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DISEASED 'BIGHT  ULNA   EXACT  SIZE

                    FIG 1.
Stuns ctocirU; enlarged ovtti'& rounJ foramina, <t acifu/arS r? ta t/i rmllcUeci formations,

    on. tfu surface oft?ie>bone .
J&\M ^
f^O^^y -7-* •'tSfeay

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7  „■«!.,.  .(?'''
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-3^g
    Right lateral section of the Ulna.
sfttwiHy carious abscesses;  sequestrum & eburnatioi
of the Iwnv en various parts .

G.Currier's Lith.33 S-pnu-e Si N.Y.
'=*?*»"*
J.Thmk.et.i'iei.aa.ii.j.T, 
EXSECTION
                  OF THE
                                                        ■ t. .

ENTIRE    ULNA       "    '■"&
     Modern surgery is chiefly indebted for the revival  of the exsection of
 bones,  and for more  precise rules regarding this class of  operations,  to
 Moreau, Percy, Champion, Pelletan, Dupuytren, Mott and Syme.   Exsections
 of the long bones in continuity are not very uncommon; but, of their com-
 plete removal, the  record is scanty.  The methodical books  refer to several
 cases, but in  such  a manner as to leave it doubtful whether the exsections
 were total or partial.  Besides, when the original reports are consulted, it
 frequently appears  that the summary statements, made on their authority,
 are not fully justified, and that they  err either in regard to the extent of the
 operation said to have been performed, or some other particular of import-
 ance to the  inquirer.  Coming down to  a  recent period,  I have  already
 described, at length, a case of the removal of the  entire lower jaw, at both
 temporo-maxillary articulations,  by  a single operation,  with a satisfactory
 result;  and the following case showTs that the Entire Ulna can be removed,
 and  the functions of  the  upper  extremity retained, in nearly their original
 perfection.
     Case.—P. Cavanagh, a  native of Ireland, aged 30, of sanguineous tem-
 perament, and small stature, strumous aspect, without syphilitic taint, a shoe-
 maker by trade, while splitting wood with a heavy axe, sprained his arm so
 severely, that, as he expresses it, the  sinews seemed to give way.  During the
night following  the accident, he was awakened by intense pain about  the
region of  the wrist joint.   This  was speedily succeeded by swelling of the 
34
upper  and forearm, as high up as the humero-scapular  articulation.   In this
condition, he consulted a physician, who prescribed an  anodyne liniment, to
be  applied to the arm.  The application was used  for five weeks, without
abatement of the pain.   Fomentations of hop leaves were then resorted to.
These  failing to bring relief, and the  malady still progressing, the patient
sought the advice of Dr. Webster, of Geneva, who made along the arm two
deep incisions, which were followed  by a slight discharge of pus and much
blood.   Cataplasms were then used for about eight weeks, with no relief to
the pain or diminution of the  tumefaction.   In  the month of July,  1852,
Cavanagh entered as a patient the surgical division of the State Emigrants'
Hospital.
    At the time of his entrance he was much enfeebled and emaciated ;  the
presence of irritative fever showed that the constitution was sympathizing with
the local disease ; the hand, forearm, arm, and shoulder presented one dense,
hard, tumefied, and shapeless mass, of a purple hue, and extremely sensitive
when handled; the pain was unremitting, being more severe by night than by
day ; the circumference of the diseased forearm was three times greater than
that of the corresponding portion of the healthy arm; and the density of the
tissues was such, that, in connection with the wan and emaciated aspect of
the patient and  the purple hue  of the  integuments,  there was reason to
conjecture  that the disease was one of malignant character.   A lotion of
acetate of  lead and tincture of opium was ordered  to  be  kept on the arm,
which  was also to be enveloped in  oil-silk.   Quinia, porter, and good diet
were likewise ordered.
    August 1st, 1852.  Three weeks having  elapsed,  and the  tension  and
swelling still remaining unabated, free and deep incisions were made through
the tissues  of the forearm; but the relief obtained by this operation was but
momentary.  The arm was now kept enveloped  in  a  flax-seed cataplasm,
with which was incorporated  some extract  of  stramonium.  During  the
months of September and October, the constitutional treatment was but little
varied.  Iod. ferri and iod. potassii were at times substituted for the quinia ;
an  anodyne draught of  morphia was regularly given at  bed-time.  The
topical applications consisted alternately of cataplasms, anodyne liniments. 
35
anodyne fomentations, eau sedative, and  extract of stramonium.  While this
treatment gave no relief to the pain, several abscesses had formed along the
ulnar region of the forearm, and  these openings  left sinuses leading to the
ulna; which, by means of the probe, could be felt denuded of its periosteum.
     The diagnosis now became more precise, and his card was ordered to be
marked " Ostitis, caries and necrosis of the ulna, possibly, also of the radius."
The general tumefaction, at this period of the disease, rendered it impossible
to ascertain  that one bone alone was affected.   The patient deriving  no
benefit  from the  use of  the various medicamental means which had  been
resorted to, was recommended to  remove from the Hospital to the  country,
for a change of air, and, at the same time, was directed to use tonic remedies
and a generous diet.   The patient consequently took his discharge from the
Hospital, December 1st, 1852.
     On the  18th May, 1853, he was again admitted, having in the interval
followed the instructions  he had received.  The  shoulder and upper arm
were now found to have resumed  their normal appearance and size; but the
elbow joint was very much enlarged, and almost incapable of motion.   The
forearm was still dense and hard, and was, moreover, much increased in size,
presenting along its  ulnar aspect a purplish hue, with various openings and
sinuses, from which,  at times,  small portions of dead bone  had been  elim-
inated during the patient's absence from the Hospital.  The wrist joint was
also limited  in its movements, and supination  and pronation could not be
performed.  The general health was somewhat improved, but the constitution
still showed signs of participation in the local malady, and a dull and aching
pain continued to extend along the arm  towards the axilla.
     The indications of treatment, now, were to keep up and improve the
general tone of the  system, and  to  use, topically, anodyne  applications,  in
conjunction with ioduretted preparations.   To this end, during  the following
seven months,  the constitution was supported by the internal exhibition of
quinia,  carb. ferri. precip., iodide of potassium, syr. iodide of iron,  sarsapa-
rilla, infusion of prunus Virginiana, wine,  porter, generous  diet, &c.;  while
locally,  anodyne and ioduretted cataplasms, fomentations, unguents, and the
warm bath,  were  sedulously employed.   But, from this treatment, no per- 
3H
ceptible amelioration was obtained ; the arm was still  much  tumefied  and
hard; the sinuses remained unclosed, discharging daily considerable quan-
tities of purulent material, in which, at times, were found minute portions of
diseased bone.   At this time, also, January 1st, 1854, the ulna could be more
distinctly traced, and felt to be enormously enlarged—apparently through its
whole extent; but there was good reason to infer, as no sinus could be traced
to the surface of the radius, that this latter bone was entirely sound.
     Medicamental and dietetic treatment had now been used for nearly two
years : the arm was still useless, and a painful incumbrance; and the ulti-
mate cure of the malady appeared to be beyond the resources of medicinal
art.  The  patient  was  becoming impatient, and anxious  to  obtain relief.
The  resources of operative  surgery  seemed now to offer the only prospect of
attaining  a  serviceable result;  and, as a point of practice, the alternative
presented itself of  amputation of the arm above the elbow, or of  exsection
of the entire diseased bone.  From some recent investigations, which I  had
been prosecuting upon  the lower animals, I  had  convinced myself that the
entire ulna, although forming an important part of the elbow-joint, could be
removed, without materially impairing either the strength of the limb or free-
dom of its movements.   Accordingly, I gave the preference to exsection of
the bone, and performed the operation on the 14th January last.
     Operation.—The patient was brought into the amphitheatre, and placed
supine upon the operating-table.   The assistants were arranged  so as to
maintain firmly the trunk and lower extremities, and be  in readiness to hand
the instruments and to sponge  the wound.   Chloroform was cautiously ad-
ministered.  While under the full influence of the anaesthetic, the position of
the patient was changed, so that he  lay partly on the left side.
     One assistant held and  supported  the  upper arm of the diseased limb,
compressing at the  same time the humeral artery; another, seizing the hand
and wrist, rotated inwards the limb from the shoulder-joint, and carried  the
pronation of the forearm so far  as  to  cause the  palm of the  hand  to look
directly outwards.   The elbow-joint was  now slightly flexed, and  the  hand
elevated.  This twisted  position  of the ulna  upon the radius placed the ulna 
37
upon the  posterior and outer aspect of the  forearm, and rendered it more
easily accessible.
     The limb thus placed, the assistants maintaining the arm and forearm
steadily, standing  upon the right side of the  patient and placing the fingers
of the left hand upon the integuments of the forearm towards the elbow,
with a strong, straight, sharp-pointed  bistoury, I made  an incision along
the posterior and  inner aspect of the ulna;  commencing  at  the lower part
of its superior third and extending downwards to a point over the extremity
of the styloid process.  This divided  the tegumentary  layers  and facia,
which were found  dense, matted and infiltrated.  The tendon of the extensor
carpi ulnar is was pulled back, and the bone exposed.   This was found rough,
greatly enlarged,  and presenting  numerous oval foramina  and  several
cloacae, which communicated  externally through the integuments.  It was
now apparent that the bone  must be  disarticulated.  To effect  this at the
carpo-ulnar articulation, a transverse incision, about an inch long, parting
from the  lower extremity of the  first incision, was made across the back of
the wrist.   The superficial tissues were  here reflected, and the tendon of the
extensor carpi ulnaris was carefully detached from its groove on the lower part
of the ulna.  The  dissection was now carried along the anterior surface of
the lower portion of the ulna,  and the soft parts were detached from the bone
as far as  the  interosseous  ligament, the ulnar artery and nerve being care-
fully avoided.  The soft parts were now detached from the posterior surface
of the ulna, avoiding  injury to the extensor tendons.   An attempt was then
made to pass a chain-saw around the  ulna  through the  interosseous space
opposite the lower part of the middle third.   This was found impossible, on
account of the approximation of the enlarged ulna to the radius, and the
almost  complete obliteration of the interosseous space.  To divide the bone
at this point, a small convex-edged saw was used.   The bone thus divided,
the interosseous ligament was detached downwards, and the  lower fragment
of the ulna was disarticulated from its inferior attachments to the radius,
fibro-cartilage and the carpus.
     It  now remained  to insulate and detach the upper fragment.  The first
incision was  prolonged upwards along  the posterior  surface of the ulna, 
38
so as to end at the upper part of the olecranon, opposite its  outer edge.
To this a terminal incision was joined, which extended transversely across
the back of the elbow-joint, as far as the inner margin of the ulna.  The
soft tissues were now dissected from the bone, upon its posterior and anterior
aspects, as far as the interosseous  ligament, and as high up as the insertion
of the brachialis intemus muscle.   The bone was  next seized  and  pulled
from the radius ; and a knife, curved flatwise, was passed close upon its inter-
osseal margin, grazing the  bone, and  dividing  the  interosseal  membrane,
upwards; the soft parts being held apart,  and the interosseal and ulnar arte-
ries protected.
     The elbow-joint  was now flexed,  and opened  behind, by entering the
bistoury close to the  inner edge of the olecranon.   The attachment  of the
triceps extensor was next divided, by cutting directly outwards.  The ulnar
nerve was  now found, and  hooked aside,  until farther dissection of the soft
tissues was effected from the inner aspect  of the joint and the upper part of
the bone.  The lateral ligament was next  divided.   The bone still remained
firmly  attached, chiefly by the coronary ligament and  the insertion  of the
brachialis anticus.  The ulna was  carried  backwards, so as to make that,
muscle  tense, and by carefully grazing the coronoid process with the knife
the tendon was detached.   Some difficulty was here presented  in avoiding
the humeral  artery, which  lay in close proximity to the enlarged coronoid
process.  The bistoury was now passed between the ulna and  radius, and
the coronary ligament divided.  A few remaining fibres were divided, and
the bone was completely  detached.
     During the operation  there was  a considerable flow of venous hemor-
rhage,  which ceased  upon removal of compression  from  the  upper arm.
The  arterial  bleeding was arrested  by  torsion of a  few arteries around
the elbow-joint.  The operation was  performed  in  the presence of many
pupils and  professional gentlemen;  and I  was ably assisted during its differ-
ent steps by Dr. Giilck and Dr. Melville,  of this city, and  by Drs. Hensley,
Gould, Harris,  and Thomas, the Resident Assistant Surgical Staff  of the
Hospital.
    Progress of Union.—After the operation/the wound  was  cleansed  of 
39
coagula,  and  the  edges  brought together by  ten points of  interrupted
suture.  The limb, after the dressing and  bandage were applied, was placed,
prone and slightly flexed, upon a well-padded splint, and fixed to this  by
circular strips of bandage.   The patient  recovered slowly from the  in-
fluence of the  chloroform, the pulse remaining below 50  for some hours:
anodyne ordered at  bed-time: next day, Jan. 15th, the pulse 100—full and
regular: oozing of blood  has  occurred to some extent: during the  night,
patient  has been restless,  and has suffered  much pain in the arm: sol.
sulph. morph.  at bed-time.
     Jan.  16th.  Pulse 100—not so full or strong:  no more oozing of blood
has occurred, and the patient feels more  comfortable, having slept, and suf-
fered but little during the night: the  first dressing removed in the  after-
noon : for four inches above the wrist-joint, the wound seems to be uniting
by first intention.
     Jan. 17th.  Pulse 83—regular: general condition good: 01. ricini order-
ed :  the wound dressed:  suppuration profuse: the  lips of the wound have
an unhealthy aspect: four of the  sutures  come away : anodyne  in  the even-
ing : the  patient is ordered to commence  in  the  morning with solution  of
sulphate of quinia.
     Jan.  18th.  Patient has slept badly, having suffered much pain, during
the  night, along the  arm:  pulse 80 : dressed the wound, which  has  as-
sumed a better appearance : suppuration less, but  little adhesion : beef-tea
ordered.
     Jan.  19th.  Pulse 90 : patient has slept tolerably well: wound dressed :
discharge of pus decreasing, and  union progressing from the wrist upwards :
free discharge of synovial fluid from the elbow-joint, upon removal of  the
dressing.
     Jan.  20th.  Pulse  84: wound dressed:  favorable  progress: full diet
allowed:   quinine  continued: no undue   inflammatory  action  at  either
articulation :  arm still kept in the same position.
     Jan.  21st.  Patient has suffered much  pain at the elbow-joint during the
night: in the afternoon,  wTound  dressed: doing well:  there is free motion 
40
at both elbow and wrist-joints :  discharge of synovia still coming from the
elbow-joint.
     Jan. 22d.  Everything going on well :  wound dressed :  but little dis-
charge, except at  the  several tegumentary  orifices  which existed between
the wrist and elbow before the removal of the bone :  but little synovial fluid
coming from the joint.
     Jan. 25th.  General  condition of the patient excellent:  pulse 80, and
natural : appetite  good :  only slight oozing of synovia from  the elbow:
no pain : splint upon which the arm rested, in a state of pronation, dispens-
ed with; forearm now  bent at a right angle, and held in a position between
supination  and pronation, while a light, well-padded splint, extending from
the elbow to the extremity of  the fingers, is placed and bandaged along the
front thereof, to support the radius: limb, thus adjusted, supported by a sling
passed around the neck: patient allowed to sit up.
     Jan. 29th.  First  splint removed, and the arm, which had been main-
tained fixed for the last four days, adjusted,  and  bandaged to another splint,
jointed and formed of two pieces; one for  the upper arm, and another for
the forearm; the joint being  opposite the  elbow, in  front: by this arrange-
ment, the forearm still kept in semi-pronation, and radius supported; while by
regulating  the angle of the splint, by a mechanism for that purpose, the fore-
arm can be gently and gradually extended.
     Feb. 5th.  During the use of both splints, dressings carefully attended to,
by removal and re-adjustment at suitable  intervals: to-day,  upon  removal
of the splints and  dressing, healing process of the wound found  to be  en-
tirely completed ; the tissues about the wrists and elbow-joints  being entirely
consolidated, and free  motion at both articulations  possible by the patient
himself, without any assistance.
     Feb. 10.   Limb  still supported by a  light bandage, and by the last
splint; for  the purpose of allowing the tissues along the line  of the inner
aspect of the forearm to become further consolidated : health of the patient
is now good:  he  walks about like a well person: he is still upon tonic
treatment,  and is allowed generous diet. 
41
     Feb. 15th.   Removed the splint: patient allowed to use  his arm : gen-
 eral health entirely restored.
     Feb. 18th.   Five weeks  after the operation, discharged  from  the Hos-
 pital cured.
     Appearance of the Arm ; and its Functions.—With the  exception of a
 depression, and the  cicatrix along the ulnar  aspect of the  forearm, there
 is no deformity  of the limb.
     The functions of  the arm  are  preserved in a  remarkable  degree  of
 perfection.   The power of prehension is unimpaired : flexion  and extension
 at both the elbow joint and at the wrist joint can be performed with facility :
 supination and  pronation can also  be effected :  abduction  and adduction
 at the wrist joint can be performed, as  also  flexion and extension  of the
 fingers, as before the operation:  sensation and nutrition are as perfect as
 in the arm and  hand of the opposite side.
     None of the large nerves or arteries were injured during the exsection of
 the bone, and the muscular tissue was carefully preserved from the action of
 the bistoury, with the exception of the  cubital origin and insertion of those
 muscles  which are attached to the upper portion of the ulna.   These had to
 be divided during the detachment of that portion of the ulna.
     Flexion, at the elbow joint, is chiefly effected by the biceps flexor,  which
 is inserted into  the  tubercle of the  radius;  but the humeral origin  of the
 other  flexor muscles—such as  the flexor sublimis digitorum  communis, the
 flexor carpi uhiaris,  the palnmris  longus,  the flexor  carpi radialis, and  the
proyiator  radii teres—remaining uninjured, they also  serve as auxiliaries in
 this function.
     The  triceps extensor  and anconceus  were, necessarily, entirely  detached
 during the operation ; but extension of the forearm is sufficiently performed
 by the action of the  extensores carpi radialis longus et brer is ;  by the extensor
 communis digitorum,  the  extensor minimi  digiti,  and by the  extensor carpi
ulnaris ;  all of which muscles pass from  the external condyle of the humerus,
to be inserted on the  posterior surface of different metacarpal and phalangeal
bones of the hand.
    Flexion of the wrist joint is effected by flexor carpi radialis, p<d7nari$ 
42
longus, flexor carpi ulnaris; extension, by the extcnsores carpi radialis and the
extensor  carpi  ulnaris.   Adduction, also, is effected  by  the  extensor carpi
ulnaris; while abduction results from  the  action of  the extensores carpi
radialis.
     Flexion of the fingers is chiefly effected by the flexor sublimis digitorum
communis, and  the extending function of the phalanges results mainly from
the action of the extensor communis digitorum.
     Pathological  condition of the Bone.—The diseased ulna is delineated in
the plate, Fig. 1,  and presents  all the characteristic  manifestations  of pro-
longed inflammatory  action of a  high grade.   The bone is  very  much
expanded  from one  extremity  to the other—at the  base of  the  coronoid
process  it  measures  in circumference 5£ inches ;  and its weight  is 8 oz.
minus 20 grs.,  the weight of  a recent, healthy, adult ulna  varying from 2\ to
to 3 oz.
     Bony vegetations have assumed the acicular form on the radial aspect of
the bone, on a line with the  attachment of  the  interosseous ligament, as far
down as the junction of the middle with the lower third ;  the acicular forma-
tions also prevailing on and below the coronoid process.   At all other points
around the upper  extremity of the bone, irregular mammillated appearances
exist, with innumerable enlarged, round, and oval foramina.  These  enlarged
foramina, in  conjunction with the hypertrophied condition of  the bone, are
characteristic  signs of protracted inflammatory action,  as was long ago
demonstrated by the Goodsirs, of Edinburgh.
     Along  the inner and posterior aspect of the bone exist some eight
cloacce, five of which are in the upper third  of the  bone: two in the middle
third;  and one near the styloid process.   One  of  these cloacce,  situated
between the coronoid and  olecranon  processes,  communicates with  the
interior of the elbow  joint;  while another, situated at the lower  part of the
bone, communicates with the ulno-carpal articulation.
    The other  cloacce pass deeply into  the interior of the bone, ramifying
extensively, like sinuses, in different directions, along the inner texture; some
of the sinuses containing portions of bone in a state of necrosis, and more or
less  detached.   From these cloacce,  which  opened  externally  upon  the 
43
integumentary surface, large quantities of purulent fluid, mixed at times with
portions of dead bone, were discharged.
     At the middle third, the circumference of the bone, by measurement, is
four inches ; being I inches larger than the shaft of an adult femur.   At this
part, also, the round and oval foramina are abundant.
     The lowTer third of the bone is also extensively hypertrophied ; being at
its upper part 3g inches; while, at the base of the styloid process, the circum-
ference is 2g inches.
     The section of the bone, as represented in the plate, Fig. 2, shows the
appearance of the central portions.  Here the influence of high inflammatory
action, and  its consequences—carious ulceration, necrosis, and eburnation—
are plainly manifested.   The greater part of the interior of the bone is exceed-
ingly dense and  compact.  The surface of the osseous section is in some parts
tinted  with a  dark purple hue;  at other parts, it is whitish and dense, like
ivory;  blastema  having been here thrown out,  so as to  obliterate the spongy
structure, the Haversian canals, the lacunas, and canaliculi.  The right lateral
half of the  section, [as seen in Fig. 2,]  also,  shows  the presence  of  two
carious abscesses in  the  interior of the  bone,  communicating externally
with cloacae and the integuments.   In one  of these  abscesses, a piece of
sequestrum is situated, partly detached.   Vide plate,  Figs. 1 and 2. 
               REMARKS

                       ON

NEURALGIA   OF  THE  FACE.

                WITH A  CASE.
    Neuralgia, wherever seated, has its phases, and gradations—its different
degrees of intensity—manifested  by pains of a trivial character, or  by the
most excruciating suffering.  These pains are, rarely, continuous, are generally
intermitting or remitting, and are most frequently accompanied by twitchings
or convulsive muscular movements. "Aut lere malum quamris intcrmittet, quamris
exiguum esse prima specie videtur, nam si acute  intcrdum impctum faciat foeda
atque atrocia  detrimenta affert,"   We find these words in Aretieus, who seems
to have been the first to present definite ideas in regard to Neuralgia of the
Face, and to have thus early designated the violent symptoms of the disease,
as seen in its highest degree of development, as well as those milder symp-
toms which are presented, in a great number of cases.
    The allusions made by previous authors, to this form of Neuralgia, are
superficial and vague.  In their writings are found observations which treat
of pains of the head, confounded, however, in a general description.
    It  is only within a comparatively recent period, that Neuralgia of the
Face has attracted the  serious  attention of medical authors; or, perhaps it
may be more  properly stated, that the malady has been surrounded by such
obscurity and perplexity, as to have baffled description.
    Andre', a  French surgeon,  in 1756, published  his researches upon  this 
45
malady,  and gave to it the name  of Tic Douloureux.  According to this
writer, the affection is characterized upar une doideur plus ou moins vice, etpar
des grimaces hideuses qui mettent un obstacle invincible a  la reception des aliments,
qui eloignent le sommeil, interceptent et lient souvent Tusage de la parole : agitations
qui,  quoique vagues et periodique  en  elles-meme,  sont neanmoins si frequentes,
quelles sefont sentir plusieurs fois dans  unjour, dans une heure, et quelquefois sont
sans reldche et se renouvellent a cJiaque minute.11  This description, as far as it
goes, refers to the disease when it has acquired a high degree of intensity, and
coincides with the malady which Fothergill,  soon after (in  1782), described
under the name of " Painful Affection of the Face."  The account given by
Fothergill is more complete, and exact, than that of the French surgeon, just
named, as we may learn by the following extract:
     " From imperceptible beginnings, a pain attacks some part or other of the
face, or the side of the head ;  sometimes about the orbit of the eye, sometimes
the ossa mcdarum, sometimes the temporal bones, are the parts complained of.
The pain comes suddenly and is excruciating ;  it lasts but a short time, per-
haps a quarter or half a minute, and then goes off;  it returns at irregular
intervals, sometimes in  half  an hour, and sometimes there  are two or three
repetitions in a few minutes.
     " The kind of pain is described differently by different persons, as may be
reasonably expected; but one sees  enough  to excite  one's compassion, if
present during the paroxysm.
     " It returns full as often in the day as in  the night.   Eating will bring it
on  some persons.   Talking, or the least motion of the muscles of the face,
affects others ;  the gentlest touch of  a hand or handkerchief will  sometimes
bring on the pain, whilst a strong  pressure on the part has no  effect."
     About the same time that Fothergill's Memoir appeared,  Thouret, another
French writer, published an article, on this subject, in the Memoires de la SocietS
Royale de Medicine.  This writer states, that the disease appears to fix itself,
particularly, in certain localities of predilection, ucomme la machoire uiferieure,
le trou mentonnier, le voisinage de Vapophyse Mastoide et la region de lajoue la plus
voisine de Toeil.   En general, he adds,  "le siege le plus ordinaire du mcd est sur le 
40
 cdti du nez, immed'uitemcut au-dessous de Vos de la pommette, a lendroit ou une
 branche principalc du nerf maxillaire super ie-ur sort du canal sous-orb ita ire."
     The authors, heretofore alluded to,  contributed  by their  observations,
 chiefly, to the symptomatology of this disease.
     Chaussier, guided  by his anatomical knowledge, made some  steps of
 advancement in determining the seat of Neuralgia of the Face.  In his " Table
 synoptique de la nforalgie" (Paris, an XI.), he makes four principal divisions of
 Neuralgia of the Face,  according  as the disease seems to be  concentrated
 upon one, or other, of the branches of the fifth pair of nerves, or, upon the facial
 nerve proper, itself.   Thus, he describes  separately—-frontal  neuralgia, infra-
 orbital neuralgia, maxillary neuralgia ; and, in a note, he admits  the existence
 of  neuralgia of the facial nerve.  The course  of  the tri-facial nerve, and  its
 anastomoses, have evidently formed a basis of this classification.
     Since the publication of Chaussier, several dissertations and theses have
 appeared, at different times, in which new cases  are related, but without the
 addition of any novel information on the subject.
     In 1834, M. F. Bellingeri, of Turin, published a memoir upon Neuralgia of
 the Face, the chief features of which are his advocacy of an intermittent form
 of neuralgia, and  the theoretical division of neuralgia into three species—the
 inflammatory,  the irritative, and the nervous ; the  first species being again
 subdivided into the sanguine,  the phlogistic, and the  rheumatismal.
     In more recent times (1835-36), the question has been agitated, by M. Be'-
 rard, as to the existence of a neuralgia of the facial nerve proper.   This phy-
 siologist has arrived at the conclusion that the nerves of. the fifth ptair alone,
 in the face, can be  attacked  with  this malady.  Upon the  other hand, in a
 later publication, M. Jobert de  Lamballe supports  an entirely different
 opinion, and maintains, that all the nerves of the face are liable to be attacked
 by  neuralgia.  Irf  regard to  this last point of discussion, we are aided in
 arriving at a correct conclusion by anatomical facts, as well as by the morbid
 phenomena which are frequently exhibited in neuralgia  of the  face.  The
portio-dura, or facial  nerve, is undoubtedly a nerve, purely of motion, at its
 origin ; but, before it emanates from the stylo-mastoid foramen, it has  been
joined by a sensitive branch from the ganglion of Meckel. Physiologically, after 
47
this junction, the facial nerve must be a mixed nerve, and must be sentient
to impressions, both normal, and abnormal.  In fact, I consider that the facial
nerve is not only the seat of neuralgia, at times, but that it is frequently the
conductor of neuralgic phenomena, and morbid sensibility, to the nervous
periphery of the face, when the true seat of the disease is  located on the trunk
of the second branch  of the fifth pair.  I make this statement, partly from
observation, and partly from the consideration of the law which regulates the
propagation of nervous sensibility, viz., that the sensation is referred to the
periphery of a nerve, or to its extreme branches, when the trunk is the seat of
irritation, or disease.   A simple illustration of this is found in the effects which
follow a blow impinging upon the ulnar nerve at the elbow.  It is well known
that the impression imparted to the trunk is conducted  to  the  ultimate dis-
tribution of the nerve, and that the sensation is referred to the little finger,
and to the ulnar border of the ring finger.
     By reference to the history of this disease, we find, that notwithstanding
its formidable character, and the numerous- attempts made to unravel its patho-
logy,  science has not been  as much enriched, as might be supposed, with facts
observed with care and precision.   With the exception of the discoveries of
Charles Bell, and others, in relation to the functions of the nerves, which are
implicated in Neuralgia of the Face, and some vague and unsatisfactory the-
rapeutic  experiments,  we have made but little  advancement, in regard to the
nature and management of this disease, since the time of Fothergill.
     As yet, authors differ concerning the anatomical lesions which should be
considered as characteristic of Neuralgia of the Face.  Some deny that any
are to be found in those cases where the signs of the disease have been indi-
cated in an incontestible manner; and one of the latest writers expresses
himself in the following indefinite language : " La nevrcdgie tri-faciale doit Ure
considerie comme une lesion de fonction done nous ignorons entierement la  cause
organique."
     The medical treatment, although embracing a vast number of therapeutic
agents, is most frequently unavailing ;  and it is well known, that the surgical
treatment, consisting principally of topical applications, and the division, on
the face,  of the branches of the fifth pair, at their exit  from their respective 
48
foramina, is, for the most part, utterly useless in affording relief, or, at best,
affords  but very temporary benefit.  The medical inquirer, then, has no
reason to be satisfied with the observations heretofore made; but, on the con-
trary, is justified and urged in bringing under  scientific scrutiny  such  new
facts as may assist in unveiling  still further the mysteries which envelope
this most painful malady.
     In  the year 1811,  a letter appeared, in the Philadelphia Medical Museum,
written in 1807,  by  Dr. Jones,  an eminent  physician,  of  that time,  in
the city of New York, and addressed by him to the celebrated Dr. Benjamin
Rush.   This  letter is a statement of Dr. Jones' own case, he having been,
for many years, a victim to  intense  neuralgia of the face.   The narrative is
drawn up with much clearness of expression,  and is worthy of insertion here,
as  emanating from a  highly  intelligent  source, and as presenting a most
graphic description of the excruciating and fearful agony experienced by those
who are afflicted with the intense form of this disease.
     Dr. Jones' letter runs thus :
                                              " New York, Oct. 15th, 1807.
     " About the middle of July, 1806, I began to feel an uneasy sensation in
the gum of the  upper jaw,  on the  right side, at a point whence one of the
molares, in a loosened state, had a  long  time  before been taken away;  the
socket  of which, however, had already been  absorbed  or  filled up, and the
gum, or alveolar border of the jaw, was even, firm, and apparent!}' sound ; yet
whenever I washed my face,  or  moved my hand gently over the cheek, a
latent  disease was perceptible.   It gradually  increased,  till it became so
extremely painful, that at times I was compelled to cry out with the intolerable
anguish it occasioned.   Eating, drinking, speaking, hawking, and spitting,
sneezing, coughing, and blowing the nose, would either of them, in a moment,
awaken the most poignant and acute pain.  Even touching the eye with the
finger, slightly rubbing the forehead, putting on a pair of spectacles, or  only
opening the mouth wide, would excite a return of the pain.   Taking into the
mouth anything hot, cold, or acid, was  sure to produce the effect with aggra-
vated violence.  The necessary mastication forbade the use, in a great meas-
ure, of solid food.  Combing the hair, shaving the right corner of the mouth,
% 
49
reading aloud, or anything that gave the slightest motion to the muscles of
the face, would occasion in the part a throbbing, which seemed to begin like
the vibration of a musical cord, extending its effects  to the cheeks, the eye,
the nose, up to the scalp on that side of the  head, and, after continuing for a
few seconds, sometimes a few minutes, and latterly for fifteen or twenty min-
utes, it would cease, and the part which had been affected would then feel as
well as if nothhig had happened.  The pain at length began to be felt severely,
upon  touching the left eye, yet, whatever it was that  excited the pain, it
always centered in the gum, on the right side of the upper jaw.
     " It continued in this way; except increasing in the duration of each,
paroxysm, till August 28th, 1807, when it almost, or  entirely left me, and I
began to flatter myself it had  been vanquished by the use of hemlock ; but
in two or  three days it returned, and became as violent and excruciating  as
ever.   The gum where the  disease is seated, I have already mentioned, is to
all appearance perfectly well, sound and smooth, with no visible vestige  of
disease  about it; and there had been no tooth in the spot for some consider-
able time before the disease  commenced.  The  gum has been repeatedly
divided by numerous longitudinal and  transverse incisions down to the bone.
This operation, in the beginning of the complaint, never failed to assuage the
pain for a time ; but the relief seldom lasted till the gum had healed.  Elec-
tricity was tried for a long time, to no purpose.  A number of topical applica-
tions  were made ; the part was covered with a blister externally, and various
embrocations  applied to the cheek without advantage.  Opium was taken in
large  quantities, and the tincture applied to the part,  both externaUy and
internally. Warm and cold bathing were alternately applied to the head and
face.  The latter application occasioned the most exquisite misery.  Peruvian
bark in substance was taken in large doses.  Huxham's tincture of the bark,
with wine, was used very  liberally.  The  volatile alkali, in a decoction of
bark, was taken agreeably  to Dr. Fothergill's prescription, in a recent publi-
cation of the successful treatment of  a case  of this very formidable disease.
None of those things effected any change that promised the final removal of
the complaint.  I  then began a steady  use  of  the extract of hemlock,
taking one grain night and morning, till I had risen to the quantity  of four- 
50
  teen grains every four hours.  This was continued till September 22d, 1807,
  when, finding it produced no diminution of the pain, I omitted the use of it
  for one week, when, the pain recurring more frequently, as well  as more
  severely than before, I again had recourse to the hemlock, and am now, with-
  out much benefit from it, or very sanguine hopes in its curative efficacy, still
  persevering in the daily use of it.   I have been  advised to have the actual
  cautery applied to the gum;  but am apprehensive that so harsh and violent
  an application would bring on tetanus with all  its alarming and distressful
  consequences, and have therefore concluded not to adventure upon the expe-
  riment.
      " This complaint will be admitted, I presume, to be a nervous affection;
  but what remains mysterious, and seems to ask for explanation is, that if a
  local disease, cutting the gum all to pieces, dissecting and dissevering it in
  all directions, should not, by dividing the nerves  and insulating them from all
  connection with the sensorium,  destroy their sensibility, or at least their
  power of communicating pain.   I am aware that while their continuity is pre-
  served, denudating  the  nerves, so as  to  expose  them to  the contact of the
 common air, does often cause them to assume a morbid action productive of
 extreme pain; but this did not happen in the present instance, for, when the
 scarifications did least  good, they did not seem, in the  smallest degree, to
 increase the evil.
     " I am upwards of sixty-two  years of age, and, except this complaint, my
 general health and appetite are good; I have, indeed, a small ulcer in one of my
 ankles, which has been healed, but from irritation has broken out again, and
 at  present  does  not seem  much disposed  to  cicatrize.   I have, during my
 whole life, been in the habit of using steady exercise, and have lived as regu-
 larly and as temperately as any man.
     " If, sir, on considering this case, which has thus far eluded the best pro-
 fessional skill of  this city, anything  occurs to your mind, which would  throw
 light  on the nature and character of my complaint, and  especially if your
 extensive research and experience should have furnished you with anything
promising for the treatment of it, by  communicting your opinions and pre-
scriptions, you will  not only give to the world a  new proof of your pre-emi- 
51
 nent skill, but you will at the same time subserve the interests of humanity,
 by administering comfort and relief to an old man, suffering under the most
 afflictive distress; you will  cause  his winter sun, now dimmed and clouded
 with despondency, to shine out afresh, with a mild and cheering ray, and at
 last go' down in a serene sky ; and, what may be of stiU more value in your
 estimation, you will enjoy the conscious merit of acting in conformity with the
 benign  precepts  and bright example of the Great Physician, who, while on
 earth, delighted in relieving the distresses of his brethren."
     Dr. Rush replied to this letter, recommending such remedies as he sup-
 posed might be most effective in arresting the  fearful disease.   We learn,
 however, from the following extract, taken from another letter to Dr. Rush,
 written  two years after the one just quoted, that all the remedies which were
 used, had proved unavailing.  Dr. Jones, in his second letter, dated Decem-
 ber 9th, 1809, thus alludes to his condition at that time....."My disease,
 sir, stiU maintains its place, unmoved by all that weight, and force, and com-
 plication of machinery,  which medical  science and skill have devised and
 applied.  The most promising and judicious prescriptions, derived either from
 enlightened  reasoning, or from experience, or  from  learned  research,  have
 alike failed, in this baffling disease, to  answer the  expectations reasonably
 entertained of them."
     I am informed by a venerable and esteemed physician, still living in this
 city, that Dr. Jones was  afterwards subjected to the operation of division of
 the infra-orbital nerve on the cheek, but without receiving material benefit;
 and further,  that, unrelieved by  any  of  the  curative means  he  had  so
 patiently resorted to, he succumbed under the prolonged and agonizing suffer-
 ing which he had endured.
     The following case  is, in many  respects, similar to  that of Dr. Jones.
 The disease was of the infra-orbital nerve; the suffering was as poignant and
 intense ;  and the remedies resorted to were even more numerous.  I know of
 no instance on record, where so much perseverance and fortitude were mani-
fested by a patient, in urging, and in submitting to repeated operations of an
extremely painful character; for, as will be seen by the following history?
besides the extraction of all the teeth upon the upper jaw, no less than twelve 
52
operations were performed on the face, as a  part  of the treatment.  This
patient has been, however, so far more fortunate than the subject of the pre-
vious case, as to have been restored to comparative comfort and ease, from a
condition bordering on insanity, and  in which  he had frequently meditated
self-destruction.
     Case.—J. C. Forbes, aged 47, a citizen of Hoboken, New Jersey, married,
of nervo-bilious temperament, by occupation a master carpenter, applied to
me for  advice, in the month of August, 1855.  He had, with the exception of
his neuralgic affection, always enjoyed good health, and had no special taint
of the system.
     He stated that he observed the first signs  of  this disease in May, 1849.
At that time, while passing a handkerchief across the upper lip and  end of
the nose, he perceived a sharp, poignant, lancinating pain, shooting from near
the middle of the upper lip, on the left side, along the furrow, at the junction
of the nose and cheek, up to the inner angle of the eye of the same side, and
passing deeper through the bone of the cheek, in the direction of the spheno-
maxillary fissure. The same pain was started when the upper  lip was touched
with the tip of the tongue, or when making an effort to swaUow.   These symp-
toms,  assuming a paroxysmal character with irregular intermissions, con-
tinued unabated until the autumn of the same  year, when  they  entirely
disappeared.
     In the  spring of 1850, the attack was renewed, commencing  as it had
done the previous year, and gradually becoming  more painful.  It was sup-
posed  by some that the trouble might originate  from disease of the teeth;
and, by the advice of a dentist, all the teeth were extracted, except a small
stump  on the right side of the lower jaw. This proceeding gave no relief; the
disease increased in severity ; the paroxysms of pain became more frequent,
and almost intolerable, extending over the entire left cheek.
     From that time  (June, 1850) until February, 1852, the patient continued
under medical treatment; he gave up his business, and sedulously tried the
most approved prescriptions; but, in vain.
     Finding no relief from the use of internal remedies, as advised by skil-
ful physicians, he consulted an Hospital surgeon, of eminence,  in this city, with 
53
the view of having an operation performed, if deemed expedient.  An opera-
tion was  advised, and performed (February, 1852),  by dissecting, from the
interior of the mouth, without external incision, the entire cheek from the supe-
rior maxillary bone ; the separation of the tissues extending across, from the
nose to the prominence of the malar  bone, and, vertically, from the alveolar
border, as high as the margin of the left orbit.  A considerable quantity of
blood flowed while the incisions were being made.  Much relief followed this
operation, and  the paroxysms seemed to  be  kept  at bay for a period  of
about eight months.
     The following November, the disease returned, with  its wonted severity,
and the patient was again put under medical  treatment, using, chiefly, large
doses  of quinine.  In the latter part of December,  1852,  the paroxysms
became so aggravated and intolerable, that  the  patient again entreated the
same surgeon to perform another operation.  This was accordingly done, by
making a V incision, below the margin  of the orbit, and dissecting the flap
upward,  so as to  expose the infra-orbital foramen.  The nerve was then
divided at its exit upon the cheek.  The patient was  again relieved, until the
autumn of 1853,  when the pain  returned, with severer  manifestations than
before.   The patient was again put under medical  treatment, galvanism
being  added, without  any advantage, to the long list  of therapeutic means
previously resorted to.
     In January,  1854, a Professor of Surgery, of some eminence, in this city,
was consulted, and performed the same operation as that last described; but,
besides the incisions  for dividing  the nerve, he cauterized, with a red-hot
iron, the divided  surface of the nerve, at the infra-orbital foramen.  Relief
was again obtained, until August of the same year.  During that month, the
paroxysms reappeared with  their previous  intensity, and another operation,
of a similar character,  was performed, in September,  by another surgeon, also
of this city; but,  without any good  result.
     In October of the same year  (1854), harassed, despondent, and worn
out with the accumulated violence of his sufferings, the patient consulted my
celebrated friend, Professor Mott.   With the hope of affording relief, the tis-
sues of the cheek were freely divided by sub-cutaneous incision, once in Octo- 
54
ber, and again  in  November, by that distinguished surgeon.  Very slight
amelioration of the pain was effected by these operations, and, on the 8th of
January, 1855, Professor Mott performed his third operation, by making a V
incision on the  cheek,  in  the  same manner as  had been previously done,
and dividing again  the nerve, at the infra-orbital foramen.
     These numerous operations, although  lulling the terrible  suffering for a
time, left no lasting impression on  the disease.  For nearly  five  months a
partial mitigation of the symptoms followed Dr. Mott's last operation, but, in
June, 1855, the pain set in afresh  with its accustomed violence; and the
patient, unable to attend to business, his means exhausted, his strong frame
shattered  with prolonged and intense agony, and his mind paralyzed with
despair, took refuge in the  New  York City  Hospital.  There he remained,  in
the Medical Department, under the care of  the physicians of that institution,
until the month of August, 1855, when he took his  discharge; having received
no benefit from the treatment prescribed.
     It was at this stage of the malady that  the patient came under my notice.
A few days after he left the Hospital, he was brought, by some  of his friends,
to consult me, in a  condition bordering on delirium; wild, and almost mad,
as he himself  stated, with the intensity of his sufferings.  He most piteously
besought me to perform some operation for him, different from those  previous-
ly tried; protesting that he was  utterly regardless of any danger that might
be incurred, or of the extent or character of the mutilation which might result.
     After hearing a recital of the various  operations to which he had been
subjected, and seeing, from his condition, that nothing really useful had been
accomplished,  it  seemed to me futile and hopeless  to recommend an operation
which would consist of the division simply of the nerve.  As  the catalogue
of medicines of  most repute in Neuralgia had been exhausted unavailingly,
it was useless  to repeat them, and ordering, for  the moment, a  strong dose of
muriate of morphine, internally, and an ointment, composed of the extracts
of belladonna, hyoscyamus, and stramonium,  with a small  proportion  of
veratria, I undertook to perform on him, the following day, the operation of
exsecting a piece of the trunk of the infra-orbital nerve.
    The condition  of the  patient,  after his  return  home  from  the Hospi- 
55
tal  until he came to me for advice, was truly appalling, and enlisted the
sympathies even of strangers.  He could neither rest, sleep,  eat, drink, nor
talk, without the occurrence of paroxysms of the most violent character.  He
would start from his couch with the wildness of a lunatic, and would throw
himself on the floor, screaming and howling from the intensity of his agony.
At times, his suffering would overcome his moral courage, great as that was,
and  he would  threaten self-destruction.   The  slightest impressions on the
external surface of the face, especially on the upper lip or cheek, or upon the
mucous lining  of the mouth, pharynx, or nose, would bring  on, most com-
monly, paroxysms of the  most aggravated description.  The intermissions
between the paroxysms, during the exacerbations or attacks of the  disease,
were variable;  sometimes lasting a half-hour or more, sometimes a few
minutes, and at others only some seconds.
     On  the 31st of August, 1855, I performed the  following operation  on
Forbes.  He was seated on a chair in a good light, and, the assistants being
properly arranged, he was put under the full influence of chloroform.  A
V-shaped incision was made, the base towards  the margin  of the orbit, and
embracing the infra-orbital  foramen.  The flap thus formed was dissected
upwards to the margin of the orbit, and  the  dissection  was extended still
farther, so as to expose half  an inch of the osseous floor of the orbit.  There
was  some difficulty in finding the foramen, and in insulating the nerve, owing
to the matting of the tissues,  as well as to the  extensive and hard cicatrices,
resulting from  the previous operations, performed at the same point.  The
nerve, at its exit from the foramen, being found, with the hammer and chisel,
a portion of bone was detached from the margin of the orbit, so as to remove
the upper semi-circumference of  the foramen  infra-orbitale.  Another piece
of bone was now easily removed  from the anterior part  of the infra-orbital
canal, and a portion of the trunk of the nerve  was thus exposed.  The nerve
was  easily detached from the canal at this part, and about a quarter of an
inch of its trunk was exsected rapidly with the scissors.
     Although chloroform  was very freely administered, it was found almost
impossible to keep up the anaesthetic influence sufficiently to annul the pain.
While apparently insensible, when the nerve was touched with the instru- 
56
ments, he would start violently, uttering a fearful shriek, and would become
almost immediately perfectly conscious.
     This operation by excision effected a greater degree of immunity from the
severe symptoms than had been afforded by the mere division  or incision of
the nerve.  Up to this period, from the time of the first attack, the patient
had not been able to eat or drink without starting  the severe pain in the
face; the neuralgic paroxysms now, however, were not incited by the act of
swallowing.  In fact, the relief was immediate, and the disease seemed to be
cured.
     This relief from suffering was not of  long duration.  In February, 1856,
the paroxysms were again renewed with as much  intensity as ever, and the
patient again demanded another operation.  His condition was one of desper-
ation, and justified a resort to any means which held out the slightest prob-
ability of success.  I proposed to him, explaining the nature  of the opera-
tion, to lay open his face, trepan the antrum maxillare, separate the trunk of
the second branch of the fifth pair from its connections, as far as the posterior
part of the  antrum, and then to exsect a still larger portion of the nervous
trunk.  An  eager and ready assent was given to this suggestion, and on the
21st of February, 1856, I accomplished the operation in the following man-
ner :  An incision was made, commencing  opposite the  lower  border of the
left orbit, below the inner angle of the eye, and carried downwards and out-
wards, so as to terminate at a point about half an inch below the infra-orbital
foramen;  another incision, beginning at the lower border  of the orbit,  and
below the outer angle of the eye, was made so as to join the lower extremity
of the first.   At the junction of these two incisions, a sharp-pointed straight
bistoury  was now  thrust  through  the  cheek, and  the upper lip divided
entirely, midway between the median line and the labial  commissure.   The
V-shaped flap first made was dissected upwards, and the other flaps were thrown
inwards, towards the nose, and externally over the malar bone.  The fore part
of the antrum  maxillare, and lower margin of the  orbit  were thus  freely
exposed.   The situation of the foramen infra-orbitale was easily ascertained,
and the crown of a trephine, three quarters of an inch in diameter, was applied
upon the anterior wall of the antrum; the trephine grazing the lower border 
57
of the foramen.  A portion of bone was thus removed, so as to expose the
cavity of the  antrum.   The membrane lining this  cavity was  found to be
thick and velvety, and to present a dark maroon color.  The anterior portion
of the trunk of the nerve was sought for and found.   With a hammer and
delicate chisel the infra-orbital canal was laid open, and the nerve detached
from its bony wall, as far backwards as the posterior wall of the antrum.  The
operation was finished by exsecting, by a rapid movement of the scissors, to
the extent of about an inch, the nervous trunk thus laid  bare and exposed.
A pledget of dry lint was placed  in  the antrum, and the various incisions
brought together by means of the Carlsbad pins as sutures.
     Notwithstanding the  complete anaesthesia under which the patient was
kept, he would, frequently, when the trunk of the nerve was touched with the
forceps or chisel, jump  from the chair, as if struck by a powerful shock of
electricity.
     After this operation the unfavorable symptoms again disappeared, and
the patient flattered himself that a cure had been effected.  The paroxysms,
with  the exception of an occasional tic, abated, and he had such confidence
in his recovery, that he accepted an offer to visit Panama, New Granada, to
engage again in business.
     On the 20th September, 1856, he left the United States, and arrived at
the Isthmus of Panama  during the  following month.   Six months were
passed there without any annoyance  from the disease.   In the  month of
March, 1857, after exposure to cold, and sleeping in a damp atmosphere, the
pain again appeared with much severity.   It now seemed to commence from
a point in the upper maxilla, opposite the alveolar border, where the first
incisor tooth had been  extracted, and to dart backwards, with great acute-
ness,  towards the spheno-maxillary fossa.   The paroxysms  of pain were as
severe, although not so diffused, as those by which the disease was usherecl in.
    Forbes was again forced to relinquish  his business, and sailed for  New
York  city, where he arrived in the  latter part of April, 1857.  He paid me
a visit, and related to  me the  story of his recent  attack, with an air  and
expression of utter despondency.   In  fact,  he was again  laboring under all
the symptoms of Tic Douloureux.
            8 
58
     On the 20th of April, at his earnest request, I performed another opera-
tion  on him.  This consisted in dissecting back the tissues of the cheek, and
exposing  the antrum maxillare.  By the use of Luer's bone-cutters, I cut
away the outer  and lateral wall of the antrum, as  low down as the alveolar
margin  of the bone, so as to destroy the loop of nerves which results from
the anastomoses between the  branches of the posterior and anterior dental
nerves.  This operation, (the tenth,) was of very little avail.
     During the following three months, he resorted to the  free use of nar-
cotics, for the purpose of  annulling the pain.  In September,  1857, Forbes
again entreated me to do something for his relief, and I dissected the cheek
from the bone, by dividing the cicatrices which had been  recently formed.
This  afforded temporary relief, resulting probably from the local depletion.
     The cheek  and left upper lip were now insensible to the touch, and the
spasms  were aroused by eating or swallowing; or they occurred spontane-
ously.   The pain was referred, chiefly, to  the  upper maxillary bone, com-
mencing at the point where the two left  incisors  had been extracted,  and
darting  backwards, in different directions, towards the base of the skull.   A
few days only of partial relief followed, when the  pains were renewed with
such severity, that Forbes again besought another attempt, to procure some
amelioration of his suffering.
     From the failure of the operation by which about an inch of the trunk
of the second branch of the fifth pair of nerves had been removed, it  occurred
to me that the portion of the trunk which was left must be still in a diseased
condition, and that the train of neuralgic phenomena which were manifested,
was  to be referred to the  peripheric ramifications, emanating from the gan-
glion of Meckel, and also  to those  branches which emanated from the small
portion  of the  trunk  of the nerve  still remaining  in front of the foramen
rottindum.
     As  Forbes' case  at this time presented itself, I was  unwilling to cut
down again through  the  cheek, and seek  for the remaining  stump of the
nerve, in  order to exsect  this as well as  the ganglion of Meckel.  With a
faint hope  of mitigating the disease, on the second of October, 1857, I again
laid  bare  the  antrum,  and the bones of the cheek, by  making, through 
59
the soft parts of the cheek and through the lip, the same incisions which had
been made in my second operation, for exsection of a portion of the trunk.
With Liier's bone forceps, I then cut away the remaining portion of the ante-
rior and lateral portions of the antrum, with a part of the posterior wall of
this cavity; removing a part of the alveolar border of  the upper maxilla, so
as to encroach partially upon the  vault of the mouth; while, towards  the
nose, the portion of bone opposite the two left incisors was removed, as wTell
as a considerable portion of  the  ascending process of the superior maxilla.
By this operation, it was intended to destroy still further the several nervous
branches, running through the texture of the bones of the face, on the affected
side.   A dossil of lint was  laid in the cavity of the wound, and the lips of
the incisions brought together by the twisted suture.  The wround healed, but
a free  communication remained from the mouth with the antrum, between
the cheek and the edge of the vault of the mouth.
     As before, a cessation of the symptoms followed the operation.   But, the
paroxysms returned in a few  weeks ; with tempered severity, however, and at
longer intervals. When the  pain did not start as if spontaneously, impres-
sions  made  upon the  nasal,  buccal,  or  pharyngeal mucous membrane,
appeared to be the exciting or  immediate  source  of the  paroxysms.  It is
upon those surfaces  that the peripheric extremities of the branches, which
take their origin from  the ganglion of  Meckel, are  distributed.  In order,
therefore, to  change  the sensibility of the mucous  surface, I  began  to
cauterize freely, upon alternate  days, the mouth  and  pharynx,  as well  as
the antrum and cavity of the nostril,  with a strong  solution of nitrate of
silver, by injecting the  solution  into the  antrum from the mouth,  through
the communicating passage now existing.  By these  means,  and the occa-
sional use of narcotics, the patient  obtained very great relief.
     In addition to the action of the nitrate of silver upon the mucous surfaces
just mentioned, on  the 3d January, 1858, a seton was introduced  into  the
back of the neck, on the left of the mesial line, for the purpose of maintaining
a continued revulsive influence in proximity to the fifth pair of nerves.  From
this time, also, ten grains of quinine were daily administered internally. During
the twelve months following the  last operation (October,  1857), Forbes had 
60
comparative immunity from his disease ; occasionally, however, he would be
attacked with sharp shocks of pain, suddenly passing through the left side of
the face.  He had also returned to his business, and eat, drank, and slept
with comfort.
     This respite  from suffering was interrupted on the 15th October, 1858,
when he had, after  exposure to  cold, some severe and sharp paroxysms.
These were excited, principally, by the act of swallowing either fluid or solid
articles of food.  After continuing for two days, the paroxysms ceased, under
the influence of a cataplasm of stramonium leaves, and the tincture of aconite
administered internally.   At the date of November 4th, 1858, he was  so well
that he was about to resume his business, and on the preceding Tuesday he
went to the polls to deposit his vote as an elector.
     Notwithstanding his ameliorated condition, it cannot be said  that this
patient is cured.   It is not improbable that he will be liable at times to be
attacked with paroxysms of his disease.
     The operation for removal of about an  inch of the trunk of the  second
branch of the fifth pair—that most likely to remedy the disease—has failed to
effect a cure.  There still remains about half an inch of the trunk of the nerve,
in front of the ganglion of Meckel, with some branches coming from this portion.
If, at any time, the stump of the nerve thus remaining should become inflamed
or irritated, by the law which governs the transmission of nervous sensibility,
the localization  of the  pain would be referred, in a great  measure, to the
periphery  of the  branches which  spring  from the remaining part  of  the
trunk, as well as of those springing from the ganglion of Meckel.   Moreover,
the pain may also be referred to the check itself, and to those other parts which
were supplied by the lateral and terminal branches of the portion of the trunk
removed; upon the same principle which we see illustrated after  amputation
of the extremities—of the thigh, for example—where, after the removal of the
limb, the patient complains of pain in the foot,  i. e., at  the former periphery
of the nerves of the  stump.
     The portion of the trunk of the nerve removed last, was about  an inch
in length.  It was found  to be red, irregular, and enlarged;  presenting near
the middle a spot of yellow degeneration.   [ Vide Plate Xo. IV, Figs. 1, 2.] 
61
     I have been thus particular in relating the details of this case, on account
of its remarkable  character—remarkable on the one hand, for its duration
and protracted course, and  on the other, for the perseverance and  courage
displayed on the part of the patient.   The facts, also, which wTere developed
during the different stages of  the treatment, led me to project an operation
for the  cure of neuralgia of the second branch of the fifth  pair  of nerves,
which is novel, and which I believe to be the only one capable of curing this
affection.
     This operation consists in exsecting the trunk of the  second  branch of
the fifth pair, beyond the ganglion of Meckel, and, at the same time, remov-
ing this ganglion,  or insulating it and its branches from the encephalon.
     The  phenomena  of  Tic  Douloureux, I believe,  can  be explained by
referring them to the laws which govern the transmission of  sensibility, and
to the anatomical  distribution of the numerous ramifications of the fifth pair
of nerves.   The intricate and  almost infinite anastomoses of these ramifica-
tions must also be taken into consideration, in the analysis of the phenomena
of this  terrific malady.  The  gray matter, also, of which the different gan-
glions connected with the several  branches of the fifth pair, are composed,
must exert  considerable influence, by intensifying the sensibility;  because
they supply a continual flow of the vis nervosa along the nervous cords, and
the net-work which they form.
     While the case  of Forbes was under my supervision, other cases of  a
similar character w^ere presented to me for my advice.  In several instances
I performed the operation of exsecting the trunk of the nerve, as above stated,
and in each  instance with a satisfactory result.   In the following pages an
account is given of three cases, treated by exsection of the entire trunk, which
I have  transferred from The Am.  Journal of Med. Sciences, of January, 1858,
without alteration. 
EXSECTION
                             OF  THE
TRUNK OF THE  SECOND  BRANCH  OF THE  FIFTH
                     PAIR  OF  NERVES,
              BEYOND  THE GANGLION OF MECKEL,
                               FOB
     SEVERE  NEURALGIA   OF  THE  FACE;
                     WITH THREE CASES.
    The accounts of neuralgia of the face, or tic douloureux, heretofore given by
authors, are of a very vague and indefinite character.  Numerous essays and
monographs  have been written on this subject, since the time of Fothergill,
who published, in 1776, an elaborate description of the disease, which attracted
considerable  attention.  In all these efforts, the pathology of tic douloureux is
described with ambiguity.  In practice the treatment has been as empirical,
as it has proved to be unsuccessful.  The seat of the disease has been referred
to distant irritations, especially in the splanchnic cavities—to a foreign body
acting  upon  the nerve—to the pressure of bone upon some portion  of the
nervous trunks.   By some authorities,  it is referred to increased vascularity
and thickening of the nerves; while Astley Cooper, on the contrary,  states,
that the nerves present their natural color, and are rather diminished in size
than enlarged.  It can scarcely be supposed that beneficial  results should
follow from treatment based upon theories so different in character. 
63
     Tic douloureux of the face, proper, or of the second branch of the fifth
pair of nerves, is by far the most common form of facial neuralgia.  This may
be explained by the more numerous  branches, which are given off by this
trunk, and by the position which these branches occupy—in some places pent
up  in  osseous canals,  and in others  subjected to exposure, to changes in
temperature, as  well as to the agency of  morbific influences, from which the
other two trunks of the fifth ,pair are exempt.
     The same laws which govern neuralgic disease of one of the branches of
the fifth pair must be applicable to the disease in the other trunks.   I believe
that the phenomena of neuralgia can be explained with as much precision, as
in any other disease which is  well understood.   In cases similar to those
described below, whatever may have been the original exciting cause, I have
no doubt that the real seat of the disease  is in the trunk of the nerve, in front
of the foramen rotundum—in some part of it, or in the whole of it.  The causes of
the disturbed and changed condition of the trunks of the nerve may be numer-
ous—prolonged irritation upon the periphery—exposure—injuries—tumors—
diseases of the teeth—pressure resulting from periosteal or osteal thickening of
the osseous foramina or canals—sudden suppression of any of  the important
secretions, as of the catamenial discharge.  From one or more of these causes,
the trunk itself may  be primarily affected, or, acting upon its  ramifications,
the irritation may be propagated to it.  Prolonged irritation induces inflam-
mation, and this generally remains passive or chronic.  Some of the termina-
tions of inflammation—such as the effusion of lymph among the interstices of
the neurilemma  or the nervous tissue itself—may become developed; leading
to a vascular, engorged, thickened and enlarged condition of the nerve, or to a
softening of it, at one or more points.  In  fact, vascular  engorgement, or
inflammation, with some of its consequences, of the neurilemma alone, or of it
and the nerve together, by whatever  cause produced, is the condition which
constitutes the pathological changes in the trunk.
     The three cases  related below afford  proof of what has just been stated.
In each instance, the exsected nerve was  found to be red, vascular, engorged,
and considerably enlarged.
     The diffused character of the pain can be easily understood, if we take 
64
 into consideration the numerous ramifications of the second branch of the
 fifth pair, and the extensive surface over which their ultimate filaments are
 distributed.   The periphery of the nerve occupies not  only the superficial
 parts of the face, but extends  deep amongst  the bones of the upper jaw, to
 the nasal fossae, to the septum nasi, to the hard and soft palate, to the pharynx,
 to the inner ear, to the orbit, and to the temporal and malar regions.
     It is well established, that if the trunk of a nerve be irritated along its
 course, the painful  sensation will be referred to its periphery.  If the ulnar
 nerve, for example, be struck where it passes behind  the internal condyle, a
 sensation of pain is excited, which is referred  to the  little finger and to the
 ulnar border of the ring finger; and if a prolonged irritation be kept up at
 this point, the skin of these fingers becomes tender to the touch, the sensibility
 being very much increased.  The pain which  is felt, at the knee, in Morbus
 Coxarius, also illustrates this law.  " The  obturator nerve,"  Sir Charles Bell
 remarks, "passes through the thyroid foramen, down to the hip-joint, and,
 after supplying the muscles, is distributed upon the inner part of the knee.
 The nerve in its course is thus involved in the inflammation which affects the
 hip-joint, and the pain is referred to its  extreme  cutaneous branches, at a
 part distant from the seat  of the disease."
     It  is by this principle—which governs the action of the stimuli upon the
 nerves  of sensation—in connection with the anatomical  distribution of the
 nervous ramifications,  that the  various  phenomena  of  neuralgia can be
 explained.   The disease  being seated in the  trunk  of the nerve, we can
 readily understand that the pain must be referred  to  the peripheric extre-
 mities  of the nerves, and will  there  be  felt, as long as the branches are in
 communication with the encephalon.
     From these views, we can see how futile the operation of division of the
 nerve at the foramen infra-orbitale must be.  Where the trunk of the nerve is
 extensively diseased, no operation can rationally lead to a successful result,
 unless all the branches emanating from the trunk are  cut off from communi-
 cation with the brain.
     I believe that in such aggravated  cases of neuralgia,  the  key of the
operation is the removal of  the ganglion of Meckel, or its  insulation from the ence- 
 
Portion of thf Trunk of the second Branch, of the. FiM. Pair ofM
                       removed, from Fories.
erves.
Fig. /.
Fio. 2.
 d. ---■
s --


 a -■




 e - -
■d
f
a. Upper surfkee.. b, lower surface, c. Cranial cxtre-mity.
d. Facial extremity, e., Portion, ofcondensed tissue, taiing
  the place- of th* piece, of JVervc first removed, with.nervous
  fiires apparently,prolonged in.it. _ f  The-Verve, enlar-
  gedat this extremity. _  The A^riUmm* is se enredS
  engorged.
Trunk of thf. second iranch of thtFi/thPa.
  exsected from. Cordtilo.
Fig. 5.
The JVerve- is  seen, enlarged and engorged.
a, facial, extremity. _ o, Cranial- exta-mity.
C, Branchei forming the. ganglion of Meckel
d, Antcriorbranch coming from the 7ran A-,
in-the infra-orbital coned.
Shell * Valeria, ael.ad.-nat
Zeft trunk of the. second branch, of' thcFifthPair
     exs ccted from^X)Tflo asset.
Fig. 3.
r'ig. 4
 Tht.2Ve.rve is seen- vascular,  engorged and enlarged.
 a., Upper surfaces.-h.JCower surface. _r. Facial'extremity
 d. Cranial extremity. __  &. Ramifications from, the trunk,
given o£Fin.theinfra-orbital canal, passing to the-face and '
 surrounded with adipo-cellztlar tissues.
fVerve. removed- in.  Case.  3__

red thiektned-and irreaula-r.

              Fi#.6.
 a., f'acierl extremity. _ o. Cranial
 extremity. _ Z/%* Acuri7e?nma ?j-
parti ai(v re mo red.
C.Ctu-rierVLith.33 Spruoe S^NX. 
 >\:\  ,-a:«>  \- '■
■  ,■:    ir-;i '■•■
■ > .1  :   ' '  *•• "
■v  itrain  rota--..-
    ■•-.  ..lid OMi;*-»'
•vi- viokn('.   <
■•  wit!'   ■:
\ .  kii',';
Hi-1
!>'.•!.,  t>»;t  ■-•»■ 
 
(15
plialon.   Where even a large portion of the trunk of the second branch of the
fifth pair has been simply exsected from the infra-orbital canal, the ganglion
of Meckel continues to provide, to a great extent, the nervous ramifications,
which will still maintain and keep up the diversified neuralgic pains.  Besides,
the ganglion of Meckel, being composed of gray matter, mud play an important
part as a generator of nervous jMiver, of which, like  a galvanic battery, it affords
a continual  supply ; while the branches of the ganglion, under the influence
of the diseased trunk, serve as conductors of the accumulated morbid nervous
sensibility.
     Case I.—Henry Rousset, a French physician, residing in Greensborough,
Caroline county, Maryland, consulted me in the  early part of October, 1856,
for severe neuralgia, which  had for several years rendered him incapable of
following his profession.   He was of nervous temperament, good constitution,
and sixty-nine years of age.
     The disease  first made its appearance in September, 1851, commencing
with severe  lancinating  pains about the region of the  left cheek and orbit.
These pains continued for five or six days, and then disappeared, leaving him
almost free from them for about four months.   At the expiration of that time,
the  neuralgic pains again  returned, with more  violence, extending over the
region of the left  cheek, and continuing, almost without intermission, for more
than a week.  After this exacerbation, the patient again became compara-
tively free from  pain for a short interval;  after which, the attacks returned
with increased severity, and were renewed with greater frequency, more espe-
cially in the cold season, and in damp weather.   As the disease  progressed,
the pain was not confined alone to the eye and cheek, but would  also attack
the lip and nose; each paroxysm being of longer  duration than the preceding.
With but slight variation, the disease went on in this way to  harass and dis-
tress the patient for four years.  About the commencement of March, 1856,
the  neuralgic exacerbations assumed a more violent form, marked by excru-
ciating  and  almost unremitting  suffering.  He  was, at this  time, unable to
eat, drink, converse, or laugh,  without having a most violent paroxysm, caus-
ing him  to shriek in anguish.  The paroxysms were more severe during the
night than day ; sleep left him ; his constitution began to give way,  and his 
66
mind became much enfeebled.  The slightest touch upon the surface of the
face, a current of air or a mouthful of water acting on the palate,  would
throw  the patient  into  a violent paroxysm  of  agony.   During this long
period of suffering, all the known remedies which have at times been extolled
for neuralgia of the face  had been tried—narcotics, tonics, anti-spasmodics,
with counter-irritants, and galvanism—without producing any appreciable
result.   In this distressed condition, the patient, wearied of existence, and
unable any longer  to endure a life so made up of excruciating torture, pre-
sented himself to me for my advice, at the beginning of October, 1856.  He
expressed himself willing to undergo  any operation, however severe, which
held out the prospect of relief.  Having no internal remedy to propose which
had not already been administered, and having no faith in the mere division
of the  nerve upon  the face, I proposed to him the exsection of the  trunk of
the second branch of the fifth pair of nerves to a point beyond the ganglion
of Meckel.  Being  a physician  himself, I explained at length my views,  (as
expressed above,) in  regard to  this malady.   He  immediately consented  to
have the operation  performed, and desired  that a near  time  should be
appointed.  I consequently agreed to  perform the operation the following
day, the 16th of October.
     Operation.—The principal instruments necessary for this operation are a
trephine, the  crown of which is three-quarters of an inch in diameter, an
elevator, chisels of different  shapes  and  sizes, a  leaden or iron mallet, the
bone forceps of Liier, small pieces of sponge tied to a  stick or  a  piece  of
whalebone, and a small fixed trephine of half an inch in diameter, which may
be used to perforate the posterior wall of the antrum.  The assistants being
properly arranged, the patient  was seated  upon  a  solid chair, opposite a
good light, and was put under the influence of chloroform.  The head was
rested  upon the breast of an   assistant, who maintained it in  position.
An incision was now made  on the cheek, commencing near the internal
angle of the eye, on the inferior edge of the orbit,  opposite the anterior lip of
the lachrymal groove.   This incision was carried downwards  and  slightly
outwards, for  about an  inch, to a point opposite the furrow on the  lower
portion of  the  ala of  the  nose;   another  incision,  terminating at the 
67
same point, commenced about half an inch below the external angle of the
eye, opposite the edge of the orbit; thus forming a V incision, in the area of
which is situated the foramen infra-orbitale.  The flap thus resulting was thrown
upwards, and the branches of the second branch of  the  fifth pair of nerves
sought for: some of these being found, they served as a ready guide to the
trunk of the nerve.  This was now insulated from the surrounding tissues up
to the point of  exit upon the face  from the foramen.  The lip was now
everted, and the mucous membrane detached from the superior maxilla, along
the line of junction between the cheek and the gum.  A sharp-pointed  bis-
toury was now inserted into the mouth,  at the apex  of the V incision, and
carried  downwards, so  as to divide entirely the tissues of the cheek  and
upper lip, along a line passing midway between the ala of the nose and the
commissure of the lips.  The two flaps, thus formed, were now dissected from
the osseous tissue beneath;  one being reflected outwards, towards  the  ear,
the other internally, towards the nose.  The whole front wall of the antrum
maxillare,  with the nerve passing through the foramen  infra-orbitale, was thus
exposed.  The crown  of the trephine was now applied  on the anterior wall of
the antrum, immediately below the foramen infra-orbitale, and an irregular
disk of bone removed, so as to expose freely the cavity of the antrum.   The
circumference of the foramen, the hardest portion of the canalis infra-orbitalis,
was now destroyed  by Liier's forceps, and a small chisel.  The trunk of the
nerve was now7 traced along the osseous canal  in the floor of the orbit, which
was broken down wTith  care, so as  not to encroach upon the tissues in the
cavity of  the orbit.  Arriving at the back of the antrum, the posterior wall
of this cavity was broken down with a small chisel,  and the portions of bone
removed.   The trunk of the nerve  was now still further insulated  from the
other tissues in the  spheno-max Wary fossa.  The posterior dental nerves being
divided, and the dissection being carried still further,  the branches given off
to form the ganglion of Meckel were reached.   These  were divided,  and also
the branch given  off to  run up towards the orbit.  Lastly, by the use of
blunt-pointed scissors, curved  on  the flat side, the trunk of the nerve was
divided from  below upwards, close up to the foramen rotund inn.   The hemor-
rhage was not very profuse, the labial  arteries being easily controlled by 
68
pressure of the fingers, and the branches of the internal maxillary artery, in
the spheno-maxillary fossa, by dry lint, or, what  is  better,  the  compressed
sponge.  The  lips  of the wound were brought together and maintained in
place by  thirteen  points of twisted suture,  the  German or Carlsbad pins
being used.
     This  severe and  trying operation is  perfectly justified by the fearful
nature of  the disease for which it was projected.  It is one of those opera-
tions which could not be supported by the patient without  the influence of
chloroform.  The handling of so large a nervous trunk with the forceps, and
the necessary contact with  the  hard instruments, while  separating it from
its surrounding connections, would, I suppose, be beyond human endurance,
without the aid of the anaesthetic influence of chloroform or ether.  For the
rest, the effects of the  cicatrices upon the countenance can scarcely be called
disfiguring, and  the patient speedily recovers, without suffering from much
constitutional disturbance.
     In this operation, and in those connected with the two succeeding cases,
I was assisted by my colleague Prof. Cox, by Drs. Proudfoot, Abrahams, Sei-
dell, Guleke, and  Casseday; and by  my pupils, Messrs. Dougherty, Scud-
der,  and others.
     Condition of the Nerce.—The trunk of the  nerve, in this  case, was much
larger  than natural, in  nearly its whole extent.  The neurilemma was very
vascular, and  the  nervous tissue  proper was also engorged  and red: the
trunk, after its removal, was so red as to have somewhat the appearance of
muscular tissue.  The length of the nerve removed was a little more than an
inch and three-quarters.   The lining membrane of the antrum was sound, as
well also as the bones of the antrum and the osseous wall of  the cattails infra-
orbitalis.   [ Vide  Plate IV, Figs.  3 and 4.]
     Progress of Union and After-treatment.—Oct.  16th. Six  hours  after the
operation, the  patient Avas visited.   His pulse was 100; there was a slight
fever; he  complained of thirst, and  lemonade was ordered.  He spoke  of a
desire he had to vomit, which he ascribed to the chloroform.   He stated that
he felt slight twitchings on the nose, and at the corner of the lip.
     17th  (Friday). The patient was remarkably  well  under the circum- 
69
stances;  sitting up; pulse 90 ;  tongue lightly covered with  a white fur;
complained of pain in the wound, also of shooting pains in the left eye;  he
remarked that  he  could stick  a  pin  into the upper lip and cheek without
causing pain, there being no sensation in that  region.  Ordered  chicken
broth, and wine and water.
     18th (Saturday). Patient improving;  wound healing; pulse natural;
no fever;  spoke of the numbed sensation in his face.
     19th  (Sunday). Pulse full  and  natural;  good appetite;  partook of a
beefsteak; in the  afternoon four suture  pins  removed; slight pain in  the
wound ; no return  whatever of the neuralgia.
     20th (Monday). Cure progressing;  healthy  suppuration  from wound;
appetite  excellent; general health much improved.
     (Tuesday,  Wednesday, Thursday.) During these days the rest of  the
pins were removed; patient felt no  pain whatever either in the wound or
cheek; wound in the antrum syringed with tepid water.
     25th (Sunday-). Patient attended church; felt no pain whatever;  in-
cision of the upper lip and cheek entirely healed.
     28th.  Patient entirely well.
     30th.  Returned home to Maryland in high spirits, and delighted at the
result of the operation.
     December 7th, 1857. Fourteen months after  the operation he writes to
me  that  he is  enjoying  excellent health, and has  been entirely free from
neuralgic pain.
     Case II.—Florence Cordello, a native of Italy, aged 54 years, of lymph-
atic  temperament,  chocolate maker by  trade, was admitted to the State
Hospital on the 14th of September, 1857, suffering from severe tic-douloureux
of the left side of the face.  The following is the account handed to me by
the Assistant Surgeon, Dr. Guleke.  In the year 1828, the patient contracted
a very severe  cold from exposure, and about this time he was  seized with
the pain for the first  time.   According to his owm description,  the  pain
started from the foramen infra-orbitale, extending upwards to the forehead, 
70
and  downwards into  the teeth ; the paroxysm lasting  about ten minutes.
He supposed it to be toothache, and had one or two teeth extracted.  An
interval of eight years took place, when he was  again  attacked with neu-
ralgic paroxysms, lasting from  five  to ten minutes.  Again, after the lapse of
a year, the paroxysms reappeared in a more severe form, and  at shorter
intervals.
     The patient, still believing his teeth to be the source of the disease, had
all of them extracted on the  left  side of the upper jaw,  but  without any
benefit.  During these attacks  he had been subjected  to  many kinds of
treatment, both internally and externally: he  also repaired to  some of the
mineral springs on the Rhine, but still to no purpose.  He continued thus to
suffer more or  less intensely from the neuralgic paroxysms, for a period of
time extending from 1837 to 1846, and with detriment to his general health.
In 1846, while  passing through the city of Heidelberg, in Germany, he con-
sulted the  celebrated Chelius with the hope of obtaining  some beneficial
result from his  advice. That professor divided the nerve as it emanated from
the infra-orbital foramen, by incisions from the mouth; and, six weeks  after,
again performed the same  operation, without  any favorable result.  During
the next six years the patient continued to suffer from neuralgic paroxysms
of more or less  intensity.
     Oppressed by extreme suffering, he again sought relief from an opera-
tion, and in 1852 the  nerve was again divided from the mouth, by forcing up
the lip ; the actual  cautery being at  the same time applied, by pushing the
instrument from the  mouth upwards into the wound, as far  as the foramen
infra-orbitale.   This operation  appeared to give some relief, and during the
two  succeeding years the patient's sufferings were  somewhat  alleviated.
About two years ago,  the paroxysms  returned in the most aggravated  form
progressed,  and continued without much abatement.   On the 1st of Sep-
tember last,  being  in New York,  he again  submitted  to  an operation for
division of the  nerve.   This time, the branches of the nerve were divided by
cutting through the  integuments,  directly upon  the infra-orbital foramen;
an operation causing  no  other effect  than insensibility to the touch in the
soft tissues near the infra-orbital foramen.   Two weeks after this, he entered 
71
the State Hospital.   The condition of the  patient was then as follows : Not-
withstanding the repeated division of the nerve, there was sensibility to the
touch over the whole region of the  cheek;  the inner  side of the lip alone
appearing to be insensible.  The patient describes the pain as starting from
the foramen  infra-orbitcde, extending up as far as  the ligamentum palpebrce
internum, and also to the external corner of the eye:  from the latter point,
the pains shot dowm in  nearly a straight line to a point  about one  inch to
the outside of the left corner of the  mouth,  and a little below a line drawn
horizontally on  a level with the commissure of the lips.  The pains, also,
extended backwards, through the  more deeply-seated  portions of the face,
shooting from the inner  corner of the eye, along the base of the nose, and
striking backwards towards the spheno-maxWary fossa.  The pain was of the
true neuralgic character, and so intense as to drive the patient into a con-
dition verging on delirium.  A slight touch on the cheek, the inside of the
mouth, or on the hard or soft palate,  swallowing, or  speaking, excited almost
instantaneously the paroxysms in their severest form.
     T/ie Operation.—The operation in this case was performed after the same
manner as  the preceding, and was modified only by the greater depth of the
antrum and face.  There was also more hemorrhage from  the spheno-maxil-
lary fossa;  this was controlled  by  compressed sponge pressed into the fossa,
Supposing  the hemorrhage might return, the lips of the wound were brought
together by adhesive plaster, one suture only being  used.  The other sutures
were inserted the following day.  The nerve was cut from  above downwards.
The ganglion of Meckel was drawn out, hanging to the  trunk of the nerve.
     Progress of Union and After-treatment.—Compressed sponge was  applied
in the deeper  portion of the wound; the external surface was  closed with
one suture; an anodyne was ordered for the night.
     Oct. 11  (Sunday). Patient slept wrell during the  night; pulse  76 ; no
bleeding; five suture-pins applied ;  ordered an anodyne.
     12th.  Patient slept well;  no  pain whatever;  pulse 84: complained of
thirst; but little appetite; spoke and swallowed without pain.
     13th.  Slept badly; had an attack of dysentery; pulse 96 ; felt  a slight
pulsating pain  in the wound, wThich, however, was doing well; stated  that 
72
there was no feeling over the surface of the left cheek, from the inner angle
of the  eye, descending along the nose  to the lip, and  upwards to the outer
angle of the  eye,  including  the lower lid;  ordered  opium and quinine.
[Afternoon), dysentery subdued; pulse 96 ; more cheerful.
     14th. Patient improving ; pulse 92 ; a number of the pins removed.
     15th. Remaining pins removed; wound presented  a healthy appearance;
pulse natural;  slight  pain felt in the course of the wound.
     16th. Removed the piece of compressed sponge, which had been placed
at the  back  of the antrum, during the operation, to  restrain the bleeding
from the spheno-maxillary fossa.
     18th. Patient doing well; eat well, and slept naturally.
     26th. Still entirely free from neuralgic pain; the whole expression of
the face changed  from  that of  suffering and anxiety, to cheerfulness and
serenity.
     28th. Discharged from  the  hospital entirely cured, and in good  health
and spirits.
     Dec. 8th. Visited the hospital;  still free  from  pain, and in good con-
dition.
    Condition of the Nerve.—The nerve in this case exhibited the same appear-
ance as  in the previous one.  It was thickened, vascular, and  engorged.
The neurilemma and  proper tissue of the  nerve were both affected.  The
length of the trunk removed  was two inches.   [ Vide Plate IV, Fig.  5.]
     Case III.—Mrs. Mary  *****  a native of Portsmouth, England,
and who had borne children, 55 years of age, of full habit and sanguineous
temperament, consulted  me, in the month of September,  1857, for severe
neuralgia of the left side  of the face.   She had been a resident of the North-
ern States  for  thirty years, and  had enjoyed,  generally, remarkably  good
health.
     On the 12th of August, 1851, while eating a plum in her garden, she was
suddenly seized with a vivid shock of pain, commencing on her cheek, and
passing through her jaw, as if caused by a sharp-pointed instrument, sud- 
73
denly driven through her face; shooting pains of this character, with inter-
missions of entire abatement, continued for several days.   A dentist was con-
sulted, who, attributing the symptoms to the teeth, extracted several of them,
but without the slightest benefit to the patient.  The paroxysms continued,
with more or less severity, for two months.
    At the end  of this time, they suddenly abated in their  severity; the
respite lasting for about six weeks.   Upon hearing of the sudden death of a
friend to whom she was much  attached, the paroxysms were again renewed,
with greater frequency; the intensity of pain increasing more and more with
each  succeeding  attack.  During the  year  1852,  the pain and paroxysms
still continued with unyielding severity.  The tic would  now last for  two
and three months, with scarcely any of  the intervals which had heretofore
occurred.  Cold  air,  the  drinking  of fluids, the slightest touch upon the
cheek,  or any sudden  mental emotion,  would invariably excite the most
fearful paroxysms.   During the year  1854, her condition was not in  any
way ameliorated; the pain, if possible,  was more  severe, and her general
health suffered from  the want of  rest.  During the year  1855, the disease
progressed  with  the  same severity.  In the  early part of the year 1856,
the paroxysms became  still more aggravated ; the patient, at  times, becom-
ing almost  delirious—starting up, running  about  her room, and screaming
like a maniac.   In  the latter part of September, she sought relief from a
surgeon in  this city, who divided,  by subcutaneous  incision, the branches
of the infra-orbital nerve, as it issues from the infra-orbital  foramen.
     About this time, she also  took large quantities of various  narcotics, and
of the carbonate  of iron.   After the operation, she experienced some relief.
The amelioration continued from October, 1856, until May, 1857, when the
paroxysms were again renewed in their severest form.
     The pain nowr became almost continual, depriving her nearly entirely of
sleep ; she was unable  to eat without torture,  the act of swallowing invaria-
bly bringing on  a paroxysm.  During  these  exacerbations,  the pain  was
diffused in different  directions, extending from a  point  a little below the
infra-orbital foramen, or from the ridge of the gums, and striking through the
superior maxillary bone, towards the deeper portions of the face, and towards
            10 
74
the orbit;  and sometimes extending towards the region in front of the ear.
She described the pain as of a beating character at times ; each shock suc-
ceeding another in rapid succession, as if keeping time with the ticking of a
clock.   During this long period of suffering, she had been under the alternate
care of several physicians; the various  remedies most approved  of in this
kind of disease had  all been faithfully  and sedulously tried;  stramonium,
aconite, belladonna, hemlock, opium, morphia, chloroform, carbonate of iron,
valerianate of ammonia, and  other medicaments  had  been  administered
internally ; while externally, in addition  to the division of the nerve, blisters,
sinapisms,  hydrocyanic acid liniment, tincture of aconite, and chloroform had
been resorted to—also  electricity and galvanism.  At  the  time I was con-
sulted, she was suffering night  and day  from repeated and  excruciating
attacks, and, as she herself stated, she had  visited the city to have an opera-
tion performed at all hazards, however desperate it  might be, if I could only
hold out any prospect whatever  of its affording relief.   Her general health
was tolerably good,  and  she  did not complain  of loss of  appetite.   I
explained to  her the nature  of the operation,  which I believed to be the only
one suited to her case.  She immediately assented to submit to it as early as
possible.
     The operation was  performed  after  the  same  procedure as  heretofore
described.  The face was in this instance, also,  very deep.  The hemorrhage
from the spheno-maxillary  fossa was considerable, and  was stopped by  a
piece of compressed  sponge, to  which  a  strong ligature was attached, by
which it could be removed.
    Progress of Union and After4reatmerd.—Nov. 5th (Thursday evening). As
soon as the operation was completed, the patient retired to her bed.   Vom-
iting came  on a few hours after, owing, probably, to the quantity of chloro-
form which had been  used.
    6th. Had slept tolerably well  during  the  night; felt  very little  pain;
pulse 80 ; no fever ; complained of some pain in the wound, but had no neu-
ralgic pain.
    7th. Left side of the face slightly swollen ;  pufnness about the eyelids ;
has no pain; has slept well without any anodyne;  states that she feels bet- 
75
ter than  she  has for months; pulse 80 ;  skin natural; slight thirst; five of
the suture pins  removed; line of incision looks as though union by first
intention was going on favorably.  Still  kept on fluids for nourishment—
gruel, rice-water, ice-water, toast-water, and chicken tea.   Ordered a gentle
aperient.
     8th. Had slept well; tumefaction of face subsiding ; complains of head-
ache ;  cloth wetted with cold water applied on forehead; same diet con-
tinued ; pulse natural; removed  the  sponge which was  used to stop the
bleeding from the spheno-maxillary fossa ;  this came away without any diffi-
culty by slight traction, a little blood following.  Complains of slight pain
in the  orbit.   Removed six  suture pins, leaving one only—that uniting the
free border of the lip.  Fluid diet as before.
     9th. Patient slept well; headache less; pulse 78 ; no neuralgic  pain ;
a weak solution of the tincture of arnica ordered, to bathe the cheek  with;
removed the  last pin; union by first intention, along the line of incision,
complete.
     From the 9th until the 16th all has progressed favorably.   No neuralgic
pain  whatever;  sleeps well;  sweUing  on  cheek  diminishing;  pain  has
entirely  left  the orbit;  secretion into the mouth from the wound in the
antrum diminished.  Ordered a gargle of the tincture of myrrh.  Appetite
has also returned.  Had been sitting  up, and walking about her room with-
out any inconvenience.  Has taken a little sulphate of magnesia; has not
required any anodyne.
     Dec. 3d.  The patient  has been progressing favorably up to this time.
The wound has healed entirely;  the line of cicatrix is becoming effaced ; not
the slightest trace of tic douloureux remaining.  There is no paralysis  of the
muscles of the face upon the side operated on.
     In this case, the nerve wTas enlarged, very vascular, thickened and  red.
About two inches of the nerve were removed.   [Vide Plate IV, Fig. 6.] 
76
     The bones of the cranium are liable to expansion, or thickening of their
texture, from inflammatory action,  most commonly  dependent  upon  some
constitutional taint.   If the os sphenoides happened to be the seat of such dis-
ease, one  or more of the foramina for the transmission of the nervous trunks
might become very much contracted.  A question might arise as to the effect
of compression, from this cause, on the trunk of the second branch of the fifth
pair, at the point where it is surrounded by the osseous sides of the foramen
rotundum.  From what  has heretofore  been stated,  in  relation  to the law
which governs the transmission of  morbid sensibility along the trunk and
branches  of  a nerve, subjected  to an irritating cause, we should infer the
supervention of neuralgia of the face, of the most severe character.  In such
a case, the operation of exsection of the trunk of the nerve, beyond the gang-
lion of Meckel, offers the best hope for relief; for, besides the removal of the
trunk of the nerve, thus far, direct  local depletion is obtained  at the seat
of the irritation ; and, moreover, the portion of the nerve, placed  in the fora-
men, will, most probably, become atrophied or diminished.
     Pathological records corroborate the opinion which locates the seat of
facial neuralgia on the nervous branches or trunks, after  they have emerged
from the  encephalon.
     After the section of the fifth pair of nerves, within  the cranium, it is a
well established  fact that the general sensibility is annulled in the superficial
and deep parts  of the  face; that their nutrition and their secretions are
more or less perverted;  and that the functions of the organs of  special sense
are disturbed.  From this physiological fact, we arrive at the important diag-
nostic conclusion, that disease, involving the trunk of the fifth pair, and the
ganglion of Gasser, so as to compromise its connections with the  grand sym-
pathetic, must be attended with pathological manifestations in the external
organs of sense;  the most remarkable of which are observed in the globe of
the eye.
     Cases illustrating this statement—important also in regard to the prog-
nosis—are related by Herbert Mayo, Abercrombie, and others.    The  follow-
ing case, published by M. Serres  (Anatom. Comp. du  cerveau, etc.), is to the
point: 
77
     " A droite, rinsensibilite' de la conjonctive e'tait telle qu'on pouvait passer
entre les paupieres et le globe de I'ceil les barbes  d'une  plume sans que le
malade s'en apercut;  il y avait immobilite complete du globe de I'oeil et de
ses de'pendances ; la narine droite e'tait e'galement insensible a I'introduction
d'un  corps  e'tranger; toutefois  l'odorat n'avait pas comple'tement disparu.
Le malade ne recevait aucune impression de 1'application du sulfate de qui-
nine sur la moitie' droite de sa langue.   Les  gencives  du me1 me cote' etaient
molles, fongueuses, noiratres, de'tache'es des os.   II y avait eu successivement
inflammation de I'oeil  droit, coarctation de la  pupille, opacity de la corne'e et
enfin perte de la vue,   L'oui'e e'tait diminue'e a droite quelques jours avant la
mort.   A Xouverture du  cadavre, on trouva la cinquieme paire ramollie  a son
origine, jaunaire et presqne ge'latiniforme.  Cette alteration s'enfoncait a une ligne
ou deux dans la protnbSrance  anmdaire.   Le gancjlion de Gasser, de  ce c6te' 6tait
dune ligne et demie plus large que du cdte' sain ;  il e'tait jaunaire.  Quant a la
petite racine du trijumeau, elle e'tait intacte." 
 
 

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