Neuralgia of the Right Trigeminal Nerve 
of Eight Years Duration; 
Excision of the Three Divisions at the Gasserian Ganglion ; 
Recovery, with Partial Destruction of the Ganglion. 
BY 
J. T. ESKRIDGE, M.D., 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF 
THE UNIVERSITY OF COLORADO; NEUROLOGIST TO THE ARAPHOE COUNTY, 
ST. LUKE'S, AND DEACONESS' HOME HOSPITALS; 
AND 
EDMUND J. A. ROGERS, M.D., 
PROFESSOR OF SURGERY IN THE UNIVERSITY OF DENVER; SURGEON TO THE ARAPAHOE 
COUNTY, ST. LUKE'S, ST. ANTHONY'S, AND DEACONESS' HOME HOSPITALS. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
July, 1895. Extracted from The American Journal of the Medical Sciences, July, 1895. 
NEURALGIA OF THE RIGHT TRIGEMINAL NERVE OF EIGHT 
YEARS' DURATION; 
EXCISION OF THE THREE DIVISIONS AT THE GASSERIAN GANGLION; 
RECOVERY, WITH PARTIAL DESTRUCTION OF THE GANGLION. 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF THE UNIVER- 
SITY OF COLORADO ; NEUROLOGIST TO THE ARAPAHOE COUNTY, ST. LUKE'S, 
AND DEACONESS' HOME HOSPITALS ; 
By J. T. Eskridge, M.D., 
Edmund J. A. Rogers, M.D., 
AND 
PROFESSOR OF SURGERY IN THE UNIVERSITY OF DENVER ; SURGEON TO THE ARAPAHOE COUNTY, 
ST. LUKE'S, ST. ANTHONY'S, AND DEACONESS' HOME HOSPITALS. 
History and Examination by J. T. Eskridge, M.D. 
James L., aged forty-five years, born in Ireland, single, engaged as a 
laboring miner in Colorado eighteen years, has been suffering from neu- 
ralgia of the right trigeminal nerve since March, 1885. His father was 
very intemperate in his youth; his mother died in childbirth. No 
nervous or mental diseases in the family. One brother died of consump- 
tion. In childhood the patient's health was excellent. He denies 
syphilis and alcoholism. Fifteen years ago he suffered from what his 
physician called scurvy. He had been living on salted food, and his 
feet and legs swelled, and he was weak. In 1883 he had an attack of 
typhoid fever. From 1883 to 1885 he suffered from rheumatic pains in 
joints while working under ground in wet mines. In February, 1885, 
he had a severe attack of rheumatism, with swollen and painful joints. 
The wrist, elbow, shoulder, knee, and hip-joints were involved. In 
March, 1885, he began to have pain in the region of the right inferior 
dental nerve. The attack was extremely severe for three weeks, and after 
this the pain was constant, but not so severe. The pain was limited to 
this nerve. Within a year from the time the neuralgia first began it 
had extended to the region of the face in front of the right ear, and 
involved an area there one or two inches in diameter. After the exten- 
sion of the pain to the region of the right ear it became intermittent. 
He would suffer for a few days from severe pain in the inferior dental nerve, 
the next day from a dull pain in front of the right ear, when he would 
be free from pain for several days. The pain in 1889 occasionally 
extended to the superior maxillary nerve. The first division of the fifth 
cranial nerve was never involved. At this time the pain became con- 
stant again, with periods of severe exacerbation. Before this time he 
had several teeth extracted on the right side from the lower jaw, but he 
obtained no relief. During the summer of 1889 he had all his remain- 
ing teeth-twenty-three in number-extracted. This seemed to intensify 2 
ESKRIDGE, ROGERS: TRIGEMINAL NEURALGIA. 
his suffering, and his pain then was not only constant, but severe. The 
next three years were spent in seeking relief from his intolerable agony, 
but he never obtained more than three or four weeks' freedom from pain 
at any one time. He first consulted me on November 25, 1892. He is 
a heavily built, muscular man, and weighs about two hundred and 
twenty-five pounds. On careful examination no symptoms of impaired 
health are found outside of the regions of distribution of the second and 
third divisions of the right fifth cranial nerve. The absence of natural 
teeth, whose place has not been supplied by artificial ones, has resulted 
in permanent contractures of the masseter muscles, and it is impossible 
for him to open his mouth to the normal extent. The gums on the right 
side of the lower jaw and the lower lip on the right side are hyperal- 
gesic, and the slightest contact of substances, especially if their tempera- 
ture is cool, often causes violent paroxysms of pain. The gums have 
remained so sensitive since the extraction of his teeth that it has been 
impossible for him to endure the presence of a plate for artificial teeth, 
and during the last three years he has been compelled to live on liquid 
or semi-solid food. Tactile-sense is a little blunted on the lower lip on 
the right side. Temperature-sense on the right side of face, especially 
on the lower portion, remains about normal, except an increased sensi- 
tiveness for cold. Vision, hearing, and smell seem to be nearly equal on 
the two sides. Taste is more acute on left side. As he had undergone 
the various forms of treatment for relief of neuralgia of the fifth nerve, 
I advised him to have the three divisions of the nerve excised at the 
Gasserian ganglion. 
He entered St. Luke's Hospital the next day with the expectation of 
having this operation performed, but after he had remained in the hos- 
pital a few days his courage began to fail him, and he asked to have the 
superficial operation, of which he had heard, instead. I placed the 
patient under the care of Dr. Edmund J. A. Rogers, one of the surgeons 
of the hospital, and he, in the latter part of November (1892), excised 
a portion of the right inferior dental nerve in the dental canal. This 
procedure was acquiesced in by Dr. Rogers and myself, the more readily 
because all his paroxysms of pain started in the inferior dental nerve. 
At the same time we informed our patient that nothing more than tem- 
porary relief from pain would be likely to follow such an operation. For 
four or five days after this operation he was entirely free from pain. For 
the next two months, or until about the 4th or 5th of February, 1893, 
he experienced a momentary shooting pain in the right side of the lower 
lip once or twice daily. During these two months he had no pain or 
sore feeling in the front of the right ear, the region which had been the 
seat of constant pain for several years. Early in February, 1893, he 
took a cold. Immediately the face pain began to increase. The right 
lower lip, which after the operation was completely anaesthetic, became 
the seat of constant pain. Although the sense of touch was absent, yet 
a cup placed to his lips caused intense suffering throughout the distribu- 
tion of the right inferior dental nerve. The pain spread over the region 
supplied by the second division of the right fifth cranial nerve. The 
slightest motion of the lips was sufficient to cause a paroxysm of neural- 
gia; even the act of swallowing was attended with severe pain in the 
second and third divisions of the nerve. After the middle of February 
he stopped work, and by the early part of March the suffering became 
so intense that he meditated suicide. Rather than take his own life, he ESKRIDGE, ROGERS: TRIGEMINAL NEURALGIA. 
3 
decided to return to St. Luke's Hospital, and have the major operation 
performed. He entered the hospital the 9th of May, and the operation 
was performed on the 23d of the same month. Before the major opera- 
tion he had grown quite nervous and depressed. The region of distri- 
Fig. 1. 
Normal distribution of the fifth nerve to the face. (From Flower.) 
Fig. 2. 
Deeply shaded area represents almost total anaesthesia in case operated upon; 
light area, partial anaesthesia. 
bution of the right inferior dental nerve remained anaesthetic to touch, 
the same as it was immediately following the excision of this nerve. 
Pain was limited to the second and third divisions of the right trigeminal 
nerve, the first division never having been affected. Immediately after 4 
ESKRIDGE, ROGERS: TRIGEMINAL NEURALGIA. 
the second operation he was relieved of pain, and he has remained 
entirely free from it up to the present date, September 12, 1893. 
Present condition. Patient has gained several pounds in weight since 
the operation, and feels quite well. 
It will be seen that the first division of the nerve was not completely 
excised. Taste is absent in the right anterior portion of the tongue. 
Smell is present and equal on the two sides. 
Hearing: right, 1/12 ; left, 1/6. Tuning-fork is heard better in left 
ear. 
Since the operation he has complained of an annoying sensation, 
which he describes as a " feeling that he is breathing through the right 
ear when the mouth is closed." He states that he has had a constant 
dull feeling in the right ear since the operation, and two weeks subse- 
quent to the operation the sound of his voice began to be intensified in 
the bones in the front of his right ear. This sensation has increased, and 
at times it is annoying. 
Condition of Eyes by Dr. E. C. Rivers. 
The palpebral opening in the right eye is considerably wider than the 
left, and is apparent at a glance. The movement of the eyes is the 
same in all directions. Pupils equal and normal in size. Reaction to 
light and convergence normal. The sensibility in the right eye is very 
much reduced all over the cornea and conjunctiva, but everywhere 
present. Patient thinks it over one-half that experienced when left eye 
is touched in the same manner. 
Vision: O.D., 20/100; O.S., 20/20. 
Hy., 4.50 D., previously corrected. 
Examination macroscopically and by oblique illumination shows : 
Right eye: Cornea superficially cloudy throughout all that portion 
unprotected by the lids. The cloudiness is due to exfoliation of the 
superficial epithelial layers, and accounts for the diminution of vision, 
as when the pupil is dilated the vision improves to 20/70. The ophthal- 
moscope shows no abnormal condition of the rest of the optic media. 
Left eye : Normal, except Hy. 
When I examined the patient, about four weeks after the operation, 
there was no sensibility of the cornea of the right eye, and no cloudi- 
ness. Vision at that time was equal to the left eye-20/20. About the 
20th of July I examined him again, and found the cornea insensitive 
everywhere except at the upper portion, at one point near the periphery, 
immediately above the middle of the cornea, where he could feel the 
contact of a probe. 
Operation by Dr. Edmund J. A. Rogers. 
The first operation, performed on November 28, 1892, was begun by 
a long free incision parallel to the ramus of the jaw and just beyond 
the face line. The flap was reflected forward, and the attachment 
of the masseter muscle scraped away from the broader portion of the 
jaw, just about the angle. A three-quarter-inch button was then tre- 
phined from the outer table of the jaw, and lifted to expose the canal. 
The nerve was then hooked out and drawn from both directions, and 
about three-quarters of an inch excised. No antiseptic was used during 
the operation. The operation at the time was very satisfactory to the ESKRIDGE, ROGERS: TRIGEMINAL NEURALGIA. 
5 
patient, and he left the hospital in a very happy frame of mind. There 
was considerable callus thrown out, but repair was so complete that 
when he returned to the hospital in May it was impossible from appear- 
ances to say which side had been operated upon. The two of my con- 
freres who examined it both named the opposite side, as there were some 
old scars on the neck there from some early skin disturbances. 
The agony that he suffered during the days that he was in the hospital 
before the second operation is beyond description. He would sit in a 
corner where no movement of air could reach him, and would not move, 
speak, or swallow if he could avoid it, on account of the severity of the 
paroxysm of pain which he endured. 
On May 21st, after thorough preparation, he was placed on the table 
for the major operation. Chloroform was used as the anaesthetic, and he 
took it very badly. After the face incision had been made and the flap 
partly reflected, his heart failed almost completely, he became cyanosed, 
and death was imminent. With difficulty he was revived, but so slowly 
and so incompletely that it was decided that he could not stand the 
operation then. The wound was closed and dressed, and he was put 
back in bed, where in a few hours he fully recovered. On the 23d, two 
days later, the operation was again undertaken, ether being now used as 
the anaesthetic. We were assisted in the operation by Drs. Parkhill and 
Bagot, Dr. Atchison, of the resident staff, giving the anaesthetic. Rose's 
operation, as detailed by him, was closely followed, with few exceptions. 
The manual labor of the first part of the operation is very trying, and 
when the second portion is reached one has already done considerable 
manual labor. The internal maxillary artery was not ligated. It 
could easily be felt, and pulsation was visible by the electric illumina- 
tor ; but it was not easily isolated, and after an aneurism-needle had been 
passed around it pulsation disappeared and did not return. No vessel 
was ligated throughout the operation. On tearing away the attached 
muscles from the base of the skull the blood oozed in slowly from all 
sides, and this, together with the great size of the patient's head (he 
requires a No. 8 hat), rendered it impossible to make any use of light 
in the deeper part whatever, and all the essential part of the operation 
had to be done by tactile sensation. The foramen ovale was easily made 
out and the nerves traced to it. I trephined well to the outer side of it, 
and then, with the chisel and mallet, cut through the intervening bone. 
I had hooks specially made from Rose's model, but found them too small 
to be of much service, working at so great a depth, and my only guide 
was tactile sense. Having made a free opening, by means of which I 
could easily feel the presumed site of the ganglion, I passed a sharply 
curved aneurism-needle under the ganglion and raised it from its bed. 
I then, by means of the sharp hook and other instruments, completely 
dismembered its substance down to my aneurism-needle. Being unable 
to see, this was a tedious and unsatisfactory proceeding. I then picked 
away the upper portion of what seemed to be the ganglion as high up 
as I dared go. I did not wash out the wound in any way, as the con- 
stant oozing of blood had kept the wound irrigated. I removed the 
coronoid process of the jaw entirely, and, to save time, followed Dr. Park- 
hill's suggestion of stitching the zygoma to the temporal fascia, instead 
of wiring it. I closed the wound completely and dressed it. No antisep- 
tic was used in the wound or in the dressing, and no vessels were ligated, 
the oozing being allowed to fill the wound as it was closed. The patient 6 
ESKRIDGE, ROGERS: TRIGEMINAL NEURALGIA. 
expressed the greatest sense of relief on coming out of the anaesthetic, 
one of his first expressions being that he " would rather undergo the 
operation once a week than endure the agony." Convalescence was slow 
and uncertain, but in the long run very satisfactory. His whole ner- 
vous system seemed to have received a shock which rendered its mechan- 
ism very uncertain. For a few weeks the patient seemed very hysterical. 
For slight causes he would become very emotional, and from very slight 
disturbances his temperature would vary many degrees. No symptoms 
of septic infection manifested themselves, and, surgically, the recov- 
ery was very satisfactory. When the wound was first dressed it was 
found completely closed, and has given no trouble since. I had pho- 
tographs of his full and side face taken the day before the operation 
and taken again now. From these it can be seen that the disfigure- 
ment is very slight. The region about and below the zygoma is 
slightly sunken, but hardly enough to attract attention. The most 
trouble in the after-treatment was from the anaesthesia of the con- 
junctiva, it being a couple of months before it could be left uncovered 
without some irritation manifesting itself. 
August 10, 1894, the patient writes that he has had no return of the 
pain, and all discomfort in the right ear and around it has disappeared.  Jodrpal 
ofthe MEDICAL SCIENCES. 
MONTHLY, $4.00 PER ANNUM. 
WITH 1895 The American Journal of the Medical Sciences enters upon its seventy- 
sixth year, still the leader of American medical magazines. In its long career it has 
developed to perfection the features of usefulness in its department of literature, and 
presents them in unrivalled attractiveness. It is the medium chosen by the leading minds 
of the profession on both sides of the zXtlantic for the presentation of elaborate Original Articles; 
its Reviews are noted for discernment and absolute candor, and its Classified Summaries of 
Progress each month present an epitome of medical advances gleaned by specialists in the 
various departments. According to unquestionable authority, " It contains many original papers 
of the highest value; nearly all the real criticisms and reviews which we possess, and such 
carefully prepared summaries of the progress of medical science and notices of foreign works that 
from this file alone, were all other publications of the press for the last fifty years destroyed, it 
would be possible to reproduce the great majority of the real contributions of the world to medical 
science during that period." * 
Ttye Medici New's. 
WEEKLY, $4.00 PER ANNUM. 
BY KEEPING closely in touch with the needs of the active practitioner, The News has 
achieved a reputation for utility so extensive as to render practicable its reduction in 
price from five to Four Dollars per annum. It is now by far the cheapest as well as 
the best large weekly medical journal published in America. Employing all the recognized 
resources of modern journalism, such as the cable, telegraph, resident correspondents, special 
reporters, etc., The News furnishes in the 28 quarto pages of each issue the latest and best infor- 
mation on subjects of importance and value to practitioners in all branches of medicine. Its 
numerous departments are designed to subdivide and present its material in the most attractive 
and convenient manner. 
In a word The Medical News is a crisp, fresh, weekly newspaper, and as such occupies a 
well-marked sphere of usefulness, distinct and complementary to the ideal monthly magazine, 
The American Journal of the Medical Sciences. 
The Year-Book of Treatment for 1895 
Gives a classified summary and review of the real advances in treatment made during 1894 in all 
departments of the science of medicine. Price, $1.50; or in combination with either or both the 
above journals, 75 cents. Ready early in 1895. 
The Medical News Visiting List for 1895 
Published in four styles : Weekly, dated, for 30 patients ; Monthly, undated, for 120 patients per 
month; Perpetual, undated, for 30 patients weekly per year; Perpetual, for 60 patients weekly 
per year. The first three styles contain 32 pages of important data and 160 pages of assorted 
blanks; the 60-patient perpetual consists of 256 pages of blanks. Price, each, $1.25. In com- 
bination with either or both above periodicals, 75 cents. Or, Journal, News, Visiting List 
and Year-Book, $8.50. Thumb-letter index for Visiting List, 25 cents extra. 
LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA, 706, 708 & 710 SAN SQM STREET.