Vol. 60, 1909 - University of North Carolina at Chapel Hill

I,
THE CHARLOTTE MEDICAL JOURNAL.
base of the skull. The point is then gently to the needle, and from I.t to 20 minims of
loweredby raising the handle, and the edge SO per cent, alcohol injected slowly, a few
of the foramen ovale is felt for at a depth drops at a time. If no general ane.sthetic
of from l,'i' lo 1;'4 inches, according to the has been given, as is the practice of the
size of the individual. Continental and American workers, the
Harris's results have shown him that in patient will cry out with pain as soon as the
practically every case the needle can be point of the needle reaches the nerve, and
made to pass through the foramen into the the further injection of the alcohol causes
Gasserian ganglion if necessary. a sharp burning pain over the area of dis-
When attempting to inject the inferior tribution of the nerve, a pain which is
maxillary nerve at the foramen ovale, if the repeated with each push of the syringe,
needle is passed straight in and too horizon- The writer prefers to have a general anestally
the wall of the pharynx will be pierced thetic given before puncturing the skin, and
at a depth of 2 to 2,'4 inches. If the point when his needle is approximately in the
be directed too far backward the middle correct position for making the injection he
meningeal artery may be injured, w'hite if allows the patient to come partially round
the needle be passed too far through the from the anesthetic. Moving the point of
foramen ovale, to the depth of 2'4 inches the needle then against the nerve will proor
more, the cavernous sinus and the inter- voke a reflex spasm of that side of the face,
nal carotid artery within the skull may be as though pain w'ere felt, and the injection
damaged. can then be made safely, without the patient
For the second division of the fifth nerve remembering anything of the pain afterthe
injection is made below the orbit into ward.
the infraorbital foramen, taking care to use There are other foramina which can be
no force when inserting the needle, or the injected with the greatest advantage, nameantrum
may be pierced. The direction of ly, the supraorbital notch or foramen, infrathe
needle must be upward and outward, orbital foramen, mental foramen, inferior
Besides injecting the infraorbital nerve, the dental foramen, and the palatine foramina,
superior maxillary nerve is also injected both anterior and posterior. The inferior
deeply at the point of its emergence from dental foramen on the inside of the ramus
the foramen rotundum in the sphenomaxil- of the lower jaw may be injected with adlary
fossa. To reach this point the needle vantage in cases in which the attacks of
is pushen through the cheek in front of the pain are limised to the lower jaw, without
coronoid process and below the malar bone, affecting the territory of the lingual nerve,
a little in front of the line of the posterior thus avoiding the numbness and loss of senborder
of the orbital process of the malar sation in the tongue which would result
bone. The needle is pushed upward and from injection of the inferior maxillary
inward until the front edge of the external nerve at the foramen ovale. There are two
pterygoid plate is reached. The point of routes to the inferior dental foramen, either
the needle is then passed in front of this inside the mouth or outside the cheek, round
bone so as to enter the pterygomaxillary the ramus of the mandible. In either case a
fissure, through which it is pushed, always stout curved needle is necessary; Schlosser
at the same angle upward, until the nerve is practices the external route, though there is
reached. This will vary in depth from 1 -'4 a real danger with this method of producing
to 2'8 inches, according to the size of the facial palsy from the alcohol running backskull,
Besides a certain degree of risk of vascuward
along the needle.
A successful injection, besides producing
lar injury there are two most serious dan- a sensation of numbness and burning for
gers to beware of after the point of the some hours over the area of the nerve deneedle
enters the splienomaxillary fossa,
namely, the danger of piercing the optic
stroyed, always causes a certain amount of
edema and a sensation of stiffness of the
nerve or of injecting it with alcohol; and parts. The burning sensation passes off
sfecondly, of passing the needle into the after a few hours, the edema disappears
sphenoidal fissure and there damaging the after two or three days, whilst there is left
oculomotor nerve. The optic foramen lies behind a sensation of numbness; and there
not more than three-eighths of an inch be- is anesthesia to touch and pin-prick on the
yond the orifice of the foramen rotundum skin and mucous membrane, corresponding
in the same straight line, and it is therefore to the anatomical distribution of the nerve,
imperative never to sink the needle to a This will last for weeks or months, accordgreater
depth than 2 inches, or even 1 ->4 ing to the amount of destruction of the
inches, in the case of a small skull, as of a nerve, but will generallv begin to diminish
woman .=; feet 2 inches in height. When after three to four months. Theattacksof
the nerve is reached the syringe, ready filled pain cease immediatelv after injection, and
with SO per cent, alcohol, is fitted tightly on the delight of the patients on finding they