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UNIVERSITY OF PENNSYLVANIA PRESSk 
PHILADELPHIA PA 
Oremt Britain; Cassell and Company. London: 
MAY, 1895 
REPORT OF ADDITIONAL CASES OF INTRACRANIAL 
NEURECTOMY. 
By LOUIS McLANE TIFFANY, M.D., 
OF BALTIMORE, 
Professor of Surgery, University of Maryland. REPORT OF ADDITIONAL CASES OF INTRA- 
CRANIAL NEURECTOMY. 
By LOUIS McLANE TIFFANY, M.D., 
OF BALTIMORE, 
PROFESSOR OF SURGERY, UNIVERSITY OF MARYLAND. 
IT was my fortune to be able to report four cases of intra- 
cranial neurectomy in the Annals of Surgery, January, 
1894. Since that time I have operated upon three cases. 
The method pursued in the last three cases is essentially that 
mentioned in the article stated ; and I have numbered them in 
sequence with those already reported. The sum total is seven 
cases, all recovering from the operation, and all with no recur- 
rence of pain up to the present time, so far as I can learn. 
The diagrams which accompany the cases now reported are 
of the same size as those reported a year ago, in order that com- 
parison may be the more easily made. It is not possible at the 
present time to speak ex cathedra as to the expediency of the 
operation in question, or the probable outcome thereof,—the 
results are not at all similar, and sufficient time has not elapsed 
to show the ultimate result. 
Case V.—E. M., white, male, aged seventy-six years, a farmer, 
suffered from neuralgia in an area corresponding to the distribution of 
the second division of the left trigeminal nerve. In June, 1890, the 
left infra-orbital nerve was divided where it appears upon the face. 
Eighteen months of relief followed, and then gradually pain returned ; 
now it is extremely severe and almost constant. Neither the first nor 
third divisions are affected. Morphia in large doses gives relief, but 
no other drug. 
Operation March 22, 1894. Anaesthesia was induced by chloro- 
form. I opened the head and removed the second division of the 2 
LOUIS Me LANE TIFFANY. 
left fifth nerve from the foramen rotundum to the Gasserian ganglion, 
which latter was exposed and carefully left intact. Oozing of blood 
from the upper part of the wound required gauze pressure, which was 
removed on the second day and the incision closed. All went well 
and the patient left hospital April 17, 1894. 
Pain ceased from the time of operation. Anaesthesia exists over 
the upper lip, skin, and mucous surface, incompletely of nostril, skin, 
and mucous surface. The skin from the infra-orbital foramen to the 
angle of the mouth is anaesthetic. The mucous membrane lining the 
left cheek has diminished sensibility, but not entire abolition of the 
same. No loss of taste ; thermic sense normal. 
Fig. i.—Showing areas of anaesthesia in Case V. 
Case VI.—L. M., white, widow, aged sixty-nine years, the 
mother of several children, gave the following history: 
Twelve years ago, without premonition, she experienced an acute 
sudden pain in the face over the right upper jaw, which lasted but a 
moment. She thought she had received a blow. No swelling, no 
discoloration of the skin, or other evidence of traumatism appeared. 
Several months later a similar pain was felt. In the course of the 
following year the paroxysms of pain became longer and more intense, 
the intervening periods of time more and more short, until the patient INTRACRANIAL NEURECTOMY. 
3 
was reduced to a condition of almost constant suffering. A paroxysm 
was induced by talking, swallowing, pressing the tongue to the roof 
of the mouth, etc. 
Before coming into my hands nitro-glycerin, quinine, gelsemium, 
aconitia, salicylate of soda, and other drugs had been used with- 
out permanent relief; morphine was being taken in doses sufficient to 
abate pain ; the patient, being aware of the unhappy results consequent 
upon the opium habit, had recourse to the drug as sparingly as 
possible. 
Surgical relief had been sought. The upper jaw nerve (right) 
was divided below the orbit in September, 1889, and electricity used ; 
ten months of relief from pain followed. In September, 1891, the 
lower jaw nerve (right) was divided, judging from the scar behind 
the upper part of the ramus; saliva is said to have flowed from the 
wound during several weeks. Relief from pain for sixteen months 
was obtained by this second operation. 
The patient came under my care May 2, 1894. There was 
present the excrutiating pain usual in cases of advanced trigeminal 
neuralgia; the territory affected was that supplied by the second and 
third branches of the fifth nerve (right). The tongue was not 
involved, but the act of swallowing was agonizing; talking induced 
a paroxysm, as did handling of the area mentioned; the patient had 
lost much flesh, yet no cause was found for the same except the volun- 
tary starvation undergone by the patient as preferable to the pain 
induced by deglutition. The teeth in both upper and lower jaws 
(right side) had been extracted hoping to afford relief from suffering, 
—needlessly, it is scarcely necessary to add. 
There seemed to be no reason for delay, so after a week of pre- 
paratory treatment (May 9, 1894) I operated. Anaesthesia was in- 
duced by chloroform. I again found that opening the dura allowed 
a free escape of cerebro-spinal fluid and permitted exposure of the 
organs sought. The intracranial portions of the second and third 
branches of the fifth nerve were removed together with the lower por- 
tion of the Gasserian ganglion, all in one piece. The upper portion 
of the ganglion was not touched. 
The patient went to operation with pulse 84, respiration 24; left 
the operating table with pulse 100, respiration 28; during the 
evening the pulse remained 100, respiration falling to 24. All 
went well. Dressings were changed for the first time on the tenth 
day, the wound then was firmly healed and dry; stitches were 4 
LOUIS Me LANE TIFFANY. 
removed and a little absorbent cotton placed over the seat of operation 
to avoid a possible shock from blow, etc. The patient went home 
June 7. 
Pain ceased from the moment of operation ; swallowing, hand- 
ling, etc., were absolutely painless; the patient gained flesh and 
spirits, The area of cutaneous anaesthesia is shown in the figure, 
which can with advantage be compared with those in the article 
alluded to. It is much larger than in any case yet coming under my 
observation, and may be due to a division of nerves passing on to the 
face from the neck, which had been severed by the incision made for 
Fig. 2.—Showing area of anaesthesia in Case VI. 
the purpose of exposing and cutting the lower jaw nerve. Just within 
the areajof anaesthesia, along a line marked by crosses, cold was recog- 
nized as cold, while heat was recognized not as heat but as motion; 
the patient always said not “you are touching me with something 
warm,” but “ you are scratching me.” 
The mucous membrane of lips, cheek, soft palate, and upper 
pharynx (right side) was anaesthetic. The surface of the tongue as far 
back as the foramen caecum was anaesthetic, perhaps farther, but of 
this I am uncertain. Taste on the tongue held outside the lips was INTRACRANIAL NEURECTOMY. 
5 
abolished; taste within the mouth seemed normal, the substance to be 
tasted being diffused, of course. 
The right anterior half of the occipito-frontalis was paralyzed, 
also the corresponding corrugator supercilii. 
The muscles of mastication supplied by the divided branches of 
the fifth were paralyzed. 
Case VII.—S. S., white, male, aged sixty-three years, married, 
several children, entered hospital December n, 1894. 
In 1890 he suffered from right facial neuralgia, and the infra- 
orbital nerve was excised. The relief which followed lasted nearly 
one year, when recurrence took place. At the present time pain very 
severe is felt in the right temporo-maxillary region, paroxysmal in 
character. The spot of greatest intensity is over the zygoma one 
inch in front of the ear, thence the pain radiates over the head, etc., 
but does not involve the territory tributary to the first division of the 
fifth nerve. The paroxysms vary in length from a few minutes to half 
an hour. Talking, swallowing, and handling the face induce pain, but 
changes of weather do not. All teeth on the right side, upper and 
lower jaws, have been extracted in the expectation of obtaining relief 
from pain. The patient had undergone treatment by drugs, so after 
a week of preparatory treatment, December 19, 1894, I resected the 
second and third divisions of the fifth nerve, together with the 
adjacent portion of the Gasserian ganglion. Anaesthesia was induced 
by chloroform. 
The bone was chiselled through, and, not giving as much room as 
was desired, rongeur forceps were used and the opening made larger. 
The bone was not replaced. The dura was opened, cerebro-spinal 
fluid evacuated, the dura and brain raised, and the operation com- 
pleted. The middle meningeal artery was not interfered with, nor 
was it in the way. To raise the dura from the bone I used a piece of 
absorbent cotton (sterile) held in bullet-forceps and wrapped around 
the ends of the forceps. I had less trouble than ever before, the 
cotton diminishing oozing as the separation occurred. Much venous 
blood came from the inner surface of the skull above the opening, I 
having torn a vessel passing between dura and diploe. I pressed into 
the cranium enough gauze to stop the bleeding, and closed the wound 
in the anterior half. A voluminous dressing was then applied. The 
patient came from the operation-table with good pulse and respiration. 
Thirty-six hours later I removed the gauze packing, and closed the 
wound by suture, save at the lower posterior angle, where I placed a 6 
LOUIS Me LANE TIFFANY. 
small shred of gauze. Two days later, December 22, the patient’s 
temperature rose from normal in the morning to 103.40 F. at 2 
p.m., and from this time until January 5 the temperature fluctuated 
from normal to 102° F., the pulse and respiration remaining normal. 
There was some pain in the head, and two or three times bleeding 
from the nose. High temperature with normal pulse and respiration 
suggests the administration of an antiperiodic, so the patient was 
given quin, sulph. gr. five every four hours, beginning December 23, 
and continuing until December 28 without result. Until January 4 
no quinine. Commencing January 4, Warburg’s tincture was given 
in drachm doses every four hours, and there was no subsequent rise of 
temperature above normal. December 31, all stitches were removed, 
the wound being healed, and January 14 the patient returned home. 
The area of cutaneous anaesthesia is shown in the diagram. The 
right half of the tongue and palate and inside of cheek are anaesthetic, 
the right side of forehead cannot be thrown into wrinkles, the right 
muscles of mastication supplied by the fifth are paralyzed, taste on 
the tongue held outside the mouth is not lost, the difference between 
heat and cold is not recognized upon the face and tongue in the 
anaesthetic area. 
Fig. 3.—Showing areas of anaesthesia in Case VII. INTRACRANIAL NEURECTOMY. 
7 
Comparing my seven cases, it would appear as if the middle 
meningeal artery is divided only when it passes through a fora- 
men or very deep groove in the parietal bone ; it does not appear 
to be in the way or to interfere with access to the foramen ovale, 
notwithstanding the fact that Taylor’s measurements may suggest 
such a condition of affairs. In no case have I found it in the 
way at its entrance to the skull, although running as a pulsating 
tube in the dura from the foramen spinosum. The opening of 
the dura and evacuation of cerebro-spinal fluid is a procedure 
followed by very great benefit; the later steps of the operation 
become vastly more easy. It is to be noted that many operators 
have torn accidentally the dura, and so given exit to cerebro- 
spinal fluid by accident; should this not have occurred, it is un- 
questionably right that the dura should be cut, and cerebro- 
spinal fluid allowed to escape. In my last four cases this I have 
done, and have not taken the trouble to sew up the dura after- 
wards, considering that the minute hole would take care of itself, 
—as has been the case. 
The anaesthetic agent in all my cases has been chloroform ; 
the age of the patients, but, especially, the desire to avoid con- 
gestion of the face and head, so often seen with ether, has induced 
me to choose this anaesthetic. 
In looking at the diagrams it will be seen that the face anaes- 
thesia varies greatly.it not being so extensive as to cover the ter- 
ritory supplied by the fifth nerve,—its divided divisions. This is 
probably due to the presence of sensory nerves, which pass from 
the neck to the face. This is particularly noticeable in Case VI. 
The persistence of the anaesthesia is, of course, to be considered. 
This probably diminishes, both in extent and intensity, although 
I am not at present prepared to give the exact statistics in regard 
to my patients. I propose later to publish more accurate dia- 
grams in regard to this. 
Distinct from the anaesthesia, however, is to be considered 
the pain, because face anaesthesia and pain do not necessarily 
go together. In a certain number of cases, there is, I believe, 
no doubt about the fact that face sensation may remain or be 
present soon after the division of the nerve, yet pain be abso- 8 
LOUIS Me LANE TIFFANY. 
lutely wanting. One of Keen’s cases shows this, and Dan- 
dridge’s case shows it also. In a case of upper jaw neural- 
gia in which I did Carnochan’s operation eleven years ago, in 
October, 1894, there is absolutely no pain, yet perfect face sensa- 
tion. In no case have trophic changes been noted in the area of 
the fifth nerve after operation, the supraorbital region being in 
no wise different from the skin of the face, save what was normal, 
and in one of my cases, No. 3, the skin, from being harsh, 
returned to a healthy condition. 
Taste deserves mention. Of the five cases in which the 
second and third divisions and adjacent ganglion were removed, 
three show persistence of taste, two absence of taste. Taste was 
tried with sugar and salt. In three of the same five cases the 
patients could recognize the difference between heat and cold in 
the anaesthetic area. In two cases the thermic sense appeared 
to be absent. Of the cases in which the thermic sense was want- 
ing, one retained taste, the other did not. The temperature in 
Case VII was extremely erratic, without corresponding elevation 
of pulse or respiration,—was it due to trauma of a heat centre? 
Of my seven cases, in two the second division only was severed. 
Their progress will be watched with interest, and compared with 
the other five in whom a portion of the ganglion was removed, 
as it may offer a means of arriving at a knowledge as to whether 
the ganglion is in fault or not. It is to be remembered that Car- 
nochan laid great stress in his operation upon the removal of 
Meckel’s ganglion, considering that the fons et origo of neural- 
gia. It remains to be seen whether the Gasserian ganglion de- 
serves to be elevated into a similar position or whether it may be 
neglected. In intracranial neurectomy for neuralgia I am inclined 
to the opinion that its removal is expedient. The length of time 
during which absence of pain is to be expected—in other words, 
whether the operation is curative or not—remains to be found out. 
My first case was operated upon twenty-nine months ago ; it 
remains absolutely well. The second case of which I have in- 
formation, No. 3, was operated upon nineteen months ago ; she 
remains well; and so with subsequent ones down to my last, in 
December, 1894. INTRACRANIAL NEURECTOMY. 
9 
In regard to the preservation of the motor root of the third 
division, I thought that I recognized it in one case quite cer- 
tainly, as published in the article referred to, but I have not 
tried to save it since, thinking that no special advantage would be 
gained thereby. 
It is proper to mention that there has come to my knowl- 
edge a case operated upon successfully, the patient recovering 
and the neuralgia not recurring. Two other cases have come to 
my knowledge in which the. operation has been followed by death. 
And two cases have come to my knowledge in which, while the 
patients recovered from the operation, recurrence of the neuralgia 
has taken place. These cases doubtless will be reported, and it 
is not necessary that I should speak more fully of them now. 
The microscopic appearances presented by the removed 
portions of ganglion and nerves will form the subject of another 
communication, the pathologist to whom they were submitted 
not yet being prepared to report.