PRACTICAL CONSIDERATIONS : THE FACE. 243 



important to secure early reposition of the fragments. The relation of the perpen- 

 dicular plate of the ethmoid through the crista galli to the olfactory bulbs and the 

 base of the brain should be remembered in severe injuries to the bones of the nose. 

 Bv reason of this relation suspension or destruction of the sense of smell has re- 

 sulted ; and even septic meningitis and death have followed accidents in which the 

 prominent early symptom was fracture of the nasal bones. 



The 7nalar bones, binding together the maxillae and the cranium, are very strong, 

 and seldom broken unless by severe force directly applied. 



Fracture of the body is apt to run into the orbit, producing a subconjunctival 

 ecchymosis near the outer canthus, and there may^also be a loss of sensation in some 

 of the teeth, the gums, the ala of the nose, and a part of the cheek, on account of 

 injury to, or pressure upon, the infra-orbital branch of the fifth nerve. 



, The zygomatic process is most subject to fracture ; that part of the arch which 

 is on the temporal side of the suture is much weaker and most apt to give way. 

 The deformity may usually easily be recognized by touch. The fragments are 

 always dri\'en inward, and sometimes become entangled in 'the fibres of the tem- 

 poral muscles. The attachment of the strong temporal fascia to the upper edge of 

 the zygoma, and of the masseter muscles to its lower edge, prevents displacement 

 upward or downward. 



The siiperior tnaxilla, on account of its very various and complicated relations 

 (being associated with nine other bones), has considerable surgical importance. Its 

 position in the same vertical plane as the forehead (instead of in advance of it, as in 

 the lower animals ) indicates the limitation of its function to mastication, the need for 

 its use in prehension having disappeared. Many of its diseases (infections, tumors, 

 etc. ) originate in the teeth or teeth-sockets, and may be avoided by early atten- 

 tion to these structures. Others arise by reason of the contiguity of the maxillary 

 antrum to the inferior turbinated bone, the mucous membrane of which is often the 

 subject of chronic catarrh. 



Injuries of the superior maxilla causing fracture must, as a rule, be direct and 

 of considerable violence. The line of fracture may involve the antrum, the nose 

 through the nasal process, the orbit through the orbital process, or the mouth 

 through the alveolar or palatine process. It may also run into the zygomatic or the 

 spheno-maxillary fossa. The force may be transmitted from the malar bone, or from 

 the lower jaw through the teeth. 



The maxilla is very vascular, and hence recovery from even serious or crushing 

 injuries is apt to be rapid and thorough. Like the nasal bones, it has attached to 

 it no muscles that can cause or perpetuate deformity, and therefore, unless it is 

 comminuted, its fragments will retain their position when once replaced. 



It is frequendy"af?ected by " phosphorus necrosis," the osteitis causing the ne- 

 crosis being probably due to the direct toxic action of the phosphorus fumes gaining 

 access through carious teeth. This theory is not undisputed. 



Tumors involving the alveolar border show first in the mouth. Tumors of the 

 body usually occupy the antrum (maxillary sinus). They are apt to grow in every 

 direction except towards the malar bone, where they meet with the greatest resist- 

 ance. They accordingly produce prominence of the eye from pushing upward the 

 floor of the orbit, bulging of the cheek from pushing outward the thin anterior wall, 

 and depression of the roof of the mouth from pressure upon the palatal plate. After 

 the anterior the most yielding wall of the antrum is the orbital. 



Abscess of the antrum gives rise to the same symptoms when it attains a large 

 size. 



The relations of the molar teeth to the floor of the antrum and of the infra- 

 orbital nerve to its roof account for the toothache and facial neuralgia that so often 

 accompany antral disease. It is said to be a fact that cystic distention does not 

 involve the lachrymal duct, while solid tumors may cause overflowing of the tears 

 (Warren-Heath). 



The chief deformity associated with the superior maxilla is cleft palate, which 

 results from a failure of the palatal plates to unite in the median line. The cleft 

 in the hard palate is always median, but when it reaches the alveolus it follows the 

 line of the suture between the premaxillary bone (os incisivum) and the superior 



