SURGERY OF THE FIFTH NERVE. 
J. EMMONS BRIGGS, M. D. 
382 Commonwealth Ave., Boston, Mass. 
Reprinted from The Journal of Surgery, Gynecology, and 
Obstetrics. SURGERY OF THE FIFTH NERVE. 
J. EMMONS BRIGGS, M. D. 
The Greek mythology portrays the sufferings of Tantalus in 
the lower regions, but neither the thirst of the ancient hero, nor 
the fear of the suspended rock can be compared with the suffer- 
ing and despair experienced by the victim of tic douloureux. 
He is a sufferer serving a life-sentence, from which death 
alone can liberate. 
In the time allotted me in which to discuss this important 
subject no general considerations of trigeminal neuralgia can 
be expected. Only the briefest possible considerations will be 
given to the extra-cranial operations, for rarely indeed do pa- 
tients consult us until they have run the gauntlet of minor 
surgical procedures. The supra-orbital, infra-orbital, and in- 
ferior dental, one or all, has been severed, and the pain has 
recurred. A patient once having obtained relief will invariably 
return for surgical aid when the pain recurs. 
Our experience with neurectomy of the trifacial nerves, when 
made peripherally, is gratifying as a temporary expedient. The 
length of the immunity from pain in my experience has been 
very variable. Sometimes only two or three months of com- 
plete relief follow, again as many years. The pain very surely 
returns and relief is again demanded. 
What to do next is much more of a problem. Shall it be 
another attempt at the same location, in the delusion that the., 
nerve has united? Such a course will be futile. We must 
plan an attack upon the nerves much closer to the brain. 
Supra-orbital neuralgias have been, in my experience, more 
lastingly benefited by neurectomy than neuralgias of the infra- 
orbital nerves. In infra-orbital neuralgias the relief afforded 
by neurectomy at the exit or along the course of the infra- 
orbital canal, is very transitory. This is accounted for by the 
fact that the orbital and the post-superior dental branches are 
given off before the nerve enters the infra-orbital canal. 
Therefore, when the condition is severe, as when it recurs after 
infra-orbital neurectomy, the trunk of the second division to- 
gether with Meckel's ganglion, must be excised, or the nerve 
must be severed between this ganglion and the brain. The 
inferior dental nerve is easily reached in the ramus of the jaw. 2 
J. Emmons Briggs, M. D. 
I have usually trephined the jaw-bone midway between the 
angle and the last molar tooth through an external incision. 
This operation is simple and more lasting in its results than 
neurectomy of the second branch, but as has been said, pain 
recurs and we must then resort to more radical measures. 
The major operations for the relief of tic douloureux rank 
among the most delicate known. They require very accurate 
anatomical knowledge and manual dexterity. 
As pioneers in this field of surgery should be mentioned the 
names of Professors Rose, Hartley, Krause, and Horsley, who 
have devised operations for the removal of the Gasserian 
ganglion. 
The excision of the Gasserian ganglion is, however, at best 
a serious, and often a mutilating operation and is accompanied 
by a high mortality. 
In Turk's tabulation of 201 cases, 83 per cent, survived the 
operation, and 77.6 per cent, could be counted upon as per- 
manently cured. Thirty-three cases died, 17 immediately fol- 
lowing operation. Eleven did not regain consciousness, and 
the remainder succumbed to meningitis, brain tumors, abscess, 
pneumonia, softening of the brain, hemorrhage, and uremic 
coma. 
The removal of the Gasserian ganglion necessitates severe 
compression of the brain by retractors. This may injure the 
structure of the anterior lobes of the brain, and the evulsion of 
the ganglion is frequently accompanied by severe shock. The 
nerve supply may be so severely injured that loss of vision 
results. 
In view of the severity of the Gasserian ganglion opera- 
tion and its sequelae, and the inefficiency of the extra-cranial 
procedures, let us consider whether there is not some middle 
ground, some operation which, while not as hazardous as the 
former, will show equally lasting results. Fortunately we 
have in the Abbe operation exactly what is demanded, an 
operation relatively safe, and as far as the writer is cognizant, 
capable of affording permanent relief. 
In the reports of two Abbe operations which are appended 
I have gone sufficiently into the technique of procedure, so 
that it will be unnecessary to consider the matter here in 
detail. Surgery of the Fifth Nerve. 
3 
Dr. Robert Abbe of New York City has described his opera- 
tion very minutely. There are, however, a few points which 
may perhaps be discussed with propriety. 
Gutta-Percha Tissue.-Dr. Abbe recommends the introduc- 
tion of gutta-percha tissue between the severed ends of the 
nerve. In this one respect I deviated from his technique. 
My reason for so doing was fear of the unknown properties 
of gutta-percha tissue; i. e., the length of time it is capable 
of retaining its integrity in the tissues, and the still greater 
fear of introducing a substance which could not be sterilized 
by heat. Gutta-percha tissue cannot be boiled nor can it be 
subjected to intense dry heat. We must rely upon chemical 
disinfectants such as a corrosive sublimate and formaline solu- 
tions. 
I made use of the gold leaf in one case, after pushing the 
distal severed ends of the nerves downward through the 
foramina by rolling the gold leaf into a ball considerably larger 
than the diameter of the foramen and crowding it forcibly 
into the canals. 
In my second case a piece of moderately thick gold leaf was 
laid over the foramen. In both cases the gold leaf was held in 
sterile forceps over an alcohol flame until red hot. No method 
of sterilization can be more positive than this. 
Paralysis.-In nearly all the intracranial operations which are 
made for the relief of tic douloureux a paralysis, either transi- 
tory or permanent, occurs. Usually the upper division of the 
facial nerve,which takes an upward course after leaving the 
parotid gland and overlies the temporal fossa is severed, re- 
sulting in a paralysis of the occipito-frontalis and orbicularis 
palpebrarum. 
The deformity resulting consists in a sagging of the brow 
and absence of frontal wrinkles. I have observed this de- 
formity to be so severe that the patient could with difficulty 
see out from under the overhanging brow. If the temporal 
branch of the facial nerve can be preserved these permanent 
deformities will not occur. It is fortunately possible to avoid 
this branch in the Abbe operation by making the vertical in- 
cision just over the condyle of the jaw. The zygoma can be 
reached and cleared by the aid of a periosteal dissector and 
a portion of it excised and the fibers of the temporal branch 
separated until the temporal fossa is reached. J. Emmons Briggs, M. D. 
4 
The skin incision is safe to the lower border of the project- 
ing condyle of the jaw or to a line with the external auditory 
meatus. If carried lower than this the temporo-facial branch 
will surely be severed. Again, if the incision is made anterior 
to the condyle of the jaw, midway between the outer angle 
of the eye and the external auditory meatus, the upper branches 
of this nerve will be severed. It is true that this skin incision 
is located too far posteriorly, but after separating the fibers of 
the temporal muscle retraction will expose as large an area of 
bone as necessity requires. A paralysis may follow too vigor- 
ous retraction in this region but it will be of short duration. 
The skin incision should commence on a line with the .ex- 
ternal auditory meatus and three-quarters of an inch anterior 
to it, carried slightly forward and upward about two and one- 
half inches. When the zygoma is reached it should be sub- 
periosteally resected or as nearly so as a bone can which 
affords muscular attachments. 
Trephining the Skull.-After subperiosteally resecting the 
zygoma and separating the fibers of the temporal muscles the 
trephine is applied to the squamous portion of the temporal 
bone on a level with the upper border of the zygoma. A hole 
about three-quarters of an inch in diameter is made and this is 
enlarged with bone-cutting forceps. The dura is gently ele- 
vated from the bone. 
Plate I shows opening in the skull. 
Hemorrhage is first encountered during this step in the opera- 
tion and may be quite free from branches of the middle menin- 
geal artery. Small strips of gauze should be packed into 
the wound and pressure exerted, especial attention being 
directed to filling in the osseous grooves in which the middle 
meningeal branches course. After from three to five minutes 
these vessels will cease to bleed. Far more troublesome hemor- 
rhage, however, occurs as the dura is progressively separated 
from the skull in quest of the foramina through which the 
second and third branches pass. The bleeding is now venous 
and rather troublesome, as it quickly fills in the deep wound and 
obscures the field of operation. Gauze packing may now be 
tamponed into the wound and allowed to remain about three 
minutes, when it may be removed and more progress made. 
Unfortunately when the gauze is withdrawn bleeding is liable Surgery of the Fifth Nerve. 
5 
to recur. I have used with far greater efficiency gutta-percha 
tissue, about which blood coagulates readily and when the 
tissue is removed quite firm clots adhere to the bleeding 
points. If hemorrhage proves so troublesome that no progress 
can be made a packing may be left in the wound for twenty- 
four hours, when the operation may be resumed. 
Mr. E. W. M., American, aged fifty-two, entered the 
Massachusetts Homeopathic Hospital about the middle of 
October, 1905, and was under close observation for two weeks 
Plate I. 
prior to operation. His symptoms commenced seven years 
ago, at first noticed only while chewing, but gradually grew 
worse. They soon became spasmodic. Paroxysms of pain 
lasted about three minutes, then intervals of three minutes, pro- 
voked by chewing, talking, or draughts of air. He gradually 
grew worse and in 1899 Dr. Maurice Richardson of Boston 
operated upon him. He resected the second branch of the 
fifth nerve within the spheno-maxillary fissure, external to the 
orbit, by removing a button from the sphenoid bone. At the 
same time the third branch was severed external to the skull at 
its exit from the foramen ovale. Then followed a period of 
two and a half years during which time Mr. M. received great 
relief. A year ago, the pain having recurred, he entered the 
Massachusetts Homeopathic Hospital and Dr. N. W. Emerson 
resected the infra-orbital branch at its exit from the infra- 
orbital foramen. This helped him slightly for about a month. 
About the middle of October, as above stated, he appeared 6 
J. Emmons Briggs, M. D. 
for readmission. His condition was indeed pitiable and he 
was desperate, declaring that he would endure his suffering no 
longer. The dangers of the operation did not in the least 
deter him; he preferred death to his present state. Severe 
paroxysms of pain accompanied by violent twitching ol the 
facial muscles occurred whenever he moved his face. 1 he 
taking of food was so painful that he would go forty-eight 
hours without tasting it. The second branch gave him the 
greatest concern, but the first and third participated to a con- 
siderable degree. 
On October 25, 1905, the Abbe operation was undertaken 
and successfully carried out. A vertical incision was made. 
The zygoma was resected, the attachments of the masseter 
muscle were partially severed, the fibers of the temporal nerves 
were separated. A trephine was applied to the squamous por- 
tion of the temporal bone and an opening made which was 
enlarged by bone-cutting forceps. The dura was then separated 
from the base of the skull and all bleeding checked by gauze 
packing. The foramen rotundum was clearly demonstrated 
and the second branch of the trifacial was severed as it entered 
the foramen. The dura was lifted still more posteriorly and 
the third branch was clearly seen as it entered the foramen 
ovale. It was cut close to the dura. Both distal ends of the 
nerve were carefully pushed downward through the foramina 
and the canals were plugged with sterile gold leaf to prevent 
reunion. Drainage was left between the dura and the skull, 
the severed muscles approximated and the external wound 
closed, except where drainage was established. On awaking 
from the anesthesia the patient was free from pain. In twenty- 
four hours the drainage was removed. The wound healed 
kindly by first intention and the patient made an uninterrupted 
recovery. He was discharged from the hospital on November 
17, 1905, twenty-three days after the operation. 
Under date of March 26, 1906, he writes as follows: "I 
went to work in a jewelry factory (a week after leaving the 
hospital), and have worked from ten to twelve hours per day 
since. Do not have any pain in my face and am enjoying the 
best of health." 
Plate II shows a moderate degree of paralysis of the occipito- 
frontalis. 
Case 2.-Mr. A. J. P., American, aged sixty-nine, entered the 
Massachusetts Homeopathic Hospital early in November, 
1905, for tic douloureux. He gave the following history: 
Has been suffering from trifacial neuralgia for several years. 
Thinking that his teeth were at fault he has had all of the 
molars of the left side extracted, but without relief. Early in 
the year 1905 he entered the hospital and was treated medically. 
Feeling that he had somewhat improved he went home for a Surgery of the Fifth Nerve. 
7 
time, but in April returned and a resection of the supra- 
orbital and infra-orbital nerves was made. 
This operation resulted in a very marked improvement which 
lasted four months. For over two months he has been suffer- 
ing from recurrence of the same twitching and spasmodic 
pain in the supra- and infra-orbital regions. 
This patient has reached advanced life, being sixty-nine years 
of age. He had a valvular lesion of the heart and was passing 
Plate II, 
only half the usual amount of urine, which contained albumin 
with hyaline and granular casts. 
The danger of the operation was explained to him but noth- 
ing could deter him from attempting the only source of relief 
afforded. He was operated upon on November u, 1905, by 
the Abbe method. The incision was made as previously de- 
scribed. The zygoma was resected and the trephine was ap- 
plied to the squamous portion of the temporal bone. The dura 
was elevated. Considerable bleeding was encountered but 
packing stopped it sufficiently so that progress could be made. 
The second branch of the fifth nerve was seen just before it 
entered the foramen rotundum. Here it was grasped with a 
tenaculum and severed with the scissors. Hie distal end of 
the nerve was pushed through the foramen and the canal was 
overlaid wjth gold leaf. The bleeding in this case was very 
annoying and the operation prolonged. The chloroform nar- 8 
J. Emmons Briggs, M. D. 
cosis, the severe and prolonged pressure upon the brain by 
retraction and packing, together with the age and general 
debility of the patient, proved almost more than he could 
stand, for he stopped breathing and was resuscitated with diffi- 
culty. In view of this and taking into consideration the fact 
that the inferior maxillary branch had never occasioned trouble, 
it was thought unwise to prolong the operation in order to 
resect this nerve. The wound was therefore closed except at 
the angle where drainage protruded. Pain ceased with the 
operation, drainage was removed in twenty-four hours, patient 
sat up on third day, and left the hospital within two weeks. 
Plate III. 
On March 23, 1906, he writes as follows: "I will say that 
I have not had any pain in my face since you operated upon 
me. That side of my face is numb but that is nothing com- 
pared with the pain." 
On August 22, 1906, Mr. P. called upon me. There is still 
numbness o the side of the face, corresponding to the distribu- 
tion of the second branch. The slight temporary paralysis of 
the occipito-frontalis has entirely disappeared as will be seen by 
the accompanying photograph, and scarcely a perceptible scar 
remains from the operation. The result appears entirely satis- 
factory. 
Plate III shows patient about one year after operation with 
no paralysis of the muscles of face.