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Excision of the Intact Gasserian Ganglion

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EXCISION OF THE INTACT GASSERIAN GANGLION.

Fallopius was the first to discover that the fifth cranial nerve is divided into three peripheral portions. It was noted later by Meckel and Vieussens that a certain flattened struct ure marked the point of division; but it remained for Hirsch to recognize, in 1765, this body as a ganglion, and to it he gave the name "Ganglion Gasserianum," in honor of his noted teacher, J. L. Gasser.

The ganglion was until 1890 numbered among the few bodily structures which had not yet been made the object of the surgeon's endeavors. On April 2 of that year, however, William Rose,' as Pickering Pick 2 says, instituted its re moval in the treatment of trifacial neuralgia. Two years later, after painstaking investigation, Fedar Krause pointed out the therapeutic indications in intractable cases and ad vanced a practical operative technique. Of the Altona sur geon, no less an authority than Konig writes " dann aber gebiihrt Krause (1892) das Verdienst dieselbe auf grund ein gehenden Studiums vertieft und ausgebildet zu haben." It is not my object in this paper to define trifacial neu ralgia nor to classify cases; it is enough for practical purposes to understand that we are called upon to treat a certain num ber of individuals suffering from so-called " tic-douloureux" of such intensity that all means other than surgical fail to re lieve them. In such cases we may interrupt the continuity of the fifth nerve by (a) dividing its branches between the gan glion and the skin, by (b) cutting the sensory root between the brain and ganglion, or by (c) removing the latter. Which course is to be chosen? (a) The peripheral procedures, while of less immediate danger, have proven of very doubtful benefit. Fowler 5 found that recurrence within three years failed in only eight out of fifty-two extensive resections of the second division; while Wagner ° concludes that but 32 per cent. of all who undergo any sort of superficial operation are permanently cured. (b) Section of the sensory root as proposed by Horsley 7 can be scarcely less dangerous than the removal of the ganglion; and besides, if "reasoning by analogy" is permissible here, we could, in view of the resemblance that exists between the Gas serian ganglion and a spinal ganglion, expect no lasting bene fit from a division of the root. We were long ago taught, as a result of experiments made by Waller, Bernard, Kahler and Singer, and Muenzer, that the posterior spinal root regen erates from the ganglion towards the cord ; while very recently Baer, Dawson, and Marshall 8 demonstrated on seven dogs that the second cervical posterior root became reformed after division with a ligature. (c) As a purely anatomical deduc tion, we have left then but one course, viz., removal of the ganglion, if a permanent cure is to be expected. And, indeed, clinical observations have borne out the truth of such a con clusion. Professor von Hacker 9 was compelled to resort to this procedure in a for the relief of which he had per formed no less than nine peripheral operations; while Hutch inson 10 goes so far as to say that nerve resection has no place in severe cases. The indications for removal of the ganglion, as classified by Tiffany " after a study of to8 cases, are (a) the involvement of more than one branch, (b) the presence of pain in an area which receives its nerve near the latter's point of exit from the skull, (c) paroxysms which are not the expression of constitutional or cerebral disease, (d) the fail ure of all other therapeutic measures.

Different surgeons have undertaken the operation in various ways, some entering the middle cranial fossa from the side, others by cutting an opening through the roof of the zygomatic fossa. In my choice of an operative procedure, I was influenced against the latter route, which is the most direct way to the ganglion, by the fact that so many vessels and other important structures must be encountered before the skull cavity can be opened; it may be further noted that it is hardly possible to completely expose the ganglion and remove it intact by this method. To arrive at such a conclu sion one has but to study the proposals of Rose," Doyen," Poirier," Jacob," and that of Quenu and Sebileau, so warmly endorsed by Tichonowitch 18 in his prize essay of recent date.

On the other hand, the high temporal operation devised independently by Hartley 17 and Krause 18 has as its chief drawback frequent and troublesome involvement of the middle meningeal artery ; and this is said with full knowledge of the fact that Krause," in answer to the criticism of Tichono writes that after following his own method twenty two times, he still considers it better than any other.

I elected Cushing's 21 inferior temporal procedure as eliminating the chief disadvantages possessed by the older temporal and infratemporal methods. Here the main point in the technique is the making of an opening so low in the tem poral fossa that the removal of the ganglion can be accom plished without the danger of injury to the middle meningeal artery ; a feature which Dollinger 22 has shown to be possible in 94 per cent. of all skulls. Thus preliminary ligation of the external carotid, as practised by Davis 23 and Spellissy 24 in their intracranial operations, is rendered unnecessary.

1. Mrs. S., sixty years of age, native of Ireland, con sulted me in September of 19oo for left-sided trifacial neuralgia ; paroxysms of which had rendered life almost unbearable for about seventeen years. At first the temporal and supra-orbital regions only had been affected, but a few years later the area supplied by the second branch became involved ; at no time, however, had she experienced pain in that part of the face to which the inferior maxillary nerve is distributed.

My patient had had a hard fall on the side of the head twenty two years earlier, a circumstance to which she attributed her malady; and during the past seventeen years had experienced attacks of two weeks' duration, alternating with intervals of about the same length, free from pain. As is so common in these cases, she had submitted, some fifteen years before, to the extraction of all the teeth on the affected side, but without relief. In the fall of 1898 evulsion of the infra-orbital branch was performed, and for a period of ten months she remained free from pain; but at the expiration of this time the agony recommenced in the regions previously affected.

When I first saw her, her sufferings were terrible to witness. Every two or three minutes, a paroxysm, lasting one minute, would seize her, and during these periods tears would stream down her cheeks, while she rocked too and fro, giving vent to moans expressive of feelings which could not be mistaken. When I proposed to her excision of the ganglion and revealed the dan gers attendant thereon, she assured me, by way of reply, that she were better off dead than alive, if such torture had to endure.

On October io, i9oo, she was chloroformed at St. Anthony's Hospital, and a horseshoe-shaped incision made ; the base of it resting on the zygoma, and its highest limit but little above the helix of the ear. The zygoma was chiselled off at both ends, re tracted downward with the soft tissues, and the lower portion of the temporal fossa opened with a chisel and rongeur forceps. The middle meningeal artery was plainly seen crossing the opening, and could be followed to the foramen spinosum, so was not in jured. Excessive venous hmmorrhage followed the separation of the dura from the bony floor of the middle cranial fossa, and, to complicate matters, an unusually large bony prominence had to be cut from the floor before the foramen ovale could be exposed.

The dural envelope of the ganglion was attacked at the fora men rotundum and split as far as the foramen ovale, then the superior layer was dissected up, completely exposing the body of the ganglion with its sensory root and three branches. The edges of these structures were freed by blunt dissection and a thin spatula introduced beneath the body of the ganglion, tearing it loose from the underlying portion of its envelope. The ganglion was now grasped in a locking forceps, especially curved to con form to the floor of Meckel's cave ; but at this point I departed part of its sensory root, at the same time tearing it from the first branch as Krause 25 advises. I feared to cut the first branch, as I had at no time been able to assure myself of the exact location of the nervus abducens, which I did not care to risk dividing.

Accomplishment of the steps just detailed was most tedious on account of constant and profuse venous hxmorrhage, which necessitated repeated packing and the loss of much time; but having finally assured myself that Meckel's cavity was empty, the soft parts were united with through-and-through silk sutures, a small gauze drain being left because of venous bleeding which could not be entirely checked.

The drain was removed twenty-four hours later, the stitches taken out on the fifth day, the patient sat up on the seventh, walked several blocks on the fifteenth, and travelled a distance of ioo miles to her home on the eighteenth day after operation. She was naturally gratified by the knowledge that an area of tactile, thermic, and pain anmsthesia coincided with the region which the fifth nerve had formerly supplied.

For four weeks after the operation there was complete paralysis of the muscles to which are distributed the third, fourth, and sixth nerves. Three weeks later, she had so far recovered the use of them that the eye was open as widely as its mate, and vol untary movements of the ball in every direction were possible, though a little jerky.

About this time a small superficial ulcer of the cornea ap peared, and at the expiration of three weeks more showed very slight disposition to heal, but had fortunately led to no involve ment of deeper structures.

On February 5, Igor, Dr. A. E. Prince, of Springfield, Illi nois, informed me that the cornea had been entirely restored.

I draw from this experience the practical conclusion that it is well to protect the eye for a much longer period than is com monly done.

II. November 26, i9oo, I was consulted by Mrs. R., a white woman, aged fifty, American by birth. From notes made at the time I take the following. Patient is in a poor state of nutrition and presents the haggard appearance of one who has been a constant sufferer. She has been for many years a victim of toothache on the right side, which, Bryant 26 writes, is twice as frequently affected by neuralgia as is the other. A part of the time, the portion of her scalp, which is innervated by the trifacial, has been the seat of darting pains which made her think of flashes of lightning. At times the area supplied by the third branch has been involved, though not to the same degree as have the other two. The teeth on the right side were extracted with temporary benefit, the pain, when it returned, being referred chiefly to the toothless gums. The marked effect of cold, damp weather on this woman's sufferings reminds one in a measure of Spellissy's 27 case of a blacksmith who became suddenly chilled after hard work over his forge, and in whom the disease later assumed so aggravated a form that surgical treatment became necessary.

A singular feature of my patient's affliction was that it was worse every second day ; paroxysms being induced by hot or cold drinks, a sudden draught, the jar of a street-car, and the con tact of her feet with the pavement in walking. So sensitive to every irritation was the mucous membrane of the mouth, that she had been unable to take solid food for almost two months, and had in consequence become greatly emaciated, as mentioned above. In addition to these physical inroads, the pain had so affected her mental condition that friends had noticed her speech becoming irrational ; and, indeed, she could scarcely describe her sensations to me, for, in her own words, "the thoughts would scatter at the very attempt." On November 27, i9oo, the Gasserian ganglion was removed at the Deaconess Hospital, chloroform being the anaesthetic used ; the operative technique in every particular resembling that em ployed in my first case. Hxmorrhage was less in amount and better controlled, consequently this operation was of much shorter duration than the other. This wound was sewn up without a drain ; there was no perceptible shock, and the patient made a perfect recovery. On the fourth day the stitches were removed, on the sixth the patient sat up, and on the seventh left the hos pital. Later she developed a troublesome suture sinus infection, which, however, resulted in no permanent harm.

Since the operation this woman's aspect has changed com pletely; the drawn, pained expression has given place to one of repose, and her weight is increasing now that she can eat all kinds of food.

The motor derangement about the eye is identical with that observed in my other patient ; but the cornea is intact, and no evidence of change in any of the special senses has manifested itself.

As in my earlier experience, the perception of tactile, thermic, and pain stimuli is entirely wanting in the skin, to which the tri geminus was formerly distributed.

On the 12th of May, isoor, I was informed that the patient's eye had opened of its own accord, during the previous week, for the first time since the operation.

time, operation, pain, root, patient, nerve and branch