REPORT OF AN OPERATION FOR REMOVAL OF 
THE GASSERIAN GANGLION. 
BY 
EMORY LANPHEAR, M. D., Ph. D. 
KANSAS CITY, MO. 
Reprinted from “ International Journal of Surgery.” OPERATION FOR REMOVAL OF THE GASSERIAN 
GANGLION. 
EMORY LANPHEAR, M. D., Ph. D., 
KANSAS CITY, MO. 
Clinical lecture delivered before the post-graduate class of the University Medical College 
March 29, 1892. 
Neuralgia of the trigeminus sometimes resists all medication and 
becomes so severe as to make life a burden ; no source of peripheral 
irritation can be detected; surgical interference becomes imperative. Ex- 
tirpation of Meckel’s ganglion can never prove satisfactory; and as 
removal of the Gasserian ganglion will certainly cure intractable trigemi- 
nal tic, its practice is justifiable. 
There are three methods of reaching the Gasserian ganglion : First, 
the intra-cranial; second, by ablation of the superior maxilla and trephin- 
ing the base of the skull; third, by opening the base of the skull through 
the pterygoid region. 
Mr. Horsley has done the first operation by opening the middle fossa 
through the temporal region, incising the dura and lifting up the tempero- 
sphenoidal lobe, so that the base of the skull can be seen by means of an 
electric illuminator; he then cuts the root of the nerve as it emerges from 
the pons and following it through the dura mater (which here divides into 
two layers to cover in the ganglion) removes the ganglion from above. 
This, it seems to me, is an operation of great difficulty as well as severity, 
and besides the not inconsiderable compression of the brain necessary to 
expose the point of attack, must, in hands less skilled then Mr. Horsley’s, 
result in more or less injury; and haemorrhage, of alarming degree, is 
likely to occur either from the contiguous sinus or the artery. Mr. Horsley’s 
only case died seven hours after operation, presumably from shock. 
The second method has been followed by Mr. Rose, in one case; the 
right superior maxilla was excised in the usual manner and the foramen 
ovale easily exposed ; a disk of bone was removed and the ganglion 
extirpated; the operation was followed by a violent panophthalmitis, 
which necessitated enucleation of the eye ; otherwise the operation was 
eminently successful. 
The third mode is, I believe, the one to be preferred and will be 
followed in the case now being chloroformed. Mr. Rose has performed 
this operation four times (see British Medical Journal, Feb. 6, 1892) suc- 
cessfully, and Prof. Andrews, of Chicago, twice. In doing it one must 
be careful in two things : First, the ganglion lying just above and 
external to the internal carotid artery, by a slip of the instrument, fatal 
haemorrhage may be incurred; Dr. Griffith will therefore stand ready to tie 
the common carotid in this patient, if necessary, while Dr. Binnie will 
assist me ; second, since division of the fifth nerve through the ganglion, 
or of its branches in front, gives rise to destruction of the parts supplied 
by it, and subsequent death (see Flint's Human Physiology, subject, “ The 
Trigeminus”) the ganglion must either be totally extirpated or the nerve 
divided behind the ganglion. Removal op Gasserian Ganglion—Lanphcar. 
3 
The patient before you, Janies S., of Chanute, Kansas, presented him- 
self about two weeks ago for surgical treatment of incurable facial 
neuralgia. He is fifty-four years of age, of good family history, of 
previous good health, non-syphilitic, and of strong constitution. For 
eighteen years he has suffered from trigeminal neuralgia, affecting the 
right side of the face. It has been progressive and for the past year has 
been so bad as to necessitate his remaining in bed; you see him pale and 
emaciated, and lines of pain upon his face. For the past five years he 
has tried all the new coal-tar derivatives and the anodynes have been 
exhausted in vain search for a remedy; morphine has no effect; his teeth 
have been extracted, but with no benefit. He has consulted rhinologists, 
neurologists, ophthalmologists, etc., without avail. When he was admit- 
ted to the hospital I prescribed: 
R Ouininse hydrobromat T)i 
Ferri sulpliat exsic t)ss 
Hyoscyaminse sulphat gr. A 
Misce et ft. pil. no. xij. Sig.: One every four hours. 
This I did because Verneuil has said that no surgeon is justified in 
operating for any neuralgia, until he has tried hyoscyamine. It did no 
good in this case. 
The head and face having been carefully shaved, the parts are thor- 
oughly scrubbed with soap and water, dried, washed with ether, dried, 
and washed with bichloride solution, The eye upon the affected 
side is irrigated with a weaker solution, and the lids stitched together with 
fine catgut; the ear is cleaned and packed with gauze ; and the field of 
operation surrounded by bichloride towels. Commencing just below the 
outer angular process of the frontal bone, an incision is made along the 
upper border of the zygoma to its posterior extremity, and curving sharply 
downwards, descends just in front of the ear and over the parotid to the 
angle of the jaw, thence along the horizontal ramus to the vicinity of 
the facial vessels. This flap of skin is dissected up, care being taken not 
to injure the parotid, Steno’s duct and the facial nerve. By making this 
incision, as Mr. Rose claims, there is gained a maximum of space with a 
minimum of disfigurement and no paralysis of the portio dura. A long 
silk ligature is passed through the flap and held by an assistant, the 
retracted flap being protected by wrapping in bichloride gauze. 
The periosteum is now stripped from the zygoma, and four holes 
drilled through the bone—two through the zygomatic process of the 
malar and two close to the root of the zvgoma. These 
are about one-third of an inch apart and are to provide passage 
for silver wires to hold the parts in apposition after trephining. 
With a He}r’s saw the zygoma is divided between these holes, the anterior 
saw-cut being directed obliquely downward and forward, and the posterior 
back as far as possible. The bone is turned down with the masseter 
muscle attached, care being taken not to injure the muscular attachment 
on the under surface through which future nutrition must come. The 
corouoid process of the inferior maxilla being thus exposed, the blade of 
a Riston bone-forceps is passed beneath it, and the bone cut through ; no 
attempt will be made to restore the bone to its position, as the atrophy 
and cicatricial contraction might interfere with movements of mastication. 
The temporal muscle is turned up out of the way, exposing the pterygoids. 
The external pterygoid muscle is separated from the skull by the 
periosteal elevator and drawn downward. Search is made for the nerve 
that it may be followed to the foramen ovale through which in makes its 4 
exit. This cannot be found, so dependence must be placed upon the 
bony landmarks. The base of a clean skull, in the hands of Dr. Thrush, 
is carefully observed and corresponding points located upon the patient. 
Having determined the probable location of the foramen ovale, a half- 
inch trephine is introduced, the center pin being driven in a little behind 
and external to the foramen. At the first stroke of the saw a gush of 
bright arterial blood appears; examination shows that the trephine has 
cut into the foramen spinosum as well as the ovale, and wounded the 
middle meningeal artery; with great difficulty this is secured and the 
trephining resumed. A disc of bone is removed and the dura cut with 
scissors. Nerve tissue is seen, but whether it be the ganglion or not, 
cannot be positively determined because of the haemorrhage; however, 
it is seized with dissecting forceps and torn away, a curette introduced to 
thoroughly clean out the nerve-tissue and an attempt made to rapidly 
check bleeding, as the patient is beginning to show signs of shock. 
Haemorrhage having been arrested, the wound is irrigated with bichloride 
solution, the fragment of the coronoid process cut off with scissors, the 
temporal muscle tucked into the fossa, and the zygoma replaced and 
wired. As no drainage can be employed the incision is rapidly closed 
with a continuous catgut suture, the face washed, iodoform dusted on 
very freely and a firm compress of bichloride gauze applied. The usual 
dressings are used. 
Both eyes will be kept bandaged for four days and the one on the 
affected side for some weeks. If we have been successful in carrying 
out our design, we shall secure healing by primary union, so far as the 
external wound is concerned. And as for immunity from the terrible 
paroxysmal pain, we may expect the most gratifying results, if we may 
judge from the relief secured in the seven cases thus far operated on. 
In reply to the question : “What effect, will this have upon masti- 
cation? ” I would say that the patient must necessarily do his chewing, 
henceforth, upon the opposite side, but as he has already done this for 
more than ten years, it can inconvenience him but little. 
In conclusion, after a careful stud}' of the operation, I must say I 
believe Mr. Rose to be correct in his assertion, that in all cases of epilep- 
tiform neuralgia of the trigeminus, where treatment has proven unavail- 
ing, extirpation of the Gasserian ganglion through the base of the skull 
is a somewhat difficult but not dangerous method of cure. 
Note.—This patient made an ideal recovery. Shock was easily 
overcome. The temperature rose to ioojf° F. on the day following the 
operation—pure surgical fever—but rapidly declined. Freedom from 
pain was absolute. The appetite speedily improved and there was a gain 
of about ten pounds in weight during the two weeks that he, remained in 
hospital. There developed a suppurative conjunctivitis upon the affected 
side, and it was feared that the eye might be lost. Treatment by irriga- 
tion with mild bichloride solution subdued it in about five days, and no 
further trouble was experienced. It is possible that it was the result of 
the introduction of the stitches into the lid, the conjunctival sac having 
been imperfectly cleaned. The patient was allowed to return to his home, 
150 miles distant, on the thirteenth day after operation. He is now, for 
the first time in years, perfectly free from pain, and well. 
Removal of Gasserian Ganglion—Lanphear.