upon the head.
Fig. 395 illustrates a common form of defect, inherently of the
cartilage and of the overlying skin. This is but one illustration of
many, two cases being rarely found exactly alike. Not infrequently
these arrests of development include the structures of the middle ear
as well. The auditory meatus may be entirely covered and concealed, or
may be absent, having failed to develop.
[Illustration: FIG. 395
Developmental defect of external ear. (Broome.)]
_Supernumerary auricles_ are usually found as small tags of skin and
cartilage in front of or below the ear. They are easily removed and
leave no disfiguring scar.
The external ear is also exposed to injury, which it frequently
receives in the way of contusions and lacerations. It is occasionally
detached. The ordinary wounds of these parts require only the
conventional treatment, while it may be possible, by replacement and
approximation of a completely detached portion, to see it re-adhere.
This happened to the writer after his horse had completely bitten a
piece out of the ear of his groom. Here, as with detached finger-tips,
cleanliness is necessary, and the parts must be kept warm and protected
after dressing. The cartilage of the ear is covered by a perichondrium
which corresponds to the periosteum. Beneath it, or beneath the skin
alone, blood may be extravasated as the result of contusions. When such
collections fail to promptly resorb they should be incised and the
contained blood released. Such lesions are referred to as _traumatic
othematomas_.
A peculiar lesion of this general character occurs occasionally in
the insane. If due to injury the latter is but trifling. It makes a
conspicuous tumor, involving usually the lower end of the auricle, and
is known as the _othematoma of the insane_. It is scarcely amenable to
surgery, nor does it often need it, but it constitutes a disfigurement
which is not only easily apparent, but diagnostic as to the cerebral or
mental condition.
The ear is the site of many _neoplasms_, both innocent and malignant.
Small papillomas are common, while fibrous tumors are likely to
develop, especially about the fibrocartilaginous lower end of the
auricle, where the ear has been pierced for ear-rings. Keloid tumors,
of still more conspicuously fibrous nature, are common about the
ear, especially among negroes. All innocent tumors may be excised,
through incisions which should be so planned as to leave a minimum of
disfigurement. (See Fig. 397.)
Of the malignant tumors epithelioma is perhaps the most frequent. It
pursues a course here similar to that which characterizes it elsewhere,
save that the dense structures of the cartilaginous ear yield but
slowly to its encroachment. The form known as “rodent ulcer” is slower
here than elsewhere. Fig. 396 illustrates a case under the writer’s
care, showing complete destruction of the external ear by a growth of
this kind, which had attained a degree and extent that did not permit
of successful treatment, and which eventually proved fatal. When
growths of this character have not progressed too far they should be
radically removed, the question of cosmetic effect being secondary to
that of their eradication. By a well-planned plastic operation much can
be done to atone for disfigurement resulting from radical operation.
[Illustration: FIG. 396
Complete destruction of auricle by rodent ulcer. (Buffalo Clinic.)]
[Illustration: FIG. 397
Congenital lymphangioma of ear. (Lexer.)]
FOREIGN BODIES IN THE EAR.
All sorts and descriptions of foreign bodies may enter the ear. Young
children have a tendency to introduce all kinds of bodies into the ear,
as into the nose, and sometimes intrude them to such a distance that
their removal is made difficult. Living insects make their way into the
meatus auditorius and even deposit their larvæ, which may subsequently
go through their developmental phases and fill the passage-way with
young insects. Among the inanimate materials which children introduce
are small buttons, pebbles, beans, peas, beads, etc. Such a foreign
body may not be at once discovered, and some of those which easily
undergo decomposition, like fresh vegetable substances, may not be
detected until they have set up trouble by decomposition. Therefore
it may be hours or days before its presence is recognized. Sometimes
it may be easily seen, again it may be concealed. When the auricle is
drawn upward and backward the external meatus is somewhat straightened,
and bodies within it are more easily made visible, especially by
reflected light. Therefore the head mirror is usually required for
their detection and removal. The substance may be one which is easily
seized and withdrawn, after certain turning or shifting motions have
been attempted, or it may be impacted so as to offer considerable
difficulties. It should never be pushed farther in, for injury might
thus be done to the membrana tympani, and the effort should be to
remove it with the least possible damage to the lining of the canal.
So essential is it to have the head kept perfectly still during these
maneuvers that it will be advisable, with young children, to administer
an anesthetic. Instances occasionally occur which necessitate incision
and liberation of the auricle, with its deflection forward, and the
consequent more complete exposure of the auditory canal. Forceps of
various fashions may be used, or occasionally a blunt hook may be made
with a probe, which may be used to advantage.
Of living foreign bodies information can be obtained more promptly,
as the annoyance caused by their movements will at once disturb the
patient.
Relief has often been promptly afforded by filling the meatus with
water or glycerin as warm as can be borne, by which the insect is
killed, after which it may be removed by irrigation or by forceps,
assisted by good illumination.
That which is essentially a foreign body may be produced by an
_accumulation of cerumen_ in wax-like form within the auditory canal.
Neglectful patients sometimes allow this to accumulate until it
constitutes not only a source of irritation but an obstacle to hearing.
Its removal is not ordinarily accompanied by difficulty, but requires
patience and often considerable effort, not only with instruments, but
with irrigation, especially with an alkaline solution, by which the
waxy substance is softened.
A phenomenon noted in many of these cases, where instrumentation has
to be practised within the vicinity of the middle ear, is coughing or
sneezing, sometimes to a degree which interferes with the work to be
done. This is a reflex to be explained through connection with the
pneumogastric nerve.
THE EXTERNAL AUDITORY CANAL.
In the fibrocartilaginous as well as in the more richly cellular
portions of this passage-way small phlegmonous processes frequently
occur. They give rise to an amount of suffering, and even of
sympathetic reaction, disproportionate to the extent of the difficulty.
They are called furuncles, or boils, sometimes occurring singly, often
in groups. A commencing process of this kind may be cut short by the
use of an ointment of 1 to 2 per cent. yellow sulphate of mercury,
but after the furuncle is well developed it is best treated by free
incision, which can be made with the freezing spray, and without much
pain to the patient.
More extensive phlegmonous destruction, assuming even carbuncular form,
is occasionally met with in this region. There will be more or less
necrosis of tissue in such cases, which will require removal, usually
with the sharp spoon. These cases are not without their danger, since
the veins connect so freely with the interior of the cranium.
_Hyperostosis_ and _exostosis_ produce either a narrowing of the
auditory canal or its complete obstruction, and sometimes even the
formation of an osseous tumor of considerable size. A thickening and
even new formation of bone may be the result of the chronic irritative
processes which frequently occur in the middle ear, but many of these
conditions occur in the newborn, in whom they are to be regarded
as congenital excesses and in whom they frequently cause permanent
impairment or loss of hearing. Some of the osteomas in this region are
of bone-like hardness, their density being sufficient to dull or even
to break the finest tempered steel instruments.
A small exostosis may be removed with the ordinary instruments of the
surgeon or the dental engine, but the larger and more dense growths
offer formidable difficulties for the operator and uncertain results
for the patient. When growths of this kind attain considerable size
they should not be attacked through the natural passages, but the
auricle should be separated and pushed forward and the auditory canal
opened.
THE MIDDLE EAR.
The middle ear has for its external boundary the membrana tympani,
which, for clinical purposes, constitutes a limit beyond which the
general surgeon should not trespass, the structures within being those
within the field of the aural surgeon. Nevertheless the student of
surgery should realize that the membrane of the drum may be ruptured in
consequence of a blow upon the external ear, or perhaps by the sudden
condensation of air produced by explosions, etc. It may, moreover,
be lacerated in consequence of various injuries to the head, basal
fractures, etc., even those involving the opposite side of the head;
it may also be injured by foreign bodies, introduced usually from
without and through the canal. While this membrane has normally an
opening by which air pressure is equalized on either side, this seems
to play but a small part in the liability to or exemption from injury
such as just described. The membrane has its own blood supply, which
can become congested to a degree permitting considerable escape of
blood after laceration. It does not follow that bleeding from the ear
is necessarily an indication of basal fracture, after injuries of the
head, unless the hemorrhage is continuous and considerable, in which
case it may be stated that the injury must be deeper and more extensive
than one of the membrane alone. If, however, cerebrospinal fluid can
be detected as escaping with and diluting the blood, or escaping
independently, then the diagnosis of basal fracture may be regarded as
certain.
After such injuries as lead to hemorrhages from the ear the external
auditory canal, should be irrigated and protected against infection by
light tamponing, etc.
It is the writer’s opinion that the general surgeon should abstain
from operative intervention in the ordinary diseases of the middle
ear, save in the presence of symptoms which accompany mastoiditis,
acute infections of the sinuses, or even of the brain itself. When it
comes to an extensive operation, such as is often required in such
instances, including not merely opening of the mastoid antrum and
cells, but exposing the dura and judging of the condition of the sinus,
with perhaps the simultaneous ligation of the jugular in the neck
and washing out of the intervening portion, then these are measures
requiring such surgical judgment and operative skill that it would seem
that the general surgeon should be peculiarly equipped for this task.
But the ordinary office operations should be left to those who make a
specialty of these diseases.
When the cavity of the tympanum is involved in a suppurative condition,
with caries of the surrounding bone and extension into the spongy
tissue of the adjoining mastoid, this abscess cavity should be cleaned
out. Therefore the more radical operations of the aurist, by which the
membrana tympani is destroyed, the ossicles of the ear removed, etc.,
are but applications of broad surgical principles to a limited region
of the body, but made justifiable by their results. Moreover, in a
more chronic type of cases, where the tympanum is filled by redundant
granulation tissue and by polypoid formations, which are producing
more or less circumscribed caries or necrotic processes in the bone,
by which bony partitions between the cranial cavity and the ear proper
are gradually thinned or lost, and by which encroachment on the
intracranial sinuses with all its dangers is incurred, they are still
to be subjected to the same general radical methods of treatment, no
matter whether it be carried out by a specialist or a general operator.
THE ACCESSORY CRANIOFACIAL SINUSES.
While these cranial cavities are connected with the respiratory tract
there are, nevertheless, good topographical and physiological reasons
for considering their lesions in this place. There is free venous
communication between each of them and the cranial cavity, and free
lymphatic communication as well from at least three of them. Infection,
therefore, may and often does travel from the smaller to the greater
cavity, and thrombophlebitis, brain abscess, or purulent meningitis may
be the ultimate result of apparently trifling infection of one of the
sinuses.
They are four in number--the _frontal_, the _ethmoidal_, the
_sphenoidal_, and the _maxillary_, or antrum of Highmore. They are
all connected with the nasal cavity, and all lined with the same
Schneiderian membrane, which affords a continuous pathway of infection.
At least two of them are cellular in character, much resembling the
mastoid cells. Their means of communication with the nasal cavity are
small, and often obstructed by catarrhal swelling and inspissated
discharge. If thus plugged their retained contents may undergo
decomposition and intensify the trouble. It has been shown that the
effect of inward currents of air through the nostrils is to suck
out from these sinuses more or less of their secretion. In this way
perhaps may be accounted for the strings of tenacious mucopus which
slowly make their way out of especially the anterior sinus openings.
Some surgeons believe that if one sinus is affected all the others on
that side of the head are more or less involved; while this may be
true in many cases, and is easily explained on anatomical grounds,
it is not strictly true of all instances, least of all in cases of
chronic empyema of the antrum, which often long remains simple and
uncomplicated.
Surgical lesions within the accessory sinuses result from infective
processes, proceed often to suppuration, often, too, with caries
of the surrounding spongy bone as well. These conditions may result
from the ordinary acute catarrhs, or follow the more specific fevers,
like influenza and the exanthems, and frequently follow diphtheria.
Traumatic causes may also conspire to produce the same effect. In the
maxillary sinus disease is often due to extension upward from carious
teeth. In syphilitic and tuberculous patients these affections will
partake to a greater or less degree of the specific nature of these
diseases.
_Symptoms_ differ according to location and are often obscure enough to
make diagnosis difficult. Perhaps the most prominent symptom is _pain_,
either deep-seated, vague, or disquieting, located in the neighborhood
of the diseased sinus; or intense and neuralgic in character, radiating
from the source of the trouble. Its severity is proportionate to the
acuteness of the case. When the frontal and maxillary sinuses are
involved there occur external swelling and tenderness. If the sinus
openings be patulous there will be more or less purulent discharge
into the nasal cavity, that which comes down from the upper sinuses
appearing beneath the middle turbinate body. Transillumination by means
of a small electric light, passed into the nostril, will demonstrate
an opacity in the region of the affected sinus which does not appear
on the healthy side. The condition is frequently associated with
nasal polypi, small or large; while granulations in time spring up
within these cavities and may even escape therefrom as these become
filled. The general clinical picture is one of nasal obstruction, with
more or less constant discharge, sometimes mucopurulent, sometimes
offensive, which perhaps may be favored by certain positions of the
head, this being especially true of the maxillary antrum. Along with
these features go a degree of headache, of local pain, and even of mild
or severe febrile disturbances, proportionate to the severity of the
lesions which produce them.
When the anterior ethmoid cells are involved pain is usually referred
to the temples rather than the forehead, though both may suffer alike.
_Treatment_ should be based upon the fact that we have affected and
infected cavities whose interiors are diseased, and whose outlets are
blocked. The more free and thorough the drainage and the cleansing
which can be given, the more prompt the results. In all well-marked
cases, then, radical treatment is indicated. The ordinary treatment by
sprays, inhalations, etc., is useless, as the source of the trouble is
not reached.
Special treatment for each sinus will now be considered.
_Frontal Sinus._--Most of the symptoms of affection of the frontal
sinus are objective, and there is frequently external swelling, with
tenderness and edema. For its relief intranasal methods will often
suffice. In almost all cases we may expect to find hypertrophic
conditions within the nose. When empyema exists there is often a
deviated septum. It is impossible to avoid the conclusion that there is
a strong relation between hypertrophic lesions and sinus retention. The
difficulty may arise from many causes, most of which lead to sneezing,
coughing, and hacking, by which the mucous membrane of the nasopharynx
is both thickened, loosened, and predisposed to polypoid changes. The
irregularities thus produced harbor more germs than usual and their
effect is, in a measure, proportionate to their numbers. For the
examination of the upper part of the nasal cavity Killian’s speculum is
of great help.
The frontal sinus differs very much in shape and size, not only in
different individuals but on opposite sides of the same individual.
It may be rudimentary upon one side and large upon the other. It
is usually more capacious in those individuals who have prominent
foreheads and resonant voices. Here, as elsewhere, it will usually
be found that the most radical operation is the best, although one
endeavors naturally to preserve cosmetic features of the nose, so
far as he can, without sacrificing the patient’s interests. The
nasopharyngeal duct is so often connected with the ethmoidal cells, as
well as the frontal, that the former may be easily affected when the
frontal sinus is diseased.
In case of sinus disease, especially when the frontal sinus is
involved, it is better to encourage patients to snuff materials back
into the throat rather than to forcibly blow the nose or expectorate
them, as the latter would tend to force into the sinus that which it
would be better to have aspirated out of it.
The frontal sinuses may be attacked from within the nose or externally.
It is perhaps the least open to mild and conservative treatment, as it
is the most difficult of access by non-operative methods. The anterior
ethmoid cells are usually connected with it and infection rarely spares
one part to involve the other alone. Therefore if it be necessary to
operate on the frontal sinus the anterior and upper cells should be
exposed at the same time. Thus operations which have for their object
continuous drainage have usually as an objection the necessity for
wearing the drainage tube for months. After opening the sinus from
without the nasal duct may be enlarged to any size and desired degree,
and a tube inserted which shall afford ample drainage downward. This
may be covered with a flap and allowed to remain for a number of weeks.
Nevertheless it is a foreign body which has to be subsequently removed
from the nose. Killian’s method is doubtless the best for most cases,
as the most anterior of the ethmoid cells, and those which extend over
the orbits, cannot be easily reached through the nose, and if disease
involve the posterior ethmoid cells its extension to the sphenoid may
be expected. The operation includes an incision from the temporal end
of the shaved eyebrow, along its curve to the side of the nose, and
down to the middle of the nasal processes. The periosteum is divided
along a line a little higher, and again in the centre of the frontal
process, the intent being to so remove it that a bony bridge may be
left after removal of the anterior lower wall of the sinus. The first
periosteal incision should correspond to the upper border of this
bridge, either above or below it. The sinus is opened at first with
a chisel, afterward with bone forceps or surgical engine. It is then
completely scraped out, leaving the supra-orbital ridge for a bridge.
Its floor is resected along with the frontal process of the superior
maxilla. Through this opening the anterior and middle ethmoid cells may
be reached and cleaned out to the middle turbinate. The ethmoid cells
may then be attacked, the sphenoidal cells inspected, and also attacked
if necessary. The opening into the nose should be made free, and a
flap should be formed from the nasal mucoperiosteum, so that there
may remain a permanent opening of sufficient size. This method may be
modified to suit various needs. After doing all the work necessary the
external wound is closed, with a tube for drainage, while the formation
of the bridge above alluded to prevents much of the sinking in of the
anterior wall of the sinus, which would otherwise occur. If the little
pulley over the superior oblique muscle has been interfered with in
the operation or loosened from its attachment there will be at least
temporary and perhaps permanent diplopia. This should be carefully
avoided. There is also danger of injury to the contents of the orbit.
For some time after the operation there will be some drooping of the
upper lid. Nevertheless the results are usually satisfactory. After the
operation the patient should be permitted to lie upon the healthy side
and be forbidden to blow his nose; he should rather attempt to aspirate
the fluid from the wound. If necessary both sinuses can be attacked at
the same time and after the same fashion, the septum being removed.
Here as with the other sinuses the test of the efficacy of the
treatment will be furnished by relief of the headache, pressure, and
pain. Should carious or necrotic bone be exposed, or should there be
indications of malignancy, much more radical surgery would be indicated.
_The Ethmoidal and Sphenoidal Cells._--For the exposure of these,
especially the latter, it is necessary to make room for work. This
would be true even in normal cases, and is still more so when the parts
are hypertrophied and the passage-way is obstructed. It is necessary
at least to remove all deviated portions of the nasal septum, and to
clear away not only all hypertrophies of the turbinates, but to remove
more or less of these bones. With a free passage-way it is possible
to expose the opening of the sphenoidal cells, whose anterior wall
may then be broken down, after which granulations may be removed with
an appropriate small spoon, or the purulent contents cleaned out with
swabs.
In dealing with the ethmoidal cells by intranasal methods it is
necessary to break down the slight compartments between them, one after
another, because of the fact that they all constitute foci of disease.
An opening at least 2 Cm. in length will usually be required, and can
be comfortably made, under suitable illumination, if all obstructions
have been removed; after this a probe is gently passed upward and
alongside of the nasal septum until it rests against the ethmoid, then
passed backward until it meets the posterior wall, which will be in the
immediate neighborhood of the sphenoidal opening, through which, by
gentle manipulation, it may be passed. At this point the presence of
polyps or a greatly thickened mucosa may be detected by palpation with
the finger within the nasopharynx, while should pus be removed by the
end of the probe it would indicate empyema of this cavity.
In all these accessory nasal sinus examinations and operations the
greatest aid will be afforded by cocaine solution, which has the
double advantage of not merely abolishing sensation, but of contracting
and rendering anemic the mucous membranes, and thus to a certain extent
shrinking them. When necessary for this latter purpose, or for the
control of hemorrhage, adrenalin may be added to the cocaine. For all
these purposes a spray of a mild solution may be first used, for its
general benumbing effect, after which it would be advisable to use a
strong solution, even saturated, very sparingly, applying it by the aid
of illumination just to the area where the effect is desired, and not
allowing it to come in contact with other parts of the nasal cavity;
this is done to avoid unpleasant symptoms from cocaine absorption.
Another benefit obtained from the use of cocaine is in thus abolishing
sensation to an extent which does away with reflex vasomotor symptoms,
shock, etc. Therefore even when a general anesthetic is used it will be
well to use at least a small amount of it for this latter purpose.
The question of instruments and of methods will depend much on the
equipment of the operator and his expertness in the necessary technique.
_The Maxillary Antrum of Highmore._--This is the largest of the
accessory sinuses, the most easily approached, and the one whose
disturbance is most quickly and easily appreciated. It may be infected
by continuity, along the Schneiderian membrane which lines it, or by
extension upward of disease from carious teeth, as well as after a
variety of injuries involving its integrity. So long as its opening
into the nose be not plugged it will, when involved in catarrhal or
suppurative inflammation, discharge into the latter a characteristic
fluid, which is especially likely to escape when the head is held
downward and to the opposite side. Any statement of this fact,
coupled with evidences of local inflammation, should enable an easy
recognition of antral disease. In more chronic cases it becomes blocked
by thickening of its membrane, the production of granulations or of
polypi, which sometimes completely fill it. When thus plugged and
filled there is a tendency to protrusion of its anterior outer wall and
floor, while the overlying cheek may become somewhat edematous, the
parts at the same time being tender. The pain from a diseased antrum
will often induce the patient to go to the dentist for extraction of a
molar tooth, which, however, affords little relief.
The relief for chronic antral disease is surgical, as in the case of
the other sinuses. Opening the antrum through a tooth socket would
seem judicious only when a diseased tooth is the cause of the lesion.
It is useful only for such otherwise uncomplicated cases. The argument
usually used in its favor is that it affords better drainage. This,
however, is not the case, since the position assumed by the head for
the greater part of the time does not locate such an opening in the
most dependent part of the cavity. Moreover, the discharge is not
always fluid, nor does it flow freely; on the contrary it is often
thick, and so adherent to the wall or roof of the cavity that it takes
a strong irrigating stream or swab to dislodge it. If the antrum is
to be opened through the mouth it would seem more surgical to open it
widely, cleanse it, and then either drain it or close it again. Other
things being equal, the best method is that which permits of both
examination and subsequent treatment. Jansen’s method is frequently
most serviceable. It includes careful cleansing of the teeth, with
disinfection of the mouth, and walling off the area to be exposed
by gauze strips in order to prevent hemorrhage into the throat. An
incision is made through the anterior mucoperiosteum, beneath the floor
of the antrum, from the first incisor to the first molar. Its edges are
then separated and the entire front wall of the antrum removed. Through
such an opening its interior can be carefully inspected and cleansed.
Should it seem desirable to go farther the inner wall may be removed
by forceps, and through this opening the ethmoid cells can be seen and
curetted up to the insertion of the middle turbinate. Then the sphenoid
surface can be inspected and the lower portion of the sphenoid cells
resected. Finally a good-sized counteropening is made inward, onto
the floor of the nose, the antrum is loosely packed, the ends of the
gauze extending into the nose, and the mucoperiosteal wound closed, in
order to secure primary union. All bone edges should be made smooth and
non-irritating; the sphenoidal cells should not be packed, but left
open for subsequent treatment.
In the presence of bone disease, malignant growth, etc., it may not be
possible to shut off the mouth again from the antral cavity. In such
cases the packing may be made more snug and the granulation process
will have to be substituted for sutures.
Special flaps or plastic methods should be devised for special cases,
as, for instance, the formation of a mucoperiosteal flap from the outer
side of the antral wall and its union posteriorly within the cavity
of the antrum with another made from the antral floor. By turning
the latter in the necessary direction a line of suture may be made
through the mouth. Any such cavity, long diseased, will call for a
radical method of attack and opening, which latter can be maintained
to permit of subsequent treatment, as an early closure would sometimes
be undesirable. Antral cavities thus left more or less open should
be treated with cleansing sprays or applications, and with such
stimulating applications as silver nitrate in various strengths of
solution, or similar antiseptic stimulants.
THE CRANIAL NERVES.
While most of the affections of the nerves are considered to be
non-operative, and to belong rather to the internist than to the
surgeon, there are, nevertheless, some nerve lesions which are only
to be relieved by surgical intervention. These may be divided into:
(1) _Wounds and injuries._ (2) _Morbid conditions_, such as (_a_)
_neuralgia_, and (_b_) _muscle spasm_.
WOUNDS OF THE NERVES.
Wounds of nerves have been considered in the chapter on Wounds, and
the possibility of nerve regeneration and repair therein discussed.
In every division of a nerve trunk of importance or size the nerve
ends should be trimmed and reunited by a suture, passed either through
the sheaths or through the nerve itself. The ends should be brought
together securely and the tension should not be too great. If this be
promptly done the best of results may be expected. This is equally true
of cranial and peripheral nerves. Clinical experience has long since
established the necessity of this procedure after all such injuries,
and _nerve suture_, or _neurorrhaphy_, is now a standard operation.
Later there was added to this measure the analogous one of _nerve
grafting_, and it has been found that nerves can be juggled with
just as can tendons, as described in the section on Tendon Suture.
Indeed the methods of nerve suture and _nerve grafting_ are strikingly
similar to those employed with tendons, where can be made either
end-to-end junction, lateral implantation, or a more properly termed
_grafting_, a trimmed end of one nerve being inserted into another. In
the arm, when the ulnar nerve has been caught in callus and completely
destroyed, both the upper and lower portions may be grafted into one
of the adjoining nerves, _e. g._, the median; this procedure seems to
reëstablish communication and serve the double purpose, in a manner
corresponding to duplex or quadruplex telegraphy over one wire. Nerves
which have been divided and entangled in scars may be disengaged, their
ends trimmed off and approximated, success being proportionate to the
length of time during which nerve degeneration may have been taking
place.
Another operation is practised on nerves, solely for the relief of
painful or disturbing symptoms, _i. e._, _neurectomy_. In cases of
intractable and hopeless neuralgia, where other measures fail, sensory
or complex nerve trunks are divided, a portion of the continuity being
resected. This operation is practised more often upon the trifacial
nerve than upon all others. It is generally successful, but in those
cases where pain is due to some central lesion it is often palliative
rather than curative. In the case of the trifacial nerve the operator
endeavors to be as radical as possible in its practice, and to remove
the Gasserian ganglion rather than portions of any of its branches.
The neuralgia for which these operations are performed may be due
either to central or constitutional causes, as well as to local
irritations, compressions, or degenerations. The term neuralgia itself
is so vague and covers such widely differing changes that nothing which
can be said in this place would clear up the problems of its pathology;
consequently attention will be directed here solely to its surgical
relief in connection with the various nerve trunks which are usually
attacked.
One other operation is practised upon nerves for the relief of pain
and spasmodic affections--namely, _nerve stretching_, or nerve
_elongation_. This is practised more often upon the sciatic than upon
any other nerve, but has been done for the relief of choreic spasm of
the arm and shoulder, by exposing and stretching the various cords of
the brachial plexus, for the relief of spasmodic torticollis, and in
various other places. Nussbaum was the first to note that obstinate
intercostal neuralgia was relieved by accidental stretching of an
intercostal nerve, and introduced the procedure.
[Illustration: FIG. 398
Various incisions for reaching different branches of the trifacial
nerve: _a_, supra-orbital; _b_, external nasal; _c_, Bruns’ incision;
_d_, inf. dent. at mental foramen; _e_, internal nasal; _f_,
infra-orbital; _g_, Carnochan’s incision. (Marion.)]
Operations upon nerves, then, include _suture_, _grafting_,
_stretching_, _division_, and _resection_. After any operation upon a
nerve trunk the parts pertaining to it should be placed in a position
of rest; and, furthermore, such position as will prevent stretching and
favor relaxation of the sutured trunk should be maintained. The writer
is credited with the first primary suture of the sciatic nerve, which
was done immediately after its accidental division, during the course
of an extensive operation. Recovery was prompt and complete. The limb
was immobilized in the extended position and physiological rest thus
maintained.
Nerves can be stretched, it has been found, to one-twentieth of their
length. Nerve trunks have much more strength than has been generally
appreciated. The sciatic trunk of a full-grown individual will bear
a stress of more than eighty pounds, while even six pounds’ pull are
necessary to tear the supra-orbital nerve. The benefit which follows
nerve elongation is ascribed to the improvement in its nutrition
produced by the damage done to its substance, and the consequently
enhanced blood supply, as well as to the severing of adhesions between
the sheath and its surroundings and between the nerve bundles within
the sheath.
The operation of nerve stretching consists simply in exposing the
nerve at a site of election, detaching it from its surroundings, and
then hooking either the finger or some smaller instrument beneath it
and pulling firmly, yet gently, in both directions; in the case of the
sciatic, for instance, the entire limb should be lifted from the table,
and even this does not entail upon the nerve trunk anywhere near a
breaking force.
The _cranial nerves_ are sought, found, and treated as follows, in
their respective cases:
The _supra-orbital nerve_ is attacked at its exit from the
supra-orbital notch, which can usually be felt, or foramen, when such
exists, either by a straight incision made directly over it, where it
can be felt, or by a curved incision through the region of the eyebrow,
which should have been shaved for the purpose, the resulting scar being
hidden by the hair as it grows again.
The _infra-orbital nerve_ is similarly treated at the infra-orbital
foramen, where it lies under the levator labii superioris. It may be
exposed by either a curved incision, parallel to the orbital margin, or
by a vertical incision, which will leave a more disfiguring scar.
The _second branch of the fifth nerve_ may be attacked from the front
by Chavasse’s modification of Carnochan’s original method, consisting
of a T-shaped incision from one corner of the eye to the other, the
vertical branch extending from its middle well down to the mouth.
After the infra-orbital nerve is identified it is secured with a piece
of silk. The anterior wall of the antrum is then removed, the cavity
opened, and a small trephine applied to its posterior wall. The nerve,
being exposed in its canal or groove, is divided anteriorly, pulled
down into the cavity by means of a ligature previously applied to it,
and now made to serve as a guide into the sphenomaxillary fossa. Here
it may be followed directly into its connection with Meckel’s ganglion,
which may also be extirpated. The nerve trunk is forcibly pulled out
of the foramen rotundum, through which it escapes from the Gasserian
ganglion.
Horsley does not open the antrum but lifts the orbital contents,
including the periosteum, follows the nerve along the canal by means
of sharp-pointed bone forceps, and thus follows it up to the foramen
rotundum, where it is evulsed as above. (See Fig. 399.)
Luecke years ago devised a method of lateral approach, attacking
the ganglion and the nerve from the temporal region. An incision is
made from the external angle of the orbit straight downward in the
direction of the molar teeth, where it is met by another extending from
the middle root of the zygoma, downward and forward. Through these
incisions the zygoma is exposed and divided. Thus an osteoplastic flap
is formed which is laid up over the temporal region, the divided piece
of bone being raised with the overlying skin and not detached. This
exposes the temporal and zygomatic fossæ. The temporal muscle is then
drawn backward with a hook, the fatty tissue which fills these fossæ
cleaned out, and the nerve sought for in the sphenomaxillary fossa,
where both it and Meckel’s ganglion may be extirpated. The flap is then
turned down and fastened in place (Fig. 400).
[Illustration: FIG. 399
Branches of the inferior maxillary nerve which most concern the
surgeon: _a_, auriculo-temporal; _b_, inf. dental; _c_, buccal.
(Marion.)]
[Illustration: FIG. 400
Exposure of Meckel’s and the Gasserian ganglia by temporary resection
of the zygoma; Luecke’s method. (Marion.)]
The _inferior dental, or third division of the fifth nerve_, may be
reached in several ways: Its terminal portion where it escapes at the
mental foramen; its upper portion by an incision two inches along
the lower border of the jaw and above the angle, the masseter muscle
being separated from the jaw, and the ascending ramus opened with a
³⁄₄-inch trephine at a point 1¹⁄₄ inches above the angle, its upper
edge ¹⁄₄ inch below the sigmoid notch. The nerve is here exposed before
it enters the canal. The lingual nerve may also be found resting upon
the internal pterygoid muscle. A ligature tied around each nerve, for
traction purposes, permits easy tracing of their trunks to the foramen
ovale, where, after vigorous stretching, they are divided. They should
then be traced downward and at least one inch of their trunks removed.
=The Gasserian Ganglion.=--When all three branches of the trifiacial
nerve are involved in painful _tic_, or when operation has already
been practised upon one or more of them and the tic has recurred, it
becomes necessary to attack the Gasserian ganglion itself.[45] This
may be approached by either one of two methods. Both are difficult
and serious, having a mortality of from 15 to 20 per cent. As Cushing
has pointed out, however, its mortality rate is scarcely as great as
the death rate by suicide in neuralgic cases of this kind. The attack
from below was first carefully worked out by Rose and then by Andrews,
and is begun in much the same way as the operation for the removal
of Meckel’s ganglion by resection of the zygoma, described above. A
flap is laid up, larger and wider, including the zygoma, with the most
complete possible exposure of the zygomatic fossa. The coronoid process
is drilled in two places, divided between the openings, which are to be
used for subsequent suture, and the temporal muscle pushed upward and
forward, out of the way, with the upper fragment. The foramen ovale is
then identified by following into it the inferior maxillary nerve, the
base of the skull being cleaned away in that neighborhood, and a small
trephine opening made between it and the foramen rotundum, connecting
these two openings by a much larger one. Through this opening the
ganglion is exposed and destroyed piecemeal or extracted as completely
as possible. The operation is exceedingly difficult, and hemorrhage,
especially from the middle meningeal artery at the foramen spinosum,
maybe so troublesome as to make it impracticable unless the carotid
be tied. I have preferred in doing this operation to make preliminary
ligation of the common carotid, which facilitates the balance of the
procedure. The exposure by this method, however, is not as satisfactory
as by that next to be described.
[45] _Osmic Acid and Other Treatment of Trigeminal Neuralgia._--While
it hardly pertains to operative surgery, it may be worth while to say
that it seems to me that no case of trifacial neuralgia should be
subjected to radical operation until at least two or three remedies
have been given a fair trial. One of these is _castor oil_ its use
being based upon the theory that such neuralgia is of toxic origin
and that a prolonged evacuant treatment should benefit it. This
would mean the administration of two or three good-sized doses of
castor oil every day for a period of two to three weeks. It is not
such a drastic remedy, thus given, as would appear, for after the
oil has once thoroughly produced its laxative effect it ceases to
distress, but serves as a very effective eliminant. The second remedy
is _gelsemium_, the best preparation being the tincture of the green
root. It seems to exercise a selective affinity for the trifacial
nerve. It should be given in large doses, pushed to the physiological
limit, _i. e._, until the patient begins to see everything in yellow
colors. Its effect on the heart must also be guarded. Fifteen drops
of the green tincture given every two hours, and for a few days, will
usually suffice to thoroughly test its efficacy.
_Osmic acid_ is used only for _intraneural injection_, its efficiency
now being under trial. Ten to twelve drops of a 2 per cent., freshly
prepared aqueous solution are directly injected into the nerve trunk
after its exposure. Murphy has been its particular advocate, and
has reported relief of pain in a number of cases thus treated. It
seems to depend for its effect upon two factors--the destruction of
nerve filaments and their substitution by connective tissue. All the
nerve branches that can be exposed should be injected; the palatine
and lingual through the mouth; the intra-orbital and supra-orbital
by incisions upon the face; orbicular-branches, as well, should be
injected, if possible. Most of those who have used it advise also
to inject a few drops into the foramina of exit, around the trunks,
which are thus infiltrated with the solution. The procedure is
painful and usually requires a general anesthetic, but it seems to
be free from danger. While the treatment has been successful in some
cases it has been equally disappointing in others, and the method
will scarcely supplant the more radical method of ganglion exsection.
Hartley and Krause, about the same time and independently, devised a
method of attacking the ganglion, after raising an osteoplastic flap
from the side of the skull, which affords a better exposure and a more
satisfactory method.
Within reason the larger the osteoplastic flap the easier the balance
of the operation. Whether it be square or horseshoe in shape, whether
it be made by chisel, by Gigli saw, or by surgical engine, matters
little. In fact experience has shown that the conservation of the bone
is not a matter of serious import, and there is no good reason why
there should be any hesitancy to remove the bone should the formation
of such an osteal flap present too many difficulties. After the dura
is completely exposed it is to be separated from the base of the skull
until the foramen spinosum and middle meningeal artery are reached.
It is better to do this quickly and with the finger than slowly with
instruments. After this separation the brain with its dural covering
is lifted by a spatula or retractor, so as to afford a good view of
the region of the ganglion. It will be necessary to double ligate the
middle meningeal artery unless preference has been given to make a
preliminary temporary or permanent ligation of the carotid. Should
this artery have been injured in raising the flap it should be secured
before going any farther, either by plugging the opening or canal with
gauze or with antiseptic wax (Fig. 401).
The upper surface of the ganglion is adherent to the dura, and these
adhesions should be separated. The second and third branches should
be identified and divided near their exit. The first branch is in too
close relation with the cavernous sinus to justify much interference.
The ganglion itself is then seized, after complete isolation, with
forceps and evulsed, with as much of its longer and shorter roots as
possible. Hemorrhage is checked by adrenalin or by pressure with gauze,
as may be required. If gauze be used for the purpose it may also be
utilized for drainage. The brain is restored to position and the flap
sutured in its proper place.
Before doing either of these operations I should prefer to place the
patient within the Crile pneumatic suit and then tilt the body to an
angle of at least 45 degrees, thus prompting emptying of the cranial
and cervical veins by gravity, while at the same time blood pressure is
maintained by the pneumatic pressure (see p. 180).
Abbe has endeavored to lessen the shock of the operation by not
formally tearing out the ganglion, but by taking out a section of
the nerve trunks between it and their foramen of exit, and then
interposing a piece of thin, sterile, rubber tissue, inserting it in
such a way that it shall effectually prevent regeneration of nerve
trunks across the interval, this rubber being intended to remain and
become encapsulated. This method of Abbe seems to have made operative
attack upon the Gasserian ganglion less formidable and less dangerous.
It remains to be seen whether it is permanently as effective as more
complete extirpation.
=The Lingual Nerve.=--In some cases of cancer of the tongue there is
such intense pain that not only has the lingual artery been tied but
the lingual nerve been stretched or exsected. It can ordinarily be
reached where it lies on the floor of the mouth beneath the mucous
membrane, at the fold between it and the tongue, where it can be felt
if the tongue be forcibly stretched. Through a small incision a blunt
hook may be passed and the nerve thus secured. Close to the first lower
molar the nerve lies in the tongue near the surface, where it can also
be found.
=The Seventh or Facial Nerve.=--This nerve has sometimes to be
stretched for spasmodic affections. When the desire is simply to reach
its trunk it may be sought through an incision behind the ear, by which
the posterior border of the parotid is exposed, the sternocleidal
insertion identified, the nerve lying in the interval between these two
landmarks. A more easy method of reaching it would probably be by an
incision in front of the ear just before its main branch divides as it
enters the parotid gland. If necessary this may be followed backward
until the main trunk is reached.
[Illustration: FIG. 401
Intracranial exsection of Gasserian ganglion; dura open, brain lifted
up. Hartley-Krause method. (Marion.)]
[Illustration: FIG. 402
Relations of the facial and spinal accessory nerves: _a_, carotid; _b_,
int. jug.; _c_, facial nerve; _d_, transv. proc. atlas; _e_, spinal
acces.; _f_, stern. mast. muscle. (Marion.)]
=Neuro-anastomosis for Facial Palsy.=--In view of the hopelessness
of facial paralysis, when resulting from destructive injuries to
the nerve trunk, the introduction of anastomotic methods has marked
a very distinct advance. Ballance, in 1895, was the first to apply
neuro-anastomotic methods to the facial nerve. He attached the
facial to the spinal accessory. His own experience, as well as that
of half-a-dozen later operators, proved that nerve regeneration is
possible, but that in this particular instance voluntary movements of
the face were often accompanied by distressing and unsightly associated
movements of the shoulder, and _vice versa_. Hence, Taylor and others
suggested the use of the hypoglossal instead of the spinal accessory,
the former being a purely motor nerve running near the facial,
intimately associated with it in function, and arising by nuclei, which
are equally closely associated in the cranial centres. The operation
is indicated in all cases of paralysis caused by lesion of the nucleus
within the brain, or the nerve trunk at the base of the brain, or along
its course. It is justifiable in Bell’s palsy, when there is complete
reaction of degeneration in the facial nerve after several months of
treatment (Fig. 402).
The steps of the operation are practically as follows: Incision is made
along the anterior margin of the mastoid and the sternomastoid muscle,
and the parotid gland is retracted forward and the posterior belly
of the digastric is exposed. It should then be pulled downward and
backward and divided if necessary. The styloid process is identified,
and the facial nerve which emerges from the stylomastoid foramen near
its base is then sought and isolated. It should be separated as high as
possible and divided close to its exit, so that one-half inch of its
free trunk may be secured before it enters the gland. Two fine silk
sutures are then passed, one on either side, through the peripheral end
of its sheath and tied, the ends remaining long, to be subsequently
used. This nerve end should be trimmed to a wedge shape. Next the
transverse process of the atlas is identified and the deep cervical
fascia divided. This will expose the internal jugular, which should be
separated and held out of the way. There will now be seen the spinal
accessory nerve, which runs obliquely downward and outward, sometimes
in front of and sometimes behind the jugular (Fig. 403). When the vein
is held forward and the fascia well retracted both the hypoglossal
(Fig. 404) and the pneumogastric nerves are seen, with the internal
carotid to their inner sides. The former may be identified either by
the electric current, which will cause contractions in the muscles
supplied by it, or it may be followed down to where it turns forward
around the occipital artery and gives off the descendens noni. Here it
should be separated until its trunk is sufficiently free, so that the
facial stump can be inserted into it without tension. The nerve being
elevated by a hook a slit is made in it, about ³⁄₄ inch long. Into this
the wedge-shaped end of the facial trunk is introduced, and held there
by utilizing the sutures which have already been passed through its
sheath. When the nerve is thus firmly held in the cleft, with its end
turned toward the direction of nerve supply, a little cargile membrane
may be wrapped around the junction and the wound closed.[46]
[46] Taylor and Clark, New York Medical Record, February 27, 1904, p.
321.
Nerve regeneration has been known to follow this procedure in a number
of cases, and it has given encouraging results. Considerable time,
however, is required, and the patients should be warned that results
are not to be quickly expected.
[Illustration: FIG. 403
Exposure required for anastomosis of facial and spinal accessory
nerves: _a_, facial nerve; _b_, sp. acces.; _c_, int. jug.; _d_,
digastric muscle; _e_, atlas, trans. proc. (Marion.)]
[Illustration: FIG. 404
Exposure required for anastomosis of facial and hypoglossal nerves:
_a_, facial nerve; _b_, sternomastoid; _c_, digastric; _d_, parotid;
_e_, hypoglossal. (Marion.)]
=The Spinal Accessory Nerve.=--The principal reason for attack
upon this nerve is spasmodic torticollis, or _wryneck_. It is
exposed through an incision along the anterior border of the
sternocleidomastoid muscle, extending two inches downward from the ear.
The nerve is found a little above the level of the hyoid bone; or,
again, it may be found by an incision along the outer border of the
muscle, opposite its centre, just above which it will be detected (Fig.
405).
=The Deep Posterior Cervical Plexus.=--When operation upon the spinal
accessory has failed to relieve long-standing and serious spasmodic
torticollis, Keen has suggested to divide the first, second, and third
cervical nerves. The operation is difficult and not always successful;
still it is worth trying. A transverse incision is made below the level
of the lobe of the ear, the trapezius being divided and dissected up
until the great occipital nerve is found. It is followed after the
necessary division of the complexus until its origin from the posterior
division is reached. The suboccipital or first cervical nerve, which
lies in the triangle close to the occiput that is formed by the two
oblique muscles and the posterior rectus, is excised. The exterior
branch of the posterior division is found lower down, and should be
divided close to the bifurcation of the main nerve (Fig. 406).
[Illustration: FIG. 405
Exposure of the spinal accessory nerve alone: _a_, digastric; _b_,
jugular veins; _c_, sternomastoid muscle; _d_, spinal accessory.
(Marion.)]
[Illustration: FIG. 406
Incisions through which the various nerves in the neck may be sought:
_a_, facial; _b_, facial and hypoglossal; _c_, facial and sp. acces.;
_d_, spinal accessory; _e_, cervical plexus; _f_, brachial plexus.
(Marion.)]
=The Cervical Sympathetic.=--The cervical sympathetic is a most
complicated nerve trunk, furnishing fibers of various functions
to the skin, and to the deeper parts fibers which are vasomotor,
vaso-inhibitory, pilomotor, and secretory in function. It supplies
the various glands, the upper viscera, the heart and bloodvessels,
and connects with nerves below, which supply even the genital organs
and the non-striped muscles of the body. The upper part has a very
important oculopupillary function, as it supplies the dilator pupillæ,
the non-striped part of the elevator of the upper lid, and the orbital
muscle of Müller, _i. e._, a small bundle of non-striped muscle which
lies behind the globe and projects across the sphenomaxillary fissure
at the back of the orbit. (By contraction of this muscle the eye may
be pushed forward.) It also supplies the submaxillary gland, the
cutaneous bloodvessels, and the sweat glands of the head and neck.
The pupil dilating fibers arise in the medulla, run backward in the
lateral columns of the cord to the ciliospinal centre, emerge through
the anterior roots of the first and second dorsal segments, and enter
the inferior cervical ganglion, thence passing upward through the
sympathetic trunk to the orbit. Therefore ocular and other symptoms are
produced not only by lesions of the external trunk, but also by lesions
within the cord at the level of the upper dorsal segments. These nerves
may be injured anywhere in the neck, or compressed by inflammatory
deposits or new-growths, or even by cicatricial tissue at the apex
of a tuberculous lung. Many cases of phthisis show inequality of the
pupils. One nerve may be injured in operations on the neck, the result
being slight drooping of the lid and flushing of the face, as well as
excessive perspiration on the injured side; the corresponding pupil
being smaller than the other because of paralysis of the dilators, but
contracting to light, as the third cranial nerve which supplies its
sphincter is unaffected. The eye will then sink back somewhat, owing to
paralysis of Müller’s muscle, and thus permit a nearer closure of the
lids. These oculopupillary symptoms are pathognomonic of paralysis of
the cervical sympathetic. Cocaine will not dilate a pupil whose dilator
has thus been paralyzed. The area of skin supplied with sweat fibers by
the cervical sympathetic includes the corresponding side of the head,
neck, shoulder, and upper part of the trunk (Fig. 407).
When the cervical sympathetic is unduly stimulated we have dilatation
of the pupil, exophthalmos, widening of the palpebral aperture, delayed
descent of the upper lid when the patient looks downward, all of which
can be imitated or produced by dropping into the eye a solution of
cocaine, which stimulates the nerve.[47]
[47] Stewart, Some Affections of the Cervical Sympathetic, The
Practitioner, February, 1905.
The surgical sympathetic is attacked surgically for three widely
variant conditions: _epilepsy_, _glaucoma_, and _exophthalmic
goitre_--the first, because of its vasomotor control of the vascular
supply of the brain; the second, because of the relation of the nerve
to the orbital circulation and nutrition; and third, because of its
relations to the thyroid and the heart. In the latter case it is
especially desirable to remove the lower cervical ganglion and the
first dorsal, if it can be reached, although the procedure here is
exceedingly difficult.
The tachycardia of Graves’ disease is due apparently to irritation of
the accelerator nerves of the heart, which come from the sympathetic,
or else to paralysis of the regulator (pneumogastric) supply. The
former spring from the lower part of the cervical cord and the upper
dorsal segments, and pass to the third cervical ganglia and to the
first dorsal, terminating in the cardiac plexus.
The operation described below is practically that advised by Jonnesco,
more or less modified by other operators, and may be varied to some
extent to meet the exigencies of particular cases. Thus whether it
shall be done through one or two incisions will depend on the will of
the operator. It is made about as follows: A long incision is made
along the posterior border of the sternomastoid. The latter may be
either retracted forward or its fibers separated, in order that the
fascia on its inner side may be reached and separated from the deeper
muscles. This fascia should be divided as high as the base of the
skull. The upper ganglion of the cervical sympathetic lies on the
inner side of the anterior tubercle of the transverse process of the
second and third vertebral processes, resting upon the muscles covered
by this fascia. The ganglion, being recognized by its shape, and the
sympathetic trunk being thus identified, the nerve should be divided
and made free, as high as possible and just beneath the base of the
skull. (See Fig. 408.)
[Illustration: FIG. 407
Diagram to illustrate the relations of the cervical sympathetic and the
mechanism of the various disturbances following lesions of its trunk.
(Stewart.)]
The lower end is to be exposed by continuation of the first incision,
or by another beginning 1 Cm. above the clavicle and extending along
the posterior border of the sternomastoid for 4 or 5 Cm. The platysma
should be entered and the tissues separated upward until the fingers
can meet in a channel thus made by connection with the upper incision.
The tissues should also be loosened downward until a point has been
reached behind the clavicle. They then should be widely retracted and
the inferior thyroid artery sought. The middle cervical ganglion is
found inside of its curve. Occasionally this ganglion is replaced by a
plexus, or the main trunk may pass behind the artery. At this level it
is to be seized and its upper divided end pulled down and out through
this opening. The nerve trunk should then be followed downward. The
artery should be freed from any plexus of sympathetic fibers around
it, all of which should be destroyed, and especially those fibers which
constitute the middle cardiac nerve, which pass to the inner side. The
main trunk is to be drawn down beneath the artery and then followed
downward and outward to the lower ganglion, where it lies behind the
clavicle, on the neck of the first rib, between the scalenus anticus
and the longus colli. The ganglion and the trunk should be separated
from the efferent and afferent branches which connect with it, as well
as from the vertebral artery; being thus made free it is again drawn
outward. Here one should divide especially the cardiac branches which
form the lower cardiac nerve, as well as the vertebral branches which
have so much to do with controlling the supply through the vertebral
artery. The ganglion, after being identified, should be finally
removed. The nerve should be traced still farther down to the first
thoracic ganglion, which has much to do with supplying the heart, and
this also should be separated and destroyed (Fig. 409).
[Illustration: FIG. 408
Sympathectomy. Exposure and removal of middle and upper ganglia.
(Marion.)]
[Illustration: FIG. 409
Sympathectomy. Seizure and removal of inferior ganglion. (Marion.)]
It is rarely necessary to provide for drainage after the operation,
unless the retraction and laceration of tissues have been very great.
My own preference is to make one long incision along the posterior
border of the sternomastoid, by which the dissection is facilitated
and the operation made less complicated and difficult. When done for
glaucoma on one side it will be sufficient to attack one nerve, but
when for epilepsy or for exophthalmic goitre the operation should be
bilateral. When for epilepsy or glaucoma it is not so necessary to
remove the lower cervical ganglion; this is indicated rather in those
cases where it is desirable to control the accelerator nerves to the
heart. The operation has given good results in all three affections
named, yet it is one of considerable difficulty. It would be made
extremely difficult by the presence of a large goitre, and in such case
it would probably be better to extirpate the thyroid rather than to
attack the nerve. (See Glaucoma, Epilepsy, and Exophthalmic Goitre.)
CHAPTER XXXVIII.
THE SPINE, THE SPINAL CORD, AND THE PERIPHERAL NERVES.
SYRINGOMYELIA.
The term _syringomyelia_ implies irregular dilatation of the central
canal of the spinal cord, having a congenital origin, tending to
relative increase later in life, with corresponding disturbance of
function, the latter including paresthesiæ, loss of sensibility to heat
and cold, more or less motor impairment and disturbances of nutrition,
more noticeable in the region of the joints than elsewhere, the latter
having been already considered in the chapter on the Joints. The
dilatation is by no means regular, may occur in various regions of the
cord, and attain a size permitting encroachment upon, and even atrophy
of, the structures of the cord itself. When functional disturbance,
especially paralytic, has become very pronounced a few surgeons have
ventured to expose the cord by a laminectomy, and endeavored to make a
more or less permanent opening with drainage of the dural cavity. Thus
Keen has operated twice, Abbe once, and Munro three times, including
twice on the same patient. Only in this last instance was any permanent
relief obtained, and this was at the expense of a second operation. It
is doubtful if any of the peculiar joint lesions of this disease will
be in any way affected by operation for this purpose.
TUMORS OF THE SPINAL CORD.
Tumors of the spinal cord may be classified as follows (Krauss):
1. Tumors springing primarily from the envelopes of the cord: (_a_)
Tumors of the vertebral column, and (_b_) tumors of the meninges, the
latter including those arising from the external surface of the dura,
or from the periosteum of the spinal canal, _i. e._, extradural tumors,
and those from the inner surface of the dura and the other membranes,
that is, intradural tumors.
2. Tumors developing in the cord proper, intramedullary. These are
generally gliomas and do not present so much the symptoms of cord
tumors as of syringomyelia.
Vertebral tumors may be carcinoma (secondary), endothelioma, sarcoma,
osteosarcoma, as well as the non-malignant and cartilaginous or osseous
tumors, and parasitic cysts, _i. e._, echinococcus. The sarcomas are
the most common of all.
=Symptoms.=--The symptoms of tumor of the spinal cord depend upon
the part involved and differ according as it involves the cervical,
thoracic, or lumbar portions or the cauda equina. They are to be
classed as _root symptoms_ and _cord symptoms_. _Root symptoms_ include
pain, paresthesia, and hyperesthesia. The pain is usually persistent,
burning, and severe, affecting one side or the other, if the tumor
be laterally placed, or both sides if central. The pain follows
the distribution of the spinal roots rather than the course of the
intercostal nerves, _i. e._, is more horizontal and less oblique. These
pains persist and have the characteristic feature of not presenting
painful points on pressure. They are commonly referred to the abdomen,
and may thus give rise to serious mistakes in diagnosis, _e. g._, they
have been regarded as due to hepatic colic, dry pleurisy, appendicitis,
etc. Pain may assume the girdle character, which is usually accentuated
by movement, and is frequently accompanied by herpes zoster. The
greater the involvement of the posterior roots the more painful the
condition. When the anterior sensory roots are involved pain may be
wanting and the disturbance assume a type of paresthesia, with final
anesthesia, in which case the patient would at first complain of
numbness and prickling sensations. There is sometimes noted a zone
of hyperesthesia on the proximal side of the anesthetic area, or
this zone, if not hyperesthetic, may be replaced by a condition of
uncertainty of sensation.
The _cord symptoms_ are the reliable ones, varying according to the
segment involved. The portions of the cord where lesions can be best
localized are, for instance, the third to the fifth cervical, including
the origin of the phrenic nerve; the fifth to the seventh cervical,
where the posterior thoracic nerve comes off; the seventh to the eighth
cervical and first thoracic segments, where originate the dilator
nerves of the pupil. The upper border of the anesthetic area points to
a lesion of the next or second higher spinal segment than the level
really represents. The lowest level of the lesion corresponds to the
highest level of the sensory disturbance. The level of the segment
area of the skin of the back does not correspond to the level of the
spinal segment involved, the latter being higher up. The point of
greatest sensitiveness over the spine is in many cases a good guide
to the segment involved, but is applicable only where the lesion is
posteriorly placed. The absence of pain or tenderness along the spine
means little or nothing, but their presence has great significance.
=Diagnosis.=--The diagnosis of a cord tumor covers, according to
Krauss, a first or subjective period, indicative of irritation along
the posterior roots, and is characterized by pain and paresthesia.
This is followed in time by a second or objective period which points
to invasion of the spinal cord, characterized mainly by weakness and
later by paralysis, with disturbed tendon reflexes. Diagnosis early
is extremely difficult, for pain and disturbances of sensation are
produced in many ways.
=Treatment.=--The treatment of spinal-cord tumors is purely surgical
and should be instituted promptly so soon as diagnosis has been made.
Only in tumors of syphilitic origin will internal treatment be of any
avail. The therapeutic test having been made, should it seem wise,
and proved futile, the case should be regarded at once as surgical.
According to Krauss’ statistics nearly 40 per cent. of all operated
cases have resulted in recovery, while in 35 cases of sarcoma 8 have
resulted in recovery and 6 in improvement. This is really a more
gratifying statement than can be made with regard to brain tumors, and
should be regarded as lending encouragement to surgical procedure.
The operative details will be discussed later in this chapter.
THE PERIPHERAL NERVES.
The remarks made concerning the surgical affections of and operations
upon nerves contained in the previous chapter, pertaining to the
cranial nerves, will apply equally well to the peripheral nervous
system.
_Constant pressure_ as well as contusions of nerves will cause more
or less paralysis. The surgeon occasionally sees manifestations of
this kind in the so-called “crutch paralysis,” due to pressure upon
the brachial plexus by the use of crutches, and in another form so
generally associated with administration of an anesthetic as to be
called “ether paralysis.” It is another form of pressure paralysis due
to indifference in letting the arm, for instance, hang over the edge of
an operating table during anesthesia or operation. It does not call for
operation so much as for electricity, massage, and similar measures.
Extreme consequences of nerve and vessel injury are portrayed in Fig.
410.
_Tumors of nerves_ are both benign and malignant, the former assuming
the fibromatous type oftener than any other, and frequently involving
more than one nerve trunk, attaining also considerable size and
impairing or destroying function by pressure. In addition to the
true fibroma of nerve sheaths we have the peculiar type of _fibromas
of nerve stumps_ seen after amputations, and the multiple neuromas,
again largely of the fibromatous type, which involve many and in
rare instances nearly all the peripheral nerves. Cases are on record
where as many as 1600 small and large tumors have been found, strung
like beads upon wires, along all the peripheral nerves throughout
the body. Another variety of fibromas of nerves involves those of
the skin and produces small _painful subcutaneous nodules_, although
these may attain a considerable size. Within the past few years there
has been a much better familiarity with that form of growth known as
_plexiform neuroma_, in which entire nerve trunks are involved, so
that they become elongated, thickened, and tortuous, and resemble a
varicose condition of the veins. The plexiform neuromas are found in
any part of the body; they produce little or no pain, but lead to
disturbances of function, as well as to peculiar irregular swellings
that may be mistaken for lymphangioma, and which are often accompanied
by pigmentation of and growth of hair upon the overlying skin. (See
chapter on Tumors.)
For the various purposes already mentioned different nerve trunks and
plexuses are made accessible for operation by the following methods.
=The Brachial Plexus.=--The brachial plexus is reached through an
incision similar to that for ligation of the subclavian artery. After
opening the deep fascia the nerves are sought and found behind the
subclavian vein and lying around the artery. This plexus is stretched
especially for the relief of choreiform spasm or painful nervous
affections. The various nerves of the upper extremity, after leaving
the brachial plexus, are made accessible to operations for grafting or
suture as below. (See Fig 406.)
=The Median Nerve.=--The median nerve lies in front of the brachial
artery and is exposed through an incision as if the artery were to
be tied in its course. It may also be found on the inner side of the
tendon of the palmaris longus, where it lies beneath the deep fascia.
=The Ulnar Nerve.=--The ulnar nerve is reached through practically the
same incision as the median, when it is sought in the middle of the
arm, but is farther back. It lies near the surface, just behind the
inner condyle, between it and the olecranon, and at the wrist it is on
the radial side of the tendon of the flexor carpi ulnaris.
[Illustration: FIG. 410
Gangrene (mummification) of arm resulting from injury to nerves and
vessels. (Preindlsberger.)]
=The Musculospiral Nerve.=--The musculospiral nerve is found between
the heads of the triceps, where it lies in the groove which winds
obliquely around the humerus.
=The Radial Nerve.=--The radial nerve lies to the outer side of the
radial artery, three inches above the wrist. Should any of the nerves
of the arm or forearm have been cut by an accident which has produced
an incised wound they should be sought for in the wound if fresh, and
in the neighborhood of the scar if older, and should be reunited by
suture, as already described.
=The Great Sciatic Nerve.=--In the lower extremity it is the great
sciatic nerve which is usually made the subject of operation. An
incision midway between the great trochanter and the tuberosity of the
ischium, by which the lower border of the gluteus muscle is exposed,
will enable the surgeon to identify the biceps, to divide the deep
fascia, and find the sciatic nerve at the outer border of the muscle.
It is sought for the purpose of nerve stretching, and it may be pulled
completely out of the wound, while the entire weight of the limb may be
suspended by it.
=The Tibial Nerve.=--The tibial nerves may be exposed through incisions
identical with those indicated for ligation of the tibial arteries.
=The Anterior Crural Nerve.=--The anterior crural nerve lies in
Scarpa’s triangle, near Poupart’s ligament, on the outer side of the
femoral artery.
Tetanus should be treated by injecting antitoxin into the main nerve
trunks, as well as into the spinal canal. The individual nerve trunks
of the brachial plexus may be exposed in the upper arm, where the point
of the hypodermic syringe needle may be inserted into their substance.
The same expedient may be employed with the sciatic or anterior crural
trunks, through the incisions just described. The same measures may be
used in cocainizing the nerve trunks, as suggested by Crile and others,
and described in the chapter on Alterations of Blood Pressure (p. 181).
Abbe has suggested to treat certain cases of inveterate neuralgia of
the peripheral nerves by an intraspinal division of the posterior nerve
roots.
There has been added to the standard operations on nerves another
measure. This consists of _grafting_ by means of foreign material;
using a section of nerve trunk removed freshly from some animal,
or inserting catgut loops between nerve ends which shall serve as
trellises upon which the growing nerve tissue may arrange itself.
Powers, of Denver, has, for instance, reported the implantation of four
inches of the great sciatic nerve of a dog into the external popliteal
of a man. The results seemed to be good so far as sensation was
concerned, but negative as regards motion. Probably no method of nerve
grafting will give so good results as the utilization of a part of the
nerve itself to be operated upon, by partially detaching and turning
back a portion of its central end and uniting it to a similar flap
made from the other end. Various operators have made use of different
materials for the purpose of forming a tube around the nerve ends, and
thus excluding other tissues. For this purpose cargile membrane is
perhaps as serviceable as any. When all other measures fail the method
by long catgut sutures may be adopted.
DISLOCATION OF NERVES.
A few of the nerve trunks may be displaced by injury in such a way
that they are liable to subsequent redislocation. The condition is
recognized by the mobility of the nerve trunk under the skin, by
peculiar sensations when the trunk is irritated, and often by tingling
sensations referred to its distribution. The condition is most common
in connection with the ulnar nerve, just behind the inner condyle.
Should nothing else give relief the trunk should be cut down upon and
retained in place by suture or by fixation of other structures around
it.
WOUNDS OF THE SPINE AND CORD.
=Penetrating Wounds.=--Penetrating wounds of the spine occur both
in military and in civil practice. Sometimes the vertebræ alone are
injured; occasionally the spinal canal will be opened, with little
injury to the bone, only the cartilage suffering. All such injuries are
serious in proportion as the cord itself may be injured. Such injuries
may be direct or indirect. Should a large vessel have been divided the
cord may suffer from pressure of clot, and should this injury occur
high in the spine, death may be caused by pressure. The severity of
such an injury is generally estimated by phenomena pertaining to the
nerve supply of parts below the wound. Should anything indicate partial
or complete division of the cord, or that a single nerve trunk has been
divided, then an operation is indicated for relief of symptoms, and for
nerve or cord suture except in those instances where destruction seems
to be too complete to warrant it.
=Gunshot Injuries.=--Gunshot injuries vary from small punctures and
penetrating wounds to extensive laceration. The lower the injury the
lower the mortality, other things being equal. Such injury to the
cervical region generally proves quickly fatal. The symptoms here are
not essentially different, save that the bullet may have done still
more harm by passing beyond the cord, and that to the signs of a
penetrating wound may be added those of a traumatic hemothorax or some
other serious complication. It is necessary to distinguish between
mere stiffness of the back and disinclination to use certain groups
of muscles and absolute loss of motility. The former may indicate
contusion and the latter severance or pressure. After some perforations
cerebrospinal fluid will escape. In one instance I opened a spinal
canal for perforating gunshot wound with complete paralysis, and found
not only that the bullet had divided the cord but had passed through
the vertebra into the lung beyond. A very curious phenomenon presented
in this case is that when the passage was well opened air passed
backward and forward through the spinal wound, the patient thus partly
breathing through his back.
[Illustration: PLATE XLVI
Intraspinal Hemorrhage, mostly Subdural, with Minute Subpial
Ecchymoses.]
The effect of _pressure from hemorrhage_ is practically the same
whether it be intradural or extradural, or occurring within the
structure of the cord itself. The presence of blood in the spinal
canal is known as _hematorrhachis_, and when occurring within the cord
itself is termed _hematomyelia_. The typical symptoms of sensory and
motor paralysis, which serious pressure upon the cord always produces,
occur when produced by mere presence of fluid more slowly than when due
to the introduction of a foreign body or to comminution of the bone.
Diagnosis is then much facilitated if by the personal history it can be
learned that there was an interval after the reception of the injury
and before the occurrence of paralysis, during which the patient had
reasonable use of the parts later paralyzed. This interval may be one
of but a few minutes’ duration or may have extended over several hours.
When, on the other hand, such an interval lasting several days has
been noted, then the intraspinal lesion must be either one of acute
degeneration or of suppurative character. (See Plate XLVI.)
The question of _operation in spinal hemorrhages_ will frequently be
raised, and is to be decided in part by the intensity of the symptoms
and in part by the character of the injury. Incomplete paralysis would
indicate a lesser degree of pressure and justify a hope that the
outpoured blood may be resorbed. This hope may be further encouraged
should symptoms improve. On the other hand symptoms of complete
paralysis, indicating serious and extensive pressure upon the cord,
would justify a laminectomy, and make it even more encouraging than
though it were done for a crushing injury. The more serious cases,
then, of spinal hemorrhage would seem to justify exploration.
Until very recently it has been held that a complete cross-division of
the spinal cord must necessarily be followed by a hopeless paralytic
condition, plus the changes due to ascending degeneration of the
upper segment. The results of laboratory experiments have made this
quite plain, and therefore it was a startling innovation in surgery
when Harte could report an experience contradicting all that we had
learned to believe in this regard. In spite, then, of the fact that
experimental suture of the cord after its division had not been
successful in animals we are now confronted by three more or less
successful cases reported by American surgeons, Estes, Harte, and
Fowler, where the spinal cord was sutured after division, with at least
partial recovery of function. In Harte’s case the operation was done
three hours after injury; in Fowler’s case ten days had elapsed. Fowler
used chromicized catgut sutures in the cord itself, with separate
sutures of the dura with the same material, the principle here being
the same as in nerve suture, and the effort being to do as little harm
as possible with the needle and the suture material. After a simple
division there is but little tension, and the ends of the cord are
easily approximated.
It has thus been proved that there is at least some possibility of
regeneration of the cord after such destructive lesions; but the cases
which permit of or justify this measure will be rare, although it is
gratifying to learn that there has been so much encouragement afforded
by experiences reported.
THE SPINAL COLUMN.
SPINA BIFIDA; SPINAL MENINGOCELE.
Spina bifida is the result of a congenital defect in the construction
of the spine with incomplete closure of the spinal canal. The defect
lies in the posterior arches of the vertebræ; the bodies are rarely
involved. For this reason these lesions are centrally placed, _i.
e._, in the middle line. The essential feature of a spina bifida is
protrusion of the spinal membranes, and they are, to all intents and
purposes, spinal meningoceles. These tumors sometimes have only the
thinnest of skin coverings; at other times they will be covered by
considerable masses of overlying fat or fibrous tissue.
These congenital tumors when more definitely described should be
classified as--
1. _Meningocele_, where there is simply a protrusion (hernia) of the
dura, which may be lined with some branches of the vertebral nerves;
2. _Meningomyelocele_, where some portion of the spinal cord proper is
included within the sac;
3. _Syringomyelocele_, where the central canal of the cord is dilated
into a cyst of some size, over which the structures of the cord proper
are more or less thinly spread out, the whole being covered with the
spinal dura.
The first form is by far the simplest and most amenable to treatment.
The other forms are much more serious, and the third form is hopeless
so far as operative surgery is concerned.
The greater proportion of these cases occur in the lumbar region, at
least 70 per cent. being met with in the lower region of the spine,
including the sacrum. It occurs occasionally in the neck and in the
mid-dorsal region.
Fig. 411 illustrates the general appearance of such a tumor. The
opening of communication may be very small or may involve the arches of
several vertebræ. So with the tumor itself, it may be small and almost
imperceptible, or it may attain almost the size of a child’s head. The
overlying skin is rarely absent; it is usually covered with a growth of
hair, and its presence in the region of the spinous processes, coupled
with the presence of any perceptible tumor, should cause suspicions of
the so-called _spina bifida occulta_.
[Illustration: FIG. 411
Spina bifida. (Bradford.)]
These tumors are situated in the middle line or very near to it, and
are compressible in proportion to the thinness of their coverings. When
small they can be collapsed by pressure, the same not infrequently
causing pressure symptoms, as the fluid is forced into the cranial
cavity, such as coughing, vomiting, vertigo, etc. If the fluid can
be easily expressed from the sac the opening may be regarded as
relatively large. If pressure makes no alteration in the size of
the growth the case should then be regarded as one where the small
original communication has been closed by natural processes. Some of
these tumors have more or less of a pedicle and others are broadly
sessile. The tendency is ever toward increase in size, being rapid or
slow according to the thickness of the protecting membranes and the
size of the opening. While spontaneous occlusion may occur there is
practically no spontaneous repair of the bony defect. _The surgeon
should beware of a tumor of congenital origin situated in or near
the middle line, anywhere from the root of the nose, over the head,
and down to the tip of the coccyx._ Such a tumor should be regarded
with suspicion until shown to be harmless. Many cases of spina bifida
are accompanied by other congenital defects, such as club-foot, or
hydrocephalus. Symptoms may or may not be present. When present they
will be of the paralytic type and affect those parts of the body below
the level of the growth. They are due to the involvement of the cord or
the nerves. The ever-present danger in such cases is of rupture with
escape of the contents, with its proportionate reduction of intraspinal
pressure, and the possibilities of infection, with rapid death from
meningitis. Inasmuch as some of these cysts have such thin walls that
transillumination is possible it will be seen how great may be this
danger.
=Treatment.=--Treatment should be made to meet the indications. Only
in cases which are deemed inoperable should some protection be relied
upon and worn. This may be afforded by a common surgical dressing or
by means of a plaster-of-Paris or waxed gauze. A molded shield may
be prepared and so arranged upon a band or girdle as to protect the
cyst from external harm. Efforts to reduce the size of the tumor by
pressure are futile and useless. The skin may be protected by covering
with collodion.
The _radical treatment_ of spina bifida should only be attempted
in favorable cases, but in such instances can be made exceedingly
satisfactory and successful. A tumor with a small pedicle may be
treated by ligation, the skin being divided by elliptical incisions,
the pedicle proper being surrounded by a chromicized or silk suture
and the sac then excised. When the pedicle is too large to be treated
in this way and yet not very large, it may be closed by sutures after
removal of the sac, and dropped downward into the spinal opening, and
the adjoining tissues made to close over it by buried and superficial
sutures. It is the larger and more sessile sacs which give rise to the
greatest difficulties. The attempt may be made to excise a greater
portion of the sac, to fold in its edges and to approximate these
with sutures of fine chromic catgut. The fold thus formed may be laid
downward and upon the spinal groove, the aponeurotic and other firm
fibrous tissues in the neighborhood being loosened sufficiently so that
they may be brought together by buried sutures, and the balance of the
wound closed. I have a number of times been able to introduce either
strips of metal foil or thin pieces of celluloid, or, better still,
ivory trimmed to fit the bony defect, and so arranged as to be sprung
into grooves made on either side of the osseous canal. If ivory be used
for this purpose the thin small sheets which are used by miniature
painters should be procured.
Such operations should be made at the earliest practical moment; in
infants especially, but probably with all young patients, the head
being maintained at a much lower level than the sacrum in order that
only the smallest quantity possible of the cerebrospinal fluid may
escape. I have also used a small amount of weak cocaine solution after
exposing the cord in the spinal canal, in order that reflex impressions
may be avoided so far as possible and shock thus prevented. With a
young patient the amount of cocaine to be thus used should not exceed
more than 2 or 3 Mg.
Osteoplastic methods have also been devised for the purpose and may be
practised in cases permitting them.
Many of these cases do not come to operation until the skin is
excoriated or ulcerated. It is exceedingly difficult under these
circumstances to make an aseptic operation. The subsequent difficulties
of maintaining asepsis should also be foreseen, especially when lesions
are located low in the spine and in little patients, as soiling from
diapers and discharges is so easy. After such operations oiled silk,
or gutta-percha tissue should be fastened around the pelvis by rubber
cement, in such a way as to make a water-tight covering for the deep
surgical dressings, and this line of junction should be scrutinized
frequently. These operations often give satisfactory results.
CYSTS AND COCCYGEAL TUMORS.
Many congenital tumors are met with about the region of the sacrum
and coccyx, some of which have the essential characteristics of
meningocele, while others are rather of the dermoid or embryonal
variety. Tumors of great size develop from the region of the coccyx,
and many are of interest to the pathologist.
True dermoids often begin to develop within the pelvis and then escape
therefrom in this vicinity, some of them containing soft epithelial
products, others being dense and hard. (See Figs. 72 and 73, p. 266.)
[Illustration: FIG. 412
Sacral cyst, showing defect in sacrum. (Warren Museum.)]
Every tumor of this general character and in this location should be
removed as early as possible unless it can be determined that it is
not only cystic but dangerously large. Of even these, however, it may
be said that to leave them is to expose the patient to more danger of
infection than is incurred during a legitimate surgical operation.
There should be, then, about such a case serious complications and
perplexities, which would tend to make a competent surgeon decline to
operate (Fig. 412).
SPRAIN OF THE SPINAL COLUMN.
=Concussion of the Spine; Railroad Spine; Litigation Spine.=--In 1866
Erichsen published a series of lectures dealing with “Certain obscure
injuries of the nervous system commonly met with as the result of
shock received in collisions on railways.” In 1875 he expanded these
lectures into his celebrated monograph on _Concussion of the Spine_, a
work which served first to arouse the greatest interest in a hitherto
neglected subject, and which has unfortunately served in later years as
a basis for many a damage suit. The injuries described by him may occur
as the result of railway accidents, hence the name often applied to the
condition which they cause--_railway spine_. Cynical observers have
noted the frequency with which these cases appear in court and have
stigmatized the condition with the name _litigation spine_. Erichsen’s
original work is now superseded by much better monographs, although
his clinical descriptions were full and complete. Nevertheless he had
no knowledge of minute changes in the nervous system and many of his
explanations were based upon theories then prevalent but now abandoned.
These injuries involve the spine as a whole, and the spinal column
is so firmly held together by powerful ligaments, and so abundantly
protected by muscular and aponeurotic coverings, that its contents
are exempt from injuries which would easily involve those of more
exposed joints. An injury which would cause serious disintegration
within the spinal cord must be so severe as to inflict other and
well-marked damage upon the surrounding structures. Consequently a
large part of the injury received consists in what may well be called
strain and wrenching of all of these component structures. These may
be accompanied by minute hemorrhages into the cord, with or without
laceration, while exudates may result therefrom which may press upon
the spinal nerve roots or cause adhesions within or without their
sheaths, all of which may lead to signs and symptoms which may persist
for a long time. But the theory to which too many have held in time
past, that a mere concussion of these parts, without other injuries,
can be followed by such extensive and durable lesions is not tenable.
Obviously these cases are of a character frequently to appear in court.
Unfortunately the signs and symptoms are so vague, so variable, and
the latter so subjective that opportunity is afforded for deception,
_opportunity of which both dishonest patients and dishonest lawyers
too frequently avail themselves_; this to an extent which has almost
brought the condition into disrepute among the better class of
practitioners and caused it to be in some sense neglected. That serious
lesions do follow injuries to the back is undeniable; that many of the
resulting conditions can be simulated is unfortunately too true.
Nervous demoralization and more or less chronic invalidism frequently
follow these injuries, producing symptoms which are mainly functional
and maybe grouped among the _traumatic neuroses_. These symptoms are
mostly ill-defined, often contradictory, and accompanied by very few
objective features.
If _malingering_ can be excluded the best way to regard these clinical
pictures is to consider them as indicating a _traumatic neurosis_--that
is, a nervous disturbance, with perversion rather than abolition
of function, comparable with similar conditions from other causes.
As Angell has said, its symptomatology is largely built up of the
emotional features, with such grotesque nervous disturbances as to be
quite inconsistent with any true organic malady. In the latter there
will always be definite indications with positive changes and normal
reactions, while each segment of the spinal cord will have its own
definite features. Quite the reverse is the case in a so-called railway
spine, where paralyses are incomplete, where loss of sensibility
fails to correspond with anatomical relations, where the reflexes are
contradictory and the complaints out of all proportion to the injury
received. Such a condition is, therefore, a psychosis or neurosis
rather than a somatic disease. (Angell.) As a mental perversion it
is often dependent upon the dominating influence of an imperative
conception, which may or may not have an honest basis. Even if a
patient be not tempted to malinger or simulate, his troubles may be
exaggerated by expectant attention, which of itself has nothing to
do with the injury, but rather with his mental attitude. This is a
predominant feature of those cases which go to trial, and while it may
persist after a settlement is reached, it should be admitted that the
morbid condition usually subsides when litigation is terminated.
These imperative conceptions are intensified by emotion, fear,
sympathy, or anxiety, while attention becomes more and more
self-centred, the condition finally terminating in a more or less
self-induced hypnotic state--a species of autosuggestion. Similar cases
of non-traumatic origin are frequently observed, which are then called
neurasthenia or hysteria. When in an individual already neurasthenic
injury occurs it almost invariably produces exaggerated symptoms.
To use Angell’s own expression: “Railway spine is a convenient and
picturesque term which hypnotizes juries, even as shock has hypnotized
patients. It is dramatic, but not accurate. The damage is not to the
spine nor to the spinal cord, but to the mind. It is a psychical
disorder, not a physical one, although it has a physical expression in
its symptomatology.”
=Treatment.=--Viewed in this light it will be seen that there is the
greatest value attaching to physiological rest, beginning immediately
after the injury and continuing until the subsidence of the symptoms.
This should be combined with measures which improve elimination and
nutrition. Confinement to bed or the room will reduce elimination,
which should never be allowed to decrease in any way. Bodily and mental
rest, combined with the above features, followed later by massage,
cold spinal douche, electricity (either for its actual or suggestive
value), and mental encouragement, constitute the principal methods of
treatment. A case of this kind tinctured by a hope of securement of
ultimate damages will be not only resistant but difficult of successful
treatment.
INJURIES TO THE SPINE.
The principal injuries to the spine proper to be considered here
consist of:
1. Fractures;
2. Dislocations, or their occurrence together;
3. Injuries to the cord and spinal column;
4. Rupture or injury of the muscles, ligaments, and aponeuroses.
FRACTURES OF THE SPINE.
[Illustration: FIG. 413
Fracture of body of the vertebra. (Warren Museum.)]
[Illustration: FIG. 414
Crush of cord and its membranes. The result of a fracture of the spine.
(Erichsen.)]
The spinal column is so strongly put together and its bones so
protected that fracture of any one of its component parts is
inconceivable except as a result of violence. This may occur by
objects falling upon it or by the body falling a distance, or from
violent twisting or wrenching. These injuries constitute but a small
percentage--about 3 per cent.--of all fractures. They occur more easily
and commonly in the upper portion than in the lower, where the vertebræ
are larger. As a result of their occupations adult males suffer much
more frequently than women or children.
=Diagnosis.=--The diagnosis of fracture of the vertebral column is
rarely difficult. The disability produced is instantaneous if the cord
itself be compressed. If the cord escape pressure there may be serious
symptoms, but without paralysis. The most serious feature, then, of
any fracture of the vertebræ is the amount of damage done to the cord
proper. The so-called gunshot fractures of the spine have already been
partially treated of above and in the chapter on Gunshot Wounds. They
constitute a somewhat different class of lesions, but have, in common
with those above alluded to, the actual fracturing of the bone and the
question of damage to the cord. In most respects they may be considered
with the non-penetrating injuries. Fractures of the spine, therefore,
may be divided into (_a_) fractures with injury of the cord, and (_b_)
fractures without such injury. In many cases it is difficult to state
whether the cord is crushed or simply more or less compressed by bone,
fluid, or exudate, until the spinal canal has been opened and explored.
When the cord is totally destroyed there will be total loss of
reflexes, with motor and sensory paralysis complete. (See Fig. 413.)
In some instances there is visible or palpable _deformity_. This is
by no means necessarily the case. It is more likely to be noted in
the upper portion of the column, where the vertebral spines are more
easily palpated. If sufficient time have elapsed there will often be
ecchymosis. The principal feature, however, of spinal fractures is the
_paralysis_, which results in most instances as above. Its careful
study is requisite both for minute diagnosis and localization of the
injury. _Paralysis, then, whether of motion or of sensation, along
with the condition of the reflexes_, deserves careful consideration in
each instance. It is of the greatest importance, because by it, rather
than by other causes, death is brought about in the majority of cases
which outlive the first twenty-four hours after injury. Even injury low
down, which causes paraplegia with loss of control of the bowels and
bladder, may terminate fatally in time, through an ascending infection
of the urinary passages, which may finally lead to pyelonephritis
and death. This has often occurred as the result of inattention to
precautions in the use of the catheter, and to carelessness on the
part of the patient. Death, then, may be caused by roundabout methods
of infection which have only accidental connection with the original
injury. Other cases die of septic infection in consequence of lack of
proper attention to bed-sores. Again, with cord involvement high up
in the dorsal region there is very likely to occur a rapid ascending
degeneration, by which, one after another, the roots of the phrenic
nerves are involved in their order from below upward, until finally
the patient dies of asphyxia from paralysis of all the respiratory
apparatus (Fig. 414).
Aside from such evidences as actual displacement of the vertebral
spines may afford the localizing diagnosis is made mainly by a study
of the paralysis. In regard to this paralysis it should be remembered
how it is produced from the very nature of the injury itself. That
occurring within from a few minutes to a few hours after the injury
is due to hemorrhage; that which occurs still more slowly is due to
exudate or the presence of pus; while a late paralysis may result
from poliomyelitis. The first form of paralysis may be produced by
hemorrhage either within the central canal (hematomyelia) or hemorrhage
within the membranes or structure of the cord itself (hematorrhachis).
There is another form of paralysis due to embolism which, however,
has but little to do with the ordinary injuries. The following table,
inserted by the courtesy of Dr. Dennis, will assist in localizing the
lesion by a study of these paralyses and reflexes due to spinal injury:
_Paralyses and Reflexes due to Spinal Injury._
_Spinal_ _Motor_
_Nerve._ _Paralysis._ _Anesthesia._ _Reflexes._
{ 1. Death from
{ pressure of
{ odontoid.
{2-3. Death from
{ paralysis of
{ diaphragm.
{ 4. Deltoid muscles Upper shoulder, Pupil.
{ of upper arm. outer arm.
Cervical.{ 5. Supinators of Outside of arm Pupil, scapular,
{ hand. and forearm. supinator, triceps.
{ 6. Biceps, triceps, Outer half of Pupil, scapular,
{ extensors of hand. triceps, post.
{ wrist. wrist.
{ 7. Pronators of Inner side of arm Pupil, scapular,
{ wrist, latissimus and forearm. post. wrist, ant.
{ dorsi. wrist, palmar.
{ 8. Flexors of wrist, Inner side of Scapular, post,
{ hand, muscles. hand. wrist, ant. wrist,
{ palmar.
{ 1. Thumb. Ulnar supply to Scapular, palmar.
{ hand.
{2-12. Muscles to back Skin over the Epigastric, 4-7;
Dorsal. { and abdomen. back and abdomen abdominal, 7-11.
{ in areas corre-
{ sponding to
{ distribution of
{ spinal nerves.