running is performed only with great care, and may be impossible.
Nerve-stretching, or Neurectasy.
Since Nussliaum in 1872 stretched the brachial plexus successfully
for jiainful spasm of the arm and hand, nerve-stretching has claimed a
good deal of attention. It has been found useless in many conditions,
but its occasional value must be recognized. In neuralgia and muscular
spasm it is sometimes undertaken before the adoption of the slightly
more serious operations, neurotomy and neurectomy. Neurectomy has
now neai'ly superseded both nerve-stretching and neurotomy in these
conditions, because of its greater efficiency. There is no objection to
performing nerve-stretching at first, for it can be followed Ijy the other
operations if it proves to be unavailing. When the operation was intro-
duced it was used in ataxia, e]3ile}>sy, tetanus, and many other nervous
diseases, but was of so little service that it is seldom em])loyed at the
present time except for the relief of neuralgias and spasmodic affections,
such as mimic spasm of the face and sjjasmodic torticollis. Dr. Ken-
neth Mcljeod advocates ' it strongly in anaesthetic lej>rosy to relieve the
nerve-fibres from the destructive pressure present, and advises in this
and other forms of neuritis that longitudinal division of the sheath of
the nerve be made before the stretching is performed.
Neurectasy is done by exposing the nerve through an incision, as in
ligating arteries. The nerve is then sepai-ated from the adjacent muscles
and fasciae, and stretched by means of the fingers or a hook passed beneath
it. When the Esmarch tourni(|uet has been used to keep the parts blood-
' Brilish Medical Journal, 1894, i. 352.
NERVE-STRETCHING, OR NEURECTASY. 9()i"3
less during the incision, it niur^t be renio\otl before elongation of the nerve
is atteBiptetl. If this is not done, the tension a])piie(l to tlie nerve is
arrested at the seat of eonstrietion eansed bv tlie bandage. The sheath
of tile nerve is not opened, and the operator desists when lie feels thati
there is danger of causing complete rupture of the nerve-trunk. The
giving way of some of the bundles of nerve-fibres is often appreciable
to the surgeon during the stretciiing process. McLeod, as alreadv men-
tioned, believes tiiat the efHcacy of neurectasy is enhanced in sclerosed
conditions following neuritis by a preliminary longitudinal incision of
the nerve-sheath.
What has been called subcutaneous nerve-stretching is sometimes
applied to the great sciatic nerve. The operation is done, without
making an incision, by flexing the hip of the etherized patient, while
the knee is kept extended, until the point of the knee is brought almost
or quite into contact with the front of the chest. The sciatic nerve is
stretched by this nianipulation, but great strain is also brought upon the
biceps, semi-membranous, and semi-tendinous muscles on the back of
the thigh, which extend from the tuberosity of the ischium to the tibia
and fibula. Benefit has been derived from this inaccurate operation, but,
on the other hand, fatal issue has also occurred. The ojicn method is a
more surgical and exact jirocedure.
Elaborate experiments have been made to determine the number of
])ounds that can be |)Ut upon the various nerves without causing com-
plete ru])ture. The statistics based upon the tensile .strength of nerves
in the cadaver are of little jiractical value. The surgeon should stop
when he has produced marked elongation of the nerve-trunk and has
felt the giving way of a few of the component fibres. It is probalile
that a force of from thirty to forty pounds is as much as should be
applied to even the largest nerves. A\'lien operating upon the facial
nerve the operator may usually apply enough force to almost lift the
head from the table. In stretching the sciatic nerve the mIioIc limb,
and even the hips, may with safety be lifted by the fingers hooked under
the nerve. These examples give a crude idea of the amount of force
usually applied in performing the operation.
The traction is exerted upon the peripheral as well as the proximal
portion of the nerve. Most of the elongation occurs in the proximal
portion, and there is no doubt that the dura mater and spinal cord may
sustain traumatic lesion during the operation, though the force is a])j)lied
at a great distance from the spinal cord. If the traction is made away
from the spinal cord, the function of the sensory fibres is, it is believed,
more impaired than that of the motor fibres. In the treatment of neur-
algia centrifugal traction is therefore indicated. Traction toward the
spinal cord seems to interfere especially with the function of the motor
fibres. It is therefore indicated in operations for the cure of muscular
spasm.
The pathological clianges caused by the ojieration are loosening of
the nerve-sheath from its attachment to the nerve, and narrowing of the
sheath, so that it makes pressure ujion the nerve-fibres. The blood-
vessels are lacei'ated and ecchymoses produced, and some of the nerve- '
fibres are torn and degenerative jjrocesses set up. Cell-proliferation
occurs in the neurilemma. Hegeneration in time succeeds the degenera-
906 STmOERY OF THE NERVES.
tioii of tlie nerve, and oeciirs more r;i|)i(lly than when the nerve lias been
subjected to accidental or intentional section. The sensory, motor, and
trophic symptoms resemble those produced by an accidental laceration
of like severity. The operation also causes inflannnatory and atrophic
chan<;es in the cord. The benefit derived from neurectasv is not un<l(r-
stood, but is ])r()bably due to separation of adlu'sions outside or within
the sheath, to some unintelligil)le alteration in nutrition, or to the fact
that the conduetiua- fibres are actually severed, not only at the point of
operation, but in distant branches. The operation may perhaps give
better opj)ortunity for the growth of new nerve-fibres. Exjicrience
seems to show that the o]ieration lias two apparentlv contrary effects: a
hyjierexcitation if the stn'tehini;- is moderate; a functional abolition if
it is complete.
Nerve-stretching done with proj)er asepsis is not a dangerous opera-
ti(m. Reflex palsy of the other side may occur, as in accidental trau-
matism of nerves. In cases which become septic pus may l)urrow within
the nerve-sheath, and thus travel beyond the limits of the original wound.
Death may take place from spinal meningitis or myelitis, due to injury
to the cord caused by the efforts at stretching. Bowlby has reported
thirteen cases of this sort. These complications, however, are rare, and
need not deter one from carefully performed ojierations.
Nerve-section, or Neurotomy ; Nerve-excision, or Neurectomy.
Intentional division of a nerve and the cutting out of a jiortion of
it are operative procedures that only differ in that neurectomy leaves the
nerve with a wider gap between the two ends. Neiu'ectomy is the better
operation, because the neuralgia or muscular spasm for which operation
is undertaken is not so liable to recur by rapid regeneration of the nerve
if the ga]> between the two ends is the wider one.
Neurotomy may be done subcutancously by a tenotome passed through
the skin, but the method is inat'curatc. The mctliod of exposing a nerve
for either operation is identical with that used in nerve-stretching. When
it has been found, it is lifted from its bed and divided with knife or scis-
sors if the operation is to be neurotomy. In nein-ectomy the nerve is
dragged upon so as to stretch both its central an<l ])cripheral jxirtions,
and a piece cut out with the knife or scissors. A\'hen the jxiint at which
division is desirable is inaccessible because the nerve lies in a bony canal,
the surgeon may pvdl upon the nerve until it is torn ott' at a distant
point.
If several nerve-trunks lie close together, as in the axilla, a weak
faradic current may be used to identify, by muscular contractions, the
j)articular nerve U])(>n which operation is to l)c performed. The current
should not be a strong one, because the moisture in the A\()inul may con-
duct it to a distance and stimulate other nerves adjacent to the one
desired.
As interruption of nerve-conductivity is the end to be desired in
these o])eratii)ns, regeneration is to be deprecated. In neurectomy a
piece of nerve several inches in length and its collateral brandies are
often cut out. Return of symptoms is usually evidence that union of
the ends and regeneration of nerve-tissue have occurred. It is possible
OPERATIONS ON SPECIAL NERVES AND GANGLIA. 907
that the recurrent pain or spasm may be (hie to supplementary or collat-
eral innervation. Attenijits have been made to prevent linion after
neurectomy l)y turning baek the extremities of the nerve or introducing
porti(Uis of nuiscle, tiiseia, or bone between them. Pieces of metal or
celluloid have even been inserted for this purpose.
Nerve-suture, or Neurorraphy ; Nerve-grafting.
Nerve-suture and nevve-graftiuir have been considered in discus,sing
the treatment of Wounds of Nerves.
Operations on Speciat^ Nerves and Ganglia.
neuves and (ian(;i>ia of the head and neck.
The Trigeminal Nerve ; Gasserian Ganglion.
The trigeminal nerve and its brandies are often subjected to neur-
ectomy, combined with nerve-stretching, for the relief of the excru-
ciating pain of epileptiform neuralgia. The great and immediate relief
afforded by tiie operation is often not permanent, but several montlis or
years of comfort fully justity the sligiit operative risk. When the pain
returns the operation should be repeated, preferably at a point nearer
the brain. Sometimes the excision of the scar-tissue at the seat of the
former operation gives relief again, even when no nerve-fibres can be
identified in the mass removed. The operator should at the same time
endeavor to stretcli tiie nerve above tiie seat of operation by pulling on
the tissues supposed to ho coimected witli the nerve-stump. Thiersch
has reeonunended neurotomy fblloweil by torsittn of the proximal end for
the relief of the pain. Wyeth has reported ' two cases successfully
treated in this manner. The nerve was given ten to twenty rotations,
wiiich were made slowly wliile the nerve was slack and therefore not
readily torn.
It is usual to be satisfied in the first operation with simply excising a
jKjrtion of the painful supraorbital, infraorbital, or inferior dental nerve
at or a short distance behind its respective foramen of exit upon the
face. After months of comfort pain may recur. Then excision is per-
formed at the foramen of exit at the base of the skull. Later, the main
divisions of the nerve, the Gasserian ganglion, or the nerve-roots may
be attacked by boldly entering the cranial cavity."
Excision of the supraorbital branch is accomplished by a horizontal
cut under the edge of the upper margin of the orbit. The point of
junction of the nasal and middle thirds of the supraorbital ridge marks
the foramen of exit. Sometimes the nerve lies in a notch instead of a
foramen. \\'Iien the nerve has been found at the bottom of the incision
the fat of the eve-socket is ])ushed downward. The nerve is then lifted
on a hook, followed along the roof of the orbit, and cut oif as far back
as possible after a strong jiull being given it to stretch the cerebral por-
tion. The terminal filaments entering the tissues of the forehead are
next torn out by pulling on the free end.
• Demr.r Mnliml Times, 1892-93, xii. 10.
' The literature of this subject is very extensive. Iiiipnrlant papers will be found in
the British Medical .Journal, IS'Jl, vol. ii.'pp- 1139, 1191, 12-19.
9n,s suRnEnr of the nerves.
'V\\(.' superior max illarvdi vision or liraiiciiot'tlic triticniiiial nerve loaves
its canal in tiie Hiior i it' the orbit by tiie intraorbital t'oraiiicn. This fora-
men is situated al)ont a(|uarter of an inch below the lower margin of the
orbit, on a line drawn from the supraorbital foramen, mentioned just
al)(>ve, to the groove between the two lower bicuspid teeth of the same
side. The concavity in the surfa<-e of the ujiper maxilla and the fact
that the elevator muscle of the lower lip covers tiie foramen cause the
nerve to seem I'ather deep when its excision is attempted.
Neurectomy of the snj)erior maxillary nerve is performed by attack-
ing it through the floor of the orbit, the roof of the antrum, or the
pterygo-maxillarv tissure. Many operations, utilizing one or other of
these routes, have been devised,' l)ut only a few that seem most desirable
will be described iierc.
The first method is easy of execution. A long curved incision paral-
lel to the lower margin of the orbit is made over the infraorbital fora-
men, the foramen and nerve identified, and a portion of the orbital edge
just above the foramen cut out with a chisel. It is well to pass a liga-
ture around the nerve to serve as a means of traction, or better, as
was long ago suggested, seize the nerve with a pair of torsion forcejis
placed at right angles to the nerve, and then twist the nerve around the
forceps. In this way the nerve can be extracted, and remains untorn for
any required length. The tissues in the orbit are pushed ujiward with a
flat spatula, and the thin bony jtartition between the orl)ital cavity and
the nerve-canal broken through with any small steel instrument. The
surgeon may, if he prefer, strip up the periosteum l)cf()re he breaks
through the bony septum over the nerve. The uncovered nerve is lifted
from its bed with a small hook, is stretched by traction on the ligature
in front, and is then cut off with curved scissors as far back as possible.
If the periosteum has been stripped up, it is possible to trace the nerve
back to the foramen rotundnm and I'cmove the spheno-palatine ganglion
with the nerve. The terminal filaments of the nerve should be torn
from the muscular and cutaneous tissues, which they supply with sensa-
tion, by a steady jndl on the already divided nerve.
Excision of this nerve and the spheno-palatine ganglion (Meckel's)
is jierformed Ity exposing the front of the upper jaw-bone by means of
a horizontal incision, slightly concave upward, under the eye. From
this an incision, not always necessary, may be carried downward toward
the mouth, but not opening its cavity. The scarring will be less con-
spicuous if the second cut follows the naso-labial groove in the skin.
The infraorliital nerve is found and a ligature tied to it. An opening
nearlv an inch in diameter, including the infraorbital foramen, is then
made through the anterior wall of the jaw, entering the antrum. A
similar ojiening is cut by ti-ephine or gouge thi-ough the ])osteri()r wall
of the antrum. This must be done carefully, as the internal maxillary
artery lies behind the bone where the opening is made. The mucous
membrane of the antral roof must then be divided, and the bone form-
ing the floor of the canal, in which tlie nerve lies, broken away. The
nerve is then pulled tlownward and made tense by means of the attached
ligature, and is followed backward across the antrum and into the
spheno-maxillary fossa. Ijong curved scissors will permit the surgeon
' See The Surgical Treatment of Neuralgia of the Fifth Neri'c, by W. Rose, London, 1892.
OPERATIONS ON SPECIAL NERVES AND GANGLIA.
909
t(i divide it behind the ganglion of Mecicel, just outside of the foramen
rotunduin in the cranial hase. Illumination hy means of a head-mirror
is essential in the successive stejis of tiiis operation. Tlie peripheral
nerve-bra nclies should be torn out of the tissues of the face, as in the
previous method.
The incision for the ptervgo-maxillarv operation is an inverted V,
with its apex at a jxjint just beiiind and below the external angular j)ro-
eess of the frontal Ixine. One brancii of the cut extends downwaixl and
backward to the tragus; the other, downward and forward upon the
clieek. The zygomatic arch is sinvcd through at each extremity, after
small holes have been drilled on both sides of each proposed saw wound
to allow a wire suture to be subsequently inserted to hol<l the bone in
position. The next step is to detach the temporal fascia from the upper
margin of the zygoma and turn downward the loosened zygoma. The
Fi(i. olO.
- e
Surcipal treatment of neuralgia of the fifth nerve (Rose) : o, zj-gomatic arch divided and turned
iliiwu ; Ij, temporal tendon ; c, superior maxillary nerve and Meckel's ganglion ; d, infraorbi-
tal nerve.
pterygo-maxillary fissure is thus exposed and the ganglion rendered
accessible. A head-mirror is necessary to illuminate the deep wound :
even then identification of the ganglion may be rather difficult. If it is
desired to remove the infraorbital nerve as well as the ganglion, that
910 SURGERY OF THE NERVES.
nerve is exposed under tlie orbit in front and the portion between the
two incisions drawn out.
The inferior dental and linjjual nerves ai'e derived from tlie third
division of tlie triii'eniinal nerve, and occasionally demand operation for
till' relief of neuraiuia. The termination of die inferior dental nerve
may be excised at the mental foramen by a cut made through the mu-
cous membrane of the mouth if it is thought best to avoid a cutaneous
scar. If a cutaneous incision is decided upon, tlie external wound
should be made under the lower border of the lower jaw at the chin and
the si<iu drawn upward so as to expose tlie mental f )ramen. The scar
is thus put in an inconspicuous place.
Renn)val of a considerable portion of the nerve is accomplished by
malving an incision two inches or more in length just below the lower
margin of the jaw, extending a short distance back of the angle. The
skin is slipped upward and tiie muscles detached as tar as necessary
from tlie external surface of tiic jaw. A half-inch trephine is then ap-
plied about an inch and a <|iiarter above the angle, so as to cut a l)utton
of bone from the entire thickness of the jaw opposite the inferior dental
foramen on the inner surface. The nerve crosses this opening from
above down\vard on its way to enter the inferior dental canal. By
means of a sharp cliisel the channel in which the nerve runs forward
can be laid open on the external surface of the bone as far forward as
the mental fin-amrn. Several iiii'lics of nerve can lie exsected by this
nu'thod of operating. The inferior dental artery will very probably be
divided, but pressure or ligation will stop the bleeding.
The nerve may also be satisfactorily exjiosed by an operation within
the mouth, which has the advantage of leaving no external scar. It is
necessary to have the mouth kc])t widely ojien by a gag placed on the
side opposite to that of operation. Incisidii is made through the mucous
membrane along the anterior border of the ascending ramus of the jaw
from the last uj)per molar to the corresponding tooth below. The
internal pterygoid muscle is separated from the internal surface of the
ascending ramus by means of the finger, which is also used to identify
the point of bone situated at the beginning of the inferior dental canal.
A sharply-curved hook or aneurysm needle is tiieii to be used to draw
the nerve from its bed and make it accessible to stretching and excision.
The internal lateral ligament of the lower jaw may be mistaken for the
nerve if care is not exercised.
The inferior dental nerve can also be reached for excision by applying
a tre])hine a half inch below the sigmoid notch of the lower jaw and
cutting away the bridge of Ixme between the trephine opening an<l the
notch, so as to deepen the latter. This prolongation downward of the
sigmoid notch to the level of the inferior dental canal exposes the inferior
dental and also the lingual nerve. This method may also be used when
it is desired to excise the third division of the trigeminal nerve â– where it
makes its exit from the oval foramen. The external incision liegins aliout
the centre of the zygomatic arch, is carried downward and liackward, and
then forward, so as to follow the angle and the ])osterior part of the lower
body of the jaw. The cutaneous flap is lifted, and the deep fascia and
masseter muscle divided transversely, below and parallel to the duct of
the parotid gland. The j)eriosteuni is separated from the bone, and a
OPERATIONS ON SPECIAL NERVES AND GANGLIA.
n\
half-inch trephine applied aliout lialf an inch Ijelow the bottom of tlie
sigmoid notcii. The pdrtioii of bone between the lower margin of the
noteii and tlie trephine (ipenino; is ent away with saw, chisel, or drill.
The surgical engine armed witli a flat burr would answer well in this
operation. Division of tlie jieriosteum on the inner side of the bone
Fig. 511.
Side view of lower jaw. showine position of treiihiiiu ii|.(.'ninjf in tlu' n|KTalion for dcc'itenin;; the
sigmoid notcli. Tiie dotted lines above the treiihine ojn'iiinti indicato tlie extent of the Itridj^e
of bone which needs removal. The inferior dental (anal and its anterior and po.sterior open-
ings are indicated.
allows the inferior dental nerve to be seen. The lingual nerve is situated
about half an incli deeper and a little in I'ront of the inferior dental. The
nerves should then be cut off close to the oval foramen above, and as far
beh)w as tiiey can be reached.
The lingual nerve may be exposed a.s above detailed or by an intra-oral
route. A string is carried through the tongue by a needle, on the side of
the middle line toward the nerve to be excised. By it the tongue is
drawn out of the mr>uth and toward the opjiosite side ; this causes the
nerve to become prominent as a cord l)cnc:ith the mucous membrane of
the floor of the mouth, between the jaw and the tongue. Tlie niucoiis
membrane is to be clipj)ed away and the ner\-e raised on a hook and
exsected. The nerve may also he fomid under the mucous membrane
close to the jaw beneath the first lower molar tooth. It is stretched
or excised in neuralgia and in malignant disease of the tongue.
^\'hen the neuralgic pain of tic dmiloiireiix returns after a period of
relief from the peripheral operations just detailed, the .surgeon isjustiiicd
in doing an intracranial openition for removal of the nerves in front of
the Gas.serian ganglion and the (Tas.scrian ganglion itself. Two routes
have been emploved for the accom])lishment of this object. One enters
the cranial cavitv by boring through the base near the oval foramen ; the
otiier makes an (Osteoplastic resection in the tein]>oral region, turns down
a fla|) of bone, and separates the dura mater from the base of the skidl.
Tile former has been advocatetl particularly l)y Kose and Andrews.' The
latter wa.s suggested In- Horsley, but has been more recently advocated
by Hartley and Krause. The temjioral route is proliably less dangerous
' Journal of Amfiiniii Medical AsMciutioii, 1891.
912
SURGERY OF THE NERVES.
tluiii tlic IimsmI. TIic opcratidii tliniiii;li the l)as(' of" tlic skull is ])orformcd
by <livicling the /vji;*)!)!;! in two plai't's, cutting oil" tlio coronoid process
of the jaw, detaching the niasscter and temporal muscles, and applying
a trejihine of special form to the hone around the oval foramen. A chisel
may be used for making the opening through the base of tiie skull. The
Gasserian ganglion so reached is scrajx'd away by a curette and the parts
replaced. The ganglion is situated at the apex of the j)etrous portion
of the temporal bone on its anterior as|)eet, and lies beneath the dura
mater with a layer of periosteum between it and the base of the skull.
The cavernous sinus is close to the ganglion on its inner side.
In the operation through the temporal region of the skull an omega-
shajx'd incision is made in the temporal fossa, with the top of its curve
near the temporal ridge, its anterit)r extremity near the external angular
process of the frontal bone, and its posterior end near the tragus of the
Fio. 512.
Showing manner of holding the cliisol in cutting the groove tlirongli the bone (Hartley).
auricle. The soft tissues are cut tJirough to tlie l)one, and a chisel which
cuts a triangidar groove is I'uijiloved to divide the bone along the same
line. A small chisel ground like an osteotome makes a very good instru-
OPERATIONS ON SPECIAL NERVES AND GANGLIA.
913
iiiL'iit tiir this purpDSO. Care must \tv taken not to drive the ehisel
throutjli tht' hone into the brain. Tliis is easily ])revente(l by usinsi the
corner of tlie ehisel to divide the hone along the line marked out in the
soft parts. This part of the operation may be performed by one of the