Regarding the point brought up by Dr. Estes: I think none of these
patients had any trouble with the heart. The histories show that
except for the condition under discussion they were quite healthy
persons.
Dr. Wilson has, I think, demonstrated that these diverticula do not
necessarily occur along the line of the bloodvessel, but that they may
take place at any point in the circumference of the intestine.
Dr. Wilson (by invitation). We have purposely omitted all mention
of literature in reading these papers, though when printed they will con-
tain a bibliography. I desire, however, to call attention here to" Dr.
Beer's paper in the American Journal of the Medical Sciences ^ May, 1904,
which is far the best report seen so far. He reported one case of his own
and carefully reviewed the literature and pathology of seventeen other
cases, making eighteen in all. It is a most excellent report and one well
worth reading. In regard to the occurrence of carcinoma Hochenegge
has reported one case of carcinoma following an ulcerated diverticuliun.
I have gone very carefully over all our cases of carcinoma of the
colon, but found none of them related to diverticula.
Dr. Gerrish. Diverticulum ilei occiirs in 2 per cent, of all cases.
The unique feature in the case reported by me was the very peculiar
arrangement of the parts. The diverticulum came from the free border
of the ileum, passed downward on one side of the mesentery, apparently
Am Surg 18
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274 DISCUSSION
squeezed itself through an arched opening in the attached border of
the mesentery, and then curved up on the other side, fastening itself
to the abdominal wall by the intervention of a thin cord. This attach-
ment is seen in a great many of these cases. I am still in the gall of
bitterness as far as my assertion that these cases of diverticulum should
be operated upon is concerned, in spite of Dr. Fitz's views. Once since
the case which I have reported I have come across a case of appendi-
citis, seen with me by Dr. Bristow, in which there was gangrene of the
appendix and abscess, and the condition of the patient was such that,
aldiough I found there was a diverticulimi, I did not dare increase the
risk to the patient's life by removing it. The patient knows that she
has this diverticulum, and will be on the lookout for any of the frequent
signs of trouble. The diverticulum in this case, as well as the one in
the case reported, had no mesentery, which I think is a very common
condition, the diverticulum being nourished through the intestine itself
from which it springs.
Dr. Brewer. Dr. Mayo has just spoken of the possible association
of carcinoma with these diverticula^ One case was recalled to my mind
which I saw some years ago in consultation. A man with left-sided
abdominal abscess. The consensus of opinion was that he had carcinoma
with a probable perforation or peritonitis resulting in this abscess. The
patient's condition was not good at operation, and the abscess was simply
drained. Contrary to our expectations the abscess closed rapidly,
the man made a rapid recovery, and for six, or eight or ten months was
perfectly well. He then began to decline in health, and gradually
acquired symptoms of obstruction. The sinus reopened, and the sur-
rounding abdominal wall became infiltrated with carcinomas. This
man probably had an acute diverticulitis with abscess, and as a result
of inflammation there developed, subsequentiy, carcinoma. He lived
for about two years after his first operation.
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REMARKS ON THE SURGICAL TREATMENT OF
. FACIAL PARALYSIS AND OF TRIGEMINAL NEU-
RALGIA, WITH EXHIBITION OF PATIENTS.
By HARVEY GUSHING, M.D..
BALTIMORE.
Two patients, who had recently been operated upon, were ex-
hibited; one of them had been a sufferer from tic convulsify the
other from tic douloureux. The historical as well as the physio-
logical relationship of these two maladies was briefly considered —
the former being an affection of the motor nerve to the expres-
sional musculature, the Nervus facialis; the latter, of the sensory
nerve to these same muscles and their overlying skin field, the
Nervus trigeminus.
Case I. — In the case of tic conwlsij, after purposeful division
of the facial nerve at its emergence from the stylomastoid foramen,
a spinofacial anastomosis was performed a year ago, this being the
speaker's eighth case of this form of anastomosis. Reasons were
given for preferring this method to the hypoglossofadal operation,
under the conviction that the results of the former are uniformly
better than when the motor nerve to the tongue has been employed.
The arguments advanced by Ballance and Spiller favoring the
h}^oglossofacial operation on physiological grounds are largely
conjectural, and the thickness of speech consequent upon the hemi-
lingual paralysis is an undesirable sequel of this method.
It was shown in the patient exhibited that she had regained in
considerable degree the normal emotional control of the expres-
sional musculature, the only instance of functional restoration of
this type heretofore recorded, so far as the speaker was aware.
Indeed, in this patient the first indication of returning movement
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276 gushing: facial paralysis
occurred six months after the anastomosis as a certain emotional
control in the act of smiling. (See Figs, i and 2.)
One other of the speaker's spinofacial operations had been per-
formed for an even more severe case of tic convulsif, and Keimedy,
of Glasgow, based his early report of this method of anastomosis on
the study of a patient who had been operated upon for the same
malady. The muscle spasm, which in severe cases becomes asso-
ciated with painful muscular cramps, ceases immediately after the
division of the facial nerve; and, with the return of control by way
of the Nervus accessorius, the spasms have not returned in any of
the recorded cases.
Case II. — ^The second patient had been recently operated upon
(eight weeks) for tic douloureux. She was the fifty-second case of
ganglion operation in the speaker's series. Her neuralgia had
begun in the first or ophthalmic division of the trigeminus, and in
the five months during which she had been suflFering had extended
into the field of the second or maxillary division, and there was an
occasional twinge in the mandibular division. Realizing that
unless completely relieved she was destined to a neuralgic life,
and not wishing to procrastinate through peripheral operations of
short-lived benefit, the ganglion operation was performed as a
primary measure.
The speaker emphasized that all operations on the peripheral
side of the ganglion in cases Df genuine trigeminal neuralgia,
whether they include nerve section, evulsions, or injections into
the nerve trunks of mordant fluids, must be regarded as measures
which serve merely to postpone the day when complete and final
severance of the nerve proximal to the ganglion must be contem-
plated, in order to secure permanent relief. This applies not only
to peripheral extracranial operations, but also to those intracranial
procedures during which only a portion of the ganglion is removed,
or in which, after intracranial division of its lower branches (max-
illary and mandibular) foreign substances are interposed either in
the course of the divided nerves or in the foramina which they tra-
verse. Particularly is this true of those patients whose neuralgia
has originated in the ophthalmic division, as in the patient shown.
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278 gushing: facial paralysis
Furthermore, when the first or ophthahnic division is left intact,
as in many of the above-mentioned procedures, it sooner or later
becomes involved in pain, even if the paroxysms have not originated
there.
On the patient shown, the speaker demonstrated the position of
the incision which has been employed in his last thirty-one cases.
It obviates the surgical division of the highest branch of the pes
anserinus which innervates the occipitofrontalis — ^an unavoidable
consequence of the omega-shaped incision employed in all other
methods of approach. Owing to this incision, and to the careful
closure in four layers of the soft parts over the temporal fossa, no
observable trace of the operation remains, for there is no appre-
ciable asymmetry of the face, either from atrophy of the masti-
catory muscles or in consequence of the loss of power to elevate
the eyebrow.
Postoperative photographs, taken on or about the tenth day
after the neurectomy, in the thirty patients similarly treated, were
shown (see Figs. 3 and 4, an example), giving further emphasis to
this improvement in the technique of the operation, so far as it
concerns the approach to the ganglion. The incision, in many of
these cases, is absolutely invisible, even on the shaved scalp a few
days after the operation, owing to the painstaking method of
closure. It was shown also that it is needless to shave more than
the temporal region of the afflicted side in preparation for these
operations, healing in all cases having been absolutely perfect, and
only one or two out of the thirty cases having been drained for
forty-eight hours, owing to a continuance of the venous oozing.
A further point in regard to the treatment of the ganglion was
then emphasized. In the speaker's last thirty cases the ganglion
has not been removed and the operation has been conducted merely
at its posterior border, between the edge of the mandibular division
and the meningeal artery. When the ganglion has been suffi-
ciently freed at this point a properly curved, blunt dissector is in-
serted under and around its sensory root (often before the root has
been brought clearly into view, for this sometimes is impossible)
and the sensory root is then carefully hooked forward and avulsed
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28o gushing: facial paralysis
from the pons, so that it is turned out of the opening which it tra-
verses at the attachment of the tentorium, and lies forward over
the ganglion. In the original operation the attempt was made to
remove the ganglion in toto, a procedure which occasions consid-
erable bleeding, particularly during the liberation of the first and
second divisions. The avulsion of the sensory root, together with
the ganglion, was always attempted in these earlier operations;
but at the present time the speaker is content with the avulsion of
the sensory root alone, and leaves the ganglion in its bed without
freeing the ophthalmic and maxillary divisions, for the liberation
of these .branches is the chief cause of operative delay in many
cases, owing to the resultant bleeding. Once only in the writer's
entire series of sixty-two ganglion operations has the meningeal
artery been injured, either at its entrance into the skull or at its
fixed point in the parietal bone.
Emphasis was also laid by the speaker on the fact that opera-
tions on the Gasserian ganglion are not measures to be attempted
other than by those who, through special training, have perfected
themselves in safe methods of conducting these delicate intra-
cranial manipulations.
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FACIAL PARALYSIS 281
DISCUSSION.
Dr. S. J. MiXTER, of Boston.
I hesitate somewhat to even discuss the paper of Dr. Gushing, con-
sidering his very remarkable successes in this branch. I have had some
experience in this line. I wish that Dr. Gushing had said a litde more
about his method of operating. The old method of removal of the whole
ganglion was, and still is, a dangerous one. In fact, as Dr. Gushing
has said, this operation will always be a dangerous one; I wish to go a
little farther than he did and say that even in the most skilful hands it
will always be a dangerous operation. No two cases are exactly alike.
When it comes to the question of choice of an operation I think it must
depend largely upon the operator's experience. Personally, during the
last few years in twenty or more cases I have done a modification of the
Abbe operation, and I think that I shall continue to do that operation
until I see some reason, which I do not now see, for abandoning it,
because my results so far have been satisfactory both to me and to my
patients. These cases extend now over a period of three to four years,
and so far as I know, and I have been able to follow these cases pretty
thoroughly, there has been no recurrence of the pain.
I divide the second and third divisions of the nerve, injecting the ner\'e
either before or after division with osmic acid introduced into the
trunk, and then after dividing the nerves push them out of sight, fill
the foramina with amalgam filling, also the fossa, making a complete
dam of considerable size between the. stumps of the nerve and ganglion.
During an operation of this sort one of my patients died almost on the
table; I have never been able to explain this death, as this operation seems
to me very much less dangerous than the old operation, which I cannot
understand anyone now using, and I consider the operation I do is
even less dangerous than the method Dr. Gushing uses. It certainly
is simpler, even though it may not be as quick.
Dr. Allen Starr, of New York (by invitation).
I want to congratulate Dr. Gushing on the results that he has obtained
in both of his cases. I have had a number of cases operated upon by
the hypoglossal operation, and I have never seen as good a result as in
Dr. Cushing's case here presented.
In regard to the treatment of trigeminal neuralgia, I have been accus-
tomed for many years to send all my cases to Dr. Hartley for operation.
I think that neurologists are pretty well con\inced that the source
of disease in neuralgia of the fifth nene is in the changes that occur in
the Gasserian ganglion. This has been shown pretty conclusively by
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282 DISCUSSION
Mills, Spiller, and Keen, who have demonstrated clearly the existence
of degenerative changes in the Gasserian ganglion. It then stands to
reason that it is useless to divide the nerves in their peripheral course.
My experience has shown me that while the peripheral operation may
relieve for a few months, possibly a year or two, the pain is almost sure
to return along the branches of the fifth nerve. Therefore, in every
case I should advise the early radical operation.
Regarding the pathology. I cannot be quite sure that the division
of the nerve trunks on the distal side of the ganglion is destined to remain
a feasible curative operation. I should much prefer to divide the nerve
between the ganglion and pons, or tear the root of the nerve out of the
pons. As Dr. Gushing has devised this operation of tearing this root
out he has conferred upon us a great benefit by making an operation that
is sure to be a successful one in every case. . It gets at the root of the
matter and it absolutely cuts off that ganglion from the conscious centres
in the brain, thus preventing any recurrence of the pain.
Dr. Stephen H. Weeks, of Portland, Maine.
I am sure we are aU indebted to Dr. Gushing for his excellent contri-
bution, but I think no surgeon would think of removing the Gasserian
ganglion until the nerves had been removed outside the cranial cavity.
It often happens after these operations that the pain sooner or latter
returns, and the only thing the surgeon can do is to remove the ganglion.
At my last operation, which was only a few weeks ago, a point occurred
to me which I think worthy of mention. In my operation I make the
osteoplastic flap, and after exposing the nerves previously to their passing
through the foramen, the first nerve that comes into view is the superior
maxillary just before it passes through the arytenoid. The proximal
end is pulled upon firmly and the ganglion will be found embedded in
its depression. The next step is seizing the inferior maxillary, by rough
dissection carefully severing from the meningeal artery close by, and
then seizing the canal and cutting it off, and then, by making traction
on the proximal end, the Gasserian ganglion is lifted from the depression
and comes direcdy into view, and then with the scissors one can cut off
, as much of the ganglion as he pleases. I believe it is an advantage to
leave a portion of the ganglion.
Dr. Gushing. I believe, with Dr. Starr, that the ganglion cells
represent the seat of war in cases of trigeminal neuralgia, although I
do not believe that any of the pathological changes in these cells which
have been found in extirpated ganglia are a specific lesion of the disease.
They represent rather the residual cell alterations resulting from earlier
peripheral operations and are comparable to the changes in spinal
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FACIAL PARALYSIS 283
posterior-root ganglia after amputations. As the ganglion cells are the
actual " seat of war," and as all of them, first or last, become involved,
those of the first division included, total extirpation or permanent sever-
ance from their encephalic connections is the only thing which can assure
a final cessation of painful impulses. Much as I respect, therefore.
Dr. Mixter^s unusual surgical skill and judgment, I am inclined to
regard the method that he has described as only a temporary measure,
particularly for cases in which the first division has been or is likely to
become involved. The very fact that he uses three different measures
to accomplish the destruction of the ganglion cells or to prevent regenera-
tion is an evidence of no great assurance in the eflicacy of any one
of them, and I doubt not but that esthesia remains in the field of the
ophthalmic division after a large percentage of these operations, indi-
cating only partial destruction of the ganglion. An operation which is
limited to the removal or destruction of the second and third divisions,
leaving the first division intact, gives no assurance of permanent relief
from pain, as I have learned to my sorrow in two earlier cases in which,
from operative difficulties, I failed to remove the entire structure. If
the skull has been once entered, a central operation, provided that
with practice it can be simply and safely done, is far preferable to any
measure or combination of measures directed toward the distal branches
of the ganglion or the lower groups of ganglion cells.
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THE DESIRABILITY OF EARLY OPERATIONS UPON
THE NERVES IN ISCHEMIC PARALYSIS.
By LEONARD FREEMAN, M.D.,
DENVER-
Volkmann's ischemic paralysis, as is well known, occurs with
few exceptions in children, following fractures of the forearm,
and is nearly always due to tight bandages or splints. The
muscles, being deprived of blood by pressure, their cells xmdergo
disintegration and absorption, and are replaced by connective
tissue. When the circulation is rapidly cut oflF, it has been esti-
mated that the muscles die in about seven hours; but when the
process is slower, death may not result for days or weeks, and may
then be only partial, permitting more or less complete regenera-
tion. The immediate result of this local muscular death is a form
of rigor mortis, causing contractures similar to those seen in the
cadaver, thus explaining why the fingers are occasionally found
strongly flexed upon removing the splints but a few hours after
their application. Such postmortem rigidity, however, is only the
first step in ischemic paralysis. The real process develops later,
resulting from the slow solidification and contraction of connec-
tive tissue. The aflFected muscles become hard and shrunken,
resembling, in extreme cases, mere bands of tough, fibrous mate-
rial. The fingers grow permanently flexed, occasionally to such
a degree that the nails dig into the palm. Rarely the dorsal
muscles are more strongly contracted than the palmar, resulting
in extension of the wrist and proximal phalanges, with flexion
of the terminal phalanges, leading to a peculiar claw-like
deformity.
Just how much the nerves are concerned in the phenomena of
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freeman: ischemic paralysis 285
ischemic paralysis seems to be uncertain. In some instances they
do not appear to be involved at all; while in others, sensory and
trophic disturbances are the causes of very distressing symptoms. A
primary neuritis is not uncommon, due directly to splint pressure,
aided by an insufl5cient supply of blood, and manifesting itself
by the usual disturbances in sensation. This may disappear,
especially if the splints are promptly loosened; or it may pass
directly into the later and more serious form of pressure neuritis,
due to cicatricial contractures of the muscles, to which I especially
desire to call attention. The damage from this latter form may be
slight, or it may be so great that the nerves are changed into fibrous
bands and almost pinched out of existence, their functions being
correspondingly destroyed. They are often irregular and nodular
when pressed upon, while above this point they are thick, soft,
and congested. Nothing could be more evident than these nerve
lesions — they are often so marked as to instantly force themselves
upon the attention of the operator. They result in sensory and
trophic disturbances of the hand, varying all the way from slight
anomalies in sensation to that deplorable condition in which the
skin is glazed, bluish, and perhaps blistered, and the sense of touch
destroyed. The hand may become so sensitive and painful as
not only to inhibit its usefulness, but to render it an intolerable
nuisance to its possessor. One of my patients, an extreme case,
even went so far as to beg me to amputate his arm if there was no
other way to relieve his distress.
It is justifiable to assume that Volkmann's paralysis originates
in the muscles, hence treatment should first be directed toward
their recovery by removal of constricting bandages and splints,
persistent massage, electricity, passive and active motion, etc.,
and in many instances success will be achieved. It must not be
lost sight of, however, that the condition of a muscle depends
largely upon the condition 0} its nerve. If the nerve is badly in-
jured, the muscle suflFers until the nerve is repaired. In other
words, a species of "vicious circle" exists — cicatricial changes in the
muscles injure the nerves by compression, and the injured nerves
in turn prevent the regeneration of the muscles. Hence we are
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286 freeman: ischemic paralysis
forced to give attention to the nerves, when involved, as well as to
the muscles.
The above considerations naturally lead to the following con-
clusions:
1. Every case of ischemic paralysis, whether slight or marked,
whether nerves are involved or muscles alone, should first be
treated by massage and electricity, combined with such active
and passive motions as are best adapted to lengthen the contracted
muscles or prevent their further stretching. The massage should
be vigorous and persistent, and the stretching of the muscles, by
simultaneous extension of wrist and fingers, as decided as the
patient can bear. As mentioned by Fergusson, however, too
violent extension, especially under anesthesia, might be disastrous,
by causing rupture of the nerves imbedded in the cicatricial muscles.
2. In many cases, under this treatment, when the lesions are
purely muscular, or when the nerves are but slightly implicated,
improvement will occur in time, followed often by more or less
complete recovery, although the tendons may require lengthening
by some plastic operation. And even when the nerves are badly
pinched, as evidenced by changes in sensation and nutrition, the
results may still occasionally be good.
3. //, however, in these bad cases improvement in nerve function