October, 1912. the Semi-Circular Canal System Is Then Attacked By

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 analgesic properties are equal to those of cocaine, and it seems to be less toxic. Adrenalin should also be added to the novocaine solution. 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 ciliary ganglion 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 distributed 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 innervated 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 maxillary nerve. 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.

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