THE FACE. 



61 



embraced the region of the pterion or junction of the coronal with the temporo- 

 sphenoidal sutures. As the bone was lifted from the dura at this point the middle 

 meningeal artery was torn and troublesome bleeding ensued. Also the point of its 

 breaking was too uncertain. Sometimes it broke too high up, sometimes too low 

 down involving the base. It was also found unnecessary to replace the bone as 

 the cavity left was filled up with fibrous tissue. For this reason Tiffany, of Baltimore, 

 advocated the making of an opening in the skull above the zygoma with a trephine 

 or gouge and mallet, and enlarging it with the rongeur forceps; the bone was not 

 replaced. This is the procedure now used. 



The operators who used the pterygoid route, by displacing the zygoma down- 

 ward, were enabled to approach the ganglion from below instead of from above, 

 therefore, a high temporal section of the bone was unnecessary and it has been 

 abandoned; the bone section keeping below the pterion and not wounding the 



N. ophthal- 

 Ganglion semilunare micus N. maxillaris 



A. meningen media 



N. niaiiflihularis 



M. pterygoideus 

 externus, upper head 



M. pterygoideus 

 externus, lower head 



M. pterygoideus interims 



N. alveolaris inferior 

 (inferior dental) 



N. lingualis 



N. buccinatorius 



FIG. 69. The upper portion of the illustration shows the operation of removal of the Gasserian ganglion (ganglion 

 semilunare). The lower portion shows the pterygoid muscles. 



middle meningeal artery thus avoids hemorrhage from that locality. Gushing 

 (Journ. Am. Med. Assoc., April 28, 1900) showed that the extensive removal of bone 

 on the base of the skull was unnecessary, and that a displacement of the zygoma 

 and temporal muscle downward, and removal of the bone down to and including 

 part of the infratemporal crest gave sufficient access. Murphy found it unnecessary 

 to resect the zygoma, and this has been our experience. 



One of the main difficulties has been the question of bleeding. It has caused 

 death and not infrequently has necessitated the packing of the wound and the 

 deferring of the completion of the operation for two or more days. This bleeding 

 came from the soft parts, the bone, the middle meningeal artery, the veins running 

 from the dura mater to the bone, the cavernous sinus, and the blood-vessels to the 

 ganglion itself. These as given by Gushing are a branch from the middle meningeal 

 soon after its entrance to the skull, a small branch from the carotid, a small branch 

 from the ophthalmic, the small meningeal through the foramen ovale, and occasion- 

 ally one through the foramen rotundiim. He calls attention to the septa in the 

 cavernous sinus as rendering wounds to it less serious than they otherwise would be. 

 If the skin incision is cast too far back, the temporal artery may be cut in front of the 

 ear. Its position can be determined by its pulsation. It or its branches are divided 

 in the upper portion of the incision and bleeding is very free. Division of the 

 temporal muscle is followed by hemorrhage from the deep temporal. The bleeding 

 from the bone is usually not troublesome, but the general oozing from the veins of 



