Remarkable Sequence of Operation for Necrosis 
at Base of Skull; a New Method of Re- 
secting the Third Branch of the 
Fifth Nerve. 
Read before the American Medical Association, at Detroit, June, 1892. 
BY 
G. LENOX CURTI^M*, 
OF NS1V YOtfr 
Reprinted from the "Journal of the American Medical Association,'' 
January 14,1893. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION 
189:;. REMARKABLE SEQUENCE OF OPERATION 
FOR NECROSIS AT BASE OF SKULL: 
' A NEW METHOD OF RESECTING 
THE THIRD BRANCH OF THE 
FIFTH NERVE. 
BY G. LENOX CURTIS, M.D., 
OF NEW YORK. 
'About a year ago a case came into my hands for 
operation, which presented unusual features of in- 
terest from-the surgical standpoint, not merely on 
account of the immediate results, but because of the 
suggestion which it afforded of a decided improve- 
ment in an important surgical operation. 
On May 15, 1891, the patient, Miss M., aged 25, a profes- 
sional nurse by occupation, presented a note from Charles 
M. Alagee, M.D., of Syracuse, N. Y., asking me to make 
a careful examination of her symptoms and condition, 
and stating his opinion that she had been suffering for the 
preceding five months from confined pus, somewhere at the 
base of the skull. He had, the note added, sent the patient 
to her dentist some two months before, but no trouble was 
found, though on the day previous to her coming to me the 
dentist had discovered pus coming from around one of the 
teeth. 
The right side of the face was considerably swollen. The 
eye on that side protruded from its socket. The sight of 
the eye was, however, normal, while the left eye, which 
retained its normal position and was apparently not involved 
in, or related to, the trouble which had forced its companion 
out of position, was almost totally blind. With the right 
eye closed, the patient could merely distinguish the differ- 4 
ence between daylight and darkness. Questioning her it 
was brought out that, as far as she knew, she had never had 
the use of the left eye. She had first detected the fact that 
it was useless to her at the age of seven years, and she had 
always supposed that its cecity had dated from her birth. 
She had no recollection of any traumatic injury to which 
the disability of the eye could be referred. Clearly there 
could be no connection between the present condition of the 
patient and the blindness, which was therefore dismissed 
from the consideration. 
The history of the case from the time serious symptoms 
were first observed, is perhaps best told in the following 
statement of the patient: 
"First appearance of head trouble was in the latter part 
of January, 1890, when I had an attack of la grippe; was 
confined to bed two days; in-the house a week. Had 
more or less headache afterward, but no serious trouble 
until July of the same year, while in charge of a patient in 
the country; I was taken in the night with a severe 
chill, followed by headache and bone-ache. There was also 
a watery discharge from the eyes and nose, and I lost all 
sense of taste and smell. Did not seem to get over what 
appeared to be a cold in the head, but at the end of the sec- 
ond week after the chill, I went on duty again. The pain 
and fulness seemed to increase until the fourth day, when 
I was obliged to take to my bed. Had more or less ear-ache 
and faint turns and dizziness, and was brought home on 
my bed. Expected to have an operation performed, but 
on reaching home, it was decided that this was not best. 
Was confined to the house with this attack seven weeks, and 
was not able to work until the latter part of October. In 
January face was somewhat swollen, followed in February 
by a discharge from the right nostril; head was relieved as 
long as the discharge kept up, but when it stopped the pain 
and pressure were intense." 
Examination confirmed the suspicion of Dr. Magee. On 
passing the electric lamp into the nostrils and posterior 
pharynx, marked opacity was observed thoughout the entire 
right superior maxillary region, and extending far back in 
the direction of the ear, indicating disease of the antrum of 
Highmore and congestion of the surrounding tissues. The 
patient's physical condition was so unfavorable, however, 
that it was decided to defer operation until she could be 
strengthened for the ordeal. She was accordingly placed 
on an anti-pyemic treatment, with such good results that on 
June 2, the operation was performed with the aid of Dr. 
Magee, who also administered the anaesthetic, and my reg- 5 
ular assistant. As in most of these cases, the operation was 
performed through the mouth, so as to avoid a scar on the 
face. The first step was the extraction of the second molar on 
the left side, the second bicuspid and the first molar having 
already been lost. The wisdom-tooth, or third molar, was al- 
lowed to remain, as its removal was unnecessary and it would 
serve a good purpose as an anchorage in case a bridge piece 
of artificial teeth should be required. A flap of gum hav- 
ing been turned back the bone was cut away from between 
the anterior surface of the wisdom tooth and the distal sur- 
face of the second bicuspid, the alveolar process being re- 
moved with it, and the cut extending along the buccal 
surface of the superior maxillary bone about a half inch. 
On entering the antrum, that cavity was found to be en- 
tirely filled with multiple mucous cysts, pus, and granula- 
tions, but there was no evidence as to the origin of the accu- 
mulation. The posterior wall was absent, and the edges of 
the bone surrounding the opening were rough and dead, 
showing that necrosis had occurred. In exploring beyond 
this opening an accumulation similar to that in the antrum 
itself was discovered, except that it contained no mucous 
cysts, being composed entirely of pus and granulations, 
extending as far back as the junction of the sphenoid and 
temporal and up on the zygomatic arch. The external sur- 
face of the pterygoid process and two-thirds of the greater 
wing of the sphenoid bone were entirely denuded of perios- 
teum. 
In all nearly a half-pint of diseased tissue was removed. 
The surface of the wing of the sphenoid, which was 
denuded, was necrosed, necessitating its removal with the 
bur and curette. As the necrosis involved the foramen 
ovale the nerve and artery were pressed aside to allow of the 
removal of the necrosis around the foramen. The necrosed 
bone removed, extended over the lower two-thirds of the 
external surface of the great wing of the sphenoid bone, the 
zygomatic surface of the external pterygoid plate, the entire 
zygomatic surface of the superior maxillary bone, and 
throughout most of the surface of the antrum, though the 
necrosis was less marked in this territory. Thorough cleans- 
ing was secured with carbolated solution followed by solution 
of bichloride of mercury. The entire woundwas then packed 
with iodoform lint, which was not changed until the fourth 
day. Fever was very slight, there having been only two 
degrees rise in temperature, and this subsided upon the 
redressing. The wound was dressed in the same way for 
two weeks, after which the dressing consisted of injections 
of bichloride of mercury and peroxide of hydrogen, twice a 6 
day, and carbolated solution every two hours. A gold tube 
was finally put in the antrum, attached to the wisdom tooth, 
to facilitate syringing out the closing wound, and as a 
drainage outlet, and in due time was removed. The patient 
was able to attend to the dressing of the wound herself after 
four weeks following the operation, and the case progressed 
favorably and rapidly. The wound in the jaw soon closed 
almost entirely, there remaining only an opening just large 
enough to pass a probe through with difficulty. There is no 
deformity of the face. The right eye, with the removal of the 
cause of its protrusion, has returned to its normal position. 
The patient's health and strength have been entirely 
restored, she having gained twenty pounds in weight since 
the operation, and having a greater degree of vigor than 
for years previous. She has been able to pursue her accus- 
tomed vocation for some ten months. 
The remarkable feature of the progress of the 
case after operation was the establishment of sight 
in the left eye. It will be remembered that the pa- 
tient had no recollection of ever having had any de- 
gree of useful vision with this eye, that, so far as 
she was aware, it had been blind from her birth. The 
first indication of incipient visual power in this eye 
was observed on the third day. On the fourth 
or fifth day the patient could count with the 
left eye unassisted, the fingers on a hand held 
at a distance of four feet. In two weeks she was 
able to distinguish objects with some degree of clear- 
ness, and could recognize those about her. By Sep- 
tember the sight had strengthened so that she could 
read the head-lines in a newspaper, two months later 
even small capital letters were easily read, and grad- 
ually, with the aid of a strong glass, ordinary print 
could be deciphered without difficulty. 
This surprising and gratifying result opens up a 
wide field for speculation as to the ultimate and 
proximate causes of the previous blindness of the 
eye, and, as well, the rationale of the removal of this 
defect. Little is hazarded in the conjecture that the 
point of interference with the natural office of the 
optic nerve, was probably at some portion of the op- 7 
tic tract on the right side, since this region was in- 
volved in the territory of diseased tissue, and the 
affected eye was on the opposite side from the lesion 
operated for. It is, perhaps, not necessary to rehearse 
here the anatomy of the parts, a brief study of which 
will show that it is scarcely possible that the malign 
influence could have been exerted elsewhere. 
As to the character of the interference, it would 
seem to have been in the nature of pressure produc- 
ing a form of strangulation, which inhibited the nor- 
mal function of the optic nerve. The history would 
lead also to the suggestion that the beginning of the 
formation of broken-down tissue was made very early 
in the life of the patient, perhaps from a tumor at 
birth, which impinged upon the optic tract, and 
thence extended slowly, passing downward through 
the spheno-maxillary fissure, and by pressure absorb- 
ing and destroying the soft and hard tissues in its 
course, until the posterior wall of the antrum was 
broken down, and the antral cavity itself became 
choked with the products, the attack of la grippe act- 
ing simply as the spark to fire the mine which had 
been so long preparing. The subsequent train of 
symptoms is self-explanatory in the light of the con- 
dition shown by the operation. 
Of course, it would be interesting and instructive 
to be able to determine exactly what was the primal 
factor in setting up the disturbance. The hypothe- 
sis above advanced seems the more reasonable in 
view of the fact that the idea of traumatism is 
scarcely admissible. The possibility of adenoids 
being at the bottom of the mischief may also be ad- 
vanced, but guesses at the remote origin of the diffi- 
culty would now be futile. 
It would be vastly more profitable to consider a 
fact which the operation conclusively demonstrated, 
namely, that resection of the third branch of the 
great trifacial at the foramen ovale, can be accom- 8 
plished in a much more skillful manner than that 
now commonly employed. As is well known to you, 
the usual method is to cut from the outside, and the 
equally usual sequence is an unsightly scar upon the 
face. In the case described I did not resect the in- 
ferior maxillary nerve, but I did curette the necrosed 
bone away from around it, and I could distinctly see 
the nerve and most of the bone which was curetted. 
This would indicate the entire feasibility of reaching 
the third division of the fifth nerve when it is neces- 
sary to resect it at the foramen ovale by operat- 
ing within the mouth. The parts are as readily 
accessible as by external operation, the wound heals 
readily, and no deformity will be caused. In oper- 
ating after the suggested method, it should be borne 
in mind that the wounds in the mucous tissue of the 
mouth are liable to become niduses for the propaga- 
tion of infectious bacteria, and it will therefore be 
necessary to guard against such a possibility by the 
adoption of the proper precautions. This, however, 
is no more than is requisite in the external opera- 
tion.