ny spf 
 
 M^j 
 
 Columliia Mnibersiitp 
 in tfje Citp of J^eta gorfe 
 
 ©epartmEitt of ^urgerp 
 ?BuU iWemorial jFunb 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/surgicaltreatmenOOhutc 
 
THE SURGICAL TREATMENT OF FACIAL 
 NEURALGIA. 
 
THE SURGICAL TREATMENT OF 
 FACIAL NEURALGIA 
 
 BY 
 
 J. HUTCHINSON, Jun., F.R.C.S. 
 
 Surgeon to the London Hospital ; 
 Examiner in Surgery, Royal Army Medical Department 
 
 NEW YORK 
 WILLIAM WOOD AND COMPANY 
 MDCCCCV 
 
TO MY FATHER 
 
PREFATORY NOTE. 
 
 Reference to the list of published writings on 
 the subject which is given at the end of this work 
 will prove how numerous, yet how widely scattered 
 they are. Professor Krause's valuable monograph, 
 published in 1896, is, however, the only one which 
 gives at all a complete review, and it is largely 
 occupied with questions relating to the physiology 
 of the fifth nerve. I have only briefly discussed 
 these points, with the view of confining the present 
 account to practical details. Considerable differ- 
 ence of opinion still exists as to the best forms 
 of operation for facial neuralgia. The hope of 
 providing a clear account of a complex and difficult 
 subject, and of making it more simple is the chief 
 reason for this work. 
 
 J. Hutchinson. 
 
 I, Park Crescent, 
 
 Portland Place, W. 
 
CONTENTS. 
 
 Chapter I. 
 
 PAGE 
 
 The Causes and Forms of Facial Neuralgia i 
 
 Chapter II. 
 Epileptiform Neuralgia ; its Course and Symptoms ... 17 
 
 Chapter III. 
 The Nature and Pathology of Epileptiform Neuralgia 26 
 
 Chapter IV. 
 The Treatment of Epileptiform Neuralgia ... ... 39 
 
 Chapter V. 
 Operations on the Gasserian Ganglion ... ... ... 75 
 
 Chapter VI. 
 
 Excision of the Gasserian Ganglion. Results and 
 
 Complications of the Operation ... ... ... 103 
 
 Reference to published papers on the Surgical Treat- 
 ment of Trigeminal Neuralgia ... ... ... 131 
 
 Index ... ... ... .. ... 137 
 
THE 
 
 SURGICAL TREATMENT OF 
 FACIAL NEURALGIA. 
 
 CHAPTER I. 
 
 Tii-E 'Causes and Forms of Facial Neuralgia. 
 
 -■ -■^■c;-,!^!\^?■ 
 THE subject of facial or trigeminal neuralgia in- 
 cludes some of the most interesting problems in the 
 whole realm of pathology and physiology. The sur- 
 geon, however, is chiefly concerned with the ques- 
 tion : " What cases of neuralgia are suited for opera- 
 tive treatment, and what are the best methods to 
 employ?" The answer, obviously, should depend 
 upon, a scientific classification, based solely upon the 
 causes of neuralgia ; at present such a classification 
 is impossible. We can distinguish the pain due to 
 errors of refraction from the more intense neuralgia 
 set up by a peridental abscess, and the pain caused 
 by a syphilitic node of the skull from that accom- 
 panying an attack of herpes frontalis. 
 
 Yet, of the gravest form of all, epileptiform or 
 major neuralgia (tic douloureux), which now fur- 
 nishes one of the triumphs of surgery, the patho- 
 logy and causation are practically unknown. What 
 
evidence exists on the subject and what theories 
 have been devised will be briefly discussed later. 
 
 The following rough classification may be sug- 
 gested : — 
 
 (i) The neuralgia due to anaemia, gout, malaria, 
 or other abnormal conditions of the blood. 
 
 (2) That due to a neuritis, e.g., the neuralgia 
 accompanying herpes, or tabes dorsalis. 
 
 (3) The pain referred from some local cause, 
 such as a carious tooth, an inflamed iris, a syphilitic 
 node, &c. 
 
 The three forms of neuralgia summarised have 
 definite causes, the removal of which is the aim of 
 the physician or surgeon. For none of them is any 
 operation indicated on the nerve-trunks which are 
 apparently involved, though destruction of the 
 terminal twigs may be occasionally indicated, as in 
 the neuralo-ia due to a hollow carious tooth. More- 
 
 o 
 
 over, in these cases the neuralgia is favoured or 
 induced by certain known conditions ; it is more or 
 less continuous, or, if spasmodic, the patient has 
 intervals of only comparative, and not complete, 
 absence of pain. 
 
 In (4) Epileptiform neuralgia (tic douloureux, 
 neuralgia major), neither local cause nor favouring 
 conditions can as a rule be assigned ; the intermit- 
 tent nature of the pain is kept up from first to last 
 with shortening intervals. In this form of neuralgia 
 any attempt of the surgeon to remove some peri- 
 pheral exciting lesion is worse than useless, whilst 
 an operation on the central part of the fifth nerve 
 
(the Gasserian ganglion) is followed by complete 
 cure. 
 
 Some other and less definite kinds of neuralgia 
 of the head might be introduced, such as referred 
 pain from visceral causes, hysterical neuralgia 
 (closely allied to the preceding), migraine, &c., 
 but these belong to the physician's rather than 
 to the surgeon's province. Dr. Henry Head, 
 F.R.S., has given a masterly account of the whole 
 subject in Allbutt's "System of Medicine" (vol. vi.)» 
 and in Pepper's "System of Medicine" (vol. v.), 
 it is also treated in a complete and interesting 
 manner. Epileptiform neuralgia (neuralgia major) 
 can as a rule be easily distinguished from the other 
 forms after it has become well established, though 
 in its early stages mistakes are very apt to be made. 
 Before discussing in detail its symptoms and treat- 
 ment, some of the more common varieties of 
 neuralgia minor may be illustrated. 
 
 The neuralgia due to eye-strain from hyper- 
 metropia, presbyopia, or astigmatism, is well-known ; 
 it is almost always frontal and ocular in distribution, 
 and is brought on by use of the eyes in near vision. 
 Its relief by correcting the error of refraction with 
 suitable glasses is immediate. Iritis and acute 
 glaucoma are often attended with more intense 
 neuralgia, having much the same distribution. 
 The extreme importance of recognising the reflex 
 nature of the pain and of instituting the proper 
 treatment for its cause cannot be over-rated. 
 
The neuralgia from glaucoma and iritis often 
 affects the temporal region, and, in the former case, 
 the upper or lower jaw may be the seat of varying 
 tenderness and pain.^ Such a distribution is never 
 met with in the neuralgia due to errors of refraction. 
 It should not be forgotten that the latter form may 
 be aggravated by systemic conditions. Thus, it 
 may be necessary to treat ansemia as well as hyper- 
 metropia, &c., or the cure will be imperfect ; and 
 Dr. Head points out that in some cases in women 
 the climacteric may share with the onset of pres- 
 byopia in inducing troublesome neuralgia. 
 
 Another important point is that eye-strain may 
 lead to paroxysmal attacks of headache of con- 
 siderable intensity accompanied by vomiting. 
 Many a case of acute glaucoma has been diagnosed 
 as one of "bilious headache" during the first day 
 or two, until it was too late to save the sight by 
 iridectomy. 
 
 It will be noticed that the neuralgia having an 
 ocular cause is nearly always referred to the fore- 
 head. True epileptiform neuralgia hardly ever 
 begins in the first division of the fifth (see page 
 17). Herpes frontalis is usually preceded by con- 
 siderable pain in this nerve, and after the eruption 
 has subsided, neuralgia may be very persistent, 
 lasting in the worst cases for some months. It 
 always however subsides ultimately, especially 
 
 ^ Head, loc. cit., p. 746. 
 
under careful treatment. The pathology is now 
 well established, largely owing to the work of Dr. 
 Henry Head ; there is a definite inflammation of 
 the Gasserian ganglion or of the ophthalmic trunk. 
 
 Another cause of severe frontal neuralgria remains 
 to be noted, namely, catarrhal or suppurative in- 
 flammation of the air sinuses in the frontal, ethmoid,' 
 or sphenoid bones. It is not merely distension of 
 the sinuses with pus which causes the intense pain, 
 for an attack which clears up entirely may be 
 attended with such severe throbbinof neuralg^ia that 
 at the time the presence of pus may be strongly 
 suspected. Influenza is a fertile source of such 
 neuralgia, as also of empyema of the frontal or other 
 sinuses. Disease of the antrum of Higfhmore 
 usually produces dull throbbing pain in the cheek, 
 though it may extend up to the forehead, and in 
 neglected cases the whole trigeminal area may be 
 concerned. The grave mistake may then be made 
 of treating the case as one of neuralgia alone, and 
 of ignoring the real cause. 
 
 A young and healthy officer became subject to one- 
 sided " facial neuralgia " of increasing intensity. He was 
 then in India, and was treated in hospital with all kinds 
 of sedative drugs without avail. Becoming steadily worse, 
 he was invalided home to England. On the voyage he 
 became hemiplegic, and was landed in an extremely 
 exhausted condition. For the first time the nature of his 
 disease was ascertained, namely, suppuration in the antrum 
 of Highmore, from which disease of the bone had spread 
 up to the base of the skull, with consecutive meningitis 
 and cerebral abscess. Operative measures were unfortu- 
 nately too late to save the patient's life. 
 
Cases such as the above are very exceptional ; as 
 Dr. Head remarks, " even in those nasal affections 
 that cause pain, it is rarely acute enough to be 
 spoken of as neuralgia." Suppurative inflammation 
 of the frontal sinus, especially if its infundibular 
 exit is blocked, and the cavity becomes distended 
 with pus, is the most likely to produce pain of a 
 high degree of severity. 
 
 Headache and neuralgia due to syphilis are of 
 great importance, since in most cases they can be 
 cured or greatly relieved by mercury and iodides ; 
 moreover, their cause is often overlooked. 
 
 Their various forms and the circumstances under 
 which they occur will be best illustrated by the 
 following examples : — 
 
 I. — Persistent Cephalalgia in the Secondary Stage 
 from Neglect of Treatment. 
 
 Dr. G. Schorstein and I once examined a man who was 
 claiming damages on account of a contusion of the head, 
 which had been followed by persistent and intense pain 
 with loss of sleep and a torpid mental condition. The 
 pain was largely occipital, with radiations down the 
 cervical spine. The headache was, as a rule, worse at 
 night, but it never left him, and his doctor had tried 
 various sedatives without giving any relief. He com- 
 plained only of this continuous ache, which had entirely 
 prevented his working for several weeks ; in fact, he was 
 confined to his room and looked a physical wreck. There 
 was no optic neuritis or vomiting, but giddiness if he 
 attempted to walk. 
 
In making a thorough examination we found a copious 
 blotchy syphilitic eruption, which had appeared within 
 three weeks of the accident. Six months had elapsed, but 
 no anti-syphilitic treatment of any kind had been attempted, 
 nor would his doctor admit the diagnosis of syphilis. The 
 man, however, did not get damages, but took a mercurial 
 course instead. It may be noted that persistent headache 
 or neuralgia occasionally results from head-injury (cerebral 
 concussion), with or without fracture of the skull, but in this 
 case the injury was certainly not the main cause. 
 
 II. — Iritis attributed to Injury. Severe Neuralgia 
 of Head. Secondary Syphilis Overlooked. 
 
 This case bore a strong resemblance to the one just 
 noted. A man working in the Docks was struck by a 
 rope which swung round his head. For four months after 
 the accident he attended Moorfields Hospital for slight 
 iritis in both eyes, and he also was treated by no fewer than' 
 six medical men in addition, on account of severe head- 
 ache. The neuralgia was constant, but worse at night ; it 
 was chiefly frontal and vertical. During the four months 
 the man was receiving compensation from the Dock Com- 
 pany, but Dr. Finlay, its medical adviser, being dissatis- 
 fied, sent the patient up to me. There was no syphilitic 
 eruption present, nor could I obtain any history of chancre 
 of the penis, but the evidence as to syphilis was conclusive. 
 
 It consisted in : (i) a well-marked bald patch on the 
 dorsum of the tongue, with two small ulcers ; (2) chronic 
 enlargement of the glands in the right groin and on both 
 sides of the neck ; (3) uveal deposit from iritis in each 
 eye ; and (4) the persistent cephalalgia with characteristic 
 nocturnal exacerbations. The man was urged to take 
 a proper mercurial course, and I believe that his symptoms 
 entirely subsided under its influence. 
 
III. — Headache due to Periostitis and Nodes of the 
 Skull in the Late Stages of Syphilis. 
 
 Many examples of this could readily be quoted. 
 In some there may be one or more definite tender 
 swellings on the skull, accompanied by radiating 
 pain ; in others the distribution is more general, and 
 no isolated node can be distinguished. There may 
 be sclerosis of large areas of bone, or a node 
 situated entirely within the cranium. Pericranial 
 gummata are usually soft and free from tension, and 
 therefore cause little pain, but occasionally a 
 localised necrosis occurs beneath them. Should 
 an abscess then form between dura mater and bone, 
 very severe cephalalgia may be produced. Opera- 
 tion under such circumstances is urgently called for. 
 As a rule, however, the symptoms yield to increas- 
 ing doses of iodides of sodium and potassium or to 
 mercurial inunction. 
 
 Syphilitic necrosis, when it involves the base of 
 the skull, may cause intense suffering, of which the 
 following case is an example : — 
 
 About ten years after contracting syphilis, a man 
 became the subject of aggressive necrosis, which destroyed 
 the whole of the palate and the nasal septum. It spread 
 to the turbinated and sphenoid bones, until a chasm was 
 left, through which the roof of the naso-pharynx was 
 exposed. The disease progressed in spite of all kinds of 
 mercurial and iodide treatment, the latter drug being the 
 more effective, but causing considerable depression. 
 
 Piece by piece the bone of the skull came away, the separ- 
 ation being attended with horrible pain which destroyed 
 
sleep for weeks together. The neuralgia was referred to 
 both temples and to the forehead, there being little 
 doubt that the fifth nerve about the Gasserian ganglion 
 was affected on both sides. 
 
 This was one of the most obstinate and deplorable 
 cases of tertiary syphilis I have ever seen. In the pre- 
 iodide days they appear to have been common. 
 
 IV. — InU'a-cra7iial guinmata may cause severe 
 neuralgia, which, as a rule, is curable by iodides. 
 
 " The anterior part of the temporal fossa is a not 
 uncommon situation for a syphilitic gumma. In 
 this position it causes neuralgia over the v^hole of 
 the temporal fossa, accompanied by marked tender- 
 ness of the superficial structures, not only over the 
 actual gumma itself, but over a vi^ide area in front 
 of it, spreading out above and in front somewhat 
 like a fan. This area corresponds to the distribu- 
 tion of the ascending branches passing from the' 
 deep parts of the fossa forwards and upwards to 
 the scalp. It does not correspond to any area or 
 combination of areas of referred pain. . . .^'^ 
 
 To this observation of Dr. Head's I am able to 
 add an explanation of the neuralgia which certainly 
 holds good in some if not all the cases, namely, that 
 the gumma leads by extension to an inflammation 
 of the wall of the cavernous sinus and thus to a 
 neuritis of the fifth nerve. 
 
 Fig. I shows two vertical sections through the 
 carotid artery and cavernous sinus. On the left 
 
 ^ Head, '* Allbutt's System of Medicine," vol. vi., p. 736. 
 
10 
 
 side, normal for sake of comparison, the relation of 
 the various nerves and the Gasserian ganglion are 
 clearly shown. On the right side of the figure all 
 traces of the cavernous sinus have disappeared ; the 
 nerves are distorted by inflammation and pressure ; 
 the carotid artery is much narrowed, and contains 
 an organised clot, which does not block the lumen. 
 The wall of the sinus is greatly thickened and was 
 adherent to the temporo-sphenoidal lobe (syphilitic 
 infiltration). The case was reported by Dr. A. H, 
 Robinson and myself^ and was, I believe, the first 
 one published which demonstrated this pathological 
 nature of ophthalmoplegia. Brief notes of the case 
 are as follows : — 
 
 F. S., a man, aged 53, under care for a tertiary ulceration 
 of one leg. In September, 1885, radiating pain came on 
 in right temple and occiput, also in the eye. This persisted 
 for seven months, being somewhat relieved by iodides, and 
 having the fan-like distribution alluded to above by Dr. 
 Head. There was also present with it complete ophthalmo- 
 plegia, which improved from time to time under iodides. In 
 April, 1886, he contracted cellulitis of his leg from infection 
 of the ulcer and died of septicaemia. 
 
 It will be seen from fig. i that all the nerves in the wall 
 of the cavernous sinus (motor and sensory) were so inflamed 
 and degenerated as to be almost unrecognisable as such. 
 The apex of the tempero-sphenoidal lobe was affected with 
 gummatous softening and was adherent to the thickened 
 dura. It is of interest to note that, although the opposite 
 sinus looked normal to the naked eye, microscopic exami- 
 nation proved that the inflammatory process had spread 
 
 ^ Ophthalmological Society's Transactions, 1887, vol. vii., p. 250. 
 
•no =■ ^ 
 
 in O - 
 
 m 
 
 o 
 
 ft P (T) 
 
 ~ -1 (a, p 
 
 (D K in 
 
 t^ s 3 X 
 
 ■ P So 
 
 3 == --^ 
 
 fi m g 
 
 
 ni O • 
 
 EL p o 
 S" "■ 3 
 
 O 2. a 
 
 a a ^ 
 
 2 O-o 
 
 p p 
 
 n 3 3 
 
 S,o P 
 
 p s s 
 
 o 2,Er. 
 
 ■^ 3 
 
 s 5' 
 P c 
 
 p S 5 
 p o O. 
 
 v3 S P 
 
 ^ P 3 
 
 w p. 
 
 P o'^ 
 
 O ?^ 
 
 -:^ 
 
 tn Si' '^ 
 
 §'= cr 
 
 o ^ 
 C re 
 
 <! 
 K 
 ?0 
 H 
 
 o 
 
 en 
 
 W 
 
 o 
 
 H 
 O 
 
 > 
 
 5 - D 
 ■-1 ?^" I— I 
 en 
 
 > 
 
 O 
 
 O 
 
 > 
 
 <: 
 
 o 
 a 
 
 hM. O 
 
.■*;.._ •^,, ^.1 
 
 "■"^^^^ 
 
 ^f^immm^ 
 
 "Xi::. i,.^ '% , 
 
 %^^M0m 
 
 
 
 i^i^ii^s^'ij**™^*' 
 
 ■'<<:. 
 
 ■ c>< 
 
II 
 
 across and would doubtless have produced similar paralysis 
 had iodides not been given freely. 
 
 In the same vol. of the Ophth. Soc. Trans. ,^ I 
 recorded an exactly similar case of ophthalmoplegia 
 and neuralgia (fan-like distribution over the side of 
 the head) which was entirely cured by iodides and 
 which doubtless had the same pathology. It should 
 be noted that in both the neuralgia was accompanied 
 by marked impairment of sensation, thus resembling 
 the cases due to pressure by a new growth in the 
 region of the cavernous sinus (see p. 38), It would 
 appear that the pain produced by tumour pressure 
 in this region is usually more severe than that set 
 up by syphilitic infiltration and inflammation of the 
 nerves, though the difference may be chiefly due to 
 the relief given by iodides in the latter class. 
 
 Inasmuch as tabes dorsalis generally occurs in 
 those who have had syphilis, it might almost be fair 
 to include tabetic neuralgia in the above list. But 
 that syphilis is not the sole cause of tabes is gene- 
 rally admitted. The occurrence of spasmodic neu- 
 ralgia in the limbs and trunk in those afflicted with 
 ataxia is very common, and Dr. Buzzard^ pointed 
 out, over twenty years ago, the important relation 
 that sometimes exists between facial neuralgia and 
 tabes dorsalis. He showed that the first symptoms 
 of tabes may be severe shooting pain in the fifth 
 
 ^ Vol. vii., p. 256. 
 
 ^ " Clinical Lectures on Diseases of the Nervous System," 
 1882, p. 143. 
 
12 
 
 nerve area ; that the tabetic neuralgia may be 
 followed by anaesthesia, and concurred with Pierret^ 
 in thinking that sclerosis of the descending spinal 
 root of the fifth nerve was probably the cause. 
 The diagnosis is a matter of much importance. Dr. 
 Buzzard writes : " In an ordinary case of trigeminal 
 neuralgia it is most common to find the pains limited 
 to the district of one or more of the three divisions 
 of the nerve. . . . But in the pains . 
 which occur in the reo"ion of the fifth nerve in tabes 
 this accurate mapping out of the district of one or 
 other division of the nerve is not, according to my 
 experience, observed." Too much must not, how- 
 ever, be made of this point, as a reference to the 
 case on p. 122 will show. More important is the 
 fact that true epileptiform neuralgia is always one- 
 sided ; that due to tabes may affect both sides of the 
 head. " Flying, so-called, neuralgic pains in the head, 
 when they attack both sides and do not 7nap out the 
 district of 07ie or other division of the fifth nerve, 
 should lead to attentive examination for symptoms 
 of tabes " (Buzzard). 
 
 Neuralgia due to Dental Causes. 
 
 Almost everyone has had personal experience of 
 the acute pain caused by carious teeth, alveolar 
 suppuration and the like. Although the cause may 
 
 ^ " Essai sur les Symptomes Cephaliques de Tabes Dor- 
 salis." Paris, 1876. 
 
13 
 
 be limited to one tooth, the neuralgia is frequently 
 wide-spread, and may be paroxysmal in character, 
 though very rarely epileptiform in the sense of 
 having intervals of complete relief. Besides the 
 two common and easily recognised causes just 
 mentioned, there are others, such as acid fermenta- 
 tion around the neck of a tooth, ulceration of gums 
 (sometimes due to mercurial stomatitis), caries or 
 necrosis of bone set up by injury in tooth-extrac- 
 tion, or the crowding out of the wisdom teeth. A 
 very severe neuralgia may be set up in the follow- 
 ing manner : a hollow tooth is stopped with a heavy 
 metal stopping before the cavity has been thoroughly 
 disinfected or the nerve destroyed. In such cases 
 weeks or months of suffering may ensue, only to be 
 relieved by the removal of the stopping or the 
 extraction of the tooth. 
 
 Without doubt, the worst and most persisting 
 cases of dental neuralgia may simulate tic dou- 
 loureux, and even lead to the discussion of operation 
 upon the fifth nerve ; but careful examination of the 
 teeth and gums, and consultation between dentist 
 and surgeon, should guard against either of two 
 errors being committed. The first is one too 
 commonly made, namely, the useless extraction of 
 normal teeth in cases of true epileptiform neuralgia. 
 The second is less apt to occur ; the performance 
 of neurectomy, or even excision of the Gasserian 
 ganglion, in a case where dental extraction, &c., 
 would suffice. 
 
14 
 
 In the foregoing account of " minor neuralgia " 
 the treatment required has been indicated by the 
 varying causes, but in a considerable proportion of 
 cases no cause can be definitely assigned. For 
 these, empirical measures may be of use, the fol- 
 lowing being a selection from the ever growing list 
 of such remedies. 
 
 I. — Internal Treatment by Medicine. 
 
 The importance of iodides (potassium, sodium, 
 and ammonium) in cases having a syphilitic origin 
 is obvious. They may possibly be of advantage in 
 a few other cases, from their influence in lowering 
 blood-pressure, but the depression they are apt to 
 cause is a drawback to their use. 
 
 Qtiinine has a great reputation, and amongst the 
 preparations of it may be mentioned the valerianate 
 (in 5-grain doses), the hydrobromide (2 to 5 grains), 
 and the salicylate (5 to 10 grains). The hydro- 
 bromide may be given hypodermically. 
 
 Cannabis Indica (in doses of one-fourth to one 
 grain) is a more dangerous drug, and should be 
 resorted to only in severe and special cases. In a 
 few cases it .appears to be the only remedy which 
 relieves, though its toxic effects may be as bad as 
 the disease for which it is given. 
 
 The same objection applies to Gelsemiuni (five to 
 fifteen minims of the tincture). Sir Victor Horsley 
 states that poisonous doses of. this drug, in his 
 
15 
 
 experience, have alone relieved true epileptiform 
 neuralgia. 
 
 Citrate of caffein is comparatively harmless, but 
 only does good in slight cases of neuralgia ; aconite 
 preparations are dangerous and rarely successful ; 
 bromides depress and are of little use. 
 
 Morphia will always check pain, but most will 
 agree with Prof. Krause in holding that it should 
 be entirely banished from the therapeutics of neu- 
 ralgia, as from those of intestinal obstruction. The 
 only exceptions, in the former case, are those where 
 the cause of the neuralgia can be recognised and 
 removed, {e.g., a carious tooth) but some temporary 
 alleviation is required for the intense pain. 
 
 Its use in epileptiform neuralgia is a grave 
 blunder, or worse. Ever-increasing doses are 
 required,^ and the patient becomes both a mental 
 and physical wreck. The operation which will alone 
 cure him is deferred, and the patient becomes less 
 and less fit to undergo it. 
 
 II. — Local Treatment of the Ne7'ves and Skin. 
 
 The inunction of various sedatives may be useful 
 — such as equal parts of mesotan (a derivative of 
 salicylic acid) and olive oil, menthol and oleic acid, 
 the unguentum aconitinse, etc. 
 
 1 In one case recorded by Prof. Billroth, the patient, before 
 the end came, was taking nearly half-an-ounce of morphia 
 hypodermically every day ! 
 
i6 
 
 Freezing the skin with chloride-of-ethyl spray has 
 been recommended, but is more Hkely to do harm 
 than good. 
 
 Galvanism and electricity in all forms have had a 
 wide trial, but all that can be said is that they are 
 occasionally useful. 
 
 The application of warm dry heat is sometimes 
 efficacious. 
 
 The hypodermic injection of osmic acid into the 
 nerve-trunk chiefly concerned is most uncertain ; it 
 may be put on a level with nerve-stretching in being 
 sometimes of temporary benefit. A 2-per-cent. 
 solution is usually employed, and the attempt made 
 to hit the nerve-trunk with the point of the syringe- 
 needle before the injection is made. The writer has 
 no personal faith in the method. 
 
CHAPTER II. 
 
 Epileptiform Neuralgia ; its Course and 
 Symptoms. 
 
 The disease to be discussed is also known by the 
 scientific name of neuralgia quinti major and by the 
 inexact but familiar term of tic-douloureux. As 
 the latter is often used to include cases of minor 
 neuralgia it is best to discard it entirely. It is im- 
 portant to define the class "epileptiform neuralgia" 
 as closely as possible, since in it alone are the 
 important operations on the Gasserian ganglion 
 indicated. Whilst examples of it are frequently 
 mistaken in the earliest stage of the disease, diffi- 
 culty can rarely arise when it is well established. 
 The chief features of true epileptiform neuralgia are 
 as follows : — 
 
 (i) It is almost invariably unilateral. 
 
 (2) It commences in the distribution of either the 
 second or third division of the fifth nerve, and tends 
 to involve both to the same extent. 
 
 (3) The first (ophthalmic) division, so frequently 
 concerned in cases of minor neuralgia, is involved 
 comparatively little in epileptiform neuralgia. 
 Radiations of pain in the ophthalmic distribution 
 
i8 
 
 and that of the cervical nerves often, however, 
 occur. 
 
 (4) The attacks of pain are paroxysmal or 
 spasmodic and tend to steadily increase in severity, 
 whilst the intervals of freedom from pain shorten. 
 
 (5) During each attack there is usually spasm 
 of the facial muscles on the affected side. 
 
 (6) No cause can, as a rule, be assigned for the 
 onset of the disease, but talking, eating, or exposure 
 of the skin to slight cold or light pressure, invari- 
 ably bring on the attacks when the disease is well 
 established. 
 
 (7) The subjects of the disease, at its onset, are 
 usually adults between the ages of 30 and 50. Males 
 are more often the subjects of it than females. 
 
 (8) Its progress is one of steadily increasing 
 severity, lasting an indefinite number of years. 
 
 Spontaneous cure is almost unknown. 
 
 (9) Medical treatment, except increasing doses 
 of morphia, has little or no effect. All kinds of 
 operations on the peripheral branches of the fifth 
 nerve may give temporary relief. 
 
 (10) Partial or complete removal of the Gas- 
 serian ganglion alone affords a permanent cure. 
 
 The summary given above will render unneces- 
 sary a detailed account of all the symptoms, which 
 has been admirably given by Dr. Head^ and other 
 writers, such as Professors Krause and Trousseau. 
 
 ^ Dr. Clifford Allbutt's "System of Medicine," vol. vi., pp. 
 28 to 233. 
 

 
 1 
 
 1 
 
 ^^^^^^^■^^ 
 
 
 Sw 
 
 ****»»i^. 
 
 
 
 T 
 
 
 Fig. 2. 
 
 From photograph taken during a severe and typical attack of trigeminal 
 neuralgia. The left fifth nerve was concerned, but it will be noticed there 
 is convulsive spasm of the facial muscles on the right side as well as of the 
 depressors of the lower jaw. The temporal artery becomes prominent 
 during an attack. The expression of agony is fairly well conveyed in the 
 reproduction. 
 
19 
 
 One of its most striking features is the strictly 
 unilateral nature of the complaint ; two exceptions 
 only to this rule are mentioned by Krause and 
 Head, in the latter case the neuralgia had lasted 
 twenty-five years. However long the duration 
 of neuralgia, there is no disturbance of sensation 
 except when produced by neurectomy or other 
 operation. The question of trophic disturbance in 
 the area of skin and mucous membrane will be dis- 
 cussed later (see page 26). 
 
 During the intervals, which at first may be of 
 weeks' or months' duration, the patient is entirely 
 free from pain ; in this respect a marked contrast 
 exists to most cases of minor neuralgia. In ad- 
 vanced cases, however, the attacks occur with only 
 a few minutes' interval. Touching the skin lightly 
 with a handkerchief or feather at first may produce 
 an attack ; later, the act of mastication or the attempt 
 to talk will bring it on. Night and day the parox- 
 ysms occur ; so that, from loss of sleep and impaired 
 nutrition, the patient's condition becomes an utterly 
 miserable one. Billroth graphically pictures such 
 a case : "I can see him now before me, emaciated 
 to a skeleton, with a rigid, staring expression, with 
 the saliva dribbling from his open mouth, with 
 white, neglected beard and long, unkempt hair." It 
 is no wonder that such sufiferers seek relief in 
 suicide, or, what is almost as bad — the morphia 
 habit. 
 
 Fig. 3 illustrates the state of mental degradation 
 
20 
 
 which was induced in one of my cases by his pro- 
 longed suffering and abuse of morphia. The upper 
 specimen of hand- writing was written by the patient 
 (a man of about 50), in answer to the strong appeal 
 to undergo the radical operation. It was the best 
 
 .(h,..c<4^j..^^ . ^^ /itn^ J^. 
 
 ^a^y^*^ . 
 
 Fig. 
 
 attempt at writing he could do, and the contrast 
 with his natural hand a year after the operation is 
 most striking. 
 
 Cases of suicide directly due to epileptiform 
 neuralgia are by no means rare, and are charitably 
 referred to temporary insanity. We may, however, 
 
21 
 
 fairly ascribe this nervous instability and loss of 
 mental control to the agony so long endured, the 
 want of sleep and rest, and to the grave effects of 
 drug-treatment. Perhaps the depressing effect of 
 many futile operations must also be taken into 
 account. Thus it will be seen there is no reason 
 to suppose that a tendency to insanity or perverted 
 mental action can indirectly cause the neuralgia ; it 
 is far more probable that the reverse takes place. 
 Epileptiform neuralgia is confined to no class, age, 
 or rank in life. Some of its sufferers are men and 
 women of the highest intellect, of the strictest lives ; 
 others have never worked hard except with their 
 hands, and many have lived freely as regards 
 alcohol and the like. The disease would appear 
 to be especially prevalent in the United States, but 
 almost every European country seems to furnish 
 its quota of sufferers. It would be, however, a 
 matter of great interest to ascertain its relative 
 prevalence in India and other tropical countries ; 
 it may be found that it is mainly confined to those 
 having a temperate or cold season. 
 
 The local distribution of the neuralgia in epilepti- 
 form cases is of much importance as an indication of 
 the form the operation should take. Analysing six- 
 teen cases operated on by Italian surgeons, we find 
 that all three divisions of the fifth nerve were in- 
 volved in only four (25 per cent.). In the other 
 twelve cases the second division (superior maxil- 
 lary) was alone concerned in two cases, the third 
 
22 
 
 in one, whilst in the remaining nine (60 per cent, 
 of the whole number) the neuralgia affected both 
 the second and third divisions. It is, therefore, 
 obvious that in 75 per cent, the surgeon had no 
 reason for attempting division of the ophthalmic 
 trunk, as removal of the lower part of the ganglion 
 would suffice for a cure. Professor Billroth, who 
 had much experience in the treatment of facial 
 neuralgia, noted that the nerve affected in the 
 majority of cases is the superior maxillary division. 
 Sir Victor Horsley observed the same fact, and 
 states that in every case in which a dental origin 
 could be assigned for typical trigeminal neuralgia 
 the upper jaw was the one concerned. 
 
 It should, however, be clearly stated that true 
 epileptiform neuralgia rarely has such an origin, 
 though it is hardly necessary to recommend that 
 the condition of the teeth and gums should be seen 
 to in any case of facial neuralgia. All carious 
 teeth should be carefully stopped, or, if that is found 
 impossible, they should be extracted. Sometimes 
 a heavy metal stopping is the cause of intense 
 neuralgia, and septic changes are only too apt to 
 occur under an elaborate crown or bridge of gold, 
 and to cause this symptom. But, as a rule, too 
 much attention is paid by the physician to the 
 teeth in cases of epileptiform neuralgia. Nothing 
 is more certain than that it may arise in patients 
 with no trace of dental caries or irritation, and that 
 the extraction of healthy teeth is a useless and 
 
23 
 
 barbarous method of treatment. In every case in 
 which I have operated on the Gasserian gangHon a 
 number of such teeth had been previously removed 
 without the shghtest benefit. Such a measure can- 
 not be too strongly condemned. 
 
 Spasm of the facial muscles is rarely absent, at 
 any rate during the severe attacks ; it is illustrated 
 by fig. 2 taken from one of my cases. 
 
 Dr. Head notes that in addition to the reflex 
 spasm of the facial muscles there may be fibrillary 
 tremor. The liability of the patient to the attacks, 
 when once started, continues as a rule during the 
 remainder of his life, unless a curative operation is 
 performed. Billroth observed one case of spontane- 
 ous subsidence, but it is almost a solitary exception 
 to the rule. It hardly ever commences before 
 the age of 30 or 35, often later. In both these 
 respects a striking contrast is afforded to migraine 
 and true epilepsy (which are also paroxysmal diseases 
 of the nervous system) ; both as a rule develop in 
 early life and tend to gradual diminution or dis- 
 appearance after the age of 50. By some observers 
 migraine is held to be a form of neuralgia which is 
 practically confined to the ophthalmic division of the 
 fifth nerve, and possibly started by exposure of the 
 supra-orbital regions to cold.^ In its distribution, 
 the age of its onset, and its tendency to cure, it 
 differs completely from epileptiform neuralgia. 
 
 ^ Anstie, Sinkler, &c. 
 
24 
 
 Has epileptiform neuralgia any relation to true 
 epilepsy ? — Trousseau discusses this point and 
 mentions two cases in which the diseases co-existed, 
 but this does not take one far. He was evidently 
 unwilling to admit their close relation, and rightly 
 so ; but he wrote that, if it proved that the family 
 histories of the subjects of epileptiform neuralgia 
 revealed ** neuroses," he would have to bracket the 
 two. The evidence hitherto collected shows that 
 the sufferers from true epileptiform neuralgia can 
 neither blame their immediate ancestors for nervous 
 bequests, nor themselves with contributing self- 
 indulgence in their habits of life. Epileptiform 
 neuralgia has no apparent relation to the use of 
 alcohol or tobacco, to syphilis, to gout, perhaps not 
 even to that vague entity, "the rheumatic tendency." 
 
 Sir V. Horsley, in enumerating the possible causes, 
 attaches most importance to three — alcoholic excess, 
 traumatism, and dental or peridental inflammation. 
 The opinion of such an authority deserves the 
 highest respect, but cases of true facial neuralgia of 
 unsurpassed intensity are met with in those who 
 (i) have been teetotalers all their lives, (2) have 
 sustained no injury whatever to the head, and 
 (3) have never known the pangs of toothache. 
 
 The late Dr. Anstie made the interesting sug- 
 gestion that in the subjects of epileptiform neuralgia 
 there was apt to be associated the taint of insanity. 
 In many of the recorded cases the patients before 
 operation are described as being strange in their 
 
25 
 
 manner, perhaps threatening suicide, or actually 
 delirious, whilst delirium has sometimes come on 
 immediately after the operation ; but these symptoms 
 of mental derangement are probably due to pro- 
 longed suffering and loss of sleep. There is really 
 no evidence of the connection between epilepti- 
 form neuralgia and any neurosis ; the disease stands 
 by itself. In the next chapter will be discussed 
 the question of its pathology. 
 
CHAPTER III. 
 
 The Nature and Pathology of Epileptiform 
 Neuralgia. 
 
 It is improbable that the typical epileptiform 
 neuralgia, for which operations on the Gasserian 
 ganglion are so successful, depends upon a true 
 neuritis. The intervals of complete freedom from 
 pain, which early in the case may be of many weeks' 
 duration, and the fact that neither motor paralysis 
 nor cutaneous anaesthesia ever attends the neur- 
 algia however inveterate, place the affection in an 
 entirely different category from the well-known 
 peripheral neuritis of the limbs. It is true ,that 
 some symptoms which might be termed trophic 
 (such as oedema, persistent congestion, or dermatitis) 
 are occasionally met with in the regional distribution 
 of the intense epileptiform neuralgia, but traumatic 
 irritation by the patient in the hope of obtaining 
 some relief is the usual cause of such symptoms. 
 In several of my cases the patient during each 
 spasm of pain used to violently grasp at the skin 
 involved as though to tear it away, and no wonder 
 such a habit led to some " trophic " effects, 
 
 W. W. Keen states that he has seen two cases of 
 corneal ulceration and opacity in conjunction with 
 
27 
 
 trigeminal neuralgia, but on reference to his notes of 
 these cases one finds no record whatever of eye- 
 trouble in one of them ; in the other, the eye concerned 
 had been the subject of chronic glaucoma, and the 
 lens had already been removed ! I know of no other 
 instances in which the neuralgia was associated with 
 trophic changes in the eye, and obviously Keen's 
 cases prove nothing. It is of course well known 
 that herpes frontalis and nasalis may be attended 
 with conjunctivitis and corneal ulcers, sometimes 
 even with sloughing of the eye. In herpes the 
 existence of a neuritis involving the Gasserian 
 ganglion has been proved, and the fact that eye 
 changes never occur in paroxysmal neuralgia of 
 the fifth nerve is a strong argument against the 
 latter being due to neuritis. 
 
 It is true that Spiller, who examined the- 
 nerves and ganglia in several cases, described- 
 globular degeneration of the myelin-sheaths, but 
 this is no proof of inflammation, and moreover, he 
 admits that the same changes may be found in 
 other nerves which are not the seat of neuralgia. 
 Spiller also described thickening of the arterial walls 
 in the Gasserian ganglion, swelling of the axis- 
 cylinders, &c. Keen considers that true pathological 
 changes were proved in six out of seven cases ex- 
 amined by Spiller, but, as in excision of the ganglion 
 it is impossible to avoid a somewhat rough handling 
 of the delicate nerve-structures, this statement must 
 be accepted with great reserve. Peculiar staining 
 
28 
 
 methods are also responsible for some of the 
 changes which have been found. This does not, of 
 course, apply to diseases of the blood-vessels in 
 the ganglion (such as extreme narrowing of their 
 lumen). It is doubtless true that arterio-sclerosis 
 has been occasionally found, but that it is often 
 present in connection with epileptiform neuralgia 
 is certainly not the case. How, then, can it be the 
 cause of such neuralgia if it only exists in a small 
 minority of the cases ? Again, typical epileptiform 
 neuralgia is met with at an age when arterial 
 sclerosis hardly occurs ; in thirteen cases out of 
 thirty-two it commenced between 30 and 40 years 
 —Billroth. 
 
 I believe the theory of vascular degeneration as 
 the chief cause, or even as a cause, of trigeminal 
 neuralgia should be entirely rejected. It is more 
 difficult to disprove the theory of spreading neuritis, 
 which has the strong support of Sir Victor Horsley,^ 
 who regards *' true neuralgia " as being synonymous 
 with neuritis, and suggests that the inflammation 
 often commences in the small dental nerves, and 
 spreads up along the larger branches to the Gasserian 
 ganglion. 
 
 Horsley, however, admits that the only changes 
 in the peripheral branches he has ever found, con- 
 sist in thickening of their fibrous-tissue sheaths ; 
 that the nerve-tubules are normal, and further, that 
 the Gasserian ganglion shows no changes except a 
 varying degree of adhesion to its dural investment. 
 
 ^ Horsley, Clinical Journal, 1897, '^'o^- ^i-> PP- ^ and 17. 
 
Fig. 4. 
 
 Section of Gasserian ganglion removed from case of inveterate trigeminal 
 neuralgia. The ganglion cells are seen to be perfectly normal. 
 
29 
 
 Spiller and Keen, on the other hand, attach import- 
 ance to degeneration of the myehn-sheaths of the 
 nerves, whilst Billroth states that microscopical 
 examination of the excised peripheral nerves proved 
 in so many cases absolutely negative that it was 
 given up as useless. 
 
 Schwab examined two Gasserian orangflia which 
 had been extirpated, the operation following others 
 which had been performed on the peripheral 
 branches of the fifth nerve. He found slight 
 changes in both ganglia, but in neither case did he 
 reoard them as sufficient to account for the neuralg^ia. 
 However, he attributed the neuralgia to one of 
 three causes, a peripheral neuritis, an interstitial 
 inflammation of the ganglion itself, and a neuritis of 
 the sensory root of the ganglion, of which, he says, 
 there are two instances recorded. It is very, 
 doubtful whether any such changes are really pre- 
 sent. Amongst those who have recorded entirely 
 negative results from thorough examination of 
 the removed ganglia may be mentioned Monari,* 
 Codivilla (three cases), myself (specimens examined 
 by Dr. Henry Head, F.R.S.), and Dr. J. Crawford 
 Renton. Prof. Krause's observations on both 
 peripheral nerves and ganglia, resected for trige- 
 minal neuralgia, have also been negative, and he 
 suggests that "perhaps the changes escape our 
 detection because they are molecular." 
 
 Fig. 4 represents a section through the ganglion 
 
 ' Monari, Beitrdge ziir Klinische Chirnrgie, Band xvii., 1896. 
 
30 
 
 from one of my cases. It shows well the ganglion- 
 cells and supporting connective tissue. It will be 
 seen that the ganglionic cells are in no way com- 
 pressed ; the fact that they differ much in size is 
 due to the section cutting through some at their 
 centres, and others at the periphery. The minute 
 cells of the neuroglia are not more numerous than 
 is normal, and nowhere is there the slightest 
 evidence of inflammation. In fact, the section 
 might be taken to illustrate the normal structure 
 of such a ganglion. 
 
 Fig. 5 is taken from a section through one of 
 the main branches of the fifth nerve just beyond 
 the ganglion, also from a case of inveterate 
 trigeminal neuralgia. The dense fibrous sheath is 
 perfectly normal, as are also the nerve-tubules. 
 Attention is drawn to a small artery cut across in 
 the nerve ; its wall is in no way altered from the 
 normal. 
 
 It may therefore be taken as proved that in many 
 cases of epileptiform neuralgia of long duration the 
 Gasserian ganglion and its main branches show no 
 pathological change, and that the disease has, 
 moreover, no relation to impaired blood-supply 
 due to arterial narrowing, &:c. The few observers 
 who have described abnormal appearances in micro- 
 scopic sections from such cases vary much in their 
 accounts. 
 
 These facts lead one to the conclusion stated 
 on p. I, that the pathology of epileptiform neuralgia 
 is still unknown. 
 
Fic. 5. 
 
 Section through a main branch of the fifth nerve, from a case of 
 epileptiform neuralgia. 
 
31 
 
 We will now consider, as throwing- some lioht 
 upon the subject, the question of tumours involving 
 the Gasserian ganglion. 
 
 Cases illustrating this, though very uncommon, 
 are yet of special interest ; they afford the clearest 
 evidence of a central origin for neuralgia of the 
 fifth nerve, and in some instances the pain closely 
 resembles that of " idiopathic " epileptiform neu- 
 ralgia. Almost always, however, there is evidence 
 of pressure on the neighbouring nerves, the carotid 
 artery, or the cavernous sinus, with marked anaes- 
 thesia, and the diagnosis of tumour can usually be 
 made before the operation. The following is a 
 brief account of the chief recorded cases of the 
 kind : — 
 
 A man, aged 50, was sent to me by Dr. Henry 
 Head, with partial oculo-motor paralysis on one 
 side, severe neuralgia of the corresponding fifth 
 nerve, and partial anaesthesia. An exploratory 
 operation by the temporal route showed an exten- 
 sive ossifying chondroma or chondro-sarcoma 
 growing from the apex of the petrous bone and 
 invading the Gasserian ganglion. Partial removal 
 of the growth was alone possible, the patient re- 
 covering from the operation. 
 
 Kosinski,^ in a case like the preceding one, 
 attempted a complete removal of the tumour, but 
 
 ^ Kosinski in Chipault's " Chirurgie Nerveuse," vol. ii. 
 P- 195- 
 
32 
 
 with fatal result. His patient was a woman, aged 
 53, whose right eye was atrophied, and in whom 
 the right facial and trigeminal nerves were paralysed, 
 A tumour could be felt in the right nasal cavity. 
 The upper jaw on that side was resected, and a 
 tumour growing from the base of the skull was 
 removed ; it penetrated into the cranial cavity. At 
 the autopsy the tumour was found to have been only 
 partially removed ; it was an osteo-sarcoma and was 
 said to have started from the Gasserian ganglion 
 itself. This, however, must have been a mistake ; 
 it was connected with the sella turcica, the sphe- 
 noidal sinus, and the bone forming the anterior 
 lacerated foramen. It is obvious that it was 
 impossible to remove such a growth, and it is 
 inconceivable that an osteo-sarcoma should start 
 in the Gasserian ganglion itself. 
 
 This was, however, the origin of a tumour 
 described by R. W. Smith as a neuroma, but which 
 should rather be termed a true sarcoma. The case 
 was of such interest that the drawing and descrip- 
 tion are here reproduced ^ (see fig. 6). 
 
 " In this instance the tumour implicated the Gas- 
 serian ganglion, and was the source of more severe 
 and uninterrupted suffering than I have ever wit- 
 nessed either in this or any other affection. 
 
 ^ R. W. Smith's " Monograph on Neuroma " was published 
 in 1849, and reproduced in 1898 by the New Sydenham 
 Society. This case was probably one of the first recorded 
 of tumour of the Gasserian ganglion. 
 
Fig. 6. 
 
 Tumour involving Gasserian ganglion (R. W. Smith's case). The growth 
 T is seen to be mainly within the dura mater, but a prolongation extends 
 through the foramen ovale along the inferior maxillary nerves (I.M.). 
 O.D. The ophthalmic division. 
 
33 
 
 " In the year 1836 an emaciated and unhealthy- 
 looking female, about 40 years of age, was admitted 
 into the Richmond Hospital, under the care of Dr. 
 Hutton, complaining of neuralgia of the right side 
 of the face. She stated that the pain had com- 
 menced several months previously, had gradually 
 increased in severity, and had now become almost 
 unsupportable ; she had lost flesh, her sleep was 
 broken, and her appetite had failed. Her counte- 
 nance indicated extreme suffering ; the pain (which, 
 although subject to exacerbations, never altogether 
 ceased) was accurately limited to the right side of 
 the face and forehead, and when indicating the 
 situations in which it was most severe the patient 
 marked with her finger the course of the branches 
 of the fifth pair of nerves, and more especially the 
 point of exit of the superior maxillary from the 
 infra-orbital foramen. Her sufferings were so 
 much increased by mastication that she ate but 
 little, and speaking aggravated the pain to such a 
 degree that she always remained silent unless when 
 interrogated, and even upon these occasions she 
 frequently replied by signs. She had no respite 
 from suffering during the day, and at night sleep 
 seldom came to her relief, nor did any of the 
 numerous remedies employed succeed in affording 
 even temporary ease. After having endured more 
 severe and more uninterrupted pain than I have 
 ever witnessed in any other instance, death termi- 
 nated her protracted agonies, four months subse- 
 quent to her admission into the hospital. 
 
34 
 
 "■Autopsy. — When the cranium was opened and 
 the brain removed, a tumour was seen in the right 
 division of the spheno-temporal fossa ; it was some- 
 what of the form and size of a walnut, and occupied 
 the situation of the Gasserian gangHon ; it extended 
 across the inner extremity of the great wing of the 
 sphenoid bone, as far forwards as the foramen 
 lacerum orbitale, and was covered by the super- 
 ficial lamina of the dura mater, which was attenuated 
 to a remarkable degree. The trunk of the fifth 
 nerve appeared to enter the posterior part of the 
 tumour, the interior of which, however, presented 
 no trace of nervous structure ; the ophthalmic 
 division crossed the anterior part of its superior 
 surface ; the superior maxillary emerged from it at 
 the foramen rotundum ; and the third division 
 seemed to be identified with a remarkable prolonga- 
 tion of the tumour, which passed through the 
 foramen ovale, the circumference of which was 
 increased to more than double its natural extent. 
 
 " The surface of the petrous portion of the tem- 
 poral bone, which supported the posterior part of 
 the tumour, was absorbed, as well as the superior 
 wall of the horizontal portion of the carotid canal ; 
 between this rough and denuded portion of the 
 bone and the deep surface of the tumour ran the 
 Vidian nerve, which throughout its whole course, 
 from Meckel's ganglion to the hiatus Fallopii, was 
 much larger than natural. The tumour was solid, 
 and of uniform consistence ; its section exhibited 
 
35 
 
 a cellular structure, without any trace whatever of 
 nervous tissue ; nerve-fibres could, however, by the 
 assistance of the microscope, be seen upon various 
 parts of its surface. The non-ganglionic portion of 
 the nerve was compressed, but not enlarged." 
 
 It is obvious that, whilst this case was recorded 
 by Dr. Smith as being an example of neuroma, 
 modern pathologists would consider it as a sarcoma. 
 
 Caponotto, in a case of neuralgia for which he 
 excised the Gasserian ganglion, found at the autopsy 
 a "cholesteatoma" the size of a nut, growing from 
 the pons varolii, at the point of exit of the roots 
 of the fifth nerve. Lampiasi ^ operated by the 
 temporal route on a case of neuralgia of the second 
 division of the fifth nerve, and found a small 
 sarcoma growing from the dura mater, which 
 adhered to the bone and pressed on the nerve. 
 He was able to remove the tumour, and improve- 
 ment resulted, both as regards the neuralgia and 
 the oculo-motor paralysis on the same side, which 
 had been present for a short time before the opera- 
 tion. It is, however, most unlikely that a cure was 
 obtained. 
 
 A detailed account is given ^ of a case of endothe- 
 lioma (or plexiform sarcoma) with a remarkable 
 clinical history. The patient, a man of 32, suffered 
 
 ^ Lampiasi, Twelfth Congress of Italian Surgeons, 1897. 
 ^ Dercum, Keen and Spiller, in Chipault's " Chirurgie 
 Nerveuse," vol. iii., p. 714. 
 
36 
 
 for a year with severe pain in the lower limbs, 
 violent neuralgia in the left fifth nerve, and in- 
 creasing weakness and somnolence. A glandular 
 tumour developed rapidly in the left side of the 
 neck ; on removal, it was pronounced to be an 
 endothelioma. The facial neuralgia increased in 
 intensity, but differed from the ordinary type in 
 not being paroxysmal and in being accompanied by 
 diminished sensation ; all three branches of the fifth 
 were moreover equally concerned. In November, 
 1899, Prof. Keen performed the Hartley-Krause 
 operation and removed piecemeal a considerable 
 tumour occupying the position of the Gasserian 
 ganglion. The ganglion itself could not be made 
 out, and the pain persisted as before. In a second 
 operation a month later more of the tumour, which 
 destroyed the upper edge of the petrous bone, was 
 removed. The dura mater was opened in both 
 operations and small granulations of the tumour 
 were seen growing on it. The patient recovered 
 from the operation, and this is doubtless all that 
 can be said with regard to a cure. It is of interest 
 to note that he had for long suffered from chronic 
 median otitis, and it might be suggested that the 
 primary growth was a cholesteatoma of the petrous 
 bone. The glandular tumour in the neck was 
 certainly secondary to the growth in the middle 
 fossa of the skull. 
 
 Hagelstan records the autopsy of a case of 
 endothelioma which infiltrated the left Gasserian 
 
37 
 
 ganglion ; Trenel, a case of " angiolithic sarcoma," 
 which also was not operated on. 
 
 Homen and Krause observed two cases of pres- 
 sure-atrophy of the ganglion, due to endothelioma 
 and cholesteatoma respectively. Krause's patient 
 died of meningitis two weeks after operation, owing 
 to leaking of cerebro-spinal fluid through the wound. 
 There is no object in separating the small series 
 of cases into those where the Gasserian ganglion is 
 pressed upon and those in which it is infiltrated or 
 destroyed by the tumour, for the distinction has no 
 practical importance. The tumour may arise in 
 connection with the apex of the petrous bone, the 
 pituitary fossa, the wall of the cavernous sinus, the 
 dura mater elsewhere in this region, and possibly 
 even from the tempero-sphenoidal lobe. 
 
 The cases given above may be classified accord- 
 ing to their nature as follows : — 
 
 (i) Sarcoma or fibro-sarcoma of the ganglion 
 itself — R. W. Smith's case. 
 
 (2) Sarcoma of dura mater, including endothe- 
 lioma, invading the ganglion — Hagelstan's, Keen's, 
 Trenel's, Homen's and Lampiasi's cases — five in 
 all. 
 
 (3) Ossifying chondroma, or chondro-sarcoma 
 growing from the petrous bone — J. .Hutchinson, 
 jun., and Kosinski. 
 
 (4) Cholesteatoma — Krause and Caponotto. 
 
 It will have been noticed in these cases of tumour 
 pressure on the ganglion that besides the neuralgia 
 
produced there is always some degree of anaesthesia ; 
 further, the oculo-motor nerves are sooner or later 
 involved, and there is frequently obstruction of the 
 orbital circulation giving rise to proptosis, &c. In 
 these respects there is a striking contrast to true 
 epileptiform neuralgia. 
 
 It may be noted, in conclusion, that in some cases 
 in which pathological changes have been described 
 in the ganglion, severe and repeated operations have 
 been performed previously on its main extra-cranial 
 branches. It is conceivable that such operations 
 may have led to ascending neuritis. 
 
CHAPTER IV. 
 
 The Treatment of Epileptiform Neuralgia. 
 
 But little can be said regarding the medicinal treat- 
 ment. In former times free purgation was held 
 to be useful. Belladonna had also a certain repu- 
 tation, but Trousseau, after many trials, pronounced 
 it useless. All forms of electricity have been tried, 
 and of course lately the X-rays have been resorted 
 to. Of the host of hypnotics and sedatives, new 
 and old, it can be said that temporary relief may 
 follow the use of any one of them, but that only, 
 disappointment results from their prolonged admin- 
 istration. Sir Victor Horsley states that he has 
 only seen marked benefit from tincture of gelse- 
 mium pushed to poisonous doses. Opium and 
 morphia alone will dull the pain, or even for a 
 time remove it, but at what a cost ! In some of 
 Trousseau's patients it was pushed up to drachm 
 doses of sulphate of morphia, or half an ounce of 
 opium each day. In some patients such pro- 
 digious doses cause no marked bad effects, not 
 even drowsiness ; but with many it is far other- 
 wise: the mental and physical condition both suffer; 
 there may be induced constant torpor with head- 
 
40 
 
 ache ; the digestion fails, and the patient may- 
 emaciate to a marked degree. 
 
 Terrible as is the suffering caused by epilepti- 
 form neuralgia, relief obtained by increasing doses 
 of morphia is only too dearly bought. When 
 once epileptiform neuralgia is well established the 
 right treatment consists in operation, and we have 
 now to consider the exact form that this should 
 take. Before doing so, however, a word of warn- 
 ing is necessary with regard to hysterical or 
 "neurotic" patients. Strange as it may seem, it 
 occasionally happens that epileptiform neuralgia is 
 simulated fairly closely, though careful examination 
 should save patient and surgeon from the mistake 
 of resorting to operation in such cases. Opera- 
 tions for hysterical conditions are never advisable. 
 Even simple incisions, made with a view of 
 impressing the patient with a kind of hypnotic 
 suggestion, only bring discredit on the surgeon in 
 the long run. How, then, can a serious operation 
 like excision of the Gasserian ganglion be justified 
 in a case of neuralgia having an hysterical basis ? 
 That such cases may simulate true epileptiform neu- 
 ralgia closely is undoubted. A good example of this 
 was the case of a woman sent to me by Dr. R. C. B. 
 Wall. She was a pallid and ill-nourished Jewess, 
 aged 44, who had borne eleven children. For the 
 last three years she had had attacks of neuralgia 
 in the right side of the head and face, strictly 
 limited, according to her statement, by the median 
 
41 
 
 line. These attacks came on shortly before each 
 menstrual period, recurred during the succeeding 
 two or three weeks, and left her with a free 
 interval only of a week or so ; but the attacks 
 were not increasing in intensity, nor were they of 
 the explosive character of epileptiform neuralgia : 
 on the other hand, the pain would last for some 
 days continuously, and sometimes numbness or 
 pain of one side of the body would accompany it. 
 The case was evidently one in which, in an 
 anaemic woman, neurasthenia, due to poor living 
 and repeated pregnancies, was to blame, and one 
 in which operation was quite out of the question. 
 Again, any case of persistent neuralgia, in which 
 there is a strong, neurotic, inherited tendency, is 
 unlikely to benefit by operation. 
 
 A man, aged 30, was seen by Dr. Henry Head 
 and myself on account of severe pain in the left 
 side of the forehead. It was not typically epilep- 
 tiform, but came on from time to time, and 
 appeared to be situated in the frontal bone itself. 
 His wife stated that he was strange in his manner 
 during the attacks and she feared he would 
 become homicidal. The patient had a dull, heavy 
 expression, and the history was that his mother 
 had died insane. He had never suffered from 
 syphilis, and nothing abnormal could be found on 
 examination of the forehead, eye, or nose. The 
 region of the frontal sinus was, however, specially 
 tender, and in the hope that some cause might be 
 
42 
 
 found for the neuralgia, I trephined the anterior 
 wall of the sinus and thoroughly explored it. 
 Nothing abnormal was found, and the patient was 
 but slightly relieved. Subsequently some opera- 
 tion was performed by Mr. Hunter Tod on the 
 upper cavities of the nose, but with the same dis- 
 appointing result. I saw the man two years after 
 this, but he was neither better nor worse, and he 
 was dissuaded from any further operation ; I am 
 convinced that his trouble was really cerebral. 
 
 Amongst the records of operation on the Gas- 
 serian ganglion are to be found several other 
 instances of "hysterical neuralgia," and in every 
 one the result was failure. Leaving these aside, 
 a very important question arises with regard to 
 the genuine epileptiform or major neuralgia. It 
 has been already noted that of the three divisions 
 of the fifth nerve the superior and inferior maxil- 
 lary are the most severely affected, and that often 
 the pain is for long periods confined to one only — 
 perhaps to a single branch of them. This is 
 especially true of the inferior dental and the infra- 
 orbital nerves. The tendency is for the disease 
 to spread, but when the neuralgia has for years 
 been practically confined to one division it seems 
 only reasonable for the surgeon to limit his inter- 
 ference to that division or branch only. In Trous- 
 seau's time such interference consisted, as a rule, in 
 a simple neurotomy or nerve-stretching. In many 
 of his cases repeated operations had been done 
 
43 
 
 on a single patient. There is no more candid or 
 masterly account of the disease than is contained 
 in his great work : ^ He sums up his experience 
 in these words: "even now, after more than thirty- 
 six years of practice, / have never known it to be 
 cured in a single case radically ^ At the same 
 time, in most cases, relief for a few weeks or 
 months was afforded by each operation. 
 
 Prof Billroth paid great attention to the subject, 
 and in his time resection of the nerves, and 
 operations on the main branches nearer the base of 
 the skull were practised. Better results were ob- 
 tained, and it is a most striking phenomenon that 
 the neuralgia is in some cases entirely cured for a 
 few years, but then returns in aggravated intensity 
 and widened area. In view of such a fact, how can 
 it possibly be true that epileptiform neuralgia is due 
 to sclerosis or other gross change in the Gasserian 
 ganglion or its main branches ? Were that true, 
 an extracranial operation, however extensive, could 
 have only the most fugitive effect upon the pain, 
 the cause of which it had not touched. 
 
 The following example is quoted as being typical. 
 Mugnai^ resected the infra-orbital nerve in a woman, 
 aged seventy-four, for severe neuralgia, with relief 
 lasting nearly three years ; then the pain returned 
 
 ^ Trousseau's " Lectures on Clinical Medicine," l^ew. Syd. 
 Soc. Trans., 1868, vol. i., pp. 105 to 116. 
 2 Mugnai, II Policlinico, July 15, 1895. 
 
44 
 
 in both second and third divisions with great in- 
 tensity. It rendered the patient half-imbecile, and 
 necessitated removal of the Gasserian ganglion. 
 Such a case might be quoted by both the advocates 
 and the opponents of extracranial operation. The 
 first operation was slight, without risk of life ; it 
 obtained comfort for the patient for three years, 
 and did not prejudice the success of the major opera- 
 tion. On the other hand, early resort to the latter 
 would have saved the cruel disappointment of the 
 recurrent pain, and the risk of the patient be- 
 coming a morphia-habitue. It is most desirable 
 to consider the following question without bias : — 
 
 To what extent are peripheral operations justi- 
 fiable in severe trigeminal neuralgia ? 
 
 This question can hardly be regarded as yet 
 decided, and three diverse opinions are held : — 
 
 (i) Neurectomy or avulsion of the affected nerve 
 with Thiersch's forceps should always be given a 
 trial, since relief for a period will certainly follow. 
 
 " The peripheral operations may be repeated, 
 a little more of the nerve being removed at each 
 time. 
 
 " The whole series of rational operations by 
 peripheral section should be exhausted before the 
 final resort to intracranial operations." ^ 
 
 (2) Since anything more than temporary relief 
 from peripheral neurectomy is quite exceptional, 
 
 ^ J. B. Deaver's " Surgical Anatomy," vol. i, p. 564. 
 ^ Lauwers and van Geruchten. 
 
45 
 
 the greater number of such operations should be 
 given up entirely. Persistent neuralgia, when con- 
 fined to one main branch of the fifth nerve, 
 especially the inferior dental, or the infra-orbital, 
 may fairly be treated by peripheral neurectomy. 
 
 (3) All extracranial operations on the fifth nerve 
 should be abandoned in favour of intracranial 
 resection of the Gasserian ganglion, its main roots 
 or primary branches. 
 
 In support of either of these alternative views, 
 various arguments and authorities might be ad- 
 duced. One thing is, however, settled — both 
 stretching and simple section of the peripheral 
 branches of the fifth nerve are practically worthless, 
 and should not be employed. It was hoped that 
 the method of avulsion, tearing put long tracts of 
 the peripheral branches as introduced by Thiersch,, 
 would give better results than the neater, and (to 
 use a somewhat discredited term) more surgical 
 method of careful excision of part of the affected 
 nerve. It is remarkable how a nerve to its fine 
 terminal twigs can be pulled out, as shown by 
 many specimens figured by Krause, in his work on 
 Neuralgia. Unfortunately, the results obtained by 
 avulsion with Thiersch's forceps are little, if at all, 
 superior to a well-planned neurectomy. 
 
 Dr. Deaver, who claims to have had much ex- 
 perience in the treatment of tic douloureux, argues 
 in favour of peripheral operations, because " the 
 period of relief following any operation is com- 
 
46 
 
 paratively speaking, but temporary in the majority 
 of cases." This argument is refuted entirely by the 
 results of excision, partial or complete, of the 
 Gasserian ganglion. After such operations, the 
 period of relief is, "comparatively speaking," per- 
 manent, since the patients are totally free from 
 recurrence, five, ten, and even more years after- 
 wards. 
 
 Now and then peripheral operation gives a lasting 
 cure ; how rare this is may be judged from Prof. 
 Billroth's statement, that he had never met with 
 such a case, though he had himself operated on 
 over thirty patients with trigeminal neuralgia. In 
 fact, cure by this means is almost as rare as spon- 
 taneous subsidence, or cure by drugs. The patient 
 with epileptiform neuralgia, involving more than 
 one division of the fifth nerve, has before him 
 these alternatives — the morphia-habit with complete 
 mental degradation, suicide, or death from exhaus- 
 tion. Peripheral operations, as a rule, offer him only 
 temporary relief, and each recurrence is usually 
 worse than the last. Excision of the Gasserian 
 ganglion, is alone certain to be followed by a 
 complete and permanent cure. These statements 
 are illustrated by the following example : — 
 
 The patient, in the first case I operated on, was a 
 temperate man, with nothing in his previous history to 
 account in any way for the neuralgia. The onset of this 
 was in 1882, when he was 42 years of age. The pain was 
 felt along the lower jaw on the left side, and for a long 
 time the attacks were short in comparison with the in- 
 
47 
 
 tervals of freedom from the pain ; in fact, up to 1884 these 
 intervals would amount to two to three months, but still 
 the neuralgia was so severe that he sought treatment for it 
 at the hospitals, and commenced to undergo a series of 
 operative measures. 
 
 (i) The teeth were removed from the left side of the 
 lower jaw without any benefit. 
 
 (2) He was under treatment in University College 
 Hospital for six weeks. 
 
 (3) He went into St. Thomas's Hospital in 1884 at the 
 end of the year, when Mr. Pitts stretched the inferior 
 dental nerve. This was followed by marked relief for 
 sixteen months, but in May, 1886, the pain returned as 
 badly as ever. 
 
 (4) He was then again in St. Thomas's Hospital several 
 times, and had the nerve repeatedly stretched, on one 
 occasion it is said twice in forty-eight hours. The pain 
 still continuing he went to Charing Cross Hospital, where 
 neurectomy was done from inside the mouth. 
 
 (5) The pain only left him for a month, and subse- 
 quently spread to the region of the superior maxillary 
 nerve, and ultimately to the back of the head ; its severity 
 increased, the intervals became shorter, and after eight 
 years' endurance of the suffering he sought further relief 
 from operation. 
 
 (6) In March, 1895, Sir F. Treves removed Meckel's 
 ganglion and the infra-orbital nerve by opening up and 
 following the roof of the antrum of Highmore. He was 
 then relatively free from pain for four months, but in the 
 autumn of 1895 he was compelled to take morphine in 
 considerable doses to get any relief. From January, 1890, 
 to September of the next year he was a complete wreck 
 from attacks of pain and spasm, and to a lesser extent 
 from the narcotic and sedative drugs that were given to 
 him. 
 
 (7) On October i, 1897, the final operation, removal of 
 the Gasserian ganglion, was performed. Before alluding 
 to this operation, we must note some further details as to 
 
48 
 
 the neuralgia. The spasms of pain were accompanied by- 
 convulsive movements of the depressors of the lower jaw, 
 and of the facial muscles on the left side. These attacks 
 of spasmodic pain ultimately came on with great regularity, 
 the intervals being sometimes only half a minute or a 
 minute. 
 
 Although he thought the pain was worse in damp 
 weather, no other condition could be noticed to have any 
 effect in producing or intensifying the pain ; for instance, 
 neither taking alcohol, nor smoking, neither exposure to 
 the heat of a fire nor to the cold of a dry frost had any special 
 effect. The attacks of pain came on as often when he was 
 resting in bed as when he was up, but they completely 
 incapacitated him from work. His memory for all recent 
 events was very defective, and, of course, from pain and 
 sleeplessness he was reduced to a miserably depressed con- 
 dition ; he was for some time of marked suicidal tendency. 
 
 The onset of each attack was most sudden ; his head 
 would be turned to the left, his mouth widely opened, and 
 his left hand pressed to the cheek in a vain effort to get 
 some relief from the pain. There was no true, superficial 
 tenderness, and the only patch of anaesthesia extended 
 from just below the V-shaped scar on the front of the 
 cheek, made in the removal of Meckel's ganglion, down to 
 the red margin of the upper lip. Inside the mouth the 
 pain was felt as badly as ever along the lower jaw, in spite 
 of the repeated operations on the inferior dental nerve, and 
 the left lower lip and the left side of the tongue (except at 
 the top) were involved. It is unnecessary to say that all 
 the known sedatives had been tried, but, with the exception 
 of morphine, none were of any material use, and the large 
 doses of this drug required, caused delusions, and much 
 depressed him. 
 
 A flap being turned down from the temporal fossa, with 
 its base at the zygoma, and the temporal vessels being 
 secured, the greater part of the squamous portion of the 
 bone was removed by trephine and cutting forceps, without 
 injuring the dura mater or the branches of the middle 
 meningeal artery. 
 
49 
 
 The temporo-sphenoidal lobe with the dura mater was 
 then gradually lifted up from the middle fossa, until the 
 foramen spinosum was reached. The onlj' difficulty so 
 far had been venous oozing from numerous minute vessels 
 in dura mater and bone. An aneurism needle was passed 
 round the middle meningeal artery, and considerable 
 trouble was experienced in effecting the double ligature 
 and division of this vessel, owing to the depth of the 
 foramen spinosum from the surface (a little over two inches). 
 The venous oozing was so troublesome that it was con- 
 sidered impossible to expose the ganglion on that day, 
 and the second part of the operation was therefore deferred 
 for a week. On the second occasion the flap of skin and 
 muscle, which had been sewn in place, was readily detached 
 from the dura mater, and after again raising the temporo- 
 sphenoidal lobe with a specially-designed broad retractor, 
 the foramina ovale and rotundum were exposed, and the 
 superior and inferior maxillary division of the fifth nerve 
 completely divided. Prior to this, the dura covering over 
 the Gasserian ganglion was lifted up from it until the 
 upper border of the ganglion and the trunk nerve were 
 reached. 
 
 The ganglion was removed in one piece. It was thought 
 at the time that the ophthalmic division, which is, of course, 
 much the smallest of the three, had been divided and 
 removed with the ganglion, but the result showed that this 
 could not have been the case, since the patient retained 
 sensation in the supraorbital and nasal nerves. However, 
 the escape of the ophthalmic nerve, which was due to one's 
 anxiety not to injure the cavernous sinus or the oculo- 
 motor nerves (an accident which has occurred in some of 
 the recorded cases) had no bad effect upon the after-result. 
 From the date of the operation up till now (a period of 
 thirteen months) the patient has had no return of pain. 
 He has got back to constant work, having been incapa- 
 citated for some years. Occasionally there is slight 
 twitching of some of the left facial muscles, but this is 
 painless and is hardly an inconvenience. The anaesthesia 
 4 
 
50 
 
 in the distribution of the superior and inferior maxillary 
 nerves only gives him trouble when particles of food get 
 down between the tongue and the jaw, or the jaw and the 
 cheek. It is of interest to note that the sense of taste as 
 regards quinine, salt, &c., is lost on the left side of the 
 tongue (dorsum), as also that of sensation to heat and cold 
 and tactile impressions. It is needless to say that his left 
 temporal, masseter, and pterygoid muscles are paralysed 
 and have become atrophic, but he seems to be singularly 
 little inconvenienced by this, and never complains of any 
 difficulty in mastication. It may be noted that he had, 
 like so many of the cases of trigeminal neuralgia, lost the 
 teeth on the affected side long prior to the operation. The 
 aperture in the bone forming the temporal fossa has been 
 almost entirely closed up, so that pulsation cannot be felt 
 and the scar has to be sought for. 
 
 The foregoing account has been largely based on Dr. 
 Head's admirable notes of the case. 
 
 Microscopic examination of the ganglion and the nerve 
 trunks leading from it did not reveal any marked abnor- 
 mality in the ganglion cells or the nerve fibres, but there 
 appeared to be great overgrowth of fibrous tissue through- 
 out the ganglion ; the arterioles in the latter, though 
 imbedded in this dense fibrous tissue, presented no signs 
 of disease of their walls. 
 
 (Note in 1904). — The patient has continued free from 
 the slightest return of neuralgia. It is now seven years 
 since the operation. 
 
 As the preceding case shows, when once the 
 neuralgia has spread from one division of the nerve 
 to another, it is useless to waste time over extra- 
 cranial operations ; but a patient with the disease 
 confined to e.g., the inferior dental nerve will hardly 
 consent to undergo the major operation on the 
 Gasserian ganglion, unless more limited interference 
 
51 
 
 has failed. The following account deals with what 
 seem to be the best of these operations. At the 
 same time a number of methods, elaborate, and 
 most of them disfiguring, which have filled such an 
 irnposing place in surgical text-books, are entirely 
 omitted. If the majority of extracranial methods 
 of neurectomy of the fifth nerve were forgotten, it 
 would be to the advantage of both surgeon and 
 patient. The extracranial operations to be des- 
 cribed relate to (i) the inferior dental nerve, and 
 (2) the superior maxillary division. Intracranial 
 neurectomy of the two main divisions will also be 
 briefly described. 
 
 I. — The Inferior Dental Nerve. 
 
 The intrabuccal method was introduced by Para- 
 vicini (of Italy), in 1858. The mouth is widely' 
 opened by a gag fixed on the opposite side, the 
 cheek being held back by a retractor ; the operator, 
 with his left index finger, feels for the anterior 
 edge of the ascending ramus, and tracing this 
 upwards and backwards reaches the "spine of 
 Spix." An incision of nearly an inch through 
 mucous membrane, internal pterygoid muscle, and 
 spheno-maxillary ligament enables the inferior dental 
 nerve to be discovered and resected. It is well 
 to trace the nerve into the inferior dental foramen 
 so as to make sure that the gustatory nerve (which 
 lies near and in front of the other trunk) be not 
 mistaken for it. Care must be taken not to 
 
52 
 
 wound the inferior dental artery. The operation 
 is performed in an awkward corner of the mouth, 
 but the alternative method proposed by Monte- 
 noveri is infinitely more difficult. He advocates 
 an incision through the skin, which commences 
 at the angle of the jaw and runs forward parallel 
 to the lower border until the facial artery is reached. 
 With knife and periosteal elevator the internal 
 pterygoid muscle is detached inwards, and the 
 operator ultimately reaches the spine of Spix and 
 the inferior dental nerve. The sole advantage 
 lies in the fact that the buccal mucous membrane 
 is not divided. Both methods are inferior to the 
 following : — 
 
 Neurectomy of the Inferior Dental Nerve 
 through a trephine aperture in the lower jaiv. 
 — The point of bone to be aimed at is indicated 
 on the ascending ramus by the meeting of two 
 lines — one perpendicular to the lower border of 
 the jaw passing upwards from its angle, the other 
 a continuation backwards of the alveolar margin. 
 This point on the side of the cheek is well below 
 the parotid duct and behind the facial vein ; the 
 skin incision of one inch should be mainly hori- 
 zontal, to avoid injury to the facial nerve, but it 
 is convenient to curve it slightly. The masseter 
 being exposed, its fibres are partly severed, but 
 chiefly separated, until the bone is reached and 
 bared with a periosteal elevator. The pin of a 
 small (half-inch) trephine is then inserted exactly 
 
S3 
 
 at the spot above-mentioned, and when the outer 
 table of compact bone is traversed, the disc is 
 removed by means of the elevator. It is almost 
 certain that the groove containing the inferior 
 dental nerve and vessels will be opened thereby, 
 and it should very carefully be cleared on either 
 side with a small chisel or bone-cutting forceps. 
 The groove should be followed upwards and down- 
 wards, with due caution not to injure the inferior 
 dental artery, until the nerve can be raised along 
 on a hook. With Thiersch's forceps a long piece 
 of both ends of the divided nerve can sometimes 
 be drawn out ; if not, as much should be cut away 
 as possible. The bone disc need not be replaced, 
 and two or three fine sutures will suffice for the 
 wound, which heals rapidly. The patient should 
 be kept on liquid or soft food for a few days. 
 
 The success of the operation depends chiefly on 
 following the landmark given exactly, and avoid- 
 ing injury to the companion artery. As a rule, 
 the dental nerve lies just in front of the latter, 
 and is readily distinguished, once the canal is 
 opened, by its whiter colour. 
 
 After this neurectomy the pain is, as a rule, 
 entirely absent for one, two, or more years, but it 
 is exceptional for no recurrence of any kind to be 
 experienced. It may be noted that immediately 
 after the operation, for a few days, the patient 
 will complain of aching, due to the traction of 
 the proximal end. The method and the amount 
 
54 
 
 of relief that is to be expected from it is illus- 
 trated by the following case : — 
 
 Samuel G., a florid, healthy- looking man, before 
 the onset of neuralgia had been a free liver and 
 suffered from slight symptoms of gout. He had 
 Dupuytren's contraction of the ring finger in each 
 hand. His father and one brother were said 
 to have died from gout. At the age of 59 the 
 right, inferior, dental nerve became the site of 
 severe neuralgia, for which all the teeth were 
 removed from the lower jaw behind the incisors 
 on the right side. No relief was obtained. A 
 year later Mr. Stanley Boyd performed an opera- 
 tion on the inferior, maxillary division just below 
 the foramen ovale. The pain was relieved for 
 about twelve months, but it returned with increas- 
 ing frequency of the attacks until it was almost 
 continuous both night and day. The pain was 
 especially severe over the right mental foramen, 
 causing reflex spasm of the facial and masticatory 
 muscles. He obtained some relief by violently 
 pinching the skin over the lower jaw, this be- 
 coming a constant habit. 
 
 As the neuralgia was confined to the inferior dental 
 nerve it did not seem to justify operation on the Gas- 
 serian ganglion, and on September 7, 1899, I re- 
 sected the inferior, dental nerve, after trephining 
 through the outer part of the ascending ramus of the 
 lower jaw. The nerve was exposed without diffi- 
 culty, and about one inch of it was removed ; the 
 
55 
 
 nerve was quite normal. For a week after the 
 operation the pain continued as bad as before, 
 but it gradually left him and he was free for 
 eighteen months, when it returned with increasing 
 intensity, involving the right cheek and both jaws ; 
 the neuralgia was occasionally referred to the eye. 
 Medicines failed entirely to relieve him, and the 
 patient got into a miserable condition, almost 
 unable to sleep, or to take food without bringing 
 on spasms of pain. On more than one occasion 
 he threatened suicide. 
 
 On October 8, 1901, the right Gasserian gan- 
 glion was operated on by the temporal route. 
 The patient had emphysema and pulmonary con- 
 gestion at the bases, and was therefore a bad 
 subject for an anaesthetic. A.C.E. was carefully 
 administered, with the patient sitting in a dental 
 chair, but owing to respiratory trouble it was 
 found necessary once or twice to lower him to 
 the horizontal position. I removed a circular 
 area of bone about three inches in diameter with 
 the trephine and cutting forceps, and succeeded in 
 exposing the ganglion without dividing the middle 
 meningeal artery ; the lower half of the ganglion, 
 or rather more, with the superior maxillary divi- 
 sion, was completely removed. Venous haemor- 
 rhage caused some trouble. No bone was 
 replaced, the drainage tube being removed on the 
 second day ; the wound healed perfectly, and the 
 patient left the hospital three weeks after the 
 
56 
 
 operation. For over two years he has continued 
 in excellent health being now 66 years old, and 
 there has not been the slightest return of pain. He 
 takes too much stimulant — a bottle of champagne 
 a day — but considers himself entitled to it, after 
 what he had gone through. The area of anaes- 
 thesia, as shown in fig. 20, includes the whole of 
 the cheek, the temporal region and both lips to 
 the middle line, as well as the ala of the nose. 
 He masticates very well, in spite of the atrophy 
 of the masseter, pterygoids, and temporal muscles 
 on the side operated on. 
 
 Note. — Early in 1904, that is, nearly three 
 years after the operation, the patient died. His 
 son stated that, so far as the neuralgia was con- 
 cerned, he had remained quite free from any 
 return. 
 
 Dr. Ewing Mears performed a somewhat similar 
 operation in 1883, only he trephined the outer table 
 of the jaw about the mental foramen, and then drew 
 out some three inches of the nerve. His case was 
 free from recurrence at the end of nine months, 
 though it is probable that the neuralgia returned 
 later. 
 
 The operation on the inferior dental nerve just 
 described is easy to perform ; it leaves no deformity, 
 and is worth doing in any case of persistent 
 neuralgia starting in the lower jaw. The patient 
 should, however, be told that whilst there is a 
 chance of permanent recovery, the relief is more 
 
T.N. 
 
 A.T.'S. 
 
 B.N. 
 
 '-J I.D.N. 
 
 G.N. 
 
 M.II.N. 
 
 Fig. 7. 
 
 The main branches of the inferior maxillary division, from a dissection in 
 the London Hospital Museum. Z. — The zygoma, cut at each end and 
 removed. T.N. — Motor branches to the temporal muscle. A.T.N. — Auri- 
 culo-temporal nerve. B.N. — Buccal nerve, joining in a plexus with branches 
 of the facial nerve to the buccinator muscle. I.D.N. — Inferior dental nerve. 
 G.N. — Gustatory or lingual nerve, M.H.N. — Its mylohyoid branch. 
 
57 
 
 likely to be for a year or two only, and that in the 
 case of recurrence a more radical operation can be 
 done on the Gasserian ganglion. 
 
 This is the only peripheral operation on the third 
 division of the fifth nerve that can be really 
 recommended. Neurectomy of the gustatory nerve 
 is hardly worth discussing ; it has occasionally been 
 practised for the pain of cancer of the tongue, but 
 the procedure has fallen into disuse. As to the 
 formidable methods of approaching the third divi- 
 sion just below the base of the skull, surgery will 
 gain by their complete abandonment. They almost 
 all involve division of zygoma and coronoid process, 
 and owing to haemorrhage and the deep awkward 
 wound, the operations are extremely prolonged and 
 difficult. The results are very poor, since move- 
 ments of the jaw are usually limited, an ugly scar 
 being left on the face, and the neuralgia quickly 
 returns. If operation is indicated upon the third 
 division alone, the intracranial method should cer- 
 tainly be preferred. Some may think this con- 
 demnation of the many elaborate methods alluded 
 to somewhat sweeping, but experience will probably 
 show that it is right. 
 
 II. — The Superior Maxillary Nerve. 
 
 In order to avoid the disfiguring division of bone 
 required by the ordinary methods of excising the 
 superior maxillary nerve in the pterygo-maxillary 
 fossa, M. Poirier^ brought forward a new method. 
 
 ^ Poirier, Bull, et mem de la soc. dn chir., t. xxv., p. 414. 
 
58 
 
 It consists briefly in two steps :— (i) the infra- 
 orbital nerve is exposed on the front of the face just 
 below the foramen, is divided, and a silk ligature 
 put round its proximal end. (2) A vertical incision, 
 one centimetre behind the junction of the malar 
 bone with the orbital margin, is made, and steadily- 
 deepened through the temporal muscle. Down in 
 the hollow, the superior maxillary trunk is ex- 
 posed (!) and seized with forceps. Traction is made 
 so as to draw the whole nerve out from the upper 
 jaw bone, as far forwards as the ligature. 
 
 There are two strong objections to the method : 
 (i) the depth of the incision and the bleeding 
 render it almost impossible to make sure of the 
 nerve ; and (2) even if it be secured in the forceps, 
 it may be impossible to draw the peripheral part 
 outwards. 
 
 Carnochan's method of reaching the pterygo- 
 maxillary fossa from the front by trephining both 
 walls of the antrum of Highmore, and following 
 back the infra-orbital nerve in its roof is well- 
 known. Many examples have been recorded by 
 Mr. Chavasse ^ and Sir Frederic Treves.^ It is a 
 difficult operation, and the neuralgia almost always 
 returns after an interval varying from a few months 
 to a year or two. 
 
 The following account is taken from the second 
 
 ^ Chavasse, Medico-Chirurgical Soc. Transactions, 1884. 
 
 ^ Sir F. Treves, "Operative Surgery," 1904, vol. i., p. 209. 
 
59 
 
 edition of the Operative Surgery, revised by Sir F. 
 Treves and myself. 
 
 "A V-shaped incision is made on the front of the 
 cheek, so placed that the apex points directly down- 
 wards, and the centre of the V is opposite to the 
 infra-orbital foramen. The incision should form 
 two sides of an equilateral triangle, each limb of 
 which measures a little more than one inch. 
 
 " The knife is carried at once down to the bone, 
 and the triangular flap formed by the soft parts is 
 turned up over the lower lid. A long silk suture is 
 introduced into the apex of the flap, in order that 
 it may be drawn well upwards out of the surgeon's 
 way. 
 
 " The infra-orbital nerve is sought for and isolated 
 as it is emerging from the foramen. The bone 
 having been cleared, a portion of the anterior wall, 
 of the antrum measuring from half to three-quarters 
 of an inch square is removed with a chisel and 
 mallet. The infraorbital foramen will be a little 
 above the centre of the part removed. The mucous 
 lining of the antrum having been divided, that cavity 
 is fully opened. In order that the rest of the 
 operation may be conveniently performed, a small 
 electric lamp is needed, which may be fixed to the 
 surgeon's forehead. In no operation is a good 
 light more essential. 
 
 " The posterior wall of the antrum is now exposed, 
 and a portion about a quarter of an inch square is 
 cut away with a fine chisel and mallet. 
 
6o 
 
 " In removing the two portions of bone some 
 surgeons use trephines — a half-inch trephine for the 
 anterior wall and a quarter-inch for the posterior. 
 The chisel is, however, by far the more convenient 
 and precise instrument, and inflicts a less degree of 
 injury upon the surrounding tissues. 
 
 "The haemorrhage is very free, and some little 
 time may now be devoted to arresting it as far as is 
 possible, 
 
 " The next step consists in dividing the mucous 
 hning on the roof of the antrum, under the course 
 of the infra-orbital canal. The bone forming the 
 floor of this canal must be broken away from one 
 end of the maxilla to the other. This is best 
 effected by means of scissors, aided by a fine, 
 carpenter's bradawl and a slender, bone elevator or 
 stout director.. The bone is thin and offers little 
 resistance, and the nerve, which must be mos,t care- 
 fully preserved and carefully followed line by line, 
 forms the guide to the surgeon's movements. 
 Much bleeding may be expected from the damaged 
 infra-orbital vessels, which can seldom be surely 
 isolated. When the posterior wall of the maxilla is 
 reached, the white and conspicuous nerve will be 
 hanging loose in the cavity of the antrum. Slender 
 dissecting forceps with long blades are needed 
 during this stage, and become still more necessary 
 when the rea^ion of the foramen rotundum is 
 reached. 
 
 " The bone of the hinder wall of the antrum must 
 
6i 
 
 be so completely removed that the nerve is seen to 
 hang free in the cavity produced. The wound may 
 now be stuffed for a while with a conical piece of 
 sponge, in order that the haemorrhage, which is still 
 free, might be held a little in check. 
 
 " By means of the long, slender forceps and a 
 director, the surgeon endeavours to make out the 
 position of the trunk as it issues from the foramen 
 rotundum, and, if possible, the precise locality of 
 the ganglion. In this attempt he is aided by the 
 infra-orbital nerve, upon which traction (by means 
 of a silk thread), is maintained. Finally, the 
 superior maxillary nerve is divided close to the 
 foramen rotundum by a pair of very slender, curved 
 scissors, and any branches which still hold the nerve 
 in position having been divided, the whole trunk is 
 removed with the ganglion attached. 
 
 " At this step of the operation also much bleeding 
 may be expected. The nerve cord removed should 
 measure not less than one-inch and three-quarters. 
 
 " The antrum having been sponged out, the skin 
 incision is united by sutures and the selected 
 dressing applied. A small drainage tube should be 
 maintained in the lower angle of the wound for the 
 first twenty-four hours." 
 
 If an extracranial operation is to be performed on 
 the superior maxillary division, probably the best 
 method is one which is attributed to an American 
 surgeon named Storrs. It is described by Dr. 
 Cook in the " Annals of Surgery," 1903, vol. xxxvii., 
 
62 
 
 p. 854. It has the merit of leaving only an incon- 
 spicuous scar on the face. The following descrip- 
 tion is in Dr. Cook's own words : 
 
 " Place the patient half reclining in a chair, 
 wedged with sand-bags. The operator seats him- 
 self on a stool facing the patient, on the side of 
 the eye on which he intends to operate. One 
 assistant is necessary to give the anaesthetic, and 
 a second to hold the retractor. The lower edge 
 of the orbit can be easily felt through the skin. 
 Make a clean incision along this edge, from the 
 inner to the outer angle of the orbit, through the 
 tissues, including the periosteum, down to the bone. 
 Then with a blunt instrument carefully elevate 
 the periosteum from the floor of the orbit, going 
 well back and exposing the spheno-maxillary fissure. 
 Lift the eyeball out of the way with a spoon- 
 shaped retractor inserted under the periosteum. 
 Usually a bluish spot will appear, showing the 
 situation of the infra-orbital nerve, covered by a 
 thin plate of bone, in its canal in the floor of the 
 orbit. Should, however, there be any difficulty in 
 locating the nerve, it can easily be done by passing 
 a probe into the infra-orbital foramen and up into 
 the orbit. Having located the nerve, with a 
 chisel or any suitable instrument remove the thin 
 plate of bone covering it. The nerve can then 
 be easily hooked up and brought to view. The 
 infra-orbital artery is usually torn at this time and 
 bleeds for a few moments, but it is of no import- 
 ance, and will soon take care of itself. 
 
63 
 
 " Having hooked up the nerve, ligate it securely 
 with a piece of silk passed around it with an 
 aneurism needle. Then cut the nerve, leaving 
 the ligature fastened to the proximal end of the 
 cut nerve. We now have the nerve under perfect 
 control. By making a slight traction on the liga- 
 ture we can bring the nerve into view, and by 
 following it on can readily crush down the thin 
 wall of the canal, removing the bone fragments 
 with suitable forceps. When the nerve enters the 
 spheno-maxillary fissure it passes out of the bony 
 canal and is only surrounded by soft structures, 
 which can easily be hooked or wiped away. 
 Should the spheno-maxillary fissure be narrow and 
 not readily admit the introduction of instruments, it 
 can easily be widened by inserting a suitable, blunt 
 instrument and by wedging or widening the walls. 
 It is remembered that the upper wall of this 
 fissure is the strong wing of the sphenoid bone, 
 and that the lower angle is the thin wall of the 
 antrum. If either bone should break in these 
 manipulations it would be the wall of the antrum 
 which would be crushed down and out of the way 
 and would cause no trouble. Havingf the nerve 
 thus free to the foramen rotundum, next slip the 
 ends of the silk ligature through a loop of wire 
 held with a small snare (the Jarvis snare of the 
 rhinologists). The loop of wire in the snare is 
 passed down the nerve to the foramen rotundum, 
 just as a tunnel sound is passed over a filiform 
 
64 
 
 bougie. When the loop of wire reaches the 
 foramen rotundum it is closed, and the nerve is 
 cut and removed. 
 
 . " To return now to the distal end of the nerve. 
 Separate the integument from the bone down to 
 the infra-orbital foramen, gather up with a hook 
 the mxesh of nerves going to the cheek and 
 drag the divided nerve through the foramen. 
 Storrs then put the nerve into the loop of a 
 threaded needle and carried it down into the 
 mouth, leaving the end which had been in the 
 infra-orbital canal suspended between the alveolus 
 and the upper lid ; this end he cut off even with 
 the mucous membrane. This was for the purpose 
 of preventing any possible restoration of any com- 
 munication between the peripheral branches of the 
 nerve and the stump left at the foramen rotundum. 
 To complete the operation, place a small gutta- 
 percha-tissue drain in the track of the nerve, ex- 
 tending from near the foramen rotundum to the 
 surface ; suture the skin wound. The drain should 
 be removed at the end of twenty-four hours." 
 
 It is stated that Dr. Storrs operated by his 
 method on some ten or twelve patients, and that 
 of these at least two remained free from neuralgia 
 for over ten years. This is an unusually favour- 
 able result from any form of peripheral operation. 
 At the same time it must be uncertain whether 
 the central end of the nerve is divided beyond 
 its branches to the palate and molar teeth. 
 
65 
 
 Further experience must prove whether the 
 intracranial excision of the superior maxillary divi- 
 sion (see page 71) or Storrs' operation is the 
 better. The former is, perhaps, the more severe, 
 and certainly the more radical of the two. I 
 think Carnochan's method will be entirely aban- 
 doned, and Poirier's is not practical. It would be 
 both tedious and unprofitable to quote descrip- 
 tions of the many ingenious variations of the 
 operation, to which different surgeons' names have 
 been attached. They are at least a dozen in 
 number, and most of them involve an extensive 
 osteoplastic operation on the outer orbital wall, 
 the zygoma, or the upper jaw. 
 
 " Mugnai's operation " may be briefly mentioned 
 from amongst these. A nearly rectangular incision 
 is made along the upper border of the zygoma,' 
 forwards to the outer orbital edge, and then down- 
 wards towards the last molar tooth over the anterior 
 edge of the malar bone. The orbital contents 
 are pushed upwards and inwards until the spheno- 
 maxillary fissure is reached ; with a wire saw the 
 malar bone is sawn through in two directions, 
 back into the temporal fossa and downwards at its 
 junction with the superior maxilla. The zygoma 
 is chiselled through and the malar bone turned 
 downwards. The subsequent steps, following back 
 the infra-orbital nerve towards the foramen rotun- 
 dum, &c., need not be described. 
 
 This method, like so many others, involves a scar 
 5 
 
66 
 
 on the face, and what is more important, an elabo- 
 rate division of bone, which may not unite again 
 well, and may even necrose. It hardly gives any 
 better access to the superior maxillary nerve than 
 Storrs' simple incision at the lower edge of the 
 orbit ; and as regards the clean excision of the 
 nerve trunk does not compare with the intracranial 
 method described. The term " Storrs' method " has 
 been used with reserve, priority of description or 
 invention in these matters being most uncertain. 
 Professor Billroth was in the habit of employing a 
 similar incision along the floor of the orbit, and 
 mentions at least one case in which he tracked 
 the superior maxillary division " back to the 
 foramen rotundum." 
 
 It will be convenient to summarise the various 
 forms of operation, and to indicate which are the 
 best to follow : — 
 
 (i) Intracranial resection by trephining the wall 
 of the temporal fossa (see page 71). By this 
 method alone the nerve is excised before it has 
 given off any branches ; it is certainly the most 
 radical and promising. 
 
 (2) The infra-orbital method : — following this 
 nerve back along the floor of the orbit to the 
 pterygo - maxillary fossa. Very little bone is 
 divided, and the scar is not conspicuous. 
 
 (3) Trephining the antrum of Highmore to 
 reach the pterygo - maxillary fossa (Carnochan's 
 method). This should be given up. 
 
67 
 
 (4) Resection of the outer wall of the orbit 
 (Mugnai's method). This has no advantages and 
 several drawbacks. 
 
 (5) The trans-zygomatic operations, by which 
 the fossa is reached from the outer side. On no 
 grounds can these be recommended. 
 
 It will be seen that the choice of the surgeon 
 lies between the first and second of the above 
 methods, and I believe the first to be the better. 
 
 III. Intracranial Resection of the Main Division 
 of the Fifth Nerve. 
 
 Two main considerations naturally suggest them- 
 selves in cases of very severe and persistent 
 neuralgia, which is confined to the distribution of 
 one of the three main divisions of the fifth nerve. 
 
 (i) It is logical to confine operative interference 
 to the division which is alone implicated. 
 
 (2) The nearer to the Gasserian ganglion that the 
 resection can be performed the less will be the risk 
 of recurrence. 
 
 It is further important to note that, even when 
 slighter radiations of pain have accompanied intense 
 neuralgia of one division, operation on the latter 
 alone will secure cessation of the pain in the 
 other. This rule is probably not absolute, but Prof. 
 Chiene of Edinburgh tells me that he has noticed 
 this result in several cases. All three divisions of 
 the fifth nerve can be completely isolated only 
 
68 
 
 inside the skull. The superior maxillary trunk 
 in whose distribution persistent neuralgia is fairly 
 common, has an intracranial course of about half 
 an inch. This portion can be completely isolated 
 and removed, so that there is no possibility of new 
 nerves growing between the ganglion and the 
 peripheral branches. 
 
 In one case of my own, given in detail (on 
 page 70), the intracranial resection of this nerve 
 was perfectly successful. The two earliest opera- 
 tions of Prof. Krause for fifth nerve neuralgia 
 concerned the superior maxillary trunk alone. 
 Subsequently he performed the major operation 
 (removal of the entire ganglion), and holds 
 that this, with division of the root of the 
 ganglion, " alone protects the patient from recur- 
 rence." This is too absolute a statement, I think, 
 from Prof. Krause's account, that it is certain in 
 some of his cases, the ophthalmic division with its 
 root fibres escaped. Certainly, in many cases in 
 which these have been deliberately spared, no re- 
 currence of the neuralgia has taken place after 
 intervals of three to five years, as in the case of 
 several of my own patients. 
 
 Dr. J. Crawford Renton,^ in two cases, deliberately 
 avoided interfering with the ophthalmic division, 
 and in both the neuralgia was entirely cured. 
 G. R. Fowler,^ in a case in which the neuralgia 
 
 ^ British Medical Journal, November, 1900. 
 
 ^ Fowler, New York Medical Record, 1894, P- 745* 
 
eg 
 
 was confined to the second and third divisions, 
 commenced an operation by the temporal route, 
 intending to excise the whole Gasserian ganglion. 
 He had previously ligatured the external carotid 
 artery, and the haemorrhage was but slight ; never- 
 theless, he found it impossible to remove the 
 ganglion, owing to its close adhesion to the dura 
 mater. He divided completely and removed parts 
 of the superior and inferior maxillary divisions. 
 The patient, who had been previously addicted to 
 large doses of morphia, entirely left off the drug. 
 At the end of two years, when he was last seen, no 
 recurrence of pain had taken place, and there was 
 complete anaesthesia in the area supplied by the 
 two divided nerves. 
 
 In seven cases of my own, in which the excision 
 was deliberately limited to the lower part of the 
 ganglion with the two lower divisions, the patients 
 have been entirely free from recurrence of pain. 
 They have been followed up for periods, ranging 
 from two to seven years. 
 
 (i) So far as I can ascertain the ophthalmic 
 trii7ik alone has never yet been the subject of intra- 
 cranial excision. 
 
 (2) The second or superior maxillary division 
 is the most suitable for intracranial resection, as 
 nearly half an inch of it is available before it 
 passes through the foramen rotundum. 
 
 The method of operating will be understood by 
 reference to fig. 8, and from the description of 
 the following case : — 
 
70 
 
 A ship's officer, aged nearly 60, but of fine con- 
 stitution, had suffered for several years from intense 
 pain in the right cheek and upper jaw. The 
 neuralgia was typically epileptiform, the attacks 
 becoming more and more frequent during the last 
 four years. He had had a number of teeth 
 removed without the slightest relief, and medi- 
 cines were equally unavailing. He struggled on 
 with his duties on board a Cape liner, and about 
 Christmas, 1902, he consulted Sir Frederick 
 Treves with regard to operative measures, who 
 kindly sent him to me with a note suggesting 
 removal of Meckel's ganglion and the infra-orbital 
 nerve. The distribution of the neuralgia was 
 always the same, and the parts were very tender, 
 though during an attack some relief was obtained 
 by the patient violently grasping the tissues of the 
 cheek. The lower eyelid, both sides of the cheek, 
 the palate and the gums on the right side formed 
 the area involved. Lachrymation and congestion 
 of the right eye were frequent. 
 
 It might be suggested that exposure on deck 
 to wind and wet was a predisposing cause of the 
 neuralgia, but the attacks were equally severe 
 when he was on land, and they occurred both by 
 day and night. He had the aspect of great suffer- 
 ing and depression. 
 
 My friend Mr. T. Crisp English assisted me 
 at the operation, which was performed with the 
 patient fixed in a dentist's chair, in order to lessen 
 
O.D. 
 
 Fig. 8. 
 
 Intracranial resection of the superior maxillary nerve. A. B. — Portion of 
 the nerve to be excised. CD. — Wall of temporal fossa cut away in the 
 operation. O.D. — Ophthalmic division. G. — Gasserian ganglion. 
 
71 
 
 the trouble from venous haemorrhage. A horse- 
 shoe flap was turned down from the temporal 
 region, having its base at the zygoma, the flap 
 including part of the temporal muscle and the 
 pericranium. With a large trephine and cutting 
 forceps the subjacent bone was removed, and the 
 dura mater exposed. As in the operation for 
 removal of the Gasserian ganglion, the dura mater 
 and temporo-sphenoidal lobe were then carefully- 
 pushed upwards and inwards, making for the 
 foramen rotundum as the first landmark. In this 
 respect the two operations differ, as in dealing 
 with the Gasserian ganglion the foramina spinosum 
 and ovale are first sought for. Considerable diffi- 
 culty was met with owing to the thin and fragile 
 character of the dura mater, and some cerebro- 
 spinal fluid escaped. Ultimately, the trunk of the. 
 superior maxillary division and part of the Gas- 
 serian ganglion were thoroughly exposed, a broad 
 spatula of soft metal being used to retract the 
 dura mater and brain. The whole of the nerve 
 was then removed, a small drain being subsequently 
 inserted, and the flap sutured in position. None 
 of the bone removed was replaced. Primary heal- 
 ing followed, and no complication of any sort 
 occurred. 
 
 The patient returned a month later to his duties, 
 and has made regular voyages to and from the 
 Cape ever since. I have waited eighteen months 
 before reporting the case in order to ascertain 
 
72 
 
 that the reHef is permanent, and am glad to state 
 that he has not had the shghtest recurrence. 
 The anaesthesia is most marked over the right 
 cheek and superior maxillary bone, and it also 
 involves the soft palate and lower eyelid. He can 
 eat and talk with perfect comfort, whereas before 
 the operation both acts brought on spasmodic pain. 
 The scar is hardly to be noticed, the gap in the 
 bone has practically filled up, and there is, of 
 course, no paralysis of masticatory muscles on that 
 side, such as follows removal of the Gasserian 
 ganglion. I am confident that no recurrence is 
 likely to take place. 
 
 It would be erroneous to suppose that the opera- 
 tion is an easy one : the depth of the nerve trunk 
 (three centimetres or more from the wall of the 
 temporal fossa) and the troublesome oozing in a 
 narrow space, where it is essential to see. and 
 define a nerve-trunk of small size, prevent this. 
 But having had the opportunity of assisting my 
 colleague, Sir Frederick Treves, in several opera- 
 tions on Meckel's ganglion I can safely assert that 
 the intracranial route is at least as easy as the 
 facial one, and I believe it affords the more certain 
 access. 
 
 Mr. Stanley Boyd performed a similar operation 
 about the same time as myself. In his case the 
 result was perfectly satisfactory for a year, but at 
 the end of that time a slight recurrence of neu- 
 ralgia was reported, though its exact localisation 
 was doubtful. 
 
73 
 
 (3) Of intra-cranial resection of the third or 
 inferior maxillary division I have had no personal 
 experience. The Gasserian ganglion reaches almost 
 to the foramen ovale, immediately beneath which the 
 trunk breaks up into a number of branches ; hence, 
 intra-cranial resection will include the adjacent 
 part of the ganglion itself, a fact illustrated by the 
 following two cases : — 
 
 Codivilla, an Italian surgeon, in 1897, operated 
 on a woman aged 53, who had suffered for four 
 years from severe neuralgia in the distribution of 
 the inferior, maxillary nerve alone. By the tem- 
 poral route he exposed the foramen ovale, divided 
 the nerve completely across, and removed it with 
 the adjacent portion of the Gasserian ganglion. 
 The neuralgia entirely ceased, the case being 
 reported in 1898, one year later; there was of 
 course atrophy of the masticatory muscles on that 
 side, with anaesthesia of the lower lip and part of 
 the cheek, and the mucous membrane over the jaw. 
 In another case, a man, aged 43, who had already 
 undergone an intracranial operation on the second 
 division, Codivilla carried out the same proceeding 
 as mentioned above, on the third division and the 
 adjacent part of the Gasserian ganglion. The 
 operation had to be done in two stages (with three 
 days' interval between them), owing to haemorrhage 
 from the middle meningeal artery. 
 
 Conchisions. — From the foregoing account, it will 
 be understood that, in the treatment of epileptiform 
 
74 
 
 neuralgia, a certain proportion of cases may fairly be 
 subjected to less radical measures than removal of 
 the Gasserian ganglion. In these cases the neu- 
 ralgia is practically confined to one main division of 
 the fifth nerve or even to a single branch. Supra- 
 orbital neuralgia has not been specially discussed, 
 but now and then a case may arise in which resec- 
 tion of this nerve is justified. The operation is so 
 simple that it does not need description. 
 
 If the neuralgia be limited to the infra- orbital 
 branches^ resection of the nerve by following back 
 the canal in the orbital floor may be tried. If the 
 neuralgia concern also the palatine branches^ intra- 
 cranial resection of the superior maxillary trunk 
 should be carried out. If the inferior dental nerve 
 be alone affected, it should be resected through a 
 trephine aperture in the outer table of the lower 
 jaw. When the neuralgia concerns several branches 
 of the inferior Tnaxillary division (e.g., the inferior 
 dental and the auriculo-temporal), intracranial re- 
 section of the trunk and adjacent part of the Gas- 
 serian ganglion is indicated. 
 
 For all other cases, those in which the neuralgia 
 has already invaded two of the main divisions of 
 the fifth nerve, the major operation on the ganglion 
 (see Chapter V.) should be carried out as affording 
 the only hope of perinanent cure. 
 
 If these rules be followed the subject is rendered 
 simple, a host of elaborate operations may be dis- 
 carded, and the disappointing results which have 
 followed them in the past may be avoided. 
 
CHAPTER V. 
 
 Operations on the Gasserian Ganglion. 
 
 The surgeon who first suggested in print the 
 operation of removal of the Gasserian ganghon 
 was Dr. Ewing Mears of Philadelphia. In the 
 Transactions of the American Surgical Associa- 
 tion for 1884, he reported a case of neurectomy 
 of the inferior dental nerve, and at the end of 
 the paper wrote : "If in any case I believed 
 , . . that the morbid condition had invaded 
 the Gasserian ganglion, I would not hesitate to 
 enlarge anteriorly the oval foramen, . . . and 
 by traction draw down the ganglion . . . and 
 proceed in a cautious manner to break it up 
 or remove it by section with small blunt-pointed 
 scissors." 
 
 It is plain that the operation proposed, which 
 Dr. Mears had no opportunity of carrying out 
 himself, was identical with Professor Wm. Rose's 
 pterygoid method which was first carried out in 
 April, 1890, the case being published in the Lancet, 
 November i, 1890. This was the pioneer opera- 
 tion, and was followed next year, 1891, by Sir 
 Victor Horsley's case of division of the roots 
 
76 
 
 above the ganglion. This latter case proved fatal 
 from shock, and it is only during the last year, 
 1 903- 1 904, that this dangerous method has been 
 revived by other surgeons. 
 
 In 1892 Dr. Frank Hartley,^ of New York, 
 and Professor Krause,^ of Altona, independently 
 devised the temporal method of reaching the 
 ganglion, and it is only from this date, i.e., twelve 
 years ago, that one can seriously estimate the 
 value of the intracranial operation for trigeminal 
 neuralgia. In 1903, Professor Krause was able to 
 report that he had followed one of his earliest 
 cases for nine and a half years, and that no recur- 
 rence had taken place. I have followed up two 
 of my own cases with the same satisfactory result 
 for seven, and seven and a half years respectively. 
 Krause claims for his " first effective extirpation of 
 the ganglion performed on January 31, 1893, that 
 it was, undoubtedly, the first operation of the kind." 
 
 Professor Krause, in 1901, stated that he was 
 convinced, after trial of the various modifications, 
 his original method gave the best exposure of the 
 ganglion. With this conclusion I am heartily in 
 accord. The temporal route alone affords free 
 access, and whilst it is necessary to remove the 
 bony floor of the fossa as far inwards as the infra- 
 
 ^ Hartley, New York Med. Journal, vol. Iv., 1892, No. 12. 
 ^ Krause, Deutsche Med. Woch., 1893, ^o- i5> ^^'^ ^ separate 
 work, Die Neuvalgie des Trigeminus, Leipzig, i8g6. 
 
71 
 
 temporal crest, there is no need to go further, as 
 some surofeons recommend. 
 
 "After ligature and section of the middle menin- 
 geal artery, the second and third divisions of the 
 fifth nerve are fully exposed by lifting up the de- 
 tached dura mater, the third division is grasped and 
 stretched by narrow curved forceps, whilst the 
 dura is pushed gently off the ganglion itself until 
 its roots are exposed; during this stage the cerebro- 
 spinal cavity is usually opened and the fluid escapes. 
 The ganglion is then seized with Thiersch's forceps 
 and drawn out, after section with a tenotome of 
 the roots and the second and third divisions." 
 Nothing is said as to section of the ophthalmic 
 or first division, but this should be cut rather than 
 torn through. 
 
 Such is an outline of Professor Krause's method, 
 which is almost identical with Hartley's operation, 
 and it has served as a model for the many surgeons 
 who have followed them, many of whom have 
 introduced more or less important modifications. 
 I will describe in detail the method now recom- 
 mended, with the understanding that the operation 
 ofiven is that suitable for those cases in which the 
 ophthalmic division is but little involved in the 
 neuralgia, i.e., the great majority which come 
 under surgical treatment. 
 
 (i) Preparation of the Patient. — The whole head 
 should be shaved and cleansed thoroughly, the scalp 
 being treated with ether and i in 20 solution of 
 
78 
 
 carbolic acid in alcohol. It is important for the 
 patient to avoid long fasting before the operation, 
 and a cup of good beef-tea may be taken three 
 hours beforehand. The best anaesthetic is prob- 
 ably the A.C.E. mixture, or one of chloroform 
 and ether without the alcohol. 
 
 (2) The Instruments, &c., required. — A dentist's 
 chair with suitable head-rest is strongly advised, 
 
 Fig. 9. — Two forms of Hoffmann's Rongeur or cutting forceps for enlarging 
 the aperture in the cranium. (Half-size.) 
 
 though some surgeons use the ordinary operating- 
 table. In this case, the shoulders and head should 
 be raised as much as possible. 
 
 A good- sized trephine is required with a diameter 
 of i^ inches ; electric head-lamp ; a broad and 
 blunt-ended dissector (fig. 10) ; Hoffmann's bone- 
 cutting forceps for enlarging the trephine hole 
 (fig. 9) ; a flexible, broad, metal retractor for lift- 
 
79 
 
 Fig 10.— Aneurism needle with fine end, and two elevators for detaching 
 the dura mater from the skull. (Full size.) 
 
 Fig. II. — Fine-toothed forceps and flexible metal retractor (Krause's form). 
 (Both half natural size.) 
 
8o 
 
 ing the dura mater and brain (fig. ii) ; an aneurism 
 needle, rather smaller and more curved than the 
 usual pattern (fig. lo) ; fine-toothed forceps (fig. 
 lo) ; a narrow knife, such as a tenotome or cata- 
 ract knife, which is best made with a blunt end. 
 
 Small sponge-holding forceps are used with soft 
 Turkey sponge. The other instruments are such as 
 are required for every surgical operation. 
 
 The retractor is one of the most important 
 instruments used in the operation, its special 
 feature being that the blade must be flexible. The 
 handle should be stiff, broad, and fairly short, so 
 that the assistant can keep a steady grip of it. 
 The angle required between blade and handle 
 varies at different stages of the operation, and a 
 stiff blade will be liable to cause injurious pres- 
 sure on the brain ; hence, flexibility is essential. 
 Krause's special retractor is figured on p. 79. ' Dr. 
 C. H. Frazier has devised another, which differs 
 only in the blade, which is narrower ; it is figured 
 in "Annals of Surgery," 1903, p. 462. 
 
 (3) An oval flap is shaped, having its base at 
 the zygoma, its upper end i|- inches above this 
 level, and its posterior border running towards the 
 condyle of the lower jaw. The whole of the flap 
 may well be made inside the hairy scalp, as the 
 scar will be then hidden by the growth of the 
 hair (fig. 13, page 81, right hand figure). 
 
 The scalpel should cut right down to the bone, 
 and the flap (including the temporal muscle and 
 
Fig. 12. 
 
 The bony floor of the temporal fossa. A. — (Shaded area) represents the part cut 
 away in the Hartley-Krause operation. Z. — The zygoma. 
 
8i 
 
 the pericranium) is at once reflected by means of 
 an elevator. The severed branches of the tem- 
 poral artery are secured with Wells' forceps. 
 
 The pin of the trephine is now inserted midway 
 between the external auditory meatus (its upper 
 border) and the external angular process of the 
 frontal bone, and, with every precaution, the disc 
 of bone is cut and removed. It is of great 
 
 Fig 13. — Outline of horseshoe flap shown in right hand figure. On the left 
 hand figure the facial incision for Rose's pterygoid operation is shown. 
 
 importance not to damage the dura mater or the 
 anterior branch of the meningeal artery, and no 
 instrument can surpass the ordinary trephine, 
 guided by the surgeon's hand. The skull here is 
 thin, but fairly uniform ; the part removed is from 
 the squamous portion of the temporal bone. With 
 a blunt elevator the dura is now carefully detached 
 inwards all round the aperture, but especially at 
 its lower margin. 
 6 
 
82 
 
 Hoffmann's forceps are used to enlarge the open- 
 ing as far inwards as the infra-temporal crest. It is 
 important to reach this line, but unnecessary to go 
 further inwards in cutting away the bone (fig. 12). 
 
 The next step is to make for the foramen 
 ovale by continual detachment of the dura from 
 
 ■F.R. 
 
 r.o. 
 
 F.S. 
 
 -r.R. 
 
 ■F.O. 
 -F.S. 
 
 -F.R. 
 
 Fig. 14. — The relative positions of the three openings in the base of the 
 skull in different subjects. F.R., foramen rotundum ; F.O., foramen ovale 
 F.S., foramen spinosum. Note the variation with regard to the antero-pos- 
 terior plane (dotted line), and the different sizes of the apertures. These were 
 selected from the examination of many adult skulls as representing the chief 
 variations that are to be met with. 
 
 the floor of the middle fossa and its elevation by 
 the retractor. An useful landmark for the foramen 
 is the preglenoid tubercle on the zygoma. It is 
 probable that the point of entrance of the menin- 
 
83 
 
 geal artery (the foramen spinosum) will be reached 
 first; it lies from i to i'5 millimetres behind, and 
 a little to the outer side of, the inferior maxillary 
 division (see F.O. and F.S. in fig. 14). 
 
 There is a certain range of variation in the size, 
 shape, and relative position of the three foramina, 
 a point illustrated by fig. 14, in which the open- 
 ings are drawn exactly the natural size. 
 
 A variable amount of haemorrhage will have 
 occurred during these manoeuvres ; it comes from 
 a number of small veins and arteries and is to be 
 controlled by pressure with small pieces of sponge 
 on holders. After the white trunk of the inferior 
 maxillary nerve has been exposed, the foramen 
 rotundum — from 15 to 20 millimetres in front of 
 the foramen ovale — is sought for, and, ultimately 
 the whole superior maxillary division exposed. 
 There must be no undue haste, a few jninutes' pause 
 whilst sponge-pressure is applied being of much 
 use, and a strong light must assist the operator's 
 work. Above all, it is essential that the assistant 
 who uses the retractor must be light-handed ; the 
 less the pressure upon the temporo-sphenoidal 
 lobe of the brain the better. 
 
 Now comes the most difficult part of the opera- 
 tion, the exposure of the Gasserian ganglion, 
 which it is useless to attempt until the bleeding 
 has practically stopped. With the "fine elevator," 
 the thin, dural sheath is carefully detached in an 
 upward and backward direction, following the two 
 
84 
 
 main nerve trunks (see fig. 15). In some cases it 
 is impossible to expose the ganglion sufficiently 
 without tying and dividing the middle meningeal 
 artery. To do this the dura should be isolated all 
 round the foramen spinosum, and the aneurism 
 needle (threaded with fine silk), passed round the 
 artery. The loop of ligature is then caught with a 
 fine-toothed forceps and drawn towards the surface ; 
 a double ligature is then applied, leaving room to 
 divide the artery between the two knots ; slip- 
 ping of the ligature is apt to occur unless this is 
 carried out with great care. Should this accident 
 happen, the foramen spinosum should be plugged 
 with a minute fragment of bone driven well in. 
 
 It will be understood that the outer layer of the 
 ofanoflion sheath is alone detached ; its adhesion is 
 always close, and cerebro-spinal fluid often escapes 
 from a small puncture. This is of no great im- 
 portance. When the ganglion has been thoroughly 
 exposed, so that the section shown by the dotted 
 line in fig. 15 can be made, and not before this, 
 the superior and inferior, maxillary divisions are 
 cut cleanly across just at the foramina ovale and 
 rotundum. The best instrument for this is a 
 narrow cataract knife or tenotome. The ganglion 
 being firmly held by the toothed forceps is now 
 divided high up, as shown in figs. 15, and 81, 
 the ophthalmic division is left intact. The haemor- 
 rhage is sure to increase at this point, but all 
 difficulty is over and the retractor pressure should 
 
C.A 
 
 p;b. 
 
 Fig. 15. 
 The cavernous sinus and Gasserian ganglion seen from above. P.B. — The 
 petrous bone. C. A.— Carotid artery. III., IV. and VI. — The oculo-motor 
 nerves showing their relation to the ophthalmic division of the fifth nerve. 
 The relative position of the middle, meningeal artery and the inferior, maxillary 
 nerve is shown. The dotted line crossing the Gasserian ganglion represents the 
 section advised in removing the latter, together with the superior and inferior 
 maxillary trunks. (From a model in the London Hospital Museum.) 
 
85 
 
 at once be left off. On no account should the 
 wound be forcibly plugged with sponge or gauze. 
 A sterilised solution of adrenalin may be of use, 
 the minute pieces of sponge being dipped in it. 
 
 Patience and a good light are the chief essen- 
 tials for a proper section and removal of the gan- 
 glion ; the operator must see exactly what he is 
 cutting, and must remember the close proximity of 
 the cavernous sinus. 
 
 The patient's head is now turned a little on' 
 the side so that blood can run out easily, a small 
 spiral drainage tube is inserted, and the flap sewn 
 in place ; no bone is replaced. A large sterile 
 dressing is then secured firmly to the head with 
 a muslin bandage ; the tube should be removed 
 next day. ^ 
 
 After Treatment. — If the patient has been, 
 addicted to morphia until just before the opera- 
 tion, it is sometimes advisable to give a hypo- 
 dermic injection on the night following it. If 
 there is evidence of marked shock, strychnia should 
 be injected. In several of my cases shock has 
 been conspicuously absent, the patient being able 
 to sit up in bed on the day following the opera- 
 tion. The wound has, in every case, healed by 
 first intention. Suppuration is, of course, a most 
 dangerous complication, and hence the most sedu- 
 lous care should be taken in previous disinfection 
 of the scalp, and in all aseptic details of the 
 operation. 
 
86 
 
 Sir Victor Horsley^ notes that bleeding from 
 the meningeal artery can be "easily controlled by 
 simply tipping in the lower end of the retractor 
 so as to kink the artery as it leaves the foramen 
 spinosum," 
 
 He advocates tearing the roots from the pons, 
 a procedure which of course always paralyses the 
 ophthalmic division. Many other surgeons carry 
 out this complete removal, which, for reasons 
 elsewhere given, I deliberately avoid, though in 
 exceptional cases (where the neuralgia is severe 
 in the ophthalmic distribution) it is certainly 
 justified. Sir Victor Horsley's method differs from 
 that given above in the last stage only, "The 
 anterior and superior borders of the ganglion 
 having been defined with a seeker and raised by 
 pulling up from its bed, it is then separated by 
 dividing the inferior division, then the middle 
 division, and, finally, by detachment of the superior 
 division of the ganglion. The ganglion is then 
 steadily drawn upon until it is found that the 
 sensory and motor roots have become detached 
 from the pons, and are extracted in its full length. 
 This is followed usually by a free flow of cerebro- 
 spinal fluid, &c." 
 
 Various points in connection with the operation 
 and its modifications require notice. The follow- 
 ing are the chief ones : — 
 
 ^ Horsley, Clinical Journal, November 3, 1897. 
 
87 
 
 I. — Should the Operatiojt be done in One or Two 
 
 Stages ? 
 
 The long duration of the operation has natu- 
 rally led some surgeons to divide it into two 
 stages, separated by a few days' interval. Severe 
 haemorrhage during the exposure of the ganglion 
 may necessitate this course, but in Krause's opinion 
 the operation should be 'completed in one stage 
 if possible. The risk of failure to procure asepsis 
 is thereby diminished, and the patient spared the 
 shock of two operations and a double anaesthetic. 
 Codivilla, in one case, met with such haemorrhage 
 from rupture of the meningeal artery, that he was 
 obliged to plug the wound, and postpone the con- 
 clusion of the operation for three days. On the 
 second occasion the bleeding was again severe, 
 but, fortunately, the operation was brought to a 
 successful issue. It is not only arterial but venous 
 haemorrhage that may be so severe as to compel 
 the operator to postpone the completion of the 
 operation. Of this, Mugnai records an example. 
 Plugging the cavity with gauze or sponge appears 
 to be attended with special risk ; the pressure on 
 the brain may cause aphasia or other paralytic 
 symptoms, and the risk of sepsis is certainly much 
 increased. 
 
 The answer to the question proposed above there- 
 fore is that whenever possible the operation should 
 be completed at one sitting, but that when excep- 
 tional difficulty arises from haemorrhage in exposing 
 
the ganglion, it is wise to defer its completion for 
 a few days. 
 
 II. — The Section of the Skull. 
 
 With regard to the exact amount of bone divided 
 or removed, a great deal of misplaced ingenuity 
 has been expended, and the long descriptions by 
 various surgeons of " their own methods of ope- 
 rating " only cause annoying and useless confusion 
 in the reader's mind. For example, " Sapersko's 
 method " includes ligature of the common carotid 
 artery (with grave risk of hemiplegia), and division 
 of each end of the zygoma (with the chance of 
 necrosis — and, in any case, unnecessary). "Doyen's 
 operation " included an extravagant skin incision, 
 which passed for some inches onto the face ; divi- 
 sion of the zygoma and coronoid process ; removal 
 of the skull wall as far inwards as the foramen 
 ovale — in fact, an increase in the severity of the 
 operation which had no compensating feature. Of 
 Doyen's three cases reported, two were fatal as a 
 direct result of the operation — a sufficient condem- 
 nation in itself. 
 
 It is unnecessary to describe the so - called 
 " Quenu's operation," and the height of absurdity 
 is reached by such terms as the " Doyen-Quenu- 
 Sebileau-Poirier method," which is gravely referred 
 to by another French writer on the subject. There 
 is a sad lack of humour in some surgical authors. 
 
 Division of the zygoma has been employed by 
 
- z. 
 
 Fig. i6. 
 
 Z. — The zygoma. F.O. — Foramen ovale. F.S. — Foramen spinosum. 
 
 A. — (Shaded area) represents the part of bone cut away in Cushing's or 
 Poiriers' operation. 
 
89 
 
 many surgeons as an aid to the free removal of 
 bone from the side of the skull ; it must be quite 
 exceptional for this to be necessary. Dr. Gush- 
 ing,^ of Baltimore, advocates the following method, 
 which he states he has carried out successfully in 
 thirteen cases : — 
 
 The usual horse-shoe flap, with its base at the 
 zygoma, is turned down ; the zygoma is divided 
 at each end, and also reflected with the masseter 
 muscle. The great wing of the sphenoid and the 
 temporal bone is then cleared as low as the origin 
 of the external, pterygoid muscle. A small orifice 
 is then made in the most prominent part of the 
 sphenoid wing, the opening being enlarged with 
 the cutting forceps until it is 3 centimetres in 
 diameter. The dura mater being detached and 
 pushed upwards, the surgeon works inwards and 
 backwards so as to expose the foramina rotundum 
 and ovale. Gushing advocates removal of the 
 entire ganglion with the ophthalmic division. The 
 zygoma is subsequently fixed in place (fig. 16). 
 
 Gushing's method, it will be seen, is in some 
 respects a reversion to Rose's original operation, 
 in that the opening in the skull is made low 
 down, and the zygoma is divided. He claims for it 
 two advantages over the Hartley-Krause method ; 
 first, a more direct access to the ganglion, and 
 
 ^ Gushing, Journal of Amer. Med. Assoc, April 28, igoo, 
 P- 1035. 
 
90 
 
 secondly, the avoidance of the middle meningeal 
 artery. As noted elsewhere, the latter vessel may 
 be avoided also in the usual temporal operation. 
 The division of the zygoma is a distinct drawback, 
 and, in addition, the coronoid process of the lower 
 jaw comes in the way. That Cushing's slight 
 modifications present any real gain may well be 
 doubted, and the complece removal of the ganglion 
 with its ophthalmic division, which he recom- 
 mends, is certainly unnecessary in most cases, and 
 may lead to the subsequent loss of the eye. 
 
 In all essentials what has been described as 
 Cushing's method is identical with M. Poirier's 
 procedure, details of which were published three 
 years before,^ i.e., in 1897. There is the same 
 oval flap, the same division and downward dis- 
 placement of zygoma, section of temporal muscle 
 and detachment of external pterygoid, exposure of 
 foramen ovale, trephining of bone forming the roof 
 of the zygomatic fossa, and removal of the whole 
 ganglion. The only possible difference that the 
 careful reader will find, is that Poirier removes 
 rather more bone, thus giving better access to the 
 ganglion. It is at least strange that Mr, Gushing 
 and Professor Kocher (who writes of the former's 
 modification as original, and constituting a great 
 
 ^ Poirier's method is figured and described in detail in 
 Chipault, Chiv. Nerveiise, vol. i., pp. 394 to 398. It was pub- 
 lished before this in the Tyav. Neur. Chiv. Chip., 1897, ii., 213. 
 
91 
 
 improvement) do not mention Poirier's work. The 
 dispute as to priority on such a matter is, however, 
 hardly worth raising. 
 
 III. — The Osteoplastic Method. 
 
 Many surgeons ' have turned down a quad- 
 rangular flap of bone with the soft tissues instead 
 of trephining. This method necessitates making 
 four small apertures in the bone to correspond 
 with each angle of the flap ; the sides may be 
 divided with a chisel, or cut entirely from within 
 outwards by means of a fine Gigli's saw. The 
 advantage of replacing the bone may well be 
 questioned. The aperture made by trephining is 
 soon closed up largely or entirely by bone, so 
 that a few months later the intracranial pulsation 
 can hardly be detected. I have never known the 
 slightest complaint made by the patient with regard 
 to the supposed weak spot. On the other hand, 
 if a large osteo-plastic flap is made, more free 
 access to the middle fossa is probably secured 
 than by trephining. This is the sole advantage 
 that can be claimed. 
 
 The following points may be urged against the 
 method : — 
 
 (i) In the manipulations carried out with the 
 drill or small trephine, the chisel, and the saw, and 
 in the necessary detachment of the dura mater, the 
 latter is extremely apt to be torn and bruised. 
 
92 
 
 (2) The middle meningeal branches are easily- 
 damaged^ and will give considerable trouble ; many- 
 cases of this could be quoted. 
 
 (3) Even more serious damage may be done to 
 the brain ; thus, W. W. Keen, in perforating the 
 skull with a Cryer's drill, experienced free haemor- 
 rhage " from a branch of the middle cerebral 
 artery " and an extensive clot formed. The patient 
 was hemiplegic after the operation, and died on 
 the third day. 
 
 (4) The flap is decidedly in the way during the 
 later stages of the operation. 
 
 (5) After all his time and trouble spent in 
 turning down the flap of bone, the operator may 
 decide that it is unsafe to replace it, owing to 
 separation of the pericranium," or other cause. 
 
 (6) Probably the replaced bone will survive, but 
 this is not certain, and its necrosis is a most 
 dangerous complication, as septic meningitis is 
 almost inevitable. 
 
 For the above reasons it appears best not to 
 employ the osteo-plastic flap, though the surgeon's 
 predilections must decide this. Should it be used, 
 the greatest care should be taken in detaching the 
 dura mater so as not to tear the meningeal artery, 
 
 ^ e.g., cases recorded by S. P. Weeks, Trans. Amer. Surg. 
 Assoc, 1897, p. 171, and W. W. Keen, Amer. Journal of Med. 
 Science, 1896, cxi., p. 68. 
 
 ^ As in a case operated on by J. Raum, in 1897, quoted in 
 Chipault's Chirurgie Nerveuse, vol. ii., p. 192. 
 
93 
 
 and the chisel alone should certainly not be used 
 for the entire section of the bone. All the electric 
 drills and cutters are unsafe as being difficult to 
 control, and apt to slip through the dura mater 
 into the brain. Professor Krause uses Doyen's 
 perforator to make two openings at the upper 
 angles of the flap ; with Dahlgren's cutting forceps 
 he then completes the upper section and also 
 divides the bone down to the level of the zygoma. 
 A spatula being passed between the bone and 
 dura, the former is grasped by forceps and bent 
 downwards so as to fracture it transversely, oppo- 
 site the zygoma. With cutting forceps the portion 
 of squamous bone and great wing of the sphenoid, 
 between the line of fracture and the infra-temporal 
 crest, is then excised bit by bit. Krause points 
 out that it is essential to remove the bone as far ' 
 inwards as the crest, but unnecessary to go further. 
 "As to resection of the zygoma it is absolutely 
 useless." Chipault, however, writing in 1904, says 
 that, in France, all operators on the Gasserian 
 ganglion employ some method involving division 
 of the zygoma, and that the simple temporal route 
 finds no advocates there. It is of special interest 
 to note that Chipault speaks of the mortality of 
 operations on the ganglion as being enormous ! ^ 
 
 ^ Chipault, Etat Acttiel de la Chir. Ncrvaise, 1904, vol. ii., 
 p. 404. 
 
94 
 
 IV. — The Question of Ligature of the Meningeal 
 
 Artery. 
 
 It is possible to remove the Gasserian ganglion 
 without division of this artery ; but undoubtedly 
 its division between two ligatures allows of the 
 dura mater being lifted up more completely, and 
 Krause has carried this out in all his operations, 
 and recommends that it should always be done. 
 There are certain variations in the position, &c., 
 of the foramen spinosum through which the artery 
 enters the skull. Thus in three of his twenty- 
 five cases Krause found a double foramen, through 
 which the two main arterial branches, anterior and 
 posterior, passed. The usual position in the adult 
 skull for the spinous foramen is 2 millimetres 
 behind, and about i millimetre outside the foramen 
 ovale (see fig. 14, page 82). 
 
 An aneurism needle with a short, sharp curve 
 is necessary ; it should be threaded with fine silk, 
 which is less likely to slip than catgut. The dura 
 mater ensheathing the vessel must be carefully 
 detached upwards, so that a space is obtained 
 between the two ligatures. With the greatest 
 care, however, one or other ligature is apt to slip 
 off. In this case Krause recommends that a rect- 
 angular hook should be pressed down into the 
 foramen spinosum. Horsley's aseptic wax may be 
 used. 
 
 I have succeeded in dealino- with the o-ang^lion 
 
95 
 
 satisfactorily, in one or two cases, without dividing 
 the meningeal artery, but this certainly cannot 
 always be done. Out of twelve cases operated on 
 by Italian surgeons, formal ligature of this vessel 
 was found to be necessary in nine. 
 
 V. — Pittgging the Foramina Rotunduin and Ovale. 
 
 Dr. Robert Abbe {^Annals of Surgery, 1903) 
 points out that the mortality following the opera- 
 tions on the Gasserian ganglion has been need- 
 lessly high, owing to the assumed necessity for 
 removal of the whole ganglion. He urges that 
 there is no need for removal of the ophthalmic 
 division in the great majority of cases, and he 
 thinks that section of the second and third divi- 
 sions, with the interposition of a small piece of 
 sterile rubber between the dura mater and the 
 foramina rotundum and ovale, will suffice to obtain 
 a cure. The object of the insertion of the rubber 
 disc, which is, of course, left in situ, is to prevent 
 reunion between the nerves and the ganglion, and 
 from the record of five cases which he reports he 
 shows that the pain did not return during periods 
 of from six months to six years. He also urges 
 that the method is simple, speedy, and safe. 
 
 With regard to Abbe's contention, the writer 
 heartily agrees in limiting the interference in most 
 cases to the lower part of the ganglion, with its 
 second and third divisions. By this means the 
 
96 
 
 mortality from shock will be lessened, as well as 
 the danger of injuring the cavernous sinus and 
 the oculo-motor nerves. At the same time Abbe's 
 method differs only from the ordinary one, de- 
 scribed in detail in this work, by the interposition 
 of the rubber disc, and therefore no special merit 
 of simplicity or safeness can fairly be claimed for 
 it. The rubber disc is probably of little or no 
 value, for the following reason : Supposing that, 
 after complete section at the ganglion, physiological 
 reunion were to occur, we should of course find that 
 the parts made anaesthetic by the operation, such, 
 for example, as the cheek and hard palate, would 
 regain sensation. In no single case that the writer 
 has followed up, or has found recorded, has this 
 result occurred ; hence, Dr. Abbe seems to be 
 providing against an imaginary risk. When the 
 lower part of the ganglion and its main branches 
 are cut, regeneration no more occurs than after 
 section of the spinal nerves in a corresponding 
 position. It is worth noting that Abbe considers 
 a vertical incision over the temporal fossa affords, 
 with strong retraction, as good access as does the 
 usual one employed, and that he regards prelimi- 
 nary ligature of the external, carotid artery as being 
 of advantage in controlling- haemorrhag-e. He 
 believes that in epileptiform neuralgia there is a 
 neuritis in front of the ganglion in some parts of 
 the peripheral branches ; but, with regard to this 
 point, his evidence is far from conclusive. 
 
I.D. 
 
 Fig. 17. 
 
 The Gasserian and otic ganglia viewed from the inner side (from original 
 dissection in the London Hospital Museum). The course of the motor root to 
 its complete union with the inferior maxillary division and the main branches 
 of the latter are shown. O.N. —Optic nerve. S.S. — Sphenoidal sinus. 
 M.B. — Middle turbinated bone. O.G.— Otic ganglion showing its branches to 
 the pterygoid muscles, the chorda tympani, &c. I.B. — Inferior turbinated 
 bone. C.T.N. — Chorda tympani nerve. I. P. — Internal pterygoid plate. 
 I.D. — Inferior dental nerve with mylo hyoid branch. YII. — Facial nerve. 
 A.T.N. — Auiiculo-temporal nerve. I. M.— Internal maxillary artery. 
 
97 
 
 Moreover, simple section of the main trunks 
 below the ganglion, as advised by Abbe, is pro- 
 bably less certain to effect a cure than the removal 
 of most of the ganglion. 
 
 . Chipault has tried plugging the foramina rotun- 
 dum and ovale with dentist's stopping material, 
 with the view of intimidating the fifth nerve. 
 
 VI. — Division of the Sensory Root alone. 
 
 It is much to be wished, in operating on the 
 Gasserian ganglion for neuralgia, that the motor 
 root, which is in no way concerned, could be 
 spared. It is, however, impossible to effect this 
 in Krause's operation, so intimately blended with 
 the ganglion and the third division is the slender 
 motor root (fig. 17 illustrates this well). Above 
 the aperture in the dura mater it is possible, though 
 extremely difficult, to isolate the sensory root and 
 to divide it alone. This procedure was carried 
 out, in one case, with apparent success, by Spiller 
 and Frazier. They dissected down to the ganglion 
 after the usual method, then divided the dura mater, 
 isolated the sensory root, and, hooking it outwards, 
 cut it across. In some respects their method fol- 
 lowed that employed by Sir Victor Horsley, in 
 his solitary case of intradural division of the gan- 
 glionic roots ; only, they spared the motor one. 
 The fatal result in Horsley 's case deterred sub- 
 sequent operators, and the uncertainty of Spiller 
 7 
 
98 
 
 and Frazier's method will, we think, have the 
 same effect. It is, however, probable that many 
 surgeons will attempt the division of the sensory 
 root above the ganglion, since during the last 
 year it has been suggested in many quarters ; and, 
 it is to be feared that, if this should happen, dis- 
 credit will be brought on the whole subject of 
 operations on the Gasserian ganglion. The sole 
 recommendation is the preservation of the motor 
 root, an extremely difficult proceeding when 
 cerebro-spinal fluid and blood are harrassing the 
 operator. It is of interest that, in the analogous 
 operation of division of the auditory nerve for 
 vertigo, the facial trunk has more than once been 
 cut also, though the distinction between them is 
 easier to make out than that between the two 
 parts of the fifth nerve. Repeated experiment 
 has convinced me that, in the cavum Meckelii, it 
 is impossible to divide the sensory portion com- 
 pletely without sacrificing the motor root (see 
 fig. 1 8) ; above the cavum it is so difficult as to 
 depend almost upon chance. Professor Krause, 
 after fruitless attempts to preserve the motor root, 
 when dealing with the Gasserian ganglion, has 
 quite given them up, and remarks that the trouble 
 caused by one-sided paralysis of the masticatory 
 muscles is insigrnificant. 
 
Fig. i8. 
 
 The Gasserian ganglion, viewed from the external and internal surface. 
 The motor root is seen to lie on the median aspect of the sensory one to which 
 it closely adheres, becoming completely incorporated with the front of the 
 internal maxillary division. The dotted line on the left figure shows the 
 section advised to spare the ophthalmic division. (Modified from Riidinger.) 
 
99 
 
 VII. — Ligature of the External Carotid. 
 
 It is natural to suppose that one of the main 
 difficulties of the operation, namely hsemorrhage, 
 would be materially diminished by preliminary 
 ligature of the external carotid artery ; but so 
 free is the collateral circulation that even the 
 arterial bleeding seems to be but little affected by 
 this procedure. I have only once employed it, 
 but in this case, the ligature being performed in 
 the middle of the operation, no apparent effect 
 was produced. G. R. Fowler tied the external 
 carotid, as a preliminary measure, in two cases ; in 
 one, "abundant bleeding occurred, as the dura 
 mater was separated from the middle fossa," and 
 the completion of the operation had to be post- 
 poned. Unfortunately, his patient died from septic 
 infection following plugging with gauze. In the 
 second case the bleeding was insignificant. Keep- 
 ing the patient in an upright, sitting posture is far 
 more effective than ligature of the external carotid, 
 since it checks both venous and arterial bleeding. 
 
 It is curious that ligature of the common carotid 
 should have ever come into vogue as a treatment 
 for intense neuralgia of the fifth nerve. On no 
 physiological theory could the impairment of blood 
 supply be likely to suppress pain, especially if, as 
 Keen has urged, the blood-vessels of the ganglia 
 are already narrowed by disease. A wide ex- 
 perience of the operation has shown that, in some 
 
100 
 
 cases, temporary relief is afforded ; in the case of 
 one patient^ the pain only recurred after three or 
 four years' interv^al, but in the majority there is not 
 even a temporary cure. Moreover, the danger of 
 hemiplegia following ligature of the common carotid 
 artery, especially in old subjects, is too great to 
 justify its being run without the gravest cause. 
 As a method of treating epileptiform neuralgia, 
 arterial ligature should, therefore, never be resorted 
 to. 
 
 The same remark holds true for excision of the 
 cervical sympathetic ganglia, which, by certain 
 writers, has been advocated as a kind of surgical 
 panacea. It could not be expected to succeed in 
 cases of neuralgia, and, experience has shown that 
 it does not succeed. Chipault is one of the very 
 few writers who has tried to make out a favour- 
 able case for it"-^ ; he had been so impressed with 
 the " enormous mortality " of operations on the 
 Gasserian ganglion that, in 1902, he had only 
 performed three such operations and preferred any 
 alternative method. 
 
 VIII. — The Pterygoid Route from Below. 
 
 To Professor Wm. Rose belongs the credit of 
 having first operated on the Gasserian ganglion 
 
 ^ Dr. J. C. Hutchinson's case, briefly reported in Trans, of 
 Am. Surgeons' Assoc, 1884, p. 489. 
 
 ■^ Chipault, Etat de la Chir. Nerveuse, 1902, vol. i., p. 443. 
 
lOI 
 
 from the under surface of the cranial base. His 
 method, which was followed by a number of other 
 operators, is a most elaborate and difficult one. 
 Undoubtedly, in some cases, the ganglion was 
 reached and excised with success, but the follow- 
 ing objections have led to its abandonment in 
 favour of the temporal route : — 
 
 (i) The division of bone required — the zygoma 
 and coronoid process — was sometimes followed by 
 necrosis, non-union, or by stiffness of the jaw, with 
 marked deformity. 
 
 (2) The haemorrhage was often severe and 
 difficult to control. 
 
 (3) The view afforded of the ganglion was 
 inferior to that obtained by the temporal route. 
 It is certain that many operators failed entirely 
 to deal with the ganglion by Rose's method ; 
 hence recurrence of the neuralgia was not in- 
 frequent. 
 
 (4) The Eustachian tube is in special danger 
 of being injured ; this may be a serious com- 
 plication. 
 
 Thus Caponotto, an Italian surgeon, records a 
 case in which the operation was followed by marked 
 rise of temperature, and bleeding from nose and 
 mouth. At the autopsy, five days later, it was 
 found that the Eustachian tube had been wounded 
 and that meningitis had ensued. 
 
 It has been already noted that Poirier's or 
 Cushing's operation is a compromise between 
 
102 
 
 Rose's and the Hartley-Krause method, and it is 
 curious that a partial reversion to Rose's operation 
 should be advocated, after it had been abandoned 
 by all authorities. Professor Rose himself^ ulti- 
 mately gave up operations on the Gasserian 
 ganglion and advocated extensive resection of, 
 first, the superior maxillary nerve, and secondly 
 (after an interval of a few weeks), of the inferior 
 maxillary division. He stated that it was hardly 
 ever necessary to touch the ophthalmic division. 
 This conclusion agrees exactly with the operation 
 advocated in this work ; only, for two extracranial 
 operations a single intracranial one is substituted, 
 which deals only with the lower part of the Gas- 
 serian ganglion and the two main trunks issuing 
 from it. 
 
 ^ W. Rose, The Practitioner, i8gg, p. 255. 
 
CHAPTER VI. 
 
 Excision of the Gasserian Ganglion. Results 
 AND Complications of the Operation. 
 
 We have to consider first the conditions which 
 result from a successful removal of the ganglion. 
 The question of subsequent disfigurement is one 
 to which some importance may be attached, as 
 after the old pterygoid operation from below the 
 face was left extensively scarred, and when the 
 zygoma was divided, it did not always unite in 
 good position. But when the temporal (Hartley- 
 Krause) operation has been performed there -is 
 remarkably little disfigurement, the scar being 
 usually hidden entirely by the scalp ; there is 
 merely some flattening of the temporal region, due 
 to atrophy of the underlying muscle. 
 
 The amount of cutaneous anaesthesia depends, 
 of course, upon whether the whole ganglion has 
 been removed, or its ophthalmic division spared. 
 In the former case the skin will be anaesthetic 
 from the chin to high up on the forehead, and from 
 the middle line to the temporal fossa. The greater 
 part of the ear and the masseteric region will 
 always retain sensation, owing to their supply 
 from ascending nerves from the superficial cervical 
 
104 
 
 plexus. These points are Illustrated by fig. 19, 
 taken from one of my cases. 
 
 If the ophthalmic division has been spared, the 
 forehead, the greater part of the nose, the upper 
 
 Fig. 19. — Distribution of the neuralgia (lower figure) and anaesthesia left 
 after complete removal of the Gasserian ganglion (upper figure). In this 
 case the pain was greatest in the parts deeply shaded ; the letters A B c D 
 mark points of especial tenderness. In the upper figure it is seen that the 
 ear and masseteric regions retain sensation. 
 
 eyelid, and (most important of all) the cornea and 
 conjunctiva vi^ill retain their sensation. The anaes- 
 thetic area is then as shown in fig. 20. It will 
 be noticed that there is a small prolongation of 
 the insensitive area at the front of the external 
 
105 
 
 auditory meatus ; this is prolonged in the upper 
 and anterior wall of the meatus itself. 
 
 Dr. Gushing states that this area includes a 
 small portion of the tympanic membrane. As 
 regards the mucous membrane of the mouth, &c., 
 the anaesthesia will be complete on the inner sur- 
 
 FiG. 20. — Area of cutaneous anaesthesia left after excision of the Gasserian 
 ganglion (the ophthalmic division being untouched). Taken from a case six 
 months after operation. 
 
 face of the lips, the gums, and hard and soft palate. 
 It is less complete on the anterior two-thirds of 
 the tongue (owing to the chorda tympani contain- 
 ing sensory fibres), and in the pharyngeal vault. 
 Sensation in the Eustachian tube is much im- 
 paired, and the nasal cavity is insensitive to touch, 
 though, of course, the sense of smell is retained. 
 
 Dr. Gushing {Johns Hopkins Bidletin, 1904) 
 has made careful and elaborate investigations of 
 
io6 
 
 the anaesthetic area in cases of extirpation of the 
 Gasserian ganglion. As might be expected, there 
 is a small range of variation in different subjects, 
 but his main results asrree with the statements 
 made above. 
 
 Does the area of anaesthesia decrease? In 
 some cases, possibly in all, a slight reduction in 
 the anaesthetic area of skin and mucous membrane 
 can be proved after some months or years have 
 elapsed. This is of no great importance, as the 
 numbness is rarely complained of. The paralysis 
 of the masticatory muscles, which must follow 
 complete division of the inferior maxillary trunk, 
 might be expected to cause far more incon- 
 venience. The masseter, temporal, and the two 
 pterygoid muscles are, after removal of the Gas- 
 serian ganglion, entirely deprived of their nerve- 
 supply, and their subsequent wasting can easily 
 be proved. It is strange how little trouble is 
 caused thereby, as the muscles of the opposite 
 side amply suffice for mastication. In every case 
 the patient eats better than before the operation, 
 since no longer does the attempt at chewing the 
 food bring on spasms of pain. When questioned 
 on the point the patients state "they can now 
 eat anything." 
 
 Is the sense of taste impaired by the paralysis 
 of the so-called gustatory nerve ? 
 
 It is certain that the "gustatory" nerve has 
 nothing to do with the sense of taste in the 
 
107 
 
 posterior third of the tongue (the region of the 
 circumvallate papillae) the glosso-pharyngeal trans- 
 mitting it from this part. With regard to the 
 anterior two-thirds of the tongue, it is generally 
 admitted that the taste-organs are supplied by the 
 chorda tympani nerve, which reaches the facial, and 
 undoubtedly ascends to its geniculate ganglion. 
 After this point the further course of the fibres is 
 doubtful, the most probable being the pars inter- 
 media of Wrisberg, and so to the brain. Dr. 
 Harvey Gushing, in an elaborate paper, with 
 many references,^ discusses the question, and 
 comes to the following conclusion : " That the 
 perception of taste is unaffected on the posterior 
 portion of the tongue, and never permanently or 
 completely lost on its anterior two-thirds after 
 removal of the Gasserian o^anMion." 
 
 Dr. Gushing noted in one or two of his cases 
 that the sense of taste was dulled for a time m 
 the front part of the tongue after the operation, 
 and suggested that this was due to "some inter- 
 ference with chorda transmission, brought about 
 by a mechanical or toxic disturbance, due to 
 degeneration of the lingual or gastatory nerve." 
 Gushing's view is, however, directly opposed by 
 the evidence of several observers.^ In one case 
 
 ^ Gushing, Johns Hopkins Hospital Bulletin, March, 1903, 
 p. 71. 
 
 ^ e.g., A. Guinard. 
 
io8 
 
 in which I had removed the lower two-thirds of 
 the gangHon some months previously, the patient 
 had certainly lost the power of distinguishing 
 quinine, salt, &:c., on the anterior part of that 
 side of the tongue. It was not merely that the 
 sense of taste over this region was dulled (in 
 Cushing's words) : it was entirely lost. The case 
 is detailed on p. 50. Thus, after excision of the 
 Gasserian ganglion, permanent anaesthesia over a 
 large area of skin and mucous membrane is left ; 
 the sense of taste is impaired on the side operated 
 on ; the masticatory muscles waste. Nevertheless, 
 the patient experiences little, if any, discomfort 
 from the loss of sensation ; he is able to take food 
 far better than before, and the disfigurement (if 
 the temporal route has been followed) is trifling. 
 There is, however, one point with regard to com- 
 plete extirpation of the ganglion that deserves 
 special note, namely, the risk of subsequent 
 keratitis, and even loss of the eye. 
 
 Neuro-pm^alytic Keratitis. — This is a serious 
 drawback to the operation of complete removal of 
 the ganglion, the danger of which is entirely avoided 
 in the modified method. 
 
 How frequently it occurs can hardly be estimated 
 from the cases recorded, especially when they have 
 been reported soon after the operation. In the 
 only one of my cases in which the eye was 
 ultimately lost, owing to spreading ulcer of the 
 cornea, the trouble developed some months after 
 the patient had left the hospital. 
 
I09 
 
 The patient was a man, aged 64, who was sent to me 
 by Dr. Simpson. He had suffered for five years from 
 severe epileptiform neuralgia. His paroxysmal attacks 
 started in the lower jaw, spreading to the whole side of 
 the cheek, the lower part of the forehead, and temple ; 
 they involved also the region behind the ear, and in a 
 severe attack the whole of the right side of the scalp. 
 This radiation 6f the pain to parts beyond the area 
 supplied by the fifth nerve has been noticed in many 
 cases, and does not contra-indicate excision of the ganglion, 
 by which operation it is put an end to. 
 
 During the attacks there was usually marked lachryma- 
 tion, and, more than once there had been conjunctivitis 
 on the affected side. The pain was not controlled even 
 by opium, and the patient's condition was a very miserable 
 one. Excision of the Gasserian ganglion was performed 
 in June, 1899, the chief difficulty met with being due to 
 the extreme thinness of the dura mater. In raising this 
 membrane from the middle fossa it was unavoidably torn, 
 with the result that the cerebro-spinal fluid escaped. 
 Owing probably to this fact, the pressure of the broad 
 retractor exerted more deleterious effect on the brain than 
 usual, and he had for some little time after the operation 
 partial paralysis of the opposite arm and leg, which slowly 
 improved. The wound healed perfectly and the neuralgia 
 has been completely cured. His anaesthesia involves not 
 only the right side of the tongue, palate, cheek, nose, &c., 
 but also that half of the forehead, the cornea, and con- 
 junctiva. With regard to the eye, all went on well until 
 several weeks after he had returned home. He then 
 developed keratitis, which slowly spread in spite of treat- 
 ment, and ultimately, as the eye was useless, I excised it. 
 
 It is difficult or impossible to estimate the pro- 
 portion of cases in vv^hich corneal trouble has 
 followed the complete operation. Naturally, surgeons 
 do not dvv^ell on this complication when publishino- 
 
no 
 
 their experience. That the risk is a real one is 
 shown by the following nine instances, which I have 
 collected from various published records : — 
 
 (i) Biondi. Central ulcer of cornea with hypopyon 
 two months after operation. The condition of the eye 
 improved after a time, and apparently did not necessitate 
 excision. 
 
 (2) G. Andrews {Internat. Med. Mag., Philad., 1892, 
 I., p. 486), " ulcers of the cornea appeared after the opera- 
 tion, when the aseptic compresses, which had been placed 
 over the eye, were removed." It is probable that these 
 ulcers were not due to complete corneal anaesthesia, since ' 
 the ganglion was supposed to have been removed by the 
 curette. The ulcers, moreover, soon healed, whereas the 
 true neuro-paralytic ones are most obstinate. 
 
 (3) W. W. Keen {Ainer. Journal of Med. Sciences, 
 Jan., 1896). At the end of the operation the eyelids 
 were sewn together ; four days later they were separated, 
 and a corneal ulcer made its appearance. The subsequent 
 history is imperfect, but it would appear that the ulcer 
 slowly improved. 
 
 (4) W. W. Keen {Ibid. November, 1898). The eye on 
 the affected side " became blind." 
 
 (5) Davis {Univ. of Pennsylvania Med. Bull., No, 2, 
 1904). Eight months after complete removal of Gasserian 
 ganglion the anaesthetic eyeball had to be excised, owing 
 to corneal ulceration. 
 
 (6) Gerard-Marchant {Bull, de la Soc. de Chir., 1896, 
 xxii., p. 585). A fortnight after the operation the cornea 
 began to ulcerate, and it remained permanently opaque. 
 
 (7) A. Depage {Bull. Acad, de Med. de Beige, 1897, vol. 
 2, p. 687). " The cornea on the operated side ulcerated ; 
 there was conjunctivitis, and the sight was almost gone." 
 
 (8) S. Coelho {Revue de Chir., 1899, xix., p. 623). The 
 ganglion was wholly removed by tearing through its roots. 
 The cornea became opaque but subsequently cleared, 
 *' except for a small opacity." 
 
Ill 
 
 (9) Bougie {Bull, de la Soc. de Ckir.y 1901, p. 403). 
 Ulceration of the cornea followed with chemosis. 
 
 From the preceding ten cases it will be seen 
 that whilst the danger is greatest, as Krause 
 points out, during the first few weeks, yet an 
 anaesthetic cornea can never be really safe. Septic 
 dust may enter without being noticed and set up a 
 chronic inflammation, which is very hard to check. 
 To this cause must be ascribed the so-called 
 trophic changes in the eye, and if the ophthalmic 
 division has been dealt with and the cornea ren- 
 dered permanently anaesthetic, the safest plan will 
 be for the patient to wear protective glasses as a 
 continual precaution. Sewing up the lids on the 
 side concerned has been carried out by some 
 surgeons, but this is an irksome measure, and, as 
 already pointed out, the temporary closure of the ' 
 lids affords no guarantee for the future. 
 
 Occasionally the eye-lesion takes the form of 
 purulent conjunctivitis, leading later to ulcerative 
 keratitis — from this Bougie's patient was unfor- 
 tunate enough to suffer. In such a case it is pro- 
 bable that the use of too strong antiseptic solutions 
 for bathing the eye is responsible for the conjunc- 
 tivitis — the surgeon's precautions having been too 
 elaborate. A very mild antiseptic lotion may prove 
 destructive to an anaesthetic corneal surface ; but I 
 would again urge that when the cornea has been 
 rendered completely anaesthetic by removal of the 
 entire Gasserian ganglion or section of its roots,^ 
 
112 
 
 there will always remain some risk of " trophic " 
 ulceration. The fear of eventually losing the eye 
 is an important drawback to such an operation, a 
 drawback which can be entirely avoided by limit- 
 ing the excision of the ganglion in the manner 
 described. 
 
 We will now consider the direct mortality of the 
 operation — the actual risk to life which it involves. 
 
 Chipault wrote, in 1902, that the mortality of 
 these operations "is enormous." How far can 
 this statement be justified ? Of Krause's thirty- 
 six cases in which the ganglion was removed, six 
 died, i.e., 16 per cent. In three of these, how- 
 ever, the death was due to " influenza," or 
 pneumonia (in one case following heart-failure). 
 All these three patients died at the end of the 
 third week after the operation, and it can fairly 
 be said that the latter was only indirectly to 
 blame, the shock which resulted, in feeble patients, 
 hastening the end. Still, as most of the subjects 
 are old, and many of them feeble, it is best fairly 
 to state Krause's mortality as 16 per cent. Lexer 
 lost one case out of twelve, of meningitis. At 
 the post mortem of this case a tumour of the base 
 of the skull was found. In a case of my own a 
 
 cartilaofinous tumour was found invading- the Gas- 
 es o 
 
 serian ganglion from the adjoining bone ; complete 
 removal was impossible. The patient recovered 
 from the operation, which was, in fact, mainly 
 exploratory. (See page 31.) 
 
113 
 
 It is obvious that cases, in which the presence 
 of a tumour complicates the operation, should not 
 be counted with the ordinary ones. Lexer's eleven 
 and my own eight cases amount to nineteen, with- 
 out a single death. Sir Victor Horsley, in 1897, 
 had done eight Hartley- Krause operations without 
 a death. He kindly tells me that, since then, his 
 personal experience has increased to approximately 
 120, with six deaths.^ No other surgeon's statistics 
 can, I believe, compare in number and lowness of 
 mortality with Sir Victor Horsley's. Taking his 
 cases with Lexer's and my own, we have 140 cases 
 with six deaths, only 4 per cent, and this includes 
 two fatal cases which some surgeons might have 
 left out. The mortality, therefore, so far from 
 being "enormous," as Chipault suggests, is very 
 slight. What has given rise to the prevailing idea 
 on the subject, which it is most important to dispel ? 
 The fact is that, in the past, the mortality has been 
 far too high, owing to inexperience, and still 
 more, to needlessly heroic or clumsy methods of 
 operating. The collection of cases made by Keen, 
 Tiffany, and others is easily consulted, and it, 
 undoubtedly, shows a mortality of 20 per cent., or 
 over. Such a heavy death-rate is, fortunately, quite 
 
 ^ Of the six fatal cases, cerebral haemorrhage was the cause 
 in three ; one patient died from septic infection (from a septic 
 case in the same ward of the hospital). In the other two cases 
 an interval of three or four months occurred after the opera- 
 tion, the cause of death being doubtful. 
 
114 
 
 needless, but it has deterred many physicians from 
 recommending the operation in suitable cases. 
 
 The following selection of fatal results has been 
 made, solely for the purpose of illustrating the 
 causes of death and the means of avoiding it, as 
 far as possible. It would have been easy to 
 extend the list, but for all practical purposes it is 
 long enough. The reader will understand that 
 in every one included the temporal route was 
 adopted : — 
 
 Fatal Cases. Hart ley -Krause Method. 
 
 (i) Bernandi. Aged 68. Severe haemorrhage. Com- 
 plete removal of ganglion. Death on fifth day from shock. 
 Nothing found at post mortem except slight ecchymosis 
 of the temporo-sphenoidal lobe. 
 
 (2) Bernandi. Woman, aged 61. Death from failure 
 of heart's action just at the conclusion of the operation. 
 At the autopsy the heart was found to be fatty. 
 
 (3) G. R. Fowler {Med. Record of New York', 1894, 
 p. 745). Severe arterial and venous haemorrhage during 
 the operation. All three divisions of the nerve dealt with. 
 Death four hours afterwards. Patient aged 45. 
 
 (4) G. R. Fowler. Patient aged 50. Severe haemor- 
 rhage during the operation, although the external carotid 
 artery had been tied. Cavity plugged with gauze. Death 
 from septic infection. 
 
 (5) A. G. Gerster {^Med. Times, 1895, P- 5i8)- Opera- 
 tion in two stages, owing to haemorrhage. Gauze plug 
 used. Death from septic meningitis and cerebritis. 
 
 (6) J. T. Finney {Johns Hopkins Hosp. Bulletin, 1893, 
 p. 91). Patient aged 69. Complete removal of the 
 ganglion, " its roots being torn from the pons varolii." 
 Death seven hours after the operation. The middle 
 meningeal aperture had been plugged with gauze. 
 
115 
 
 (7) G. R. Fowler {Medical Record of •New York, 1894, 
 p. 745). Patient aged 45. Very abundant haemorrhage, 
 arterial and venous. All three divisions were cut. Death 
 (evidently from shock and haemorrhage) four hours later. 
 This case is specially noteworthy on account of the com- 
 paratively early age of the patient. 
 
 (8) W. W. Keen {Amer. Journal of Med. Set., 
 January, 1896). Patient aged 6t,. Two days after the 
 operation the temperature rose, and within a week the 
 patient died of septic meningitis. The infection was 
 undoubtedly due to one of the assistants, who had put 
 one of the instruments used in his mouth before the 
 operation. 
 
 (9) W. W. Keen. Complete removal of the ganglion ; 
 the cavernous sinus was freely opened in dealing with the 
 ophthalmic division. The haemorrhage was arrested by 
 plugging. The patient was found to be hemiplegic after 
 the operation ; did not regain consciousness, and died on 
 the third day. 
 
 (10) Lange (reported by Keen in Chipault's Chirurgie 
 Nerveuse). Patient aged 63. The operation was attended 
 by special difficulty and accidents, the bone-cutting forceps 
 breaking and injuring the brain. The ganglion could not 
 be removed, and the haemorrhage was severe. After the 
 operation, hemiplegia was noticed on the same side, death 
 resulting from cedema of the lungs. No explanation was 
 found post mortem for the hemiplegia. 
 
 (11) W. Meyer, Patient aged 30. Suppuration in 
 connection with a ligature followed the operation, and 
 death three months later from cerebral abscess. 
 
 (12) W. P. Nicholson (reported by Keen, loc. cit.). 
 Patient aged 62, Skull very thick; middle meningeal 
 artery buried in it. Formidable haemorrhage checked by 
 gauze-plugging. Death four days later. No meningitis. 
 
 (13) J. Ransohoff {ibid.). Patient aged 50. Excessive 
 haemorrhage. Death from shock. 
 
 (14) L. A. Stimson {ibid.). All three divisions dealt 
 with. The patient's breathing stopped during the eleva- 
 
ii6 
 
 tion of the brain ; the pulse became very rapid, the 
 breathing again enfeebled, and death ensued in six hours. 
 (15) L. M. Tiffany {Annals of Surgery, March, 1895). 
 Patient aged 71. Paralysis of the opposite arm followed 
 the operation. The wound healed quickly, but had to be 
 reopened at the end of a week in order to remove blood- 
 clot. In the third week septic infection proved fatal. 
 
 The main risks of the operation are seen to be 
 three : shock (sometimes caused by injurious pres- 
 sure on the brain), haemorrhage, and septic infec- 
 tion ; it may be said these three are one. Severe 
 haemorrhage is generally due to opening the 
 cavernous sinus during the attempt to completely 
 remove the roots of the ganglion and its ophthalmic 
 branch ; to check the bleeding the operator resorts 
 to plugging with gauze, which causes injurious 
 pressure on the brain and increases the risk of 
 septic infection. 
 
 If the patient be operated upon in the vertical 
 (sitting) posture, as Krause recommends, the bleed- 
 ing is rarely severe, especially if the interference 
 is limited to the lower two-thirds of the ganglion. 
 In any case plugging with gauze should be avoided ; 
 a small drainage-tube should invariably be left in 
 the wound for twenty-four hours, and, of course, 
 the greatest care should be taken to avoid sepsis. 
 It may be noted that the latter ought never to 
 occur, the temporal region being a most favourable 
 one to render aseptic, and wounds made here heal 
 very kindly. The danger of causing injurious 
 pressure by the retractor, during the operation. 
 
117 
 
 should be borne in mind throughout the operation. 
 In one of my cases it was the cause of temporary 
 hemiplegia, and several other examples of it have 
 been recorded. Thus, Krause records one case in 
 which an extravasation of blood occurred into the 
 right cerebral hemisphere, the patient ultimately 
 recovering. Biondi noticed temporary aphasia in 
 one case, and in two others slight auditory defect, 
 due, doubtless, to pressure on the temporo- 
 sphenoidal lobe during the operation, the defect 
 persisting for some six months. 
 
 An instance of severe " pressure paralysis " 
 following operation on the Gasserian ganglion is 
 recorded by Dr. Howard D. Collins [Annals of 
 Surgery, 1903, vol. xxxviii., p. 665), The haemor- 
 rhage during the operation was severe, and as the 
 osteo-plastic flap method was used, it is possible' 
 that an accumulation of blood-clot may have been 
 to blame for the subsequent paralysis ; Dr. Collins, 
 however, attributes it solely to the retraction 
 employed during the operation. For days after- 
 wards the patient was drowsy and lethargic ; there 
 was partial paralysis of both opposite arm and leg, 
 and complete paralysis of all the oculo-motor 
 muscles on the same side. After some weeks all 
 the paralytic symptoms improved and ultimately 
 cleared off, though the patient's memory was said 
 to be permanently affected. 
 
ii8 
 
 Oculo-motor Complications following the Operation. 
 
 These occur almost solely when the whole 
 ganglion, including the ophthalmic division, has 
 been removed ; they vary much in degree, and 
 may be either temporary or permanent. In some 
 cases merely ptosis or impaired movement of the 
 globe in one or other direction results ; in others 
 the paralysis may be for a time complete. Of the 
 latter Mugnai records an example. At the end 
 of three weeks, movements of the eye were re- 
 gained, but ptosis persisted. Other instances of 
 temporary paralysis are recorded by G. Andrews^ 
 (two cases out of five operated on by him), by F. 
 Hartley,^ and others. In a case recorded by Davis^ 
 " the third and fourth nerves were paralysed for a 
 time, and the sixth nerve was probably destroyed." 
 As, however, the affected eye had to be excised 
 later, owing to keratitis, the oculo-motor paralysis 
 did not matter very much. Lexer observed para- 
 lysis of one or other oculo-motor nerves in four out 
 of twelve cases operated on by himself; in three, 
 the paralysis passed off, but in the fourth case para- 
 lysis of the sixth nerve persisted. 
 
 Professor Krause noted temporary paralysis of 
 ocular muscles in five out of twenty-five of his 
 cases. 
 
 ^ Andrews, quoted by Keen in Chipault's Chinivgie Nerveuse, 
 vol. iii., p. 691. 
 
 2 Hartley, Annals of Sicvgery, 1893, I., p. 512. 
 
 ^ Davis, Univ. Pennsylvania Med. Bull., 1904, No. 2. 
 
(fi • •^ ■ - (1) 
 
 c rt 1- u rt > 11 
 
 o .- o -c '^' C > 
 
 'm 9-'!r. '^ o i; S 
 
 -13 HI ' 
 
 I- <j ij -^ 
 
 
 1>'^ 
 
 
 ' .2 
 
 o -5 b c 
 
 fl) ;r. c: f-o " 't^ iZ 
 
 2 c S ^ _^ '. ^ S 
 ^£05-5q^„S 
 
 ._2 — S .S O .2 jj 
 S S 3 o ^ 'c'^ 
 
 t/j 
 
 in a 
 
 i«bi^'5 
 
 £ 1 i; j3'-i M 
 
 ^ s 
 
 
 *^ <D 
 
 ^ S^rt S <" 
 
 *— ^ 
 
 
 O -^ 
 
 
 
 n2 
 o 
 
 c-2 
 
 ^ §;s 1 '-2 
 
 .2 Si 
 
 1, c 2 ^- "3 o 
 
 
 oj ca -o 1) 
 
 U 5- 
 
 •l^U^a ^ 
 
 u5 '^ 
 
 O 1 O ctf ^i, o 
 
 _ JZ 
 
 
 •a "5 
 
 (L) ^ 
 
 H s' 1 " i 
 
 ^ 1) 
 
 • ^ > 2 o 
 
 O) 
 
 
 <u 
 
 3 C . I— ( i_ 3 
 
119 
 
 It is obvious that this compHcation is a frequent 
 one, if, in the hands of so experienced an operator 
 as Krause, it occurs in 20 per cent. ; but it may 
 be avoided with almost complete certainty, provided 
 that the ophthalmic division is spared. The close 
 relation of the latter to the fourth and sixth nerves 
 in the wall of cavernous sinus is well shown in fig. 
 21. 
 
 Laceration of the Dura Mater. — This has often 
 occurred during the operation : indeed, during the 
 last stage, when the thin covering of the ganglion 
 itself is being reflected, it can hardly be avoided 
 in many cases. The cerebro-spinal fluid escapes 
 and, for a time, may hinder the completion of the 
 operation, but, provided asepsis is secured, no other 
 harm will result. During the early separation of 
 the dura from the temporal fossa, every care should 
 be taken not to perforate the membrane, which, 
 however, varies greatly in toughness and degree of 
 adhesion to the bone. Occasionally, it tears at the 
 slightest touch, but in other subjects it is firm and 
 readily detached. 
 
 Laceration of the Wall of the Cavernous Sinus. 
 — This happened in two of Krause's twenty-five 
 cases ; in both, the severe haemorrhage was ultimately 
 stopped by compression (plugging with sponge). 
 Several other instances have been recorded, and 
 it is noteworthy that, where plugging with gauze 
 has been necessary, death has resulted from slough- 
 ing of dura mater or septic infection in many cases. 
 
120 
 
 Wound of the cavernous sinus Is a most serious 
 complication for this reason, and also, because it 
 renders the proper completion of the operation 
 impossible. 
 
 In concluding this review of the various accidents 
 that may occur during and after excision of the 
 Gasserian ganglion, I may point out that, provided 
 the modified form of the operation be carried out, 
 (removal of the superior and inferior maxillary 
 trunks, with the greater part of the ganglion, but 
 sparing the ophthalmic division), the risks are 
 diminished in the following respects : — First, there 
 is no anaesthesia of the cornea, and, hence, no 
 risk of loss of the eye. Second, there should be no 
 danger of injuring the oculo-motor nerves, nor of 
 wounding the cavernous sinus. Third, the severity 
 of the operation is rendered less, the degree of 
 haemorrhage, and the chance of injurious pressure 
 on the brain being both materially diminished. 
 
 Those who advocate the complete removal of all 
 three divisions of the nerve with high section of 
 the roots will, no doubt, reply that by leaving the 
 ophthalmic trunk recurrence of the neuralgia will 
 take place in it. They may fairly be asked to 
 prove that this has ever occurred. 
 
 It must be admitted that, in certain cases, opera- 
 tion on the Gasserian ganglion, whatever form it 
 takes, is to some extent a failure. 
 
 There is, of course, no reason why neuralgia 
 should not recur on the opposite side of the head, 
 
121 
 
 and were arterio-sclerosis one of the causes (as 
 asserted by Keen), one would expect this to occur 
 fairly frequently ; but nothing is more character- 
 istic of epileptiform neuralgia than its unilateral 
 nature, even if it exists many years. Amongst the 
 records of several hundred cases, I have been able 
 to find only two or three, in which recurrence 
 on the opposite side has followed operation. R. 
 Winslow,^ in 1895, removed partially (by curetting) 
 one Gasserian ganglion. The patient suffered 
 subsequently from diplopia, mental defect, and 
 aphasia; all these symptoms cleared off In 1896 
 she " complained of neuralgia on the other side 
 of the head." In no case yet recorded has the 
 neuralgia on the opposite side approached in 
 intensity the original trouble. 
 
 Lexer, out of ten cases, observed recurrence of 
 the neuralgia on the same side in one, and on 
 the opposite side of the head in another case. 
 Salomoni {Clinica Ckirurgica, Feb. 1893), after 
 operation on the Gasserian ganglion on one 
 side, records that neuralgia recurred on the opposite 
 one some two months later. The ultimate result 
 is not stated. 
 
 I have had the misfortune to encounter one of 
 these cases in which recurrence of a certain kind 
 (chiefly limited to the other side of the head and 
 face) has followed excision of the Gasserian ganglion. 
 
 ^Maryland Med. Journal, May 2, 1896. 
 
122 
 
 The notes are as follows : — 
 
 Ellen P., a stout, and previously healthy woman, began 
 to suffer at the age of 37 from neuralgia on the right side 
 of the lower jaw. With the idea of relieving this, the 
 teeth were removed, whether decayed or not, from first 
 the lower, and then the upper jaw, as far forwards as the 
 canine. No rehef whatever followed this procedure. From 
 the first, the pain was of the spasmodic, intermittent type, 
 the intervals (at first a few months) becoming shorter, 
 until, at the end of five years, she was hardly ever free 
 from pain. When she came under surgical treatment, 
 being sent to me by Dr. F. M. Mackenzie, she had endured 
 the neuralgia for six years, and her health was much 
 lowered in consequence. Medicines had but little or no 
 effect in relieving her. 
 
 The pain was most intense in three positions : — (i) over 
 the lower jaw ; (2) in the cheek, and (3) in the temple. 
 From these areas the spasmodic pain radiated upwards 
 towards the right eye, which constantly watered, and 
 towards the vertex. In addition, the right side of the 
 neck was painful, and the whole right side of the scalp 
 was so tender that she could not bear to comb her' hair. 
 Mastication was accompanied by pain, so that she took 
 only soft or fluid food with difficulty. The alveolar surface 
 on the affected side was extremely tender, and the act of 
 removing her tooth-plate, or merely talking, invariably 
 brought on an acute spasm. 
 
 It will be noted that in this case the neuralgia involved, 
 primarily, the inferior maxillary division, but had spread 
 to the superior maxillary one, whilst areas supplied not 
 by the fifth nerve, but by the cervical nerves, were painful 
 and tender. 
 
 As in many other examples, operation on the Gasserian 
 ganglion was successful in removing the referred as well 
 as the direct pain. Operation on February 25, 1903, 
 after preliminary shaving of the right side of the scalp 
 and disinfection of the skin. The patient was throughout 
 
123 
 
 in the upright position in a dentist's chair. No trouble 
 was met with as regards haemorrhage or exposure of the 
 gangHon. The middle meningeal artery was left un- 
 divided. The lower half of the ganglion and both superior 
 and inferior maxillary divisions were removed, the 
 ophthalmic trunk being deliberately spared. The bone 
 was not replaced, a small spiral drain being inserted for 
 twenty-four hours. The wound healed by first intention. 
 
 Fig. 22. — Anaeathetic area left after removal of lower part of Gasserian 
 ganglion. A, ophthalmic nerve area (intact). B, side of nose (sensation 
 retained). C, lips (sensation largely lost). D, complete antesthesia. E, 
 sensation impaired in temple. F, masseteric region (sensation retained). 
 
 When she left the hospital on March 20th she com- 
 plained of headache, and, later on, the left side of the face 
 and head became subject to stabbing pain. She could, 
 however, sleep well (before the operation her nights were 
 a misery to her) and took food with enjoyment. I saw 
 her from time to time and was anxious lest the neuralgia 
 should develop severely on the left side. A second opera- 
 tion and removal of the other Gasserian ganglion was not 
 
124 
 
 to be contemplated without much hesitation, owing to the 
 complete paralysis of masticating muscles that would 
 ensue. Fortunately, under the administration of tonics, 
 chiefly nux vomica, with the occasional use of phenacetin, 
 the threatening symptoms passed off. At the end of ten 
 months from the operation she was in excellent health, 
 and free from pain — was, in fact, " another woman." The 
 bony aperture has filled up so that no pulsation can be 
 detected ; the scar is well hidden by the hair, and it is 
 almost impossible to detect, at first, on which side the 
 operation was done. The anaesthesia of the face, which 
 gives her no trouble, corresponds to the distribution area 
 of the auriculo-temporal, the infra-orbital, the buccal, and 
 mental nerves. The distribution of the nasal branch of 
 the ophthalmic is apparently more extensive than usual 
 in this case, and, hence, the nose has retained sensation. 
 
 Since the above was written, she has had some return of 
 vague neuralgic pains on the left side, and the final ending 
 of the case must remain uncertain. 
 
 In the case just narrated, the headache and other 
 nervous symptoms experienced, after an othervi^ise 
 successful operation, could not be ascribed to the 
 patient's leaving off morphia, as she had not been 
 addicted to it previously. In another case of my 
 own, in which enormous doses of morphia had 
 been resorted to hypodermically, in order to get 
 some respite from the pain — the arms were scarred 
 all over from the punctures — it seemed doubtful 
 whether the patient would be able to discontinue 
 the drug suddenly ; but not a single dose was given 
 after the operation, and the patient's mental con- 
 dition was quite normal. It may, however, be 
 advisable in some cases to rapidly diminish the 
 
125 
 
 dose and, perhaps, to substitute injections of dis- 
 tilled water ; or sedatives, other than morphia, may- 
 be tried. In one case recorded by W. Keen,^ the 
 sudden interruption of morphia, after the operation 
 on the gangHon, "produced profound, mental de- 
 pression ; after bromides, strychnine, and chloral 
 had been tried without success, the administration 
 of codeine, in doses of three-quarters of a grain, 
 calmed the hallucinations and pain." 
 
 It only remains to notice the cases in which 
 recurrence of epileptiform neuralgia has followed 
 on the same side as the operation. These can be 
 put into two classes ; either the patient was neurotic 
 or hysterical (z.^., not really a suitable subject for 
 the operation), or the operation has failed to deal 
 adequately with (perhaps has never even touched) 
 the Gasserian ganglion. Of the former there are' 
 a few examples recorded. For instance. Professor 
 Krause observed recurrence of the neuralgia on 
 the side operated on in only one of his thirty-six 
 cases (reported 1903). This case was a neuras- 
 thenic medical man, in whom peripheral operations 
 had been fruitless. Removal of the Gasserian 
 ganglion, which Krause was led to perform against 
 his will, had no better result, the cause of the 
 neuralgia evidently being cerebral. 
 
 Of the second class, that in which a wholly 
 inadequate operation has been done and the 
 
 ^ Keen, Trans. Philadelphia Med. Soc, 1894. 
 
126 
 
 neuralgia has returned, many more instances could 
 be quoted ; indeed, it is surprising how many 
 have been published. I once had the opportunity 
 of proving that in a supposed excision of the Gas- 
 serian ganglion, performed by one of the best 
 operators in London, the ganglion had never been 
 reached. The patient was a man aged 50, the 
 subject of terribly severe neuralgia. He under- 
 went the operation by the pterygoid route ; it was 
 performed in two stages and was an extremely 
 protracted affair, owing to haemorrhage, &c. A 
 short respite from pain followed, and it was fully 
 believed that the ganglion had been dealt with. 
 However, the very limited ansesthesia that followed 
 might well have been due to the division of cuta- 
 neous nerves in the extensive skin incisions. The 
 patient's neuralgia returned worse than ever. He 
 took to injecting morphia hypodermically in almost 
 incredible amounts, and became, physically and 
 morally, a complete wreck. 
 
 After his disappointing experience, it was naturally 
 difficult to induce him agfain to undergro surgical 
 interference, and I expected that the operation 
 would prove unusually difficult, owing to the pre- 
 vious division of the bone round the foramen ovale, 
 &c. This, however, did not prove to be the case. 
 The middle fossa had been perforated about half 
 an inch to the outer side of the foramen ovale, 
 and the ganglion, with its branches, was quite 
 intact. Nothing could be a stronger commentary 
 
12/ 
 
 on the difficulty of really dealing with the ganglion 
 from below (by the pterygoid route). The only 
 trouble I experienced in this operation was due to 
 haemorrhage, chiefly from the meningeal artery. 
 The attempt to stop this bleeding, by plugging 
 the foramen spinosum with wax or a spicule of 
 bone, failed, and I therefore tied the external 
 carotid in the neck. The two maxillary nerves 
 were then divided and the ganglion excised. 
 
 As an instance of the slight nature of the shock 
 following this operation, this patient was sitting up 
 and writing a letter within twenty-four hours of it, 
 Although he had got used to injecting eight or 
 ten grains of morphia per diem, he was fortunately 
 resolute enough to discontinue the practice entirely 
 as soon as he found the neuralgia had left him. 
 He wrote six months after the operation : " From' 
 being a hopeless invalid, I have become as strong 
 and well as at any time during my life, with prac- 
 tically no pain. I have never touched morphia 
 since the operation and have not felt the least desire 
 for it." 
 
 It is now (1904) six years since the second 
 operation, and the patient is in good health and 
 free from any recurrence. 
 
 I have heard of some other cases in which, after 
 operation by Rose's method (the pterygoid route), 
 the neuralgia was supposed to have been cured, 
 although, subsequently, recurrence in a severe form 
 developed. The explanation is, that the ganglion 
 
128 
 
 was never properly dealt with, owing to the 
 difficulties due to haemorrhage and insufficient 
 exposure. The same criticism applies to some 
 cases operated on by the temporal route. The 
 sharp spoon is an instrument which has been used 
 by several operators, who appear to think that the 
 ganglion is readily destroyed by a little indis- 
 criminate scraping in the region of the cavernous 
 sinus. The instrument is unsuitable and dangerous, 
 and should never be employed in this particular 
 operation. Failure is only to be expected if the 
 surgeon relies on this blind groping in the dark, 
 instead of a clean dissection of the ganglion. 
 Equally hazardous and uncertain is the attempt to 
 twist and drag away the ganglion as soon as one 
 of the main divisions is exposed. 
 
 It is a curious fact that the extensive surgical 
 interference involved in trephining the skull,' with 
 its attendant loss of blood, may cause the neuralgia 
 to cease for days, weeks, or even months, although 
 the ganglion and its main branches have been hardly 
 interfered with at all. The real test of success is 
 complete anaesthesia in the districts normally supplied 
 by the divisions of the fifth nerve concerned. 
 Unless this anaesthesia be clearly made out after 
 the operation, recurrence is almost certain in the 
 future. Now and then the operator has described 
 division of the roots, whilst sensation was perfectly 
 retained in the skin, which is normally supplied by 
 their branches {e.^., in a case recorded by W. Keen, 
 
129 
 
 though not operated on by him, Chipault, vol. Hi., 
 p. 694). There must obviously be a mistake on 
 the part of the operator in such cases. Gerster 
 records a case^ in which, after "destruction of the 
 ganglion," sensation recurred within a month, in 
 both second and third divisions. 
 
 In a case published by M. Lardy (Chipault's 
 Chirurgie Ne7'^veuse, vol. ii.), the Gasserian ganglion 
 was supposed to have been extirpated, yet sensation 
 was perfect in the whole area supplied by the fifth 
 nerve. The patient was a woman, and the neuralgia 
 "was entirely cured." It is easy for the operator to 
 persuade himself that a little piece of dura mater 
 represents the ganglion. It is impossible to believe, 
 for a moment, that removal of the Gasserian ganglion 
 can be attended by no anaesthesia in the skin of 
 the face. 
 
 The difficulties and drawbacks of the operation 
 have been fully discussed, since it was only fair to 
 do so. But, in conclusion, it may be pointed out 
 that few procedures in the whole range of surgery 
 are so successful as excision of the ganglion for 
 true epileptiform neuralgia. With the improved 
 methods of operating and the proper selection of 
 cases, the risk to life is very small, and the prospect 
 of permanent cure is great. 
 
 By limiting the excision, and sparing the oph- 
 thalmic division, whenever possible, the risk to the 
 eye is done away with. 
 
 ^Annals of Siivgevy, Jan., 1896, p. 58. 
 
130 
 
 The deformity which results is hardly worth the 
 name ; it simply amounts to atrophy of the corre- 
 sponding temporal muscles. The introduction of 
 the Hartley- Krause method forms one of the most 
 important surgical gains of the last twenty-five 
 years, fertile as that period has been in the progress 
 of surgery. 
 
REFERENCE TO PUBLISHED PAPERS ON THE 
 
 SURGICAL TREATMENT OF TRIGEMINAL 
 
 NEURALGIA. 
 
 Tiffany, (L. McL.) Intracranial operations for the cure of 
 facial neuralgia. "Annals of Surgery," 1896, xxiv. 
 575 to 736. Details are given of 108 cases, collected from 
 various sources. 
 
 Sex and Age. — Patients varied in age from 20 years to 79, 
 few being younger than middle life ; males v^^ere very 
 slightly in excess. 
 
 Operation. — Two-thirds subjected to the Hartley-Krause 
 operation, nearly one fourth to that of Rose, the remainder 
 to other methods. There were forty-seven operators, 
 twenty-five of them operating once each. 
 
 Results. — Twenty-four deaths, causes of death as follows : — 
 shock 8, sepsis 8, brain trauma 3, brain abscess (from 
 trauma?) i, apoplexy i, cause uncertain 3 cases. 
 
 BiAGi, L. {II PoUclinico, November, igoi). Opposes resection 
 of the Gasserian ganglion on account of its dangers, and 
 advocates dragging away the main branches of the fifth 
 nerve instead. He narrates three cases in which the 
 latter proceeding was carried out " with good result." 
 
 Fehleisen, F., and Westerfeld (" Report of the Surg. 
 Department of the German Hospital, San Francisco, 
 1901.") They narrate one case in which, after removal 
 of the Gasserian ganglion, sensation returned in the 
 peripheral distribution of the fifth nerve, although at the 
 post-mortem, removal " was found to have been complete." 
 No explanation is suggested, and probably a very simple 
 one would suffice. 
 
 Krause, Fedor (" Verhandlungen der Deutschen Gesellschaft 
 fiir Chirurgie 30 Kongress," 1901). An important account 
 of his experience up to that date, twenty-five cases of 
 "typical extirpation of the Gasserian ganglion." The 
 report is quoted frequently in this book. 
 
132 
 
 Krause, Fedor, " Die Neuralgie des Trigeminus, nebst der 
 Anatomie und Physiologie des Nerven," Leipzig, i8g6, 
 pp. 260, with two photographs and 50 illustrations in the 
 text. 
 Laguaite {Lyon Medicale, 1896, Tome 83, p. 375). Ligature 
 of external carotid, Poirier's method followed, whole of 
 ganglion removed. Neuralgia was cured, but the eye 
 was lost. 
 
 Keen W. W. and Spiller W. G. [Amer. Jouvn. Med. Sciences, 
 1898, vol. cxvi. p. 503). Four cases reported, two fatal 
 from injury to bram and haemorrhage during operation. 
 In one other the eye became ulcerated. 
 
 Weeks, S. H. [Trans. Amer. Surg. Assoc, 1897, vol. xv. p. 
 171). Interesting case reported. Meningeal artery torn 
 in turning down flap of bone. 
 
 Abbe, " Annals of Surgery," 1896, vol. xxiii. p. 60). Two 
 cases recorded. 
 
 Keen, W. W. {Amer. Journ. of Med. Sciences, 1896, vol. cxi. p. 
 68). Five cases recorded, in each a flap of bone was 
 turned down, and in every one profuse haemorrhage from 
 meningeal arteries resulted therefrom. One case died 
 from septic meningitis, the others did well. In one case 
 the patient had sustained eight previous operations for 
 the neuralgia, in another no less than thirteen. 
 
 Gerster, A. G. "Annals of Surgery," 1896, vol. xxiii. p. 58. 
 One case reported. 
 
 Gerard-Marchant {Bnll.de la Soc. de Chiv., 1898, vol. xxiv. p. 
 884). Three cases : all recovered. In one the eye was 
 subsequently lost by trophic ulceration. 
 
 Depage, a. {Bull. Acad, de Med. de Beige, 1898, 4th series, p. 
 294). One case, severe meningeal haemorrhage, recovery. 
 
 Depage {Ihid. 1897, p. 687). A second case, in which the 
 eye was subsequently lost. 
 
 Hutchinson, J., Jr. {Brit. Med. Joiivn. Nov. 5th, 1898). 
 Report of case and discussion of the operation. 
 
 Hutchinson {Med. Societys Transactions, 1900, pp. 274-282). 
 Report of several cases, &c. 
 
 Thomas, J. L. {Bvit. Med. Journ., 1899, vol. ii. p. 1080). Two 
 cases reported of excision of Gasserian ganglion : in both 
 haemorrhage was severe ; in one, operation could not be 
 completed on this account. 
 
133 
 
 Thomas, J. L. {Brit. Med.Journ., 1898, vol. i. p. 487). One case, 
 operation not completed owing to severe haemorrhage. 
 
 MacLaurin, C. [Australian Med. Gaz., 1901, vol. xx. p. 36). 
 Report of one case in which extra-cranial operations and 
 trephining had previously failed. 
 
 Meyer, W. " Annals of Surgery," 1896, vol. xxiii. p. 61. 
 Interesting case of sudden death from temporo-sphenoidal 
 abscess, one month after operation on the Gasserian 
 ganglion. 
 
 MuGNAi A. ("7/ Policlinico, 1897, p. 877.") One case reported. 
 
 Crawford Renton, J. [Brit. Med. Joiiv. 1900, vol. ii. p. 1435). 
 One successful case. 
 
 Renton [Brit. Med. Jour. November i8th, 1904). Note on case 
 in which neuralgia had been mainly frontal, and in which 
 extensive removal of supra-orbital nerve failed to relieve. 
 
 Schwartz, [Bull, et Mem. Soc. de Chir., 1898, vol. xxiv. 
 p. 857.) Case reported with very bad result (loss of eye 
 &c.), after use of Doyen's method. 
 
 Spellissy, J. M. " Annals of Surgery," 1900, vol. xxxi. p. 463. 
 Case reported in which external carotid artery was tied 
 during the operation. Result good. 
 
 Grieshammer, [Munchener Med. Wochenschvift, 1901, No. 20). 
 
 Schwab, Sydney J. ("The pathology of trigeminal neuralgia, 
 illustrated by the microscopic examination of two Gas- 
 serian ganglia." " Annals of Surgery," June, 1901. 
 
 Sir Victor Horsley [The Clinical J ournal , 1897, vol. xi. pp. 8 
 to 14, and 17 to 23). (Two lectures, giving a full account 
 of the operation of complete excision of the Gasserian 
 ganglion based on eight personal cases). 
 
 Davis [Univ. of Pennsylvania Med. Bulletin, No. 2, 1904). Dis- 
 cussion of the various modern methods of operating for 
 trigeminal neuralgia. 
 
 Coelho [Revue de Chir. 1897, vol. xix. p. 623). Case of 
 operation in two stages. The cornea became opaque but 
 ultimately cleared. 
 
 Bland-Sutton, J. [Med. Press, 1898, vol. i. p. 549). Success- 
 ful case. 
 
 Guenard, a. [Bnll. de la Soc. de Chir. 1898, vol. xxiv. p. 840). 
 One case, not very clearly reported. 
 
 Jaboulay [Lyon Medicale, 1901, vol. xcvii. p. 192). Operation 
 by Poirier's method with resection of the zygoma. 
 
134 
 
 The following papers are less important, or inaccessible to 
 the author. 
 
 Barclay, W. M. Surgical treatment of Tic Douloureux, 
 
 removal of the Gasserian ganglion. Bristol Med. Chir. 
 
 Jour. i8g6, xiv. 55). [This paper gives a tabulated list 
 
 of thirty-seven cases, operations, results, &c.] 
 Camineti, R. Recherches sur I'anatomie chirurgicale du 
 
 ganglion de Gasser (" Trav. de neur. Chir. " (Chipault), 
 
 1900, V. 323). [No cases] . 
 Carson, N. B. The surgical treatment of trifacial neuralgia, 
 
 with report of a case of removal of Gasserian ganglion. 
 
 {Med. Rev. St. Louis, 1899, xxxix. 199, 219). 
 Chipault. Resection, du ganglion de Gasser. {Rev. de 
 
 Chirurgie, 1900, xxii. 393. [No cases] . 
 DiEULAFE. Sur une cas d' extirpation du ganglion de Gasser. 
 
 Arch. Med. de Toulouse, 1897, iii. 97. 
 DoLLiNGER, J. Intercranielle extirpation du ganglion Gasseri. 
 
 {Pest Med. Chir. Presse, i8gi, xxxv. 177). 
 DoLLiNGER, J. Die intrakranielle entfernung des ganglion 
 
 Gasseri, ohne Unterbinding der arteria meningea media. 
 
 Centr. f. Chirur, 1900, xxvi. 1089, ^^^"^ Brit. M. J. 
 
 Epitome, 1901, i. 18. 
 Doyen. On extirpation of the Gasserian ganglion. Travaux 
 
 de Neurologic Chirurgicale par Chipault, 1898, iii. 225. 
 
 [No cases] . Resume by H. P. de Forest, " Annals of 
 
 Surgery," 1896, xxiii. 69. [No cases] . 
 Fergusson, a. H. Removal of the Gasserian ganglion. 
 
 Chicago Med. Rec. 1898, xiv. 405. 
 Friedrich (P. L.) Krankengeschichten und Heilausgange 
 
 nach Resection und extirpation des ganglion Gasseri, 
 
 neuralgie — Recidiv nach ganglion-extirpation. {Deut. 
 
 Zeits. f. Chirur, Hi. 1899, 360). 
 Friedrich, P. L. Zur chirurgische Behandlung der Gesichts- 
 
 neuralgie, einschlieslich der resektion und exstirpation 
 
 des ganglion Gasseri. {Mitt, ad Gvenzgeh. d. Med. u. Chir. 
 
 Jena, i8g8, iii. 340). 
 Halstead, a. E. Removal of the Gasserian ganglion for 
 
 relief of trifacial neuralgia, with report of a case. 
 
 Chicago M. Rec. 1897, xiii. 389. 
 
135 
 
 IsRAELsoN. Zur Casuistik der resection des ganglion Gasseri 
 
 bei Trigeminus neuralgia, St. Petersh. Med. Wochen., 1897, 
 
 xiv. 356. 
 Jacob, O. Du danger de leser le sinus sphenoidal dans la 
 
 resection du ganglion de Gasser, Presse Med. 1900, ii. 3. 
 
 [No cases] . 
 Jacob, O. Un procede de resection du ganglion de Gasser. 
 
 Rev. de Chimrgie, 1899, xx. 29. [No casesj . 
 Krogius. Resektion af ganglion Gasseri for en svar trigeminus 
 
 neuralgi, Finska Jdksallsk handl., Helsingfors, 1897, xxxix. 
 
 512. 
 Lexer. Zur exstirpation des ganglion semilunare bei Tri- 
 geminus nenx Silgie, Milnchen. Med. Wochens., 1898, xlv. 60. 
 Meyer, W. Facial neuralgia cured by excision of the 
 
 Gasserian ganglion, " Annals of Surgery," 1896, xxiii. 58. 
 Monari, U. Ein fall von resektion des Gasser' schen ganglions.' 
 
 Beitr. ztiv Klin Chir., Tubingen, 1896, xvii. 495. 
 Murphy, J. B. Surgery of the Gasserian ganglion with 
 
 demonstration, report of two cases, Amer. Med. Surg. Bull. 
 
 N. Y. 1896, X. 437, also Southwest Med. Rec. 1896, i. 345. 
 PoiRiER, P. Resection du ganglion de Gasser, arrachement 
 
 protuberantiel du trijumeau, Gaz. des Hop. 1896, Ixix. 
 
 808, also Btdl. et Mem. Soc. de Chir. 1896, xxii. 574. [No 
 
 cases.] 
 Reed, R. H. Successful removal of the Gasserian ganglion, 
 
 Colnmhiis M . J . i^'^'j, xviii. 113. 
 Renton, J. C. Notes of the cases of excision of the Gasserian 
 
 ganglion for epileptiform neuralgia, B. M. J. 1900, ii. 
 
 1435- 
 Rose, W. On the practical value of extensive removal of 
 
 nerve trunks in the operative treatment of trigeminal 
 
 neuralgia. Practitioner, 1899, Ixii. 255. [No cases] . 
 Schwartz, Ablation du ganglion de Gasser pour une nevralgie 
 
 trifaciale rebelle. Insucc^s therapeutique, troubles ocu- 
 
 laires, Bull, et Mem. de la Soc. de Chir. 1898, xxiv. 859. 
 Serrate, L. Intervencion quiriirgica en el ganglio de Gasser, 
 
 Rev. de Med. y drug, prdct. Madrid, 1898, xlii. 565. 
 Weeks, S. H. Removal of the Gasserian ganglion, Trans. 
 
 Amer, Surg. Assoc. 1897, xv. 171. 
 
136 
 
 W6LFLER. Demonstration eines Falles von resection eines 
 
 ganglion Gasseri, Pvag. Med. Wochens. 1898, xxiii. 178. 
 Yarre, C. Ueber nervenregeneration nach extirpation des 
 
 ganglion Gasseri als Ursache recidirender trigeminus 
 
 neuralgie, Vevhandl. d Dent. Gesell. f. Chinirgie, 1899, 
 
 xxviii. 256. 
 Sapeszko, K., papers in Russian, one of which is abstracted 
 
 in the CentralblaU fiiv Chinirgie, 1901, No. 16. 
 ScHLOFFER, H. " Zur Technik der Trigeminusresektion " 
 
 [Prague Med. Wochenschrift, igoi, No. 44). 
 Serenni, W. {CentralblaU filr Chinirgie, 1901, No. 16). One 
 
 case only is recorded. 
 Spiller, G. and H. Frazier. " The Division of the Sensory 
 
 Root of the Trigeminus for the Relief of Tic Douloureux," 
 
 Pennsylvania Med. College, Dec, 1901. 
 ViLlar. (Revue de Chinirgie, 1901, No. 11). 
 Bougle. {Bull, et Mem. de la Soc. de Chirurgie, 1901, No. 14). 
 
IN DEX. 
 
 Abbe, Dr. R., removal of Gasserian ganglion, method, 95-96. 
 
 Acid fermentation round the neck of a tooth, neuralgia due to, 13. 
 
 Adrenalin, 85. 
 
 Air sinuses, inflammation of, causing neuralgia, 5. 
 
 Alcohol, relation to epileptiform neuralgia, 24. 
 
 Allbutt's " System of Medicine," cited, 3. 
 
 Alveolar suppuration, neuralgia due to, 12. 
 
 Amer. Journal of Med. Science, cited, 92 note'', no, 115. 
 
 Ammonium, iodide of, 14. 
 
 Anaemia, neuralgia due to, 2, 4. 
 
 Anaesthesia. See also Cutaneous Anaesthesia. 
 
 Region of, after resection of: superior maxillary nerve, 72 ; inferior maxil- 
 lary nerve, 73. 
 
 Tabetic neuralgia, following, 12. 
 
 Tumour pressure on Gasserian ganglion, in cases of, 31, 36, 38. 
 Anaesthetic for use in excising Gasserian ganglion, 78. 
 Andrews, G. : 
 
 Corneal ulcers following extirpation of Gasserian ganglion, case of, 1 10. 
 
 Temporary oculo-motor paralysis, case recorded by, 1 18. 
 Aneurism needle, diagram of, 79. 
 " Angiolithic Sarcoma," 37. 
 
 " Annals of Surgery" cited, 61, 80, 95, 116, 117, 118 note", 129. 
 Anstie, Dr., cited, 23 note, 24. 
 
 Anterior lacerated foramen, osteo-sarcoma connected with bone of, 32. 
 Antrum of Highmore : 
 
 Suppuration in : case of, quoted, 5 ; region of pain from, 5. 
 
 Trephining, to reach the pterygo-maxillary fossa, Carnochan's method of, 
 58-61, 66. 
 Aphasia, following extirpation of Gasserian ganglion, 87 ; case of, 121. 
 Arterio-sclerosis as a cause of epileptiform neuralgia, 28. 
 Astigmatism, 3. 
 
 Ataxia, spasmodic neuralgia in limbs and trunk with, II. 
 Atrophy of right eye in tumour of Gasserian ganglion, 32. 
 Auditory meatus, external : 
 
 Insensitive area after excision of Gasserian ganglion, 104-5. 
 
 Relation of, in trephining skull to excise Gasserian ganglion, 81. 
 
138 
 
 Auditory nerve, division of, for vertigo, cutting of facial trunk in operation 
 
 of, 98. 
 Avulsion of fifth nerve branches in epileptiform neuralgia, 45. 
 
 Beitrdge zur Klinische Chirurgie, cited, 29. 
 Belladonna, administration of, in epileptiform neuralgia, 39. 
 Bernandi, fatal cases of excision of Gasserian ganglion, 114. 
 Billroth, Prof., cited, 15 note, 19, 22, 23, 28, 29, 43, 46, 66. 
 Biondi, extirpation of Gasserian ganglion by. 
 
 Brain, effects of pressure on, during operation, 117. 
 
 Corneal ulcer following, case of, no. 
 Blood, abnormal conditions of, producing neuralgia, 2. 
 
 Blood-vessels, degenerative changes in, as a cause of trigeminal neuralgia, 28, 
 Bone, caries or necrosis of, causing neuralgia, 13. 
 Bougie, corneal ulcers with chemosis following extirpation of Gasserian 
 
 ganglion, case of, in. 
 Boyd, Mr. Stanley, 54, 72. 
 
 Brain, injuries to, in operating on Gasserian ganglion, danger of, 92. 
 Brit. Med. Journal, cited, 68 note '. 
 Bull. Acad, de Med. de Beige, cited, no. 
 Bull, de la Soc. de Chir., cited, no, in. 
 Bull, et ma?i. de la Soc. du Chir., cited, 57 note. 
 Buzzard, Dr., cited, 11 andnote^, 12. 
 
 Caffein, preparations of, in neuralgia, 15. 
 
 Cancer of the tongue, 57. 
 
 Cannabis indica, administration of, in minor neuralgia, 14. 
 
 Caponotto, cases recorded by : 
 
 Cholesteatoma causing neuralgia, 35. 
 Injury to Eustachian tube, loi. 
 Carious teeth, neuralgia due to, 2, 12-13, 22. 
 Carnochan, intracranial excision of superior maxillary nerve, method of, 58- 
 
 61, 65, 66. 
 Carotid artery, pressure on, in tumour of Gasserian ganglion, 31. 
 
 „ „ common, ligature of: in excising Gasserian ganglion, 88: as 
 
 a treatment for neuralgia of fifth nerve, 99-100, 
 „ „ external, hgature of, advisability of, in excising Gasserian 
 
 ganglion, 96-99. 
 ,, canal, absorption of wall of, in tumour of Gasserian ganglion, 34. 
 Cavernous sinus : 
 
 Hemorrhage due to opening of, 116. 
 
 Laceration of wall of, in excising Gasserian ganglion, danger of, 96, 119- 
 
 120. 
 Nerves in wall of, inflammation of, 10. 
 Tumour in region of, 11, 31, 37- 
 mentioned, 85. 
 Cavum Meckelii, division of sensory portion of Gasserian ganglion in or 
 above, 98. 
 
139 
 
 Cephalalgia, persistent, cases of, quoted^ 6-7. 
 
 Cerebral artery, middle, case of hsemorrhage from, induced by perforation of 
 the skull, 92. • 
 ,, hemisphere, right, extravasation of blood into, from brain pressure 
 during operation, 117. 
 Cerebro-spinal fluid, escape of, in operating on Gasserian ganglion, 37, 86, 
 
 109, 119. 
 Cervical sympathetic ganglia, excision of, in facial neuralgia, 100. 
 Chavasse, Mr. , cited, 58 and note ^. 
 Chiene, Prof., cited, 67. 
 Chipault : 
 
 Chirttrgie Nerveuse, cited, 90 note ; 92 note^, 93 and note'', 97, 115. 118 
 
 nole^, 129. 
 Cited, on : excision of cervical sympathetic ganglia in trigeminal neuralgia, 
 100 and note^ \ mortality after excision of Gasserian ganglion, 112. 
 Chisel, use of, 53. 
 
 Cholesteatoma, of pons varolii, 35 ; of petrous bone, 36. 
 Chondro-sarcoma invading Gasserian ganglion, 31-32. 
 Chorda-tympani nerve, taste organs supplied by, 107. 
 Climacteric in women, neuralgia due to, 4. 
 Clinica Chirurgica, cited, 121. 
 Clinical Journal, cited, 28, 
 
 Codeine, administration of, after sudden interruption of morphia, 125. 
 Codivilla, cited, 29, 87 ; intra-cranial resection of inferior maxillary division 
 
 of fifth nerve, 73. 
 Coelho, S., cited, 133 ; corneal opacity following extirpation of Gasserian 
 
 ganglion, case of, no. 
 Collins, Dr. H. D., case recorded by, 117. 
 Conjunctiva, sensation retained in, after partial excision of Gasserian ganglion, 
 
 104. 
 Conjunctivitis, following total excision of Gasserian ganglion, in. 
 Cook, Dr., quoted, 62-63. 
 Cornea : 
 
 Sensation retained by, after partial excision of Gasserian ganglion, 104. 
 Ulceration of : following total extirpation of Gasserian ganglion, cases of, 
 lio-lil ; accompanying trigeminal neuralgia, 26-27. 
 Coronoid process, division of, loi. 
 Cryer's drill, 92. 
 Gushing, Dr. : 
 
 Anaesthetic area after excision of Gasserian ganglion, 105-106. 
 Method of removing Gasserian ganglion, 89-90, loi. 
 Taste, perception of, after removal of Gasserian ganglion, 107. 
 Cutaneous anaesthesia after excision of Gasserian ganglion, area of, after total 
 excision, 103-104 ; after partial excision, 104-105 ; question of decrease 
 in area, 106. 
 
 Dahlgren's cutting forceps, 93. 
 
 Damp, influence of, in intensifying pain of epileptiform neuralgia, 48. 
 
I40 
 
 Davis : 
 
 Cases recorded by: corneal ulcer following extirpation of ganglion, no ; 
 oculo-motor paralysis after extirpation, Il8. 
 
 Cited, 133. 
 Deaver, Dr., on peripheral operations for epileptiform neuralgia, 45-46; 
 
 Surgical Anatomy, cited, 44. 
 Delirium, 25. 
 Dental nerve, inferior, resection of, 74. 
 
 ,, neuralgia. See Minor neuralgia. 
 Depage, A., case of corneal ulcer following excision of Gasserian ganglion, 
 
 no. 
 Dercum, cited, 35 note. 
 Deutsche Med. Woch., cited, 76 note"^. 
 Dieulafe, cited, 134. 
 
 Diplopia following extirpation of Gasserian ganglion, 121. 
 Doyen : 
 
 Operation for removing Gasserian ganglion, 88. 
 
 Perforator, pattern of, 93. 
 Dura mater : 
 
 Exposure of, in trephining wall of temporal fossa, ']\. 
 
 Detachment of, in exposing Gasserian ganglion, 81, 83-84. 
 
 Injury to, in breaking down skull wall, danger of, 81, 91. 
 
 Laceration of, in removing Gasserian ganglion, 119. 
 
 Sarcoma of, 35 ; cases of, 25, 36-37. 
 
 Tumours involving, 36, 37. 
 
 Ear, sensation retained by, after removal of Gasserian ganglion, 103-104. 
 
 Electric drills and cutters, danger of, 93. 
 
 Electricity in treatment of epileptiform neuralgia, 16, 39. 
 
 Elevators, diagram of, 79. 
 
 Empyema of sinuses, neuralgia due to, 5. 
 
 Endothelioma of Gasserian ganglion, 36-37 ; case of, 35-36- 
 
 English, Mr. T. Crisp, cited, 70. 
 
 Epilepsy, relation to epileptiform neuralgia, 23-24. 
 
 Epileptiform neuralgia : 
 
 Age of onset of, 23. 
 
 Causation, 24-25, 43. 
 
 Characteristics of, 12, 17-18. 19, 121. 
 
 Climate, influence of, 21. 
 
 Dental neuralgia simulating, 13 ; relation to, 24. 
 
 Differential diagnosis of, 3. 
 
 Epilepsy, true, relation to, 23-24. 
 
 Exciting causes of, 19. 
 
 Eye changes in, 26-27. 
 
 Facial muscles, afiection of, in, 23. 
 
 History of case of, and its treatment, 46-50. 
 
 Ignorance as to pathology and causation of, 1-2. 
 
 Liability to attacks, 23. 
 
141 
 
 Epileptiform neuralgia — continued. 
 
 Medicinal treatment of, 14-15, 39-40. 
 Mental and moral degeneracy due to, 19-21. 
 Migraine contrasted with, 23. 
 Operative treatment of : 
 
 Extra-cranial operations : 
 
 Avulsion of fifth nerve peripheral branches, 44-45. 
 Inferior dental nerve, on, see that title. 
 Ligature of common carotid artery, 99-100. 
 Neurotomy, 42-43. 
 Resection of nerves, 43, 45. 
 Superior maxillary nerve, on, see that title. 
 Temporary nature of results, 45-48. 
 Cervical sympathetic ganglia, excision of, 100. 
 Intra-cranial operations : 
 
 Gasserian ganglion, extirpation of, see that title. 
 Inferior maxillary nerve, on, see that title. 
 Superior maxillary nerve, on, see that title. 
 Reference to published papers, 131-134. 
 Pain in : 
 
 Character of, 2, 48. 
 Distribution of, 4, 21-22. 
 
 Tumours of Gasserian ganglion, resemblance to pain of, 31. 
 Pathology ; 
 
 Degenerative changes in nerves and ganglia, 27-30. 
 Eye-changes, 26-27. 
 
 Neuritis, theory as to causation from, 26-29, 96. 
 Vascular degeneration, 28. 
 Recurrence of, on the same side after removal of Gasserian ganglion, 125- 
 
 129. 
 Simulation of, 40-41. 
 Transference of, to opposite side after removal of Gasserian ganglion, 
 
 cases cited, 121-124. 
 Treatment of, see subheadings, medicinal and operative. 
 " Trophic" symptoms, 26. 
 " Essai sur les Symptomes Cephaliques de Tabes Dorsalis," Pierret, cited, 
 
 1 2 and note. 
 Etat Actuel de la Chir. Nerveuse (Chipault), cited, 93 note^. 
 Ethmoidal air sinus, inflammation of, 5. 
 Eustachian tube : 
 
 Danger of injury to, in Rose's pterygoid operation, loi. 
 Sensation in, after excision of Gasserian ganglion, 105. 
 Eye lesions following total extirpation of Gasserian ganglion, 108-12. 
 Eye symptoms in epileptiform neuralgia, 26-27, 70- 
 
 Eyelid, upper, sensation retained by, after partial excision of Gasserian 
 ganglion, 104-5. 
 
 Females, liability of, to epileptiform neuralgia, 18. 
 
142 
 
 Fibrillary tremor of facial muscles, 23. 
 Fifth Herve : 
 
 Gasserian ganglion. See that title. 
 
 Involvement of, in epileptiform neuralgia, 21-22, 67. 
 
 Neuritis of, 9. 
 
 Operations on, see Epileptiform neuralgia — operative treatment. 
 
 Region of pain in, in tabetic neuralgia, 12. 
 
 Sarcoma of Gasserian ganglion, involvement in, 34-35. 
 Finlay, Dr., 7. 
 
 Finney, L. J., fatal cases of excision of Gasserian ganglion by, 114. 
 Foramen ovale : 
 
 Exposure of, in excising Gasserian ganglion, 49, 89, 90. 
 
 Position with regard to : foramen rotundum, 83 ; foramen spinosum, 94. 
 
 Plugging of, 97. 
 
 Relation of, in incising for removal of Gasserian ganglion, 82. 
 
 Variations in size, shape and position relative to foramina rotundum et 
 spinosum, 82, 83. 
 
 mentioned, 71. 
 Foramen rotundum : 
 
 Exposure of, in excising Gasserian ganglion, 49. 
 
 Position with regard to foramen ovale, 83. 
 
 Plugging of, 95-97. 
 
 Relation of : in excision of Gasserian ganglion, 89 ; in excision of 
 superior maxillary nerve, 60, 61 ; in trephining wall of temporal fossa, 
 71 ; in incising for removal of Gasserian ganglion, 82 ; in Storrs' extra- 
 cranial operation on the superior maxillary nerve, 63. 
 
 Variations in size, shape, and position relative to foramina ovale et 
 spinosum, 82, 83. 
 
 mentioned, 65, 69. ' 
 
 Foramen spinosum, 71, 82, 83, 84, 94. 
 Forceps, diagram of, 79. 
 
 Forehead, sensation retained in, after partial excision of Gasserian ganglion, 104. 
 Fowler, G. R. , cited, 68 and note'' , 99, 114, 115. 
 France, method of extirpating Gasserian ganglion in, 93. 
 Frazier, C. H., retractor devised by, 80. 
 Freezing the skin in minor neuralgia,; 16. 
 Frontal bone, 5, 81. 
 
 „ neuralgia, 3, 4-5. 
 Frontal sinus : 
 
 Anterior wall of, trephining of, 42. 
 
 Inflammation of, neuralgia due to, 6. 
 
 Galvanism, 16. 
 Gasserian ganglion : 
 Extirpation of — 
 Complete : 
 
 Cavernous sinus, danger of lacerating wall of, 119-120. 
 Corneal ulceration, danger of, 109- 112. 
 
143 
 
 Gasserian ganglion : continued. 
 
 Extirpation of — continued. 
 
 Complete : continued. 
 
 Cushing's method, 89-90. 
 Horsley, Sir Victor, method of, 86. 
 Keratitis following, risk of, 108-111. 
 Oculo-motor complications following, 118- 1 19. 
 Sensation, recurrence of, in peripheral branches of fifth 
 nerve case cited, 131. 
 Cutaneous anaesthesia after, area of, 103-105. 
 Disfigurement after, 103, 129. 
 Dura mater, danger of lacerating, 119. 
 France, methods employed in, 93. 
 Mortality following, 93, 95, loo, 112 et seq. 
 Osteoplastic method, 91 ; "pressure paralysis " following, 117. 
 Partial : 
 
 Codivilla's operations, 73. 
 
 Intradural division of roots (Sir V. Horsley), 97. 
 
 Ophthalmic division, sparing : 
 
 Advantages of, 119, 120, 129. 
 Hartley- Krause temporal method : 
 Case quoted, 85-86. 
 Description of, 77 et seq. 
 Disfigurement after, 103. 
 Gain to surgery of, 130. 
 Haemorrhage, severe, in, 87. 
 History of operation, 75-76. 
 Precautions necessary, 87, 116-117. 
 Treatment after operation, 85. 
 Two stages, dividing operation into, 87-88. 
 Krause, Prof., method of, 76-77, 94. 
 Plugging of foramina rotundum et ovale, 95, 97. 
 Prognosis of, 129. 
 
 Sensory root, alone, division of, 97-98. 
 Permanency of results obtained by, 46. 
 Recurrence of neuralgia on same side after, 125-129. 
 Rose's pterygoid method, loi, 103, 126-128. 
 Temporol-sphenoidal abscess following, 133. 
 
 Transference of neuralgia to the opposite side after, cases cited, 121-124 
 Upright position of patient, importance of, 99. 
 Various methods as to, 88. 
 otherwise mentioned, 2-3, 13, 17, 18, 68. 
 Pathological changes observed in epileptiform neuralgia, 27-30, 
 Pressure atrophy of, 37. 
 Resection of nerves, exposure in, 71, 73. 
 Sarcoma of, case of, 33-35. 
 Tumours involving, 31. 
 Gauze, plugging with, danger of, 114, 119. 
 Gelsemium, administration of, in neuralgia, 14-15, 39. 
 
144 
 
 Gerard-Marchant, no. 
 
 Gerster, A. G., cases recorded by, 114, 129. 
 
 Gigli's saw, 91. 
 
 Glaucoma, acute, neuralgia due to, 3-4. 
 
 Gout, 2, 24. 
 
 Guinard, A., cited, 107 note'^. 
 
 Gums, ulceration of, 13. 
 
 Gustatory nerve : 
 
 Neurectomy of, 57. 
 
 Paralysis of, interference with perception of taste after, 106-108. 
 
 HAEMORRHAGE, 87, lOI, II4-I16. 
 
 Hagelstan, cited, 36. 
 
 Hartley, Dr. F., removal of Gasserian ganglion, 76 and note ' ; oculo-motor 
 
 paralysis after excision, case recorded, n8. 
 Hartley-Krause method of extirpating Gasserian ganglion, 36, 102. 
 Head, Dr. H., cited, 3, 4 and note, 5, 18 and note, 19, 23, 29, 31, 41, 50 ; 
 
 quoted, 6, 9. 
 Headache : 
 
 Eye-strain, due to, 4. 
 
 Syphilitic, treatment of, 6. 
 Hemiplegia : 
 
 Danger of, following ligature of common carotid artery, 100. 
 
 Temporary, due to pressure on brain in operating, 117. 
 Herpes frontalis, i, 2, 4, 5, 27. 
 Hoffmann's bone-cutting forceps, 78, 82. 
 Homen, cited, 37. 
 Horsley, Sir Victor : ^ 
 
 Cited, 14, 22, 24, 28. 
 
 Gasserian ganglion, operations on, mortality statistics for, 113. 
 
 Gelsemium in treating neuralgia, on, 39. ^ 
 
 Intradural division of ganglionic roots by, 75-76, 97. 
 
 Quoted, 86 and note. 
 Horsley's aseptic wax, 94. 
 
 Hutchinson, Dr. J. C., case of, cited, lOO and note ^. 
 Hysterical neuralgia, 3, 40-42. 
 Hypermetropia, 3, 4. 
 
 Inferior dental nerve : 
 
 Liability to epileptiform neuralgia, 42. 
 
 Neurectomy of : intrabuccal method, 51-52; Montenoveri's method, 52 : 
 
 trephine aperture in lower jaw, through, 52-53 ; case quoted, 54-55- 
 Stretching of, in epileptiform neuralgia, 47. 
 Inferior maxillary division of fifth nerve, intracranial resection of, 73, 74, 102. 
 Influenza, 5. 
 Infra-orbital artery, 62. 
 
 ,, foramen, 59, 64. 
 
 ,, nerve : 
 
 Liability of, to epileptiform neuralgia, 42. 
 
H5 
 
 Infra-orbital nerve— continued. 
 Removal of, 47. 
 Resection of, 43-44, 74. 
 
 Tracing superior maxillary nerve by, method, 58-61. 
 Mentioned, 58, 62, 64, 65, 66. 
 Infra-temporal crest, 82, 93. 
 
 Insanity, relation to epileptiform neuralgia, 24-25. 
 Internal. Med. Mag. Philad., cited, no. 
 Intracranial gummala, neuralgia due to, 9. 
 
 Instruments, bone-elevator, 60 ; bradawl, carpenter's, 60 ; chisel and mallet, 
 59, 60 ; Cryer's drill, 92 ; Dahlgren's cutting forceps, 93 ; director, 60, 
 61 ; Doyen's perforator, 93 ; electric drills and cutters, danger of, 93 ; 
 forceps, 58 ; Gasserian ganglion, for removal of, 78-80, 93 ; Gigli's 
 saw, 91 ; Jarvis snare, 63 ; scissors, 60, 61 ; Thiersch's forceps, 44 ; 
 trephine, 60. 
 Iodides, in treatment of neuralgia of syphilitic origin, 14; in syphilis, 6, 8. 
 Iridectomy, 4. 
 Iritis : 
 
 Neuralgia due to, 3-4. 
 Syphilitic origin of, 7. 
 Italian surgeons, method of removing Gasserian ganglion in vogue with, 95. 
 
 Jarvis snare, 63. 
 Jaw, lower : 
 
 Condyle of, relation to incision for extirpating ganglion, 80, 81. 
 
 Coronoid process, removal of, in excision of Gasserian ganglion by 
 Cushing's method, 90. 
 Jaw, upper, 22, 58. 
 Jaws, neuralgic pain in, 4. 
 
 yohns Hopkins Hospital Bulletin, cited, 107 note ', 114. 
 Journal of Amer. Med. Assoc, cited, 89 note. 
 
 Keen, Prof. W. W. : 
 
 Cited, 26, 27, 29, 35 note, 36, 92 note\ 99, 113, 121. 
 
 Corneal ulcers following extirpation of Gasserian ganglion, no 
 
 Fatal cases of ganglion excision, 115. 
 
 Morphia, interruption of, after operation on ganglion, 125. 
 Keratitis following total extirpation of Gasserian ganglion, 108-I11. 
 Kocher, Prof., cited, 90. 
 Kosinski, cited, 31 and note, 32. 
 Krause, Prof. : 
 
 Cited, 15, 18, 19, 29, 37, 45, 97. 
 
 Gasserian ganglion, extirpation of, methods, cases recorded, &c., 68, 76 
 andnote"^; 87, 93, in, H2, 117, 118, 119, 125. 
 
 Retractor of, 80 ; diagram, 79. 
 
 Lancet, cited, 75. 
 
 Lange, fatal case of excision of Gasserian ganglion, 115. 
 
146 
 
 Lampiasi, cited, 35 and note. 
 
 Lardy, M., case of extirpation of ganglion unattended by anaesthesia, 129. 
 
 Lauwers, cited, 44 note". 
 
 " Lectures on Clinical Medicine" (Trousseau) quoted, 43 and note^. 
 
 Lexer, removal of Gasserian ganglion by : 
 
 Mortality among cases, 112, 113. 
 
 Oculo-motor paralysis after, cases recorded, 118. 
 
 Recurrence of neuralgia after, 121. 
 Limbs, lower, pain in, in endothelioma of Gasserian ganglion, 36. 
 
 Mackenzie, Dr. F. M., 122. 
 
 Major neuralgia, see epileptiform neuralgia. 
 
 Malar bone, 58, 65. 
 
 Malaria, 2. 
 
 Males, liability of, to epileptiform neuralgia, 18. 
 
 Maryland Med. Journal, cited, 121 note. 
 
 Masseter muscle, paralysis of, after excision of Gasserian ganglion, 106. 
 
 Masseteric region, sensation retained in after removal of Gasserian ganglion, 
 
 103-104. 
 Masticatory muscles, paralysis of, after excision of Gasserian ganglion, 106, 
 
 108 ; one-sided paralysis, 98. 
 Mears, Dr. Ewing : 
 
 Case of, cited, 56. 
 
 Removal of Gasserian ganglion first suggested by, 75. 
 Meatus, anterior wall of, insensitive area after excision of Gasserian ganglion, 
 
 105. 
 Meckel's ganglion, case of removal of, 47. 
 Median otitis, 36. 
 
 Medical Record of New York, cited, 114, 115. 
 Medical Times, cited, 114. 
 
 Medico-Chirurgical Soc. Transactions, cited, 58 note'^. 
 Meningeal artery : 
 
 Division of, in removing Gasserian ganglion, 49, 84, 94-95. 
 
 Hsemorrhage from, controlling, 86. 
 
 Injury to, in removing ganglion, danger of, 81, 90, 92-93, 132. 
 Meningitis, septic, following excision of Gasserian ganglion, 37, 114, 115. 
 Mental and moral degeneration due to epileptiform neuralgia, 19-21, 24-25. 
 Mental defect, case of, following total extirpation of Gasserian ganglion, 121. 
 Menthol, 15. 
 
 Mercury, syphilis treated by, 6, 7, 8. 
 Mesotan, 15. 
 Meyer, W., 115. 
 Migraine, 3, 23. 
 Minor neuralgia : 
 
 Causes of, 12-14, 22. 
 
 Epilepsy, relation to, 24. 
 
 Treatment, 14-16. 
 
147 
 
 Monari, died, 29 and nole. 
 
 " Monograph on Neuroma," R. W. Smith, quoted 32 and note, 35. 
 
 Montenoveri, 52. 
 
 Morphia : 
 
 Administration and injection of, 15, 39-40, 85. 
 
 Sudden interruption of, 124-125. 
 Mortality from operations on the Gasserian ganglion, 93, 95, 96. 
 Mouth, ansestliesia of mucous membrane of, after excision of Gasserian 
 
 ganglion, 105. 
 Mugnai : 
 
 Cited, 87. 
 
 Infra-orbital nerve, resection of, 43 and note -. 
 
 Intra-cranial excision of superior maxillary nerve, method of, 63-66, 67. 
 
 Oculo-motor paralysis following total extirpation of ganglion, 118. 
 Myelin-sheaths of nerves, degenerative changes in, in epileptiform neuralgia, 
 27, 29. 
 
 Necrosis, syphilitic, involving base of skull, 8-9. 
 Nerves : 
 
 Local applications in minor neuralgia, 15-16. 
 
 Pathological changes observed in epileptiform neuralgia, 27, 28, 29. 
 
 Right facial and trigeminal, paralysis of, 32. 
 Neuralgia : 
 
 Causes of, classification of, 2-3. 
 
 Epileptiform, see that title. 
 
 Dental causes, due to, see Minor Neuralgia. 
 
 Eye-strain, due to, 3. 
 
 Syphilis, treatment of, 6. 
 
 Tabetic, 11- 12. 
 " Neuralgia des Trigeminus, Die," cited, 76 and ttote-. 
 Neurectomy, 13, 19, 44. 
 
 Neurotomy in cases of epileptiform neuralgia, 42-43. 
 Neuritis, 2, 9, 26-27, 96. 
 
 New York Med. Journal, cited, 68 note'', 76 note^. 
 Nicholson, W. P., fatal cases of excision of ganglion of, 115. 
 Nodes of the skull, 8. 
 
 Nose, area of cutaneous ansesthesia in, after excision of Gasserian ganglion, 
 104, 105. 
 
 Oculo-motor nerves : 
 
 Danger of injury to, in complete extirpation of Gasserian ganglion, 96. 
 
 Involvement of, in tumour of Gasserian ganglion, 31, 32, 35, 38. 
 
 Paralysis of, 31, 35, 118- 1 19. 
 Oleic acid, 15. 
 Olive oil, 15. 
 "Operative Surgery," Treves, cited, 58 note^. 
 
148 
 
 Ophthalmic division of Gasserian ganglion, removal of, unnecessary in epilep- 
 tiform neuralgia, 22, 84, 86, 95, 104-105. 
 ,, ,, of fifth nerve, involvement of, in sarcoma of Gasserian 
 
 ganglion, 34 ; neuralgia not transferred to, after resec- 
 tion of superior or inferior branches, 68-69 ! neuralgia 
 invohang, unsuitability of cases of, for removal of Gas- 
 serian ganglion, 77. 
 
 Ophthalmological Society'' s Transactions, cited, \o note, 11. 
 
 Ophthalmoplegia, case demonstrating pathological nature of, lo-ii. 
 
 Opium, epileptiform neuralgia treated by, 39-40. 
 
 Orbital circulation, obstruction of, in tumour pressure on Gasserian ganglion, 
 381. 
 ,, margin, 58. 
 
 Osmic acid, hypodermic injection of, 16. 
 
 Osteo-sarcoma involving Gasserian ganglion, removal of, 32. . 
 
 Pain : 
 
 Causes of, distinguishing between, i. 
 
 Character of, in different forms of neuralgia, 2 ; in epileptiform neuralgia, 
 18, 19, 26, 48. 
 
 Tumours involving Gasserian ganglion, of, 31, 33. 
 Paralysis, oculo-motor, 31, 35, 118-I19. 
 Paravicini, cited, 51. 
 Pars intermedia of Wrisberg, 107. 
 Pepper's " System of Medicine," 3. 
 Pericranial gummata, 8. 
 Pericranium, 71 ; danger of separation of, in osteoplastic method of removing 
 
 Gasserian ganglion, 92 and note". 
 Peridental abscess, I. 
 
 Periosteum, 62. ^ 
 
 Periostitis in tertiary syphilis, headache from, 8. « 
 
 Petrous bone : 
 
 Cholesteatoma of, 36. 
 
 Tumours involving, 36, 37. 
 Pierret, cited, 12 and note. 
 Pitts, Mr., 47. 
 
 Pituitary fossa, tumour involving, 37. 
 Plexiform sarcoma, case of, 35. 
 Poirier, M. : 
 
 Excision of Gasserian ganglion — method, 90 and note, loi. 
 
 Intracranial excision of superior maxillary nerve — method, e,"] and note, 
 58, 65. 
 Policlinico, II, cited, 43 note^. 
 Potassium, iodide of, 14. 
 Practitioner, The, cited, 102 not^, 
 Preglenoid tubercle on the zygoma, 82. 
 Presbyopia, 3. 
 
149 
 
 Pterygoid muscles : 
 
 Paralysis of, after excision of ganglion, io6. 
 
 Relation of external muscle in excising Gasserian ganglion, 89, 90. 
 Pterygo-maxillary fossa, excision of superior maxillary nerve in, see superior 
 
 maxillary nerve. 
 Ptosis following total extirpation of Gasserian ganglion, 118. 
 
 QuENU's operation, 88. 
 
 Quinine, administration of, in minor neuralgia, 14. 
 
 « 
 Ransohoff, J., case of, cited, 115. 
 Raum, J., cited, 92 note^. 
 Refraction, pain due to errors of, i. 
 Retractors, 79, 80, 116-117. 
 Renton, Dr. J. C, cited, 29, 68 and nole^. 
 Revue de Chir., cited, no. 
 
 Rheumatic tendency, relation to epileptiform neuralgia, 24. 
 Rontgen Rays, in the treatment of epileptiform neuralgia, 39. 
 Rose, Prof. Wm. : 
 
 Pterygoid method of excising Gasserian ganglion, 75, 81, 89, loo-ioi. 
 
 Resection of maxillary nerves advocated by, 102 and note. 
 
 Salomoni, cited, 121. 
 
 Sapersko's method of removing Gasserian ganglion, 88. 
 
 Sclerosis of descending spinal root of fifth nerve, 12. 
 
 Schorstein, Dr. G., 6. 
 
 Schwab, cited, 29. 
 
 Sella turcica, 32. 
 
 Sensation, impairment of, see Anaesthesia. 
 
 Sensory root of Gasserian ganglion, division of, 97-98. 
 
 Sepsis, danger of, in operations on Gasserian ganglion, 87, 114-I16. 
 
 Septic meningitis, danger of inducing, through replacement of bone, 92. 
 
 Shock in excising Gasserian ganglion, cases of fatal result from, 114-I16. 
 
 Sinkler, cited, 23 note. 
 
 Skin : 
 
 Anaesthesia of, after excision of Gasserian ganglion, see Cutaneous 
 
 Anesthesia. 
 Application to, in minor neuralgia, 15-16. 
 Skull, section of, in removing Gasserian ganglion ; various methods, 88 ; 
 
 Cushing's method, 89-90; Poirier's method, 90; osteo-plastic method, 
 
 91-93 ; Krause's method, 93. 
 Smith, R. W., " Monograph on Neuroma," quoted, 32 and note, 35. 
 Sodium, iodide of, 14. 
 
 Spasm of facial muscles in epileptiform neuralgia, 23. 
 Spasmodic neuralgia in limbs and trunk, 11. 
 Spiller, cited, 27, 29, 35 note. 
 Spiller and Frazier, sensory root of Gasserian ganglion divided by, 97-98. 
 
150 
 
 Spine of Spix, 51. 
 
 Spheno-maxillary fissure, 62, 63, 65. 
 
 Spheno-temporal fossa, tumour in right division of, 34. 
 
 Sphenoid bone, 63, 89. 
 
 Sphenoidal air sinus, 5, 32. 
 
 Stimson, L. A., fatal case of excision of Gasserian ganglion by, 115. 
 
 Storrs' extra-cranial operation on the superior maxillary nerve, 61-65, 66. 
 
 Strychnia, injection of, 85. 
 
 Suicide induced by epileptiform neuralgia, 20-21. 
 
 Superior maxillary nerve : 
 
 Excision of, in the pterygo-maxillary fossa, 
 Carnochan's method, 58-61, 65. 
 Mugnai's method, 65-66. 
 Poirier's method, 57-58, 65. 
 
 Intra-cranial course, length of, 68. 
 „ resection of, 68, 69-70. 
 
 Involvement of, in epileptiform neuralgia, 21, 22 ; in sarcoma of Gasserian 
 ganglion, 34. 
 
 Resection of, 74, 102. 
 
 Storrs' extra-cranial operation on, 61-65, 66. 
 Supra-orbital neuralgia, 74. 
 Syphilis : 
 
 Epileptiform neuralgia, relation to, 24. 
 
 Headache and neuralgia due to, 6, 8-9. 
 
 Tabes dorsalis and, il. 
 
 Tabes dorsalis, 2, 11-12. 
 
 Taste, perception of, after removal of Gasserian ganglion, 106-108. 
 
 Teeth : 
 
 Extraction of, injuries in, 13. 
 
 Stopping of, neuralgia due to, 13, 22. 
 
 Wisdom, neuralgia due to crowding out of, 13. 
 Temporo-sphenoidal lobe, 37, 71. 
 Temporal bone, 34, 89. 
 
 ,, distribution of neuralgia, 4. 
 Temporal fossa : 
 
 Neuralgia over, due to syphilitic gumma, 9. 
 
 Relation of, in Mugnai's excision of superior maxillary nerve, 65. 
 
 Trephining wall of, in excising superior maxillary nerve, 66, 71. 
 
 Vertical incision over, in gaining access to Gasserian ganglion, 96. 
 Temporal muscle, 58 ; section of, in excision of Gasserian ganglion, 90 ; 
 
 paralysis of, after excision of Gasserian ganglion, 106. 
 Tenotome, use of, 84. 
 Thiersch's forceps, 44, 45, 53. 
 Tic douloureux, see Epileptiform Neuralgia. 
 Tiffany, L. ^l., cited, 113, 116. 
 
Tobacco, relation of, to epileptiform neuralgia, 24. 
 Tod, Mr. Hunter, 42. 
 Tongue : 
 
 Cancer of, 57. 
 
 Taste organs in, 107. 
 Trans. Amer. Surg. Assoc, cited, 75, 92 noU^, 100 note' . 
 Trans. Philad. Med. Soc, cited, 125, 
 Traumatism, relation to epileptiform neuralgia, 24. 
 Trav. Netir. Chir. Chip., cited, 90 note. 
 Trenel, cited, 37. 
 
 Trephine, use of, in excising Gasserian ganglion, 81. 
 Treves, Sir F., cited, 47, 58 and note^, 59, 70, 72. 
 Trigeminal neuralgia, see Neuralgia. 
 Trousseau, Prof., cited, 18, 24, 39, 42. 
 Tumours involving Gasserian ganglion. 
 
 Recorded cases of, 31-37 ; classification of, 37. 
 
 Section of, 34-35. 
 Tympanic membrane, aneesthesia of portion of, after excision of Gasserian 
 ganglion, 105. 
 
 Univ. of Pennsylvania Med. Bull., cited, no, 118 note^. 
 United States, prevalence of epileptiform neuralgia in, 21. 
 
 VAN Geruchten, cited, 44 note''-. 
 
 Venous haemorrhage, 55. 
 
 Vertigo, 98. 
 
 Vidian nerve, 34. 
 
 Viscera, pain referred to fifth nerve from, 3. 
 
 Wall, Dr. R. C. B., 40. 
 
 Weeks, S. P., cited, 92 note. 
 Wells' forceps, 81. 
 Winslow, R., case of, cited 121. 
 Women, liability of, to neuralgia, 4. 
 
 Zygoma, division of, in extirpating Gasserian. ganglion, 67, 88-89, 90, 93, 
 106 ; mentioned, 65, 71, 80. 
 
RD595 
 riutchin3on,J. 
 
 COLUMBIA UNIVERSITY LIBRARIES (hsLsix 
 
 RD 595 H97 C.1 
 
 The surqical treatment of facial neuralc 
 
 2002273624 
 
 Ji