vent the occurrence of post-operative hernia are in error," then it seems to me the prevention must lie in better methods of making abdominal incisions.

Three things are necessary in the choice of an abdominal incision. It should be so placed as to avoid important nerve trunks and vessels, while giving easy access to the pathology, and it should permit of firm closure under conditions that will prevent hernia. It is more important to avoid cutting intercostal nerves than the blood-vessels already mentioned. The anastomosis of the bloodvessels is rich and their severance does not amount to much. They, of course, should be avoided when possible. But the cutting of an intercostal nerve may cause atrophy of the muscular structure which which it supplies and thus cause a weakening of the abdominal wall.

In making incisions, if we cut the aponeurosis and split, not cut, the muscles, we will give additional strength to the abdominal wall. We will fail to cut also nerves and bloodvessels which lie in the plane of the

The six lower intercostal nerves run in a general direction corresponding with the direction of the ribs between the internal oblique and the transversalis muscles until they reach the outer edge of the recti, when they penetrate and cross at practically a right angle.

Madelung showed in 144 cases collected from the literature and from seven cases of his own (to this I can add one case of my own) that the abdominal incision had bursted open at various times, up to and including as late as the seventeenth day after laparotomy. This has occurred in both sexes of every age, and after all sorts of abdominal conditions. Low incisions and median rather than lateral have been the worst offenders. The eighth or ninth day is shown to be the critical time. It has occurred after the use of every kind of suture material and after every kind of closure. The principal factor in its cause is coughing.

If we believe Madelung when he says, "Those who believe that the use of a certain material or of a certain form of suture will successfully pre

recti run in a diverging or in an oblique direction from the linea alba, and that their fibers can be readily separated in cross or oblique incisions, then the advantages of such incisions must be readily conceded.

The best incision for the pelvis is without doubt that of Pfannenstiel's. The incision is made transversely through the skin, fat, aponeurosis of external oblique and external sheath of the recti muscles, about an inch above the pubes. The internal oblique is split transversely, in the direction of its fibers. Then the recti muscles are separated in the median line, or either one may be split longitudinally. No blood-vessels or nerves of any importance are encountered. The opening of the aponeurosis and muscular structure run in different directions, almost at right angles to one another, thus practically insuring the prevention of ventral hernia. It permits of a very strong closure. The entire aponeurotic opening is underlaid with solid muscle except at the small point where the longitudinal opening between the two recti cross. The muscle layer is overlaid by a solid heavy aponeurosis except at the small point.

The action

pelvic work.

The incision through the skin is usually made below line of hair; when the hair grows the scar is concealed. This is especially marked when the patient has a plentiful supply of hair. I have patients in whom it is almost impossible to say from the abdominal appearance that they have undergone an abdominal operation. There is an undoubted value in the concealing of scars, particularly in young unmarried females. Pfannenstiel has reported more than a thousand such incisions without a hernia, Amann has had more than twelve hundred, and I have thirty-eight.

As far as the avoidance of nerve and vessels are concerned, the Kustner incision, which divides the skin and fat transversely and the fascia longitudinally, has no advantage. The fact that the appendix is now usually removed at the time of abdominal incision for pelvic trouble need not be urged as a disadvantage. In only one of my cases had I difficulty in its removal, and in this case the appendix lay up behind the cecum. In this case it was necessary to make an additional

McBurney incision in order to remove it. In this case the appendix could not have been removed through the usual median incision.

In my thirty-eight through this incision almost every variety of pelvic work was done, including extrauterine pregnancy, hysterectomy for fibroids. and anterior suspension of the uterus. In such cases I always use Amann's method, in which the round. ligaments are shortened by way of the internal inguinal openings. I have never used a true Gilliam, which I consider a very poor substitute for the original, namely, Amann's. For the removal of the appendix in all ordinary cases a cross incision is equally as good as the McBurney. The fascia and skin are cut crosswise and the muscles are readily separated, giving plenty of room. I can see no advantage here, as far as cosmetic effects are concerned, in the cross incision over any other incision. W. J. Mayo's transverse incision and closure for umbilical hernia is in accord with the facts here presented. Its success proves the truth of the principle involved. Professor Peterson's transverse incision of the skin and subcutaneous fat down to the fascia and then lateral oblique incision for AlexanderAdams operation recognizes also some of the advantages already spoken of.

Through this incision the following operations have been done:

Subserous fibroids removed..

what he has said. I have used this incision for a number of years and have not yet seen the formation of a hernia, although in four cases there was a disturbance of wound healing. There is, however, a limit to the use of this transverse incision, and that is the limited space which it affords. Let us take, for instance, the larger tumors, those that extend upward as high as the umbilicus, and we find that they are not as easily removed through this incision as they are through a longitudinal incision, but outside of this fact the advantages in my mind are all in favor of this transverse incision, and I hope that as a result of the paper of Dr. Walker the profession will more frequently use this latest incision.

DR. WALKER (closing): I was very much interested in the remarks of Dr. Gellhorn, and I wish to say that we can remove very large tumors through this incision, and we can, in my judgment, go still further and by means of the transverse incision reach the stomach, the pancreas and gall-bladder. But I would not undertake to say that we can reach the kidney, in every instance, as it depends entirely upon the character of the kidney lesion and how it is located. It has struck me since using this incision that it has many advantages over the other incisions in doing a majority of the operations in the pelvis.

3 times

2 times

3 times

1 time

SOME REFLEX NEUROSES ARISING FROM OCULAR AND NASAL ABNORMALITIES.*

IT

BY J. A. STUCKY, M.D.,

LEXINGTON, KY.

T cannot be doubted that "the more refined we become in the crucible of civilization, the more we pay th penalty of that civilization, through the neurotic tendencies which we either inherit or acquire," hence our reflex neuroses are not the property of the primitive man, but of the civilized. The strenuous life we lead in our ambition to surpass all rivals and associates causes us to "burn the candle at both ends," frequently resulting, in one way or another, in over-tension or neurasthenic conditions.

"Many causes have been suggested for the various reflex nervous disturbances originating in peripheral end-organs, but the locum tenens of the exciting cause has often proven an illusion. The eye is conceded to be the most important etiological factor in many of the systemic reflexes by our most careful scientific observers, and only in the last few years has attention been given to the nasal origin of systemic reflexes."

Stoewer states that many reflexes are cured by the removal of painful scars or points of irritation. from the nose and ear, and Starr concedes that local spasmodic twitchings of the head and neck may possibly be caused by naso-pharyngeal irri

tation.

*Read before the Thirty-fifth Annual Meeting of the Mississippi Valley Medical Association, October 11-14, 1909.

A point made by Ziegler and often confirmed by me, is "that many ocular symptoms are duplicated or caused by intranasal lesions," and there is a "deadly parallel" of reflex symptoms that will tax one's diagnostic ability as well as his intuitive insight to properly locate; cases in which we have to eliminate the ocular element by exclusion before proceding with the nasal treatment.

The three most active etiological factors in the nasal cavities that I have found to be the cause of these perverted or reflex nerve impulses are: 1. Pressure contact.

2. Hyperesthesia.

3. Nasal obstruction.

1. The most important and the most frequently found causative agent is the middle turbinate, the least pressure against the septum, antral wall, or inferior turbinate causing chorei form twitching of the eyelids, spasmodic movements of the face, head and neck, but more frequently it produces intense frontal headache, eyeache and mental depression.

2. Nasal hyperesthesia is caused usually by systemic disturbance, lithemic in character, resulting in irritation of the tubercle of the septum, leading to vascular dilatation, causing pressure contact against the middle turbinate. Irritation of this sensitive area is so provocative of eye trouble that Ziegler has named it the "eye spot of the nose." Touching with probe often precipitates a supraorbital neuralgia, eye pain, lachrymation, and other evidences of reflex irritation. There can be little doubt that when a hyperesthetic area is infringed upon by pressure contact some reflex disturbance is produced. If the middle turbinate is the cause of this pressure, it must be removed or broken and

set over.

3. Nasal obstruction. Any interference with free nasal breathing through the superior portion of the nose necessarily results in interference with ventilation and drainage of the accessory sinuses, increasing the sensitiveness of the whole system and rendering it more liable to reflex disturbances.

A prominent business man consulted me some months ago, suffering with twitching of the upper eyelid and blepharospasm, rhythmic in character, with decided drooping of the upper eyelid. He had consulted his family physician, who referred. him to an oculist. The latter, finding no refractive error, or any ocular cause for the trouble, referred him back to his physician, who in return referred him to a neurologist. Thus he was "driven from pillar to post" for several weeks, his trouble growing no better, and his nervous system considerably worse from anxiety, uncertainty and embarrassment, caused by the conspicuousness of his affliction. The middle turbinate was found to be pressing hard against the septum and inferior turbinate, and when I removed this pressure relief was very prompt. I have had several other cases similar to this, who were annoyed by spasmodic

twitching of the eyelids and embarrassed by their unintentional making of wry faces, which were due to intranasal pressure.

I have relieved several children of "habit chorea" by correcting a refractive error and removing adenoids. The relation of eye-strain and nasal abnormalities to chorea is recognized by Ranney, Stevens, Cheney, Starr, Gray, Wood, Weir Mitchell and Osler.

Many gastric neuroses can be attributed to eyestrain and nasal abnormalities, especially that form of the latter which interferes with free and unobstructed ventilation and drainage of the nasal accessory sinuses, causing a hypersecretion of mucus, which drains posteriorly into the pharynx and is unconsciously swallowed, and gastric digestion is thereby impaired.

The relation of eye-strain to neurasthenia is generally recognized by neurologists, but the nasal origin of the exciting cause of this condition is not appreciated as it should be. Pressure-contact and obstruction to free breathing may cause lowered oxidation and faulty metabolism, and abnormal systemic balance can only be re-established by correction of these physical defects. Neurasthenics are more liable to suffer from insomnia and sudden wakefulness when there is nasal obstruction or interference with ventilation of the superior sinuses. of the nose. This arises from lowered oxidation in the same way that we are awakened by the sudden closeness of the atmosphere in a bedroom. I have records of five cases of amblyopia, three of whom had such marked choked disks, such persistent headache and frequent attacks of vertigo, that cerebral tumor was suspected. All of these were entirely relieved of the pain and vision restored by removal of the middle turbinate and relieving the sphenoid sinus and ethmoid cells of pus and granulations.

I have already reported one case of ophthalmoplegia externa which was entirely relieved by the radical operation of Killian upon the frontal ethmoid and maxillary sinus. Since reporting this case (1907) I have had one other of the same kind, in which the ethmoid and sphenoid alone were the cause. This case recovered most satisfactorily by cleaning out the pus, polyps and granulations from these cavities.

It is not difficult to account for the serious ocular disturbances resulting from intranasal and sphenoid sinus disease, after what has been proven by the exhaustive work of Onodi-Zuckerhandlug and Loeb, who have shown the close and intimate relation of the optic nerve with the sphenoid bone and the posterior ethmoid cells, and it is difficult to comprehend how this nerve can escape involvement in affections of this sinus, as the separating layer of bone is frequently as thin as paper and contains. many dehiscences. The involvement may vary from a simple edema to an active retrobulbar inflammation. Next to refractive errors and other ocular

defects, I believe nasal abnormalities to be the most prolific cause of migraine, and in cases of this disease the nose as well as the eye should be carefully examined. Just here let me say that a thorough examination of the nose for diagnostic purposes cannot be made without first spraying the nose with a weak solution of adrenalin, 1 to 7,000 in normal saline solution. The pressure-contact may be so small, or situated so far back of the anterior portion of the middle or inferior turbinate, the mucous membrane so swollen, that the point of irritation or adhesion will be easily overlooked without the use of this agent. In many cases it takes very little to block the small openings through which the accessory sinuses are ventilated, and the oxygen of the imprisoned air is slowly absorbed by the lining mucous membrane, creating a rarefied condition and resulting in a negative pressure and consequent swelling of the lining membrane and an increased blood supply to this region. Venous stasis and pressure of the congested tissue on the nerve endings result in the reflex vasomotor disturbances in the circulation of the neighboring structures. As a result of this interference with the interchange of air between the nasal chambers and accessory sinuses we have sub-oxidation, pain and neuroses. I have already written and published my observations of the mental depression and melancholia resulting from intranasal and nasal accessory sinus disease, and closer clinical observations convince me that this subject has not as yet received the investigation and publicity from our clinicians and pathologists that its importance justifies. The relief of the condition referred to in this paper is amenable either to surgical or systemic treatment, often both being necessary to bring about the desired result.

As pointed out by Ziegler, the salient points to be borne in mind when searching for the exciting cause of reflex neuroses are:

1. The eye and nose are most important factors in the etiology of reflex neuroses, and should, therefore, be thoroughly examined and positively excluded before beginning a search for other causes. 2. Ocular and nasal reflexes possess many manifestations in common, which should be carefully differentiated at the earliest possible moment.

3. Eye-strain, whether from ametropia or subnormal accommodation, should be accurately corrected in order to eliminate the eye as a causative factor.

4. Pressure-contact in the nose will always excite some reflex disturbance when any hyperesthetic area is infringed upon, and should, therefore, be eliminated.

5. Every obstruction in superior part of nose to free breathing should be eliminated.

6. Recurrence of any reflex neuroses demands re-examination and renewed search for the original exciting cause.

7. Lithemic conditions and faulty intestinal metabolism should be carefully considered in every case of reflex neuroses, whether arising from ocular or nasal abnormalities.

DISCUSSION.

DR. S. L. BERNSTEIN, Cleveland, O.: I want to emphasize particularly one point, i.e., the removal of adenoids in chorea. In a number of cases within the past few years the removal of adenoids has been the only means of curing the patients, with the addition in one or two cases of the care of the teeth. The salicylates, arsenic, relief from school work and relaxation of tension were of no avail. I ain very much pleased with the doctor's paper, in that respect particularly.

DR. FRANK P. NORBURY, Kankakee, Ill.: I would take exception to one statement made in the paper, i.e., in regard to migraine following nasal obstruction. If the doctor had said neuralgic pains, I would agree with him. In my experience with migraine I would hesitate to say that nasal obstruction was a factor. Migraine is a family neurosis accompanied with metabolic changes, rather than any local condition or change. Neuralgic conditions are often the result of nasal obstruction. A case I saw last winter was due to some irritation of the trifacial nerve, and was relieved by an operation on the nose. In regard to mental disease associated with nasal obstruction, I would question whether nasal obstruction is a factor in the production of melancholia excepting in a contributory way. Taking into consideration what alcoholism means in its full scope, I would say that nasal obstruction would not have much bearing on the production of that condition.

DR. H. N. MOYER, Chicago, Ill.: If we take Dr. Stucky's paper as emphasizing the importance of the relations of the nose and accessory sinuses to certain disorders, and the value of investigating this question, I would consider the paper highly valuable. He tells us to look for certain nervous reflexes, but just what he means by "reflex" as used in the paper, I do not understand.

I have never seen a case of migraine that was due to eye strain or nasal obstruction. It is barely possible that when Dr. Stucky says migraine he means merely a neuralgic headache. Migraine is a paroxysmal headache, beginning usually about puberty, often accompanied by marked constitutional disturbance; the headache is usually one side, and in 90 per cent. of the cases there is a marked heredity. There are free intervals between the attacks. It is incurable, but tends to get well spontaneously at about the age of forty-five.

That headaches are caused by intra-nasal conditions, I believe. The accessory sinuses are the cause of very grave maladies.

DR. STUCKY (in closing): Dr. Bernstein spoke of the effect of removing adenoids in choreic children. I do not think it is the presence of a stenosis alone in the posterior nares that produces the trouble. These children already have nasal obstruction that is more than mechanical. The little sinuses just in the state of development I believe have this suboxidized condition, causing a negative pressure, and