Surgery of the Gasserian Ganglion, with 
Demonstration and Report of 
Two Cases. 
Stenographic report made at the meeting of the Mississippi Valley Medical 
Association, at St. Paul, Minn., September 15,1896. 
J. B. MURPHY, M. D., 
CHICAGO, ILL. 
REPRINTED FROM WESTERN MEDICAL REVIEW, OCTOBER, 1896. 
LINCOLN: 
Western Medical Review Publishing Co. SURGERY OF THE GASSERIAN GANGLION, 
WITH DEMONSTRATION AND REPORT 
OF TWO CASES.* 
J. B. MURPHY, M. D 
In speaking of the surgery of the gasserian 
ganglion, I will confine my remarks largely to the 
technique of the more recent operation, after re- 
viewing some of the results of operations which 
have preceded or led to the operation which is 
adopted at the present time. The gasserian gan- 
glion, situated, as it is, on the petrous portion of 
the temporal bone, is in a very inaccessible posi- 
tion. It is desirable in some cases to remove this 
ganglion for the purpose of curing intractable 
neuralgias of the facial nerve, or what is com- 
monly known as migraine. As you know, all 
methods of treatment by internal medication with 
all the varieties of anodynes, and more recently 
the medical treatment now in vogue, large doses 
of castor oil, have failed. If a case had been re- 
lieved by the anodyne treatment, it was only tem- 
porary, and was followed by another attack of 
increased intensity. The operations for its relief 
may be classified as follows: 1. Division of the 
branches of the trifacial in the face or mouth. 
2. Division of the nerves at the base of the cra- 
nium (Kroenlein). 3. Extraction of the ganglion 
from the base (Rose). 4. Intradural extraction of 
the ganglion (Horsley). 5. Extradural excision 
of ganglion (Hartley-Krause). The operation 
most effectual and least dangerous before the 
present one (Kroenlein’s) consisted of division of 
the zygomatic process, turning it down with the 
CHICAGO, ILL. 
* Stenographic report made at the meeting of the Mississippi Valley Medical 
Association, at St. Paul, Minn., September 15, 1896. 2 
most important muscle, dividing the coronoid pro- 
cess of the inferior maxillary, dividing the tempo- 
ral muscle and reflecting it upon the cranium, 
finally dividing the nerve at the base of the cra- 
nium, that is, dividing the third branch of the 
nerve at the foramen ovale and the second branch 
at the foramen rotundum. The operation was 
almost as extensive and, if not as dangerous, was 
more difficult than the operation for the removal 
of the ganglion itself. The results with this oper- 
ation were only temporary relief in a very large 
proportion of cases; for that reason it was deemed 
advisable to attack the nerve within the cranium. 
Dr. Rose, of London, in 1890, was the first to open 
the cranium from the base. He followed the same 
procedure as Kroenlein, making a division of the 
parts mentioned, passing into the base of the cra- 
nium at the foramen ovale, and chiseling out an 
opening sufficiently large to permit of the extrac- 
tion of the ganglion through the opening. The 
opening was necessarily small, consequently the 
operator had very imperfect light, and it was very 
uncertain whether the ganglion was extracted in 
toto in any of these operations. The Rose method 
was performed, I think, for the first time in Amer- 
ica by Dr. Edmund Andrews of Chicago. He has 
performed the operation three times. On account 
of the difficulty and dangers of this operation, 
coupled with the uncertainty of incomplete ex- 
traction of the ganglion, it was necessary to aban- 
don the procedure. The next method was devised 
by Victor Horsley, of London (1891), who reasoned 
that as the ganglion was situated between the 
two layers of the dura, with its roots on the inner 
side of the dura at the base, it could best be 
reached by incising the dura and elevating the 
convolutions. In the Horsley operation an open- 
ing should be made in the cranium above the zygo- 
matic arch, with a horseshoe-shaped osteoplastic 
flap; finally incise the dura and elevate it with a 3 
retractor, as I show you here. Pass this long 
curved retractor beneath the convolutions and 
gently elevate the brain, so that the ganglion and 
motor root on the inner side can be reached and 
extracted from the side of the medulla. We can 
readily see that this is a difficult procedure, as the 
brain is not a resisting substance and the retract- 
ors tear or lacerate the brain tissue before the 
ganglion is exposed at its base. The operation 
was performed by Horsley with a fatal termi- 
nation. 
In the latter part of 1891 Frank Hartley, of 
New York, conceived the idea of attacking the 
ganglion from within the cranium and without 
the dura. This is the operation to which I shall 
direct your attention to-day, and is the one which 
I will perform, with the assistance of Dr. Mayo, 
so that you may see how readily the ganglion and 
root of the nerve can be reached and extracted by 
this method. 
We will next consider the dangers of the opera- 
tions. In the operation from the base (Rose’s op- 
eration) the dangers were found to be hemorrhage 
and infection; in the majority of fatal cases found 
in the literature on the subject, infection was due 
to injury to the eiistachian tube, as the channel 
which the surgeon follows in getting to the base 
of the cranium at the foramen ovale is in close 
proximity to that tube. The mortality of the op- 
eration was eighteen per cent. In Horsley’s oper- 
ation there was danger from hemorrhage, infec- 
tion, and mutilation and laceration of the brain. 
He performed the operation once and the patient 
died six hours after. 
We will now consider briefly the technique of 
the Hartley operation. In this operation, after 
we have made our incision through the skin and 
exposed the bone, we chisel an opening through 
the cranium, and if we have a De Yilbiss instru- 
ment we can remove as large a piece of the era- 4 
nium as we desire, in a very short time. The 
chisel of Hartley or Krause's saw, which is very 
convenient, may be used. The De Vilbiss instru- 
ment lias the advantage that it does not cut the 
dura when the instrument is pressed; when it 
is opened it pushes the dura out of the operative 
field. Last week I used it in excising a large de- 
pression in the skull. It worked admirably and 
Fig. I.—Primary incision. 
saved time. Make an omega incision (see Fig. 1) 
in the flap and cut the bone so that the base of the 
other incision will be just above the zygoma; ele- 
vate the bone and its fractures below the level of 
the zygoma. Press the Kocher blunt dissector be- 
tween the dura and bone, lift the bone gently, and 
push the dura back. As soon as this is done we 
are liable to have hemorrhage from the middle 5 
meningeal artery. Should this occur we can com- 
press the bone with forceps or push the artery into 
the canal and introduce a catgut plug. The hem- 
orrhage from the dura is considerable when the 
flap is elevated. The flap is now turned down and 
allowed to remain. As soon as the bleeding has 
ceased, pass the linger along beneath the dura, 
gently elevating it until the base of the fossa is 
reached. At this stage there is profuse hemor- 
rhage from the vena santorini and the arteria 
meningea media. This artery occasionally enters 
the base through a separate foramen, and has been 
ruptured in elevating the dura from the bone. 
Whenever rupture takes place the foramen should 
be packed with catgut and allowed to remain. 
The venous hemorrhage may be so excessive that 
it may become necessary to stop the operation at 
this point and plug the fossa with gauze, allowing 
it to remain three days before completing the op- 
eration. Excessive hemorrhage was encountered 
in three of Dr. Keen’s cases. The doctor, in com- 
menting on the cases, stated that he introduced a 
piece of gauze sixteen by twenty inches, which did 
not produce sufficient pressure on the brain to 
cause unpleasant symptoms. As soon as the base 
is exposed, introduce the retractor, which holds 
up the dura. As the specimen is passed around, 
notice the foramen ovale where the inferior max- 
illary division finds exit, and just in front of it 
the foramen rotundum for the superior maxillary 
division. After both openings have been exposed, 
divide the layer of the dura between the two divi- 
sions of tlie nerve, allowing the periosteal portion 
to remain attached to the bone beneath the roots 
of the nerves. The upper layer can then be ele- 
vated from the surface of the nerves and ganglion 
with very little danger of perforating it. This is 
a very important point in the operation. Proceed 
along the upper surface of the nerve to the gan- 
glion, which is situated between the two layers of 6 
the dura, one beneath and the other above. As 
soon as this point is reached the blunt dissector 
is used to elevate the dura; with it separate the 
two layers of the dura, following along up the 
nerve. Peel the dura off until the ganglion is 
thoroughly exposed. After the dura is peeled off 
a short distance it may possibly be torn; there 
will then be an escape of cerebro-spinal fluid. If 
the sinus be torn the hemorrhage will be profuse. 
Control it with the finger or with a compress on 
the retractor. Cleanse the cavity with a sponge 
until the parts become dry. With two of these 
retractors the sinus can be readily compressed if 
torn. The opening in the dura can be compressed 
in the same manner to suppress the flow of cere- 
bro-spinal fluid. If necessary the optic division 
of the nerve can be removed ; it is difficult, as it is 
situated in the wall of the cavernous sinus. If 
an endeavor be made to remove the optic division 
from the cavernous sinus, the chances are the 
sinus will be opened and hemorrhage will follow, 
thus compelling the suspension of the operation 
for the time being, to be completed at another sit- 
ting. As soon as the ganglion is exposed, pass 
the blunt hooks which we have for that purpose 
under the roots of the nerves, elevate the nerves, 
and make considerable traction from the openings 
toward the center. As soon as the roots are thor- 
oughly drawn in and divided close to the foramen, 
elevate the ganglion from its fossa and grasp it 
with a pair of large hemostatic forceps. I have 
found the eight-inch forceps of Billroth good for 
this purpose. The nerves being divided, the dis- 
tal ends are pushed out of the foramina. This is 
done to lessen the possibility of subsequent regen- 
eration of nerve tissue in case the ganglion is 
not completely removed. When the roots are di- 
vided remove the booklets which have been used 
for the purpose of elevating; separate the roots 
and the ganglion from the periosteal portion of 7 
the dura by gently elevating it; make a turn and 
a half of the Billroth forceps on the ganglion and 
the motor root will come in one mass with the 
ganglion. 
In the first case which I operated I was an- 
noyed considerably by hemorrhage. It retarded 
me for five or six minutes after I had the nerve ex- 
posed and had placed the forceps on the ganglion. 
As soon as the hemorrhage was under control I 
proceeded and the nerve was extracted. 
This method is very advantageous, as it affords 
an excellent view of the field of operation. I like 
the position suggested by Keen, i. e., placing the 
patient on the back and operating from the side. 
In this position we can have a strand of gauze in 
the lower part of the wound, which will siphon 
the blood out as rapidly as it appears. When the 
ganglion is extracted it should be examined to see 
if it has all been removed. The ganglion is not a 
large body; it is much smaller than is generally 
supposed. In some of the recorded cases a part 
of the ganglion was removed. This should not 
occur if the dura be retracted sufficiently with the 
blunt dissector. In both of my cases the perma- 
nent arrest of hemorrhage was produced with a 
plug of gauze, which was removed forty-eight 
hours after the operation through a small opening 
left in the bone. The osteoplastic flap was re- 
placed and retained by periosteal and cutaneous 
sutures. In the second there was some escape of 
cerebro-spinal fluid when the gauze was extracted; 
the provisional suture which was inserted at the 
time of the operation was tied and prevented the 
further loss of fluid. The danger of injury to the 
brain is not great. The danger from sepsis when 
the dura has been lacerated is considerable; in 
these cases the drain should always be used. It 
is surprising in such cases how quickly patients 
rally from the operation. The first patient on 
whom I operated left the hospital two weeks after 8 
the operation. The first operation consumed 
forty-two minutes, the second fifty-seven. This is 
an operation of considerable anxiety, because we 
are at a disadvantage in controlling hemorrhage; 
if the carotid be injured its control is almost im- 
possible. 
As to the results obtained from operative inter- 
ference: There have been fifty-seven cases col- 
lected up to date, and of this number there were 
five deaths. Two of the patients were seventy 
years of age. One died shortly after the opera- 
tion as a result of shock, the other six days after 
the operation, without any special symptoms. 
Nothing was revealed post-mortem to account for 
the patient’s'death. For an operation which af- 
fords relief from such great suffering the mor- 
tality is small, one in eleven, and an idea of the 
suffering of these patients can only be gathered 
from those who are afflicted. They are willing to 
undergo any operation in the hope of obtaining 
relief. One of my patients, when informed of the 
dangers of the operation, expressed himself as fol- 
lows: “Anything you can get out of this better 
than death is clear profit.” 
Fig. 2 shows the line of complete anesthesia 
three weeks after the operation. 
Recent reports from 1113- cases show that there 
has been no return of the neuralgia, and neither 
have they suffered from ocular symptoms. 
Mrs. Kate M., Lincoln Neb.; housewife; age 
53. Family history; Mother 85 years old, living, 
and health}-; father deceased, the result of an ac- 
cident; two sisters are living and enjoying good 
health; husband and one boy are well. Patient 
enjoyed excellent health until sixteen years ago, 
when she was attacked with the present trouble. 
Was married at the age of twenty. Had one 
child; no miscarriages nor abortions. Never suf- 
fered from gout, rheumatism, nor any kind of dis- 
ease. Had sustained no injury to the head. Had not suffered from severe emotional excitement nor 
mental over-taxation previous to present illness. 
M enstniatiou normal. 
Present history: Sixteen years ago, after a hard 
day’s work, patient was attacked with a “stroke” 
or “shock” which prostrated her to the floor. The 
“shock” consisted of a severe sharp pain in the 
Fig. '1.— of complete anesthesia. 
entire right side of the face. The pain was in- 
tense and lasted about ten minutes. She could 
not open her jaws and remained for a time as 
though completely paralyzed. This was the onset 
of the attacks of chronic neuralgia for which she 
now seeks relief. The “attacks” occurred every 
few hours in the beginning, but for the last six 
years a spasmodic contraction of the muscles of 10 
the right wide of the face, with closure of the right 
eye, accompanied by intense pain, occurs every 
fifteen or twenty minutes, day and night. Ex- 
citement, pressure on the face, or a slight draught 
will bring on an attack. In the interval between 
the attacks the face is painful. The right half 
of the tongue appears to be the most painful spot. 
For that reason conversation is carried on in a low 
muttering tone, and has to be interrupted fre- 
quently when the attacks come on. 
Examination.—No deformities or irregulari- 
ties in the head or face; sight normal; nose free 
from obstruction. Teeth on the right side had all 
been extracted with the hope of relieving the neu- 
ralgia. No defect in the mouth or fauces; exter- 
nal meatus and drum normal. Heart and lungs 
normal; no irregularity in abdominal organs; pel- 
vic organs normal; urine normal; no enlargement 
of glands; epitrochlear glands normal. The area 
of pain extends from right superciliary ridge 
down the entire right side of the face to the lower 
margin of mandible, from the anterior border of 
the ear forward to the middle line of the forehead, 
nose, lips, and tongue. An electrode placed over 
any part of the face produced intense pain. 
The patient’s condition was really pitiable, and 
when on the table, before the anesthetic was ad- 
ministered, she said: “Doctor, promise me that 
you will do one of two things; either cure me of 
this neuralgia or kill me.” 
Operation.—The patient was operated upon 
December 24th, 1895; chloroform was used. The 
head was placed in a somewhat elevated position 
and turned to the side. The details of the opera- 
tion were as described above. The evening after 
the operation the patient was conscious and she 
said she was entirely relieved from pain, suffering 
only from the soreness at the position of the 
wound. Forty-eight hours after the operation 
the gauze packing was removed. A small quan- tin* of serum, blood and detritus escaped, but no 
cerebro-spinal fluid. Tlie patient expressed great 
relief after the gauze was extracted, as she said 
the pressure seemed to be taken out of her head. 
At no time did her temperature reach 100 degrees. 
Her improvement was very rapid. She was able 
to sit up in a week and in two weeks left the 
hospital. The accompanying cut shows the line 
of incision and also the line of anesthesia three 
weeks after the operation. A letter from the pa- 
tient, dated August 20th, states that she has had 
no return of pain. The only inconvenience ex- 
perienced is the absence of sensation on the right 
side of the face. 
John G., Ossian, Iowa; male, age 52; German; 
merchant; married; several children, all well. 
Received a bullet wound in the army. Enjoyed 
excellent health up to seven years ago, when he 
began to have attacks of pain on the right side of 
the face. In the winter time he would have them 
every day, or at the most, every second day. In 
summer he might go for a week without an at- 
tack. The last winter they increased very much 
in severitv and duration. 
He is of phlegmatic temperament; responds 
slowly to questions; appears to be suffering from 
some mental disturbance. Complains of pain in 
an area about the size of a dollar above the right 
superciliary ridge. When the “attack” is on the 
pain extends over the greater portion of the face. 
Eyes, nose, mouth, and ears normal; has some 
digestive disturbance; lungs and heart normal; 
urine negative. 
Date of operation, April 9th, 1896. Incision 
the same as described above. In this case the 
dura was opened and a considerable quantity of 
cerebro-spinal fluid escaped. The packing was 
withdrawn seventy-two hours after operation. 
That was also followed by a discharge of cerebro- 
spinal fluid, which was stopped by tying the pro- visional suture. The patient made a rapid recov- 
ery; the numbness of his face annoyed him con- 
siderable. There was no pain after the operation. 
The ganglion and root were removed in one mass: 
it was given to Dr. Evans for examination. 
Information received from patient August 14th 
states that he is not suffering from pain and en- 
joys excellent health since the operation. In 
neither of the patients was there any inconven- 
ience expressed from the loss of sensibility in the 
eye. Convalescence was rapid; the patient was 
up and about the room in a week and left the hos- 
pital three weeks after the operation.