Operative surgery . morrhage so often attendant on the approach fromabove. Paralysis of the corresponding occipito-frontalis muscle is a com-mon sequel. The firm attachment of the masseter suggests the preserva-tion rather than the removal of the resected zygoma. The small size of theopening, its comparatively obscure and protected situation, renders a bonyflap of no special benefit. The bone at the upper part of the area ofapproach is thin and should be attacked with caution, to avoid injury, espe-cially of the meningeal artery, which passes immediately beneath. Thethickest portion is below,
Operative surgery . morrhage so often attendant on the approach fromabove. Paralysis of the corresponding occipito-frontalis muscle is a com-mon sequel. The firm attachment of the masseter suggests the preserva-tion rather than the removal of the resected zygoma. The small size of theopening, its comparatively obscure and protected situation, renders a bonyflap of no special benefit. The bone at the upper part of the area ofapproach is thin and should be attacked with caution, to avoid injury, espe-cially of the meningeal artery, which passes immediately beneath. Thethickest portion is below, and can be removed with the rongeur. Fragmentsof bone should be carefully excluded from the wound, as they may causemuch trouble. The ganglion should not be liberated until after the superiorcovering is raised and the branches are exposed and liberated, thus post-poning the bleeding that so often attends the elevation of the ganglion, alsofacilitating the uncovering of the ganglion and the elevation itself. The lib-. FiG. 323.—Intracranial neurectomy, Cushings method. The liberating of the ganglion. a. The middle meningeal arteiy. b. The size of operative opening, c. The abducensnerve, d. The opening in skull, e. The middle meningeal artery. /. The semi-lunar ganglion, g. The reflected dura. h. The dura propria of ganglion. eration and extraction of the ganglion and its connections are difficult, andare greatly facilitated by preliminary training on the dead body. Only expe-rience can practically adjust the degree of force needed to safely accom-plish the purpose. Manipulation at the foramen ovale, injury of the cav- 306 OPERATIVE SURGERY. ernous sinus in freeing the first division and the ganglion, and injury fromattendant mishaps, each causes a haemorrhage more or less severe, but whichusually yields to gauze pressure of a few moments duration. The sixthnerve is frequently injured in isolating the ophthalmic division, and thesympathetic always because of its direct and indi
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