The principles and practice of modern surgery

by Roswell Park

—When all three branches of the trifiacial nerve are involved in painful tic, or when operation has already been practised upon one or more of them and the tic has recurred, it becomes necessary to attack the Gasserian ganglion itself.[45] This may be approached by either one of two methods. Both are difficult and serious, having a mortality of from 15 to 20 per cent. As Cushing has pointed out, however, its mortality rate is scarcely as great as the death rate by suicide in neuralgic cases of this kind. The attack from below was first carefully worked out by Rose and then by Andrews, and is begun in much the same way as the operation for the removal of Meckel’s ganglion by resection of the zygoma, described above. A flap is laid up, larger and wider, including the zygoma, with the most complete possible exposure of the zygomatic fossa. The coronoid process is drilled in two places, divided between the openings, which are to be used for subsequent suture, and the temporal muscle pushed upward and forward, out of the way, with the upper fragment. The foramen ovale is then identified by following into it the inferior maxillary nerve, the base of the skull being cleaned away in that neighborhood, and a small trephine opening made between it and the foramen rotundum, connecting these two openings by a much larger one. Through this opening the ganglion is exposed and destroyed piecemeal or extracted as completely as possible. The operation is exceedingly difficult, and hemorrhage, especially from the middle meningeal artery at the foramen spinosum, maybe so troublesome as to make it impracticable unless the carotid be tied. I have preferred in doing this operation to make preliminary ligation of the common carotid, which facilitates the balance of the procedure. The exposure by this method, however, is not as satisfactory as by that next to be described.

[45] Osmic Acid and Other Treatment of Trigeminal Neuralgia.—While it hardly pertains to operative surgery, it may be worth while to say that it seems to me that no case of trifacial neuralgia should be subjected to radical operation until at least two or three remedies have been given a fair trial. One of these is castor oil its use being based upon the theory that such neuralgia is of toxic origin and that a prolonged evacuant treatment should benefit it. This would mean the administration of two or three good-sized doses of castor oil every day for a period of two to three weeks. It is not such a drastic remedy, thus given, as would appear, for after the oil has once thoroughly produced its laxative effect it ceases to distress, but serves as a very effective eliminant. The second remedy is gelsemium, the best preparation being the tincture of the green root. It seems to exercise a selective affinity for the trifacial nerve. It should be given in large doses, pushed to the physiological limit, i. e., until the patient begins to see everything in yellow colors. Its effect on the heart must also be guarded. Fifteen drops of the green tincture given every two hours, and for a few days, will usually suffice to thoroughly test its efficacy.

Osmic acid is used only for intraneural injection, its efficiency now being under trial. Ten to twelve drops of a 2 per cent., freshly prepared aqueous solution are directly injected into the nerve trunk after its exposure. Murphy has been its particular advocate, and has reported relief of pain in a number of cases thus treated. It seems to depend for its effect upon two factors—the destruction of nerve filaments and their substitution by connective tissue. All the nerve branches that can be exposed should be injected; the palatine and lingual through the mouth; the intra-orbital and supra-orbital by incisions upon the face; orbicular-branches, as well, should be injected, if possible. Most of those who have used it advise also to inject a few drops into the foramina of exit, around the trunks, which are thus infiltrated with the solution. The procedure is painful and usually requires a general anesthetic, but it seems to be free from danger. While the treatment has been successful in some cases it has been equally disappointing in others, and the method will scarcely supplant the more radical method of ganglion exsection.

Hartley and Krause, about the same time and independently, devised a method of attacking the ganglion, after raising an osteoplastic flap from the side of the skull, which affords a better exposure and a more satisfactory method.

Within reason the larger the osteoplastic flap the easier the balance of the operation. Whether it be square or horseshoe in shape, whether it be made by chisel, by Gigli saw, or by surgical engine, matters little. In fact experience has shown that the conservation of the bone is not a matter of serious import, and there is no good reason why there should be any hesitancy to remove the bone should the formation of such an osteal flap present too many difficulties. After the dura is completely exposed it is to be separated from the base of the skull until the foramen spinosum and middle meningeal artery are reached. It is better to do this quickly and with the finger than slowly with instruments. After this separation the brain with its dural covering is lifted by a spatula or retractor, so as to afford a good view of the region of the ganglion. It will be necessary to double ligate the middle meningeal artery unless preference has been given to make a preliminary temporary or permanent ligation of the carotid. Should this artery have been injured in raising the flap it should be secured before going any farther, either by plugging the opening or canal with gauze or with antiseptic wax ([Fig. 401]).

The upper surface of the ganglion is adherent to the dura, and these adhesions should be separated. The second and third branches should be identified and divided near their exit. The first branch is in too close relation with the cavernous sinus to justify much interference. The ganglion itself is then seized, after complete isolation, with forceps and evulsed, with as much of its longer and shorter roots as possible. Hemorrhage is checked by adrenalin or by pressure with gauze, as may be required. If gauze be used for the purpose it may also be utilized for drainage. The brain is restored to position and the flap sutured in its proper place.

Before doing either of these operations I should prefer to place the patient within the Crile pneumatic suit and then tilt the body to an angle of at least 45 degrees, thus prompting emptying of the cranial and cervical veins by gravity, while at the same time blood pressure is maintained by the pneumatic pressure (see [p. 180]).

Abbe has endeavored to lessen the shock of the operation by not formally tearing out the ganglion, but by taking out a section of the nerve trunks between it and their foramen of exit, and then interposing a piece of thin, sterile, rubber tissue, inserting it in such a way that it shall effectually prevent regeneration of nerve trunks across the interval, this rubber being intended to remain and become encapsulated. This method of Abbe seems to have made operative attack upon the Gasserian ganglion less formidable and less dangerous. It remains to be seen whether it is permanently as effective as more complete extirpation.

The Lingual Nerve.

—In some cases of cancer of the tongue there is such intense pain that not only has the lingual artery been tied but the lingual nerve been stretched or exsected. It can ordinarily be reached where it lies on the floor of the mouth beneath the mucous membrane, at the fold between it and the tongue, where it can be felt if the tongue be forcibly stretched. Through a small incision a blunt hook may be passed and the nerve thus secured. Close to the first lower molar the nerve lies in the tongue near the surface, where it can also be found.