524 The Journal of Laryngology, [October, 1912.

The semi-circular canal system is then attacked by opening the pars jyetrosa in the space between the posterior arm of the external canal and the anterior arm of the posterior canal. By working forwards and backwards along the course of the external canal the vestibule is opened. The fossula rotunda is then enlarged and the bony wall of the cochlea between the fenestra i*otunda and the fenestra ovalis along with the stapes removed, thus leaving the bony walls of the Fallopian aqueduct standing out like the arch of a bridge (end on as it were) between the cochlea—vestibular system in front, and the canaliculo-vestibular system behind. Careful curetting is then performed and the cavity disinfected with some strong antiseptic solution. For the relief of severe labyrinthine vertigo I have in two cases divided the eighth cranial nerve in the posterior fossa, in one case with a successful and in the other with a fatal result. In four cases I have limited the operation to the canaliculo-vestibular system (without interfering with the cochlea), with three complete cures and pne case of partial relief; while in six other cases I have completely extirpated the labyrinth by means of my " bridge " operation with the following results: Four cures, one partial relief, and one failure. Of the twelve cases, nine were males and three were females. The youngest patient was aged twenty-six, the eldest sixty-five. In all of the cases prolonged local and medicinal treatment had been carefully carried out, but unfortunately without result. The immediate reasons for operating were : (1) The failure of general and local treatment. (2) The risks run by the patient owing to the occurrence of sudden and severe attacks of vertigo. (3) The mental depression produced by forced inactivity.

THE TECHNIQUE OF REGIONAL ANESTHESIA IN RHINO-LARYNGOLOGY. BY DR. JULES BROECKHAEKT.

(Translated by DAN MCKENZIE).1

REGIONAL anaesthesia, which has been employed in olo-rhino- laryngology for but a short time, seems likely to render us great service and to make considerable progress in our special domain. It consists essentially in the anaesthesia being effected on the nerve 1 From La presse oto-laryngologique beige, November, 1911. October, 1912. Rhinology, and Otology. 525 trunk at some distance from the actual field of operation, so that the sensibility throughout the whole of the territory supplied by that trunk is suppressed. The procedure is based upon the experimental finding that certain anaesthetic agents, such as cocaine, novocaine, and eucaine, when brought into contact with nerve-fibres, penetrate to their axis-cylinders and induce what is known as physiological section of the nerve, or nerve-block. Many different local anaesthetics have been extolled as anal- gesics, but innumerable trials seem to show that it is cocaine which possesses the strongest anaesthetic powers. Cocaine it is that pro- duces the most pi'olonged analgesia, especially when used in com- bination with adrenalin, which, by provoking isehaemia of the tissues on which it acts, retards the absorption (and consequent removal) of the alkaloid. The solution we prefer for I'egional anaesthesia is the following, known by the name of cudrenine, of which each cubic centimetre contains: cocaine hydrochlor. 0'02 grin., adrenalin hydrochlor. 0"0006 grin. Codrenine may be used in full strength, or it may be diluted with normal salt solution : Codrenine 1 c.c, normal salt solution 1 c.c. Xovocaine is sometimes employed instead of cocaine. Its anal- gesic properties are equal to those of cocaine, and it seems to be less toxic. Adrenalin should also be added to the novocaine solu- tion. Here is the formula employed by Prof. Keclus : Novocaine 50 cgrm., adrenalin (1-1000) 25 drops, normal salt solution 100 grin. The syringe we use is a Kecord syringe of a capacity of 4 c.cm., and furnished with two rings. The needle is 6 cm. long, graduated in centimetres, and gilded in the middle of its length. It is rather larger than the ordinary needles. A small movable catch on its stem permits us to determine the depth to which the needle is to penetrate. The general technique of regional anaesthesia presents no difficulties. After the site of operation has been rendered aseptic the needle is inserted at a marked spot, and the piston is slowly pushed on so as to eject some of the analgesic solution during the passage of the needle through the tissues. The point of the needle may, at a given moment, find itself in the interior of a blood-vessel. For this reason it is advisable to detach the syringe from the needle before proceeding to inject a large amount of the anaesthetic. If the point of the needle is lying in a vessel of any size blood will then escape from it drop by drop. In that

III 526 The Journal of Laryngology, [October, 1912.

case all we have to do is to withdraw the needle a little, or else to insert it a little deeper. Anaesthesia of the region will not be complete until ten minutes after the final injection, especially if the solution contains adrenalin, which, by its vaso-eonstrictor action, delays absorption considerably. The anaesthesia, when it has been well done, lasts from one to one and a half hours. All the nerve-trunks with which we are concerned in rhinology belong to the first or second division of the trigeminal. In the case of tlje buccal cavity and the lower jaw we have to deal with the third division, while in the case of the larynx it is the superior laryngeal nerve that specially interests us.

Anatomical Considerations. The nasal fossas are innervated by the splieno-palatine nerve (branches from Meckel's ganglion), and by the nasal nerve. The spheno-falatine nerve, a branch of the superior maxillary division of the trigeminal, after a course of 1 to 3 mm. comes into relationship with Meckle's ganglion, with which it communicates J-• before breaking up into its terminal branches. Among these are : (1) The superior nasal, which supplies the mucosa of the middle and superior turbinal; the nasu-palatine, which is distributed to the middle and upper part of the septum, as well as to the anterior quarter of the vault of the palate and to the mucous membrane behind the incisor teeth ; (3) the anterior palatine, which supplies a great part of the palatine vault, and also shares in the innervation of the iuferior meatus and inferior turbinal. The nasal nerve, the most internal of the three terminal branches of the ophthalmic division of the fifth, follows the inner wall of the orbit, then after supplying the long root of the and some ciliary nerves, it gives off the infra-trochlear nerve. The nasal nerve then traverses the anterior ethmoidal foramen1 to reach the cranial cavity, where it lies on the cribriform plate of the ethmoid. It enters the corresponding nasal cavity through the nasal fissure, and divides into two branches, of which the internal supplies the anterior part of the septum, while the external runs

1 Both the French nomenclature and Dr. Broeckhaert's description of the course and branches of these nerves markedly differ from those given in standard English works on anatomy. Consequently, in order to avoid confusing our readers, we have taken the liberty of modifying the original text so as to bring it into conformity with the accepted English teaching.—D. M. October, 1912.] Rhinology, and Otology. 52? along the posterior aspect of the nasal bone, and, appearing on the face between the nasal bone and the lateral cartilage, is dis- tributed to the skin of the tip of the nose (together with the skin of the vestibule and the anterior part of the nasal fossa. —Broeckhaert). The iufra-truchlear runs forward beneath the pulley of the superior oblique and gives off within the orbit a branch to the lachrymal sac and its passages. It emerges from the orbit between the facial artery and the angular vein and is directed horizontally to the root of the nose, furnishing a certain number of twigs to the integument of the bridge of the nose, and some fronto-palpebral filaments which supply the medial part of the upper eyelid and anastomose with branches of the supra-troehlear nerve.1 The nostril, or nasal vestibule, receives its sensory nerves from (1) a branch of the external nasal division of the nasal nerve (2) nasal filaments of the infra-orbital nerve. The sensory nerves to the bridge of the nose are furnished by (1) the infra-trodtlear, which innervates the skin of the root of the nose; (2) the e denial nasal, which is distributed to the skin of the tip of the nose; and (3) nasal branches of the infra-orbital communicating with branches of the external nasal. The frontal sinus and anterior ethmoidal cells are supplied by the nasal nerve (Broeckhaert).2 The posterior ethmoidal cells and the sphenoidal sinus are inner- vated by (1) the spheno-ethmoidal or posterior ethmoidal branch of the nasal nerve, an inconstant twig which passes by the posterior ethmoidal foramen (Broeckhaert), and (2) the superior nasal nerve, a branch of the spheno-palatine. The sensory nerves of the maxillary ant ruin all come from the superior . A certain number of osseous filaments are distributed to the maxillary bone and a certain number of mucous filaments supply the mucosa of the maxillary antrum. w These nervous filaments proceed from the dental branches of the 8' superior maxillary nerve, which arise during the passage of that nerve through the infra-orbital groove and canal. One of these dental branches, the least slender, is known as the anterior dental nerve. It descends in a small osseous canal in front of the maxillary antrum, and sends numerous filaments to the mucous membrane of

1 We have adopted Dr. Broeckhaert's description of the infra-trochlear nerve, as it is more minutely detailed than that given in the English text-books.—D. M. '' According to English writers the frontal sinus receives its sensory supply from the supra-orbital nerve.—D. M. 528 The Journal of Laryngology, [Octoler, 1912. that cavity, with which it is often in immediate contact. In addition to this source, the antrum of Highmore receives part of its nerve- supply from the posterior palatine nerves, the terminal branches of the spheno-palatine nerve. The posterior palatine nerve, which descends towards the vault of the palate by the posterior palatine canal, Ci frequently gives off in its passage small offshoots to the maxillary sinus which lies immediately in front of it" (Baril).1 The inferior maxillary division of the fifth, which emerges from the cranium by the foramen ovale, breaks up after a short course in the anterior latero-pharyngeal space (in the depths of the zygomatic fossa) into two stout bundles : the anterior, comprising, among others, the unreal nerve; and the pW^r/o?-, from which proceed muscular branches; the auric ulo-temporal • the lingual; and the inferior Jental. Those which specially interest us are the buccal, the lingual, and the inferior dental. The , after a short course between the two heads of the external pterygoid muscle, divides into two terminal branches, of which the buccal, exclusively sensory, continues the direction of the original trunk, and passing over the tuberosity of the maxilla, reaches the outer aspect of the buccinator muscle, supplying the skin and mucous membrane of the cheek. The reaches the lateral aspect of the tongue, and, close to the stylo-glossus muscle, follows a submucous course as far forward as the point of the tongue. It is the sensory nerve of the inferior aspect of the point, and of the anterior two thirds of the dorsum of the tongue. The inferior dental nerve traverses the dental canal and emerges at the mental foramen. It supplies with sensation the lower teeth and gums, and, by means of its terminal branch, the is the sensory nerve of the chin and lower lip. The superior larynyeal nerve, a little way above the greater cornu of the hyoid, gives off the external laryngeal nerve, which passes to supply the crico-thyroid muscle, and then, perforating the crico-thyroid membrane, gives sensibility to the mucous membrane of the subglottic region of the larynx. The main trunk of the superior laryngeal nerve passes between the thyro-hyoid and crico-thyroid muscles, piercing the latter along with the superior laryngeal artery to go to the mucous membrane of the epiglottis,

1 English writers describe three posterior palatine nerves; presumably the above remarks apply to the large posterior palatine nerve, as it lies nearest the antrum.—D. M. October, 1912.1 Rhinology, and Otology. 529 the base of the tongue and the supra-glottic portion of the larynx, including the posterior aspects of the cricoid and arvta3noid cartilages.

Technique of Regional Anaesthesia in the Nose, Pharynx and Larynx. I. The First Division of the Trigeminal. (1) Lifra-trochlear Nerve.—To anaesthetise the trunk of this nerve the skin lying below the inner part of the upper margin of the orbit is raised between the finger and thumb, and into the fold so formed the needle is inserted. After insertion the point of the needle—while the fluid i.s being* injected—is made to move through an nrc of a circle parallel to the orbital margin. (2) Nasal Nerce.—The nasal nerve may be anaesthetised at two places: (a) in the orbit before it enters the anterior ethmoidal foramen ; (//) after its appearance from under the nasal bone (ex- ternal nasal nerve). (a) In the Orbit.—The needle is applied perpendicularly in the supero-internal angle of the orbit, at the extremity of an imaginary line representing the depression which unites the root of the nose with the frontal region. After piercing the skin the sensation is experienced of being in a free space. We now seek to penetrate between bone and periosteum, the needle being made to scrape the surface of the bone. In this layer it is inserted to a depth of between 2h and 3 cm. As it advances (the liquid being ejected as it goes along) the point of the needle is inclined successively up and down so as to insure its contact with the nerve-trunk, which is 1 stretched out horizontally between the periosteum and the anterior orbital foramen. With experience one learns to recognise the sen- sation of the needle in contact with the nerve. (b) External Naval Brandt.—The depression in the lower margin of the nasal bone which corresponds to the emergence of the external nasal nerve is easily felt through the soft parts. This landmark having been duly noted, the needle is inserted and the subcutaneous injection made at that spot.

II. Regional Anaesthesia of the Superior Maxillary Nerve. (1) The trunk of the superior maxillary nerve, shortly after its exit from the cranium by the foramen rotund urn, can be reached either by the retro-maxillary route, by the route of the orbital floor, or by the buccal route. 530 The Journal of Laryngology, [October, 1912.

A. Retro-maxillary Route. (a) Poirier's Method.—Originally recommended by Poirier for the section of the second division of the trigeminal in cases of intractable neuralgia, this method, slightly modified, can be adapted to regional anassthesia of the superior maxillary trunk. It is as follows : We commence by marking the superior border of the zygomatic arch and the angle it makes with the external angular process of the frontal bone. That done, the needle is inserted perpendicularly just above the superior border of the zygomatic arch, 1 cm. behind the external angular process. Passing between the fibres of the temporal muscle the needle encounters the outer wing of the pterygoid process, the anterior edge of which forms the posterior lip of the pterygo-maxillary fossa, into which the foramen rotundum opens. After it impinges upon the pterj'goid plate the needle is withdrawn a little, and then passed in again a little more in front, so as to bring it past this lip of the pterygo- maxillary fossa. When it is evident that the pterygoid plate has been missed then one is aware of having penetrated to the pterygo- maxillary fossa. This method, in our opinion, is blind and uncertain. In many cases the needle is prevented from reaching the nerve l>y the upper end of the pterygo-maxillary fossa being on a lower level than that of the upper border of the zygoma. In other cases the osseous ridge on the zygomatic aspect of the sphenoid, which limits anteriorly the surface of insertion of the external pterygoid muscle, is so strongly marked that it covers the upper part of the zygomatic fossa, and so presents an impassable obstacle to the needle. (Potherat.) (b) Munch's Method.—The method employed by Munch is the same as that adopted by Baudouin and Levy for the destruction by alcohol of the second division of the fifth in intractable neuralgia of the face. The needle is entered perpendicularly under the zygomatic arch at a point corresponding to a line drawn vertically downwards from the posterior border of the orbital process of the malar bone. From this point the needle is directed slightly upwards and back- wards in the direction of an imaginary line drawn horizontally backwards from the inferior extremity of the nasal bone. At a depth of 5 cm. the point of the needle touches the trunk of the nerve in the roof of the pterygo-maxillary fossa. This method has been well received, but it seems to lack precision. October, 1912.] Rhinology, and Otology. 531

B. The Route by the Orbital Floor. This method seems to us to be the most certain. At all events, in practice it has always given us satisfaction. The procedure is simple. The needle is inserted immediately above the inferior margin of the orbit about 1 cm. from its infero-external angle. As it is advanced, care must be taken to direct it a little outwards and to make it scrape along the bony floor of the orbit until the finger pushing the syringe can feel that the needle has penetrated to soft tissue. From this point onward it is in the spheno-maxillary fossa, which it traverses from before backwards along the nerve- trunk. The outward trend of the needle should be maintained as far as this point. It is important not to exceed a depth of 4 cm., because to pass deeper would be to over-reach the mark—Meckel's ganglion. By this route the needle keeps internal to the bony ridge which so often bars the zygomatic route to the pterygo- inaxillary fossa.

c. The Buccal Routes. (a) OawaWs Method.—The needle is inserted behind the wisdom tooth and passed through mucosa, submucosa, and external pterygoid muscle; then it passes upwards in the zygomatic fossa along the outer wing of the pterygoid process, until finally it strikes against the greater wing of the sphenoid. It is then guided forward along the angle formed by the junction of the pterygoid process with the greater wing of the sphenoid, until the osseous resistance is lost. By this time the point of the needle is lying in the deepest part of the pterygo-maxillary fossa and in the immediate vicinity of the foramen rotundum. • (b) B aril's method utilises as its avenue of approach the posterior palatine canal, the buccal orifice of which, in the dry skull, is situated at the base of the third molar tooth. Running upwards ,,»•*•:. and slightly backwards, this canal, which is about 4 cm. long, normally leads to the foramen rotundum. Baril's technique is as follows : " The mouth is opened widely. A platinum needle, 5 cm. in length, is boldly inserted into the gum about 4 mm. to the inner side of the neck of the second molar. The barrel of the syringe rests upon the lower lip, and it is advanced so that after a progress of about 1 cm. the point of the needle arrives at the foot of the third molar. Here it comes to the orifice of the large superior The Journal of Laryngology, [October, 1912. palatine canal after one or more attempts. Some of the solution is injected as it passes up, and progress is arrested at about 4\ cm. " Jt is important, in order to strike the palatine foramen, not to direct the needle too much upward and backward, in which case it- would miss the canal, slip up along the inner wing of the pterygoid process and perforate the pharyngeal mucous membrane. This error is easily perceived, for the liquid which is injected passes into the pharynx and excites swallowing and retching movements. The needle is then withdrawn and directed more vertically." A careful study of many skulls lias let! us to doubt the efficacy of this method. We have been able to assure ourselves that the I..*1 posterior palatine canal, which ought, according to Baril, to be at least 2 to '3 mm. wide, is very often too narrow to admit the needle. It is generally easy to enter the canal, but our investigations have shown that in 25 per cent, of cases the needle would not penetrate for more than a few millimetres. We have determined, further, that the canal is sometimes directed so obliquely backwards that it does not lead to the foramen rotundutn. In many cases the needle, on emerging from the canal, comes to impinge on the outer surface of the pterygoid process, or on the roof of the zygomatic fossa, in which event it cannot come into contact with the superior maxillary nerve. These anatomical considerations have led us to regard Baril's method as only suitable to a limited number of cases. (2) The Infra-orbital Branch.—The cutaneous route alone seems worthy of oar consideration. The buccal route, which we. believe to be impracticable for the introduction of the needle into the iufra-orbital canal, we shall therefore leave on one side. The infra-orbital foramen is often appreciable to palpation. It is situated at the level of the junction of the inner third with the middle third of the inferior margin of the orbit. It maybe found, as has been correctly stated, on a line drawn from the infra-orbital depression to the commissure of the lips, about \ cm. below the margin of the orbit. Another landmark, easy to find, is the suture between the malar bone and the orbital margin of the superior maxilla, which is situated, with remarkable frequency, immediately above the infra-orbital foramen. .The needle is inserted, with an upward direction, in the region of the. infra-orbital foramen. As soon as it has penetrated some little distance a few drops of the solution are expressed. When the pain occasioned by the puncture has disappeared, the needle is pushed in deeper until the bone is felt; withdrawing it then a October, 1912.] Rhinology, and Otology. 533 little way, we endeavour to discover the orifice of the infra-orbital canal, remembering that the canal runs from below upwards, and from within outwards. Save in the rare case of multiple orifices (forty-four times in 217 skulls), or of the presence of an ungual process so prominent as to cover almost the whole of the infra-orbital foramen, hardly any difficulty will be experienced in introducing the needle as far as a depth of ^ to 1 cm.

III. Regional Anaesthesia of the Inferior Maxillary Nerve.

(1) TRUNK OF THE INFERIOR MAXILLARY. It is not easy to reach the third division of the trigeminal as it issues from the cranium. The foramen ovale, by which it emerges, is situated very deeply, quite at the bottom of, and behind the depression, hidden by the coronoid process of the mandible, on a line almost parallel to the zygomatic arch. "It is almost always concealed by the upper part of the bony pointed arch, joining the posterior border of the greater wing of the sphenoid to a small bony spine situated anterior to the spine of the sphenoid, what we may designate the retro-ogival spine" (Chipault). Two routes have been followed to come at the trunk of the inferior maxillary ; the first, the buccal route, was advocated by Ostwald in 1900; the other, the zygomatic route, is that which is most generally adopted.

A. The Buccal Route. The injection is made with the mouth well open and the field of operation well illuminated. As in the search for the foramen rotundum, Ostwald inserts the needle behind the wisdom tooth and perforates the tissues lying posterior to the superior gingivo-buccal recess. He follows as his guide the outer wing of the pterygoid process. Having thus reached the upper wall of the zygomatic fossa, against which the point of the needle strikes, he directs himself posteriorly, and, as soon as the osseous resistance comes to an end, tumbles straightway into the oval window.

B. The Zygomatic Route. There are two sets of methods by this route—the supra- zygomatic and the sub-zygomatic. (a) Supra-zygomatic Methods.—The search for the foramen 534 The Journal of Laryngology, [October, 1912. ovale by this route is not always a simple and easy matter. Orientation is quite often very difficult, and the examination of a series of skulls enables one to determine how many variations there are which render the foramen inaccessible by this route. The needle, inserted perpendicularly above the arch of the zygoma, proceeds till it strikes the outer wing of the pterygoid process. It is then directed backwards so as to reach the foramen ovale. It should not be inclined too much in a downward direction or it will miss the foramen and perforate the pharyngeal apo- neurosis. (b) The sub-zygomatic method, extolled by Levy and Baudouin for injecting alcohol in intractable neuralgia of the inferior maxil- lary nerve, is, in our opinion, the method of choice for regional anaesthesia of the third division of the fifth nerve. We proceed to attack the nerve in a space, li cm. square, bounded above by the base of the skull, below by the internal maxillary artery, behind by the temporo-mandibular articulation and the middle meningeal artery, and in front by the pterygoid muscle. It contains no vessel of any importance. The landmark for the insertion of the needle is the tubercle of the zygoma, which is easily felt on palpation. The needle is introduced in front of the tubercle in such a way as to graze the lower border of the zygomatic arch. Having reached a depth of 3| cm. the needle is arrested by the outer wing of the pterygoid process, the posterior border of which constitutes an important landmark. It is there directed backwards and arrives inevitably at the foramen ovale. (2) The Buccal Nerve, although the buccal nerve can easily be reached by the cutaneous route, we prefer the buccal route. Con- sequently we shall deal only with it. The most useful landmark for finding the nerve in the mouth is the furrow of the buccal nerve, bounded externally by the anterior border of the descending raraus of the lower jaw, and internally by the anterior border of the internal pterygoid muscle. The mouth being held open and well illuminated, the external lips of the anterior border of the ascending ramus, which is also the external boundary of the furrow of the buccal nerve, is recog- nised by the index finger. It is internal to this important land- mark that the anaesthetic should be injected from the middle of the level of the centre of the last upper molar as far as the crown of the last lower molar. All we have to do is to insert the needle, so to say, under the mucous membrane, from which the trunk or October, 1912.] Rhinology, and Otology. 535 the nerve is only separated by a thin couch of adipose tissue and by a few fibres of the buccinator muscle. (3) The Lingual Nerve.—The regional anaesthesia of the lingual nerve is easily effected. The point of the tongue is drawn out of the mouth by an assistant and held to the side opposite to that of the site of injection. The point of the needle is inserted under the mucous membrane in the linguo-gingival fold,, h cm. from the reflection of the mucous membrane from the side of the tongue. A line of injection is made commencing at the outer (? inner) side of the last lower molar and extending forward for a distance of 3 or 4 cm. in the linguo-gingival hollow. The nerve, placed super- ficially in the slender bed of cellular tissue which underlies the mucous membrane, is thus bathed in the amesthetic solution. (4) The Inferior Dental Nerve may be reached either before its entrance into the osseous canal of the mandible, or at its exit from the mental foramen.

A. Above the Mandibidar Foramen. Here, again, we may reach the nerve either by a buccal or by a cutaneous route. (a) Buccal Route.—This method, often a blind one, has as its landmark the lingula (" spine of Spix") which dominates the entrance to the dental canal. When the lingula is well developed it can be easily felt with the finger ; at other times it is small and difficult to discover. Again, the spheno-maxillary ligament may be abnormally developed and completely mask the nerve, so as to present an insurmountable difficulty. Sicard, in this method, employs a curved needle mounted on a hollow handle. (h) Cutaneous Route.—Schlosser reaches the lingula by the cutaneous route anterior to the mastoid, crossing the postero- internal border of tho mandible. The risk of injuring the facial nerve by this method is shown by Schlosser's three cases of con- secutive facial paralysis.

B. At the Mental Foramen. The needle is inserted under the skin in the region of the mental foramen. If the foramen is sufficiently large to receive the needle, a certain amount of solution may be injected into the canal itself. It will be remembered that the mental foramen is found on the anterior aspect of the inferior maxilla, almost always in a line with the second bicuspid; sometimes a little in front of it. 536 The Journal of Laryngology, [October. 1912. The nerve can also be auaesthetised by introducing the needle in the gingivo-labial recess, after having turned down the lower lip.

IV. Regional Anaesthesia of the Faucial Tonsil. The faucial tonsils receive their sensory supply from the glosso- and from the middle palatine nerve, one of the terminal branches of the spheno-palatine. The glosso-pharyngeal innervates exclusively the lower pole of the tonsil, while the lower two thirds of the anterior pillars are supplied by special branches of the same nerve, the tonsillar hranches, which come off from the main trunk at the point where it reaches the side of the base of the tongue. The middle palatine nerve is distributed to the upper pole of the tonsil and to the posterior pillar of the fauces. Relying upon these anatomical facts Rnprecht recommends the following procedure for the regional ana3sthesia of the faucial tonsil. Begin by introducing the needle into the base of the anterior pillar and so into the plica triangularis, expressing the solution slowly. In this way anaesthesia of nearly the whole of the upper third of the anterior pillar is gradually effected. Then make a similar injection into the upper part of the same pillar. In order to complete the anaesthesia of the tonsil, next inject the liquid into the parenchyma of the gland, passing the needle, at the same time, into the region of the upper pole. The anesthesia thus produced is not complete for eight or ten minutes.

Y. Regional Anaesthesia of the Larynx. (1) The Superior Laryngeal Nerve.— (a) Frey's Method.—This is begun by seeking for the position of the greater cornu of the hyoid bone and the postero-superior angle of the thyroid carti- lage. The point where the nerve passes into the larynx is midway between those two landmarks. The patient is seated with the head raised a little. The larynx is steadied by the left hand placed on the side opposite to that of the injection. The needle, directed horizontally towards the middle line, is inserted a little below the seat of election. Having traversed the resisting skin, the needle is felt to reach a free space. At this moment its point, at a depth of about one centimetre, is lying deep October, 1912.] Rhinology, and Otology. 537 to the tliyro-liyoid muscle and superficial to the thyro-hyoid mem- brane. The needle is then directed a little posteriorly so as to bring it more into the direction of the nerve, and the solution is injected as the needle is gently brought back again forward and inward. Frey's method, which is rather uncertain, does not, according to Chevrier and Cauzard, guarantee success to the inexperienced operator. " There is nothing to indicate when the needle has reached the thyro-hyoid membrane, and thus there is the risk of remaining on this side of the thyro-hyoid muscle and so missing the nerve." (b) Method of Cheerier and Cauzard.—These authors take as their landmark the superior border of the thyroid cartilage, "always easy to feel if we begin at the ponmm Adami." The skin is pricked with a curved needle two centimetres from the middle line and one or two millimetres below the level of this border. The solution is gently injected so as to anaesthetise the skin and the sub- jacent planes, and the needle is then directed straight into the depths as far as the thyroid cartilage. Here it is arrested, and the detachment of the thyro-hyoid muscle is then sought by injecting a little more of the solution. Finally, "lowering the syringe so as to carry the point of the curved needle upwards and a little back- wards, the injection is made as the needle advances ; the mass of the injection is projected into the plane of the nerve and towards its situation/' Gentle massage of the region from below upwards and from before backwards with the thumb ensures the diffusion of the cocaine. (2) The. Recurrent Lanjnyeal Nerve.—So far, cocainisation of the recurrent laryngeal nerve has hardly ever been employed save in certain forms of laryngeal spasm. As we have demonstrated elsewhere, there is nothing to prove that the human larynx owes its sensibility to any nerves other than those proceeding from the superior laryngeal and the anastomotic branch of Galen ; and this even although we may be convinced that the trunk of the recurrent laryngeal, or as we have more properly designated it, the recurrent eesophago-laryngeal, comprises not only centrifugal motor fibres for the muscles of the oesophagus, trachea and larynx, but also centripetal fibres—particularly in relation to the cellular elements of the tracheal glands and mucous membrane—and of " medulli- petal" fibres, belonging to the sympathetic system. Be that as it may, in order to aiuesthetise the recurrent laryn- geal nerve, or at least those of its branches specially intended for 538 The Journal of Laryngology, [October, 1912. the larynx, we have recourse to the following procedure, for which we are indebted to Cbevrier and Cauzard: " At the extremity of the angle which the upper border of the thyroid cartilage forms at the middle line, the needle is inserted, while at the same time an injection is made. Search for and avoid contact with the inner surface of the thyroid cartilage. Direct the needle obliquely downwards, backwards and outwards towards the postero-inferior angle of the cartilage, and inject the anaesthetic solution. It will distend the recess and bathe the terminal branches of the recurrent. From 1 to 2 c.cm. of the solution is all that is needed to surround the nerve."1

A CASE OF ACUTE CEREBRO-SPINAL MENINGITIS OF NASAL ORIGIN.

BY H. L. GREGORY, M.A., M.B., B.C.CANTAB., M.R.C.S., L.E.C.P., Highgate, London, N. ,r t ON Sunday, June 23, 1912, I was called to see a boy, aged seventeen, who was complaining of pain in the head. He was a fairly healthy lad, but had been, his mother said, always easily tired. As a child he had had nocturnal enuresis. A year ago (May, 1911) I attended him in an ordinary attack of influenza. In October, 1911, he was treated by a surgeon for chronic nasal catarrh, by removal of the inferior and part of the middle turbinates and an adenoid mass. For a short time after the operation the right antrum was dull on transillumination, but it cleared up satisfactorily. He was usually constipated. Later on I was told by his mother that since the operation there had been at times a discharge from the nose with some blood in it, and complaint of headache on stooping, but apparently these were thought to be matters which would right themselves. The surgeon who had operated told me that he had seen the patient fairly recently and that there had never been any evidence of ethmoidal suppuration, and the patient regarded himself as cured. So much for the history, the latter part of which was only elicited by questions two days after my first visit. 1 Eeaders studying this article are advised to follow out the anatomical direc- tions on the dry skull,—Trans.