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.