DISCUSSION OF OPERATIVE TECHNIQUE AND RESULTS.
Duration vs. Hemorrhage. My first operation required for its completion a little more than three hours, but my ond, something less than two hours ; while Krause," with all his experience in this field, took three hours for one case. Poirier 29 claims to have done his own operation in fifteen minutes on the cadaver, and in fifty minutes on the living subject. Indeed, I have carried out Cushing's technique on the cadaver in less than half an hour ; still, I must agree with Kocher 80 that the time requited for the removal of the glion on the cadaver is no criterion for the same on the living, where the control of hemorrhage must be taken into account. Among others, Krause, and Keen report cases in which the operation had, on account of pro fuse hxmorrhage, to be completed at a second sitting; the wound remaining packed for the few days intervening. To avoid this dual procedure, Lexer 88 had a patient brought into the sitting posture, and was thus able to complete an oper ation in which venous hxmorrhage was so serious that it could not be controlled by plugging the wound.
Just how perplexing and embarrassing this ganglion pper ation may, under certain circumstances, become, is illustrated by the case of in which, on uncovering this structure, the meninges were torn, cerebrospinal fluid deluged the field, profuse hemorrhage commenced, particles of brain substance were lost, and pulse as well as respiration stopped for a time.
It is not without interest to mention in this connection the measures which have been adopted by surgeons who have had the misfortune to tear the middle meningeal artery. Fried rich 35 left a silver probe in the foramen spinosum for two days; Murphy 36 plugged it with catgut, and Lexer," after stuffing this opening with iodoform gauze, allowed the wound to heal over the same.
Importance of the Intact Anatomical Specimen. That I accomplished my purpose and removed both ganglia intact is, as it seems to me, clearly demonstrated by the accompanying illustrations from photographs.
The practical importance of this point appears to us in its true light when we consider Tiffany's 38 statement, made after reviewing 108 cases, that " recurrence after known re moval has not yet been reported." That this structure has, however, not been completely excised in nearly all cases is shown by Marchant and Herbert," according to whom it was accomplished but fifteen times in ninety-five intracranial attacks on the trigeminus. Cushing lays great stress on the removal of the ganglion sufficiently well preserved that it may be subjected to a microscopical examination ; the value of which becomes apparent when it is shown that noted oper ators have removed from Meckel's fossa structures which were found to contain absolutely no ganglion cells. had such an experience with an endothelioma, and Gerard-Mar chant another with a myxomatous growth.
Far from any failure in finding ganglion cells, Tif fany 41 and Monari 42 intentionally left behind that portion of the body which gives rise to its first branch, hoping in this way to avoid corneal ulceration; but the practice has, it seems, fallen deservedly into disuse.
The microscopical examination of my two specimens, kindly made by Dr. Schwab, shows all that can be desired in the way of ganglion cells in both of them.
The Danger in the Operation. The mortality rate has always been rather high in these cases; seventeen of the ninety-five reported by Marchant and Herbert 43 terminated fatally ; while in 128 Krause 44 operations the death-rate was 15.6 per cent., as vouched for by the originator of that well-known method. Bryant 45 quotes Tiffany for a mor tality of 22.2 per cent. in the Io8 cases collected by him in 1896. Carson," with zoo cases, brought Tiffany's table up to the date of his own paper which appeared in 0399; and of these last wo extirpations, but eleven resulted in death.
Other Undesirable Effects. Temporary paralysis of the muscles supplied by the motor-oculi and abducens nerves, as occurred in both my cases, often results from pressure of tampon and spatula; and Richardson 47 claims that it is im possible to protect these structures in every case. Among those who report having injured them are Friedrich," De page," Lexer," and Cushing," most of them men of wide experience in this field. On the other hand, three cases were reported by Friedrich 53 in which there were no eye symptoms ; but in one only had the ganglion been com pletely removed.
Insensibility of the cornea and permanent decrease in the secretion of tears, as mentioned by have, in cases operated upon by Lexer," and others, been productive of a keratitis such as I observed in my first case. In most instances this complication terminated favor ably, though Erdmann 57 was forced, in one to enu cleate the eye in consequence of it. Among other serious manifestations may be mentioned atrophy of the optic nerve, which Gerard-Marchant 58 observed after one of his opera tions.
Marchant and Herbert noted disturbance in taste, smell, and hearing, while Richardson and Walton, as well as Gutierrez," mention decided impairment of speech in con sequence of pressure upon the temporosphenoidal lobe during the operation ; all of these sensory phenomena were noticed to some degree by my first patient. In a case reported by De page," the injury to the brain must have been extensive, as paralysis of one leg and retention of urine supervened.
As a matter of course, the division of the muscles of mas tication, which is unavoidable in the temporal operation, leads to unilateral loss of function ; but this proves of small conse quence, for, as Krause 82 remarks, the patients use in chew ing only the opposite side of the mouth, where the sense of taste is unimpaired ; equally unimportant is the laming of those muscles which are supplied by the motor portion of the tri facial. There is, however, sometimes an unusual limitation of the extent to which the mouth can be opened, as a result of excessive contraction of the scar which is necessarily produced in the substance of the masseter and temporal muscles.
Permanent Results.These have been almost uniformly satisfactory where the operation has been withstood. In one single case reported by Garre," thin nerve strands were dem onstrated in the foramina rotundum and ovale one year after supposed complete removal of the ganglion. Friedrich also had a recurrence in the entire area supplied by the tri geminus, and attempts to explain the same by what he calls peripheral regeneration." In a résumé of this most important aspect of the subject, Keen 64 decides that neuralgia of the original intensity recurs in from i per cent. to 2 per cent., and that a milder form has returned in 4 per cent. to 5 per cent. of all cases.
As far as my two cases are concerned, the therapeutic results can be portrayed in a few words : both patients experi enced violently painful paroxysms shortly before passing under the influence of the anmsthetic, but since awakening from it neither has known one twinge of this most excruciating of all the agonies with which disease racks mankind.