Remarks on Resection of the Gasserian 
Ganglion. 
BY 
W. W. KEEN, M.D., LL.D., 
PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY, 
JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. 
With a Pathological Report on Seven Ganglia 
Removed by Professor Keen. 
BY 
WILLIAM G. SPILLER, M.D., 
PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM IN THE 
PHILADELPHIA POLYCLINIC. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
November, 1898. Extracted from The American Journal of the Medical Sciences, November, 1898. 
REMARKS ON RESECTION OF THE GASSERIAN GANGLION.1 
By W. W. Keen, M.D., LL.D., 
PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY, JEFFERSON MEDICAL 
COLLEGE, PHILADELPHIA. 
WITH A PATHOLOGICAL REPORT ON SEVEN GANGLIA REMOVED BY 
PROFESSOR KEEN. 
By William G. Spiller, M.D., 
PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM IN THE PHILADELPHIA POLYCLINIC. 
Up to the present time I have done eleven operations for the removal 
of the Gasserian ganglion. The first of these cases was reported in the 
Transactions of the Philadelphia County Medical Society for 1894 and 
in the Medical and Surgical Reporter for March, 1894, in conjunction 
with Dr. John K. Mitchell. It was the fourteenth operation done on 
the patient. From the date of that operation, October 18, 1893, the 
patient has been well. Although his condition of mental anxiety lest 
the pain should return, and his mental instability as a result of his 
long-continued use of opium, are very marked, yet practically he is 
well of his neuralgia. He still has pain, but not the old tic. 
In The American Journal of the Medical Sciences for Jan- 
uary, 1896, I reported five additional cases. The later history of these 
cases is as follows : 
Case II.-The operation was done June 18, 1894. No ganglionic 
cells or nerve-fibres were found in the tissue supposed to have been 
removed from the site of the ganglion. The pain returned in six 
months, though not so badly as before. It still continues (September, 
1897). 
Case III.-Died in a week from septic infection. 
Case IV.-The operation was done May 2, 1895, and at present, 
September 29, 1897, she is entirely well. 
Of Cases V. and VI. I append a brief summary, since the examina- 
tion of the specimens from these two cases is an important part of the 
pathological report which follows. 
1 Read at the twenty-fourth annual meeting of the American Neurological Association, held 
in New York, May 26, 27, and 28, 1898. 
This paper was written for the volumes published ih celebration of Prof. Durante's comple- 
tion of twenty-five years' surgical teaching in the University of Rome. 2 
KEEN, SPILLER: GASSERIAN GANGLION. 
Of the remaining five cases (VII. to XI., inclusive), which have 
never been reported, I give only a brief resume of each, sufficient to 
compare with the pathological report. I shall publish them more 
fully hereafter. 
In conjunction with my own remarks on the removal of the ganglion, 
and as a very important addition to our knowledge of the pathology of 
tic douloureux, I have been so fortunate as to secure the co-operation 
of my friend, Dr. William G. Spiller, who has examined with great 
care the seven specimens which I had removed and which were as yet 
unexamined. In all of these ganglionic tissue was found. These 
specimens cover the cases V. and VI. of my second paper and all the 
five additional cases (VII. to XI., inclusive) here briefly reported. I 
consider myself most fortunate in being able to enlist the services of so 
accomplished a neuro-pathologist as Dr. Spiller, and the value of his 
contribution will be seen not only in the text, but in the beautiful 
illustrations, for which we are indebted to the skill of Miss A. G. 
Newbold. 
It will be observed that of the eleven, ten were secondary operations, 
multiple peripheral operations having been done in all the cases before 
the ganglion itself was attacked, with the exception of one case (Case 
VIII.). In this case, all of the branches being involved, I removed 
the ganglion at once. All of the operations were done by the Hartley- 
Krause method. Of the eleven three died, one from direct and avoid- 
able infection (Case III.), the other two of shock. 
In six cases (VI. to XI.) an attempt was made to remove the entire 
ganglion, and the illustrations from photographs show that I was per- 
fectly successful in Cases VI. and XI. in removing the entire ganglion 
with its roots, and reasonably successful in removing at least the gan- 
glion itself in all the others. In Case VI., in which the entire ganglion, 
including its second and third divisions, and its sensory and motor roots 
were removed, Dr. Spiller was able to obtain sections which showed the 
microscopical condition of the ganglion as well as its physical relations 
with its sensory root and peripheral branches all in a single slide. As 
the motor root joins the third branch on the distal side of the ganglion, 
it could not, of course, be cut in the same plane as the other portion of 
the ganglion. In Case VIII. we were fortunate also to have a gang- 
lion from a case in which no peripheral operation whatever had been 
done. 
One disadvantage Dr. Spiller has labored under is that I was not 
aware at the time of my operations of the technical value of Nissl's 
method, or I should not have preserved the entire specimens in Muller's 
fluid, which prevents their examination by that method. The cellular 
changes, therefore, could not be studied in all their details, but the 
advantages of the selected method of hardening for an examination of KEEN, SPILLER: GASSERIAN GANGLION. 
3 
the alterations in the intra-ganglionic nerve fibres are very great. The 
next specimen I have Dr. Spiller shall have perfectly fresh, and be 
able to examine it by the Nissl method. 
Case I. Breaking up of the Gasserian ganglion after thirteen prior oper- 
ations; done in two stages, on account of packing to arrest the hemorrhage ; 
recovery ; cure for four and a half years.-Dr. K., aged forty-one years. 
He had suffered from neuralgia for thirteen years, and had had thirteen 
operations done, including removal of a large part of the upper jaw, 
as well as various branches of the nerves. Date of operation, October 
18, 1893. The anterior branch of the middle meningeal passed through 
a canal and was, of course, torn in turning down the flap. In chisel- 
ling the posterior portion of the flap the posterior branch was also 
divided and the dura wounded. Both vessels were secured after much 
Fig. 1. 
The dark portion indicates the area of imperfect sensation. 
trouble. The hemorrhage, on lifting the middle lobe, was so great that 
the cavity was packed, and the operation completed in a second stage 
after three days, the ganglion being broken up. The piece of gauze 
was found to measure thirty-seven by six inches, or two hundred and 
twenty-two square inches. This remained in the skull for three days, 
during which time his temperature had risen to 100.8°, and the respi- 
ration had gone down to from six to ten in a minute, with a slight 
aphasia. Immediate recovery followed the completion of the operation. 
He has suffered from temporary twinges of the pain, but except these 
he has been free from pain. His general health has never been very 
good. This patient was examined in September, 1897, by Dr. Spiller, 
whose notes are appended. 
" Dr. K. states that he has real pain at times below the right eye and 
on the side of the nose, but has no paroxysms. 
"Sensation is imperfect in the area indicated (Fig. 1), but evidently 
not entirely lost. He perceives pressure on the right side of the tongue, 4 
KEEN, SPILLER: GASSERIAN GANGLION. 
but no pain from the stick of a pin. Sensation on the inside of the right 
cheek is much impaired, but not destroyed. Tactile sensation is pre- 
served on the back of the right side of the tongue and on the soft palate. 
" He cannot taste salt, vinegar, or quinine on the right side of the 
tongue, even at the tip. 
" The right masseter muscle contracts well, and the lower jaw is moved 
from side to side (pterygoid muscles). 
" On account of the continuance of some form of pain, the absence of 
total anaesthesia, the preservation of the motor root of the fifth nerve, 
as indicated by the contraction of the muscles of mastication, and the 
probably intact or nearly intact condition of the first and third branches, 
it is evident that only a small portion of the ganglion was destroyed." 
Case II. Breaking up of the Gasserian ganglion; done in two stages, 
on account of hemorrhage, after eight prior operations; recovery; recur- 
rence of attacks.-C. H. B., aged about thirty-five years. Neuralgia 
began in April, 1886, apparently from the filling of a tooth. From 
1889 to 1890 subcutaneous neurotomy was twice done, the antrum 
drilled, the right infra-orbital resected three times, and the right 
carotid was tied. The last five operations were done by Dr. John B. 
Roberts. In March, 1890, the sight of his right eye began to fail, 
and in February, 1891, another surgeon removed the crystalline lens. 
When first seen in June, 1894, the right eyeball was utterly useless, the 
face was shrunken over the antrum, and for three years he had never 
been free from pain. 
Operation, June 18, 1894. The middle meningeal ran in a groove 
and was torn in turning down the flap ; secured by ligature. On lift- 
ing the temporo-sphenoidal lobe, the hemorrhage was so profuse that 
the wound was packed with gauze, measuring sixteen by six inches 
■(ninety-six square inches). Cultures at the first operation and when 
the gauze was removed were sterile. The second and third divisions 
were torn loose from the ganglion, and the ganglion itself broken up. 
Dr. Burr reported that neither nerve fibres nor nerve cells were 
found in the supposed tissue of the ganglion. In September, 1897, the 
patient wrote that he had frequent sharp attacks of pain. 
Case III. Breaking up of the Gasserian ganglion after two prior 
operations; rupture of middle meningeal at the foramen spinosum; in- 
fection after operation; death from septic meningitis.-Mrs. E. E. H., 
aged sixty-three years. Neuralgia began in 1883. In 1889 inferior 
dental removed by Dr. Thomas G. Morton. On February 23, 1892, I 
removed the inferior dental nerve, which had been reproduced, and the 
lingual nerve by trephining the vertical ramus of the jaw. Recurrence 
of pain in November, 1893. At no point was there complete anaesthesia 
on the left side of the face; but, on the contrary, a large part of the 
skin was hyperaesthetic. 
Operation, February 20, 1895. The anterior branch of the middle 
meningeal ran in a canal and was ruptured. While lifting the temporo- 
sphenoidal lobe the middle meningeal ruptured at the foramen spinosum ; 
arrested hemorrhage by packing with gauze. During the operation a 
gentleman, not one of my regular assistants, without my knowledge, 
infected an instrument which was used in the wound. She died at the 
end of a week. Pyogenic cocci were found by culture. 
Case IV. Breaking up of the Gasserian ganglion after five prior 
operations; done in two stages, on account of hemorrhage; recovery; cure KEEN, SPILLER: GASSERIAN GANGLION. 
5 
for three years ; necrosis of bone in the flap.-Mrs. S. R., aged sixty 
years. Neuralgia in the second and third divisions of the right fifth, 
for which five operations had been done, the last being a division of 
both of the branches at the foramina rotundum et ovale. 
Operation, May 23, 1895. Rupture of anterior branch of middle 
meningeal, which ran in a long canal in the bone. On lifting the 
temporo-sphenoidal lobe, the hemorrhage was so severe and continuous 
that I packed a piece of gauze, afterward found to be twenty-three by 
fourteen inches (three hundred and twenty-two square inches), into the 
wound. Three days later packing removed and ganglion broken up. 
Dr. Kyle reported undoubted ganglion cells in the tissue removed. 
The central portion of the section showed slight, if any, variation from 
the normal, but the outer portion showed some inflammatory infiltra- 
tion. Sections of the nerves showed a thickened neurilemma (inflam- 
matory), with infiltration of round and spindle cells. No apparent 
change in the axis cylinders or white substance. 
At the present time (May, 1898) she is still free from pain and her 
general condition good. Some of the bone in the flap necrosed. 
Case V. Curetting of the ganglion after two prior operations; rupture 
of the middle meningeal at the foramen spinosum; post-operative corneal 
ulcer; recovery ; cure for two years and a half.-Mrs. F., aged fifty-four 
years, was first seen July 15, 1891. Neuralgia, at first confined to the 
right inferior dental, had existed for twelve years following an abscess 
at the root of a tooth. In 1886 a half inch of the right inferior 
dental was removed, with relief of pain for eighteen months. It then 
returned in the superior maxillary division. 
Fig. 2. 
Gasserian ganglion (a) and second and third divisions (6 and c respectively) from Case V. 
July 17, 1891,1 operated both on the inferior dental and the superior 
maxillary. The inferior dental was found reproduced and as large as 
the median nerve. This gave relief for over eighteen months. October 
6, 1895,1 operated on the ganglion. (Fig. 2.) In lifting the temporo- 
sphenoidal lobe the middle meningeal tore directly at the foramen 
spinosum. It was controlled by the Allis dissector, for which was sub- 
stituted, first, the left forefinger, and then a small piece of iodoform 
gauze, which was packed into the canal. This iodoform gauze was 
removed on the third day. In a week the wound was entirely well. 
On the third day after the operation a corneal ulcer developed. She 
went home November 27, 1895. The ulcer, which had been most 
skilfully treated by Dr. de Schweinitz, was then healing, and after very 
many vicissitudes, in the course of a year under the care of her physi- 
cian, Dr. Moore, of Spartanburg, S. C., she recovered entirely. When 
last heard from, early in 1898, she was entirely well. 6 
KEEN, SPILLER: GASSERIAN GANGLION. 
Case VI. Removal of entire Gasserian ganglion, with its second and 
third divisions and both its sensory and motor roots back to the pons in a 
piece four centimetres long, after four prior operations; recovery; complete 
cessation of pain for two years and a half; post-operative corneal ulcer.- 
C. W. E., aged thirty-three years, was first seen November 16, 1895. 
Neuralgia began five years before, after an attack of diphtheria. In 
March, 1895, the right upper teeth and the right alveolar process were 
removed. Since then three other operations have been done, including 
the removal of the infra-orbital nerve and opening of the antrum. 
Fig. 3. 
Centimetres. 
Ganglion. 
Sensory 
root. 
II. division. 
Motor root. 
III. division. 
Gasserian ganglion, with the II. and III. divisions and the sensory and motor roots removed 
from Case VI. The nerve bundles are well shown. The motor root is elongated by the acci- 
dental reversal of one of its bundles. (From a photograph which unintentionally was enlarged 
about one-third, but the scale of centimetres which was photographed with the specimen will 
serve for comparison.) 
Operation, November 22, 1895. The eyelids were first stitched together. 
On lifting the temporo-sphenoidal lobe the middle meningeal tore just 
above the foramen spinosum. It was secured with a ligature. The 
ganglion was twisted out complete, as is seen in the drawing. (Fig. 3.) 
A profuse hemorrhage occurred as the ganglion was removed, which I 
judged to be from the cavernous sinus. It was arrested by packing a 
strip of gauze, ten by one and one-half inches. After an uncomfort- 
able night, the next day he had severe frontal headache, and his tem- 
perature had risen to 104°. Though the gauze had only been in for 
twenty-four hours, I deemed it necessary to remove it, and no hemor- 
rhage followed. The wound was entirely healed on the eighth day. 
Four days after the operation the stitches were taken out of the lids, 
but within twenty-four hours signs of corneal ulceration began. The 
lids were then stitched together again. After a great deal of difficulty KEEN, SPILLER: GASSERIAN GANGLION. 
7 
Dr. de Schweinitz, who cared for his eye, was able to save it, but with 
only partial vision. 
This patient was examined by Dr. Spiller, October 5, 1897, and his 
notes are appended. 
" C. W. E. states that he has not had the slightest pain since the gan- 
glion was removed ; he has not even once had any indication of a re- 
turn of the suffering. With the exception of a ' drawing sensation,' 
he has had no parsesthesia in the affected area. He has had no trouble 
with fish-bones and cherry-stones remaining in his mouth. When he 
masticates he uses only the muscles of mastication on the left side. 
The hair grows as well on the top of the head, in the eyelashes, 
moustache, and beard on the right side as on the left, and he has to 
shave the beard on the right side as often as on the left. The skin also 
is normal. These are interesting statements in view of the supposed 
trophic functions of the fifth nerve. 
Fig. 4. 
The dark shading indicates the area of complete anaesthesia for all forms of sensation ; 
the light shading indicates the area of hypaesthesia. 
"Sensation. Complete anaesthesia exists on the right side of the face in 
the area indicated in the drawing. This area shades off into the region 
of normal sensation, as is also indicated in the drawing. (Fig. 4.) The 
total anaesthesia extends to the median line of the face, but the hyp- 
aesthesia extends a slight distance beyond the median line into the left 
side of the face. The right nostril is completely anaesthetic. The 
inside of the mouth and the right side of the tongue, including the 
point, are anaesthetic on the right side. The back of the tongue and 
the soft palate, as well as the left side of the tongue, are sensitive. The 
right cornea, conjunctiva, and auditory canal are anaesthetic. 
" The sensation of the face was tested for heat, cold, pain, and touch. 
On the left side of the face sensation is normal. 
"Taste. He has no sense of taste for vinegar, sugar, or salt on the 
right side of the tongue, even at the point, but all these substances are 8 
KEEN, SPILLER: GASSERIAN GANGLION. 
tasted at the back of the right side of the tongue and still better on 
the left side of the tongue. 
"Motion. There is no contraction whatever in the masseter and tem- 
poral muscles of the right side of the face, while on the left side the 
contractions seem to be unusually vigorous. The muscles of mastica- 
tion on the right side are entirely atrophied. Saliva at times drops 
from the right side of the mouth. 
" Ocular condition. He has some sight in the right eye ; he can count 
the fingers held before him, and says he sees them sharply, but that 
most objects have a hazy outline. He cannot read with the right eye. 
The left eye is good. The conjunctiva of the right eye is much in- 
jected, and the cornea is slightly hazy as compared with the left. The 
eyelashes of the right lower lid grow inward and irritate the eyeball, 
and he has had most of them pulled." 
Case VII. Removal of the Gasserian ganglion after tivo prior opera- 
tions, with portions of its roots; recovery; cure for tivo years and five 
months, and no return as yet of the severe pain, but some parcesthesia.- 
Mr. J. McM., aged seventy-six years, was first seen with Dr. Charles 
A. Currie, December 28, 1895. A tall and vigorous man, apparently 
much younger than his age ; arteries free from atheroma. Twenty 
years ago, without apparent cause, neuralgia began in the second divi- 
sion of the right fifth nerve. Nine years ago the late Dr. Agnew re- 
sected the infra-orbital nerve, and, as the pain returned shortly after- 
ward, three years ago Dr. Thomas G. Morton again resected the same 
nerve. Soon after the second operation the pain again returned, and 
has extended to all the branches of the fifth, coming in paroxysms only 
a minute or two apart and extending over the forehead, cheek, and 
jaw, the point of severest pain being a little in front of and below the 
ear and in the tongue. He is scarcely able to speak. Meat is only 
eaten when finely cut up, and even then causes severe pain. The ante- 
rior wall of the antrum is gone. 
Operation, December 31, 1895. One-half grain of morphine and one- 
twentieth of strychnine were given before the operation, and the latter 
was repeated twice during the operation. As in all the other opera- 
tions, ether was used, the operation lasting two hours. An osteoplastic 
flap was turned down and the anterior branch of the middle meningeal, 
which was torn in doing so, secured. When I had turned down the 
flap I found that the dura was so firmly adherent to the bone that the 
outer layer of the dura had adhered to the bone over a considerable 
extent and left the brain covered only by the thin inner layer. At one 
point the dura was ossified over an area of one-half inch. Other small 
areas of ossification were also found under the temporo-sphenoidal lobe. 
The third division was at least one-half inch away from the middle 
meningeal, and was quite small, less in cross section than the second. 
In isolating the third division considerable hemorrhage took place, 
though no vessel was seen ; it was arrested by pressure. The ganglion 
was then seized and, after dividing the second and third divisions, was 
twisted out, the roots being imperfectly removed. The third division 
tore and had to be removed separately. I particularly noted whether 
avulsion of the ganglion caused any shock. Dr. Spencer, one of my 
assistants, held his finger on the pulse at the moment, and no percep- 
tible effect was produced either upon the pulse or in any other way 
that could be noticed. The eyelids had been stitched together before KEEN, SPILLER: GASSERIAN GANGLION. 
9 
the operation. In ten days he went home, his highest temperature 
having been 100'. Since then he has remained entirely free from pain. 
For the histological examination of the specimens, see Dr. Spiller's 
notes of Case VII. Dr. Spiller's notes of the patient's condition are 
added. 
"At the present time, May, 1898, his general health is excellent, he has 
gained twenty-five pounds, has no return of the tic douloureux, but has 
some obscure "creeping" feeling in his right face. His eye waters 
somewhat, but otherwise there is no trouble. 
" Mr. McM. stated that when he ate cherries or fish the stones or bones, 
as the case might be, collected on the right side between the teeth and 
cheek, and were not noticed until two or three hours later, when they 
were moved to some more sensitive area of the mouth. 
" He has never had a return of the old severe pain, but has had 
' three or four different kinds of pain ' on the right side of the face. 
At times he has a sense of itching, which begins at the right ala nasi, 
and is followed by a sensation as of worms creeping over the anaesthetic 
area. This seems to be in reality a form of paraesthesia and not of pain. 
Fig. 5. 
The dark shading indicates the area of total anaesthesia. 
" The area of total anaesthesia is indicated by Fig. 5, and, by com- 
parison with Fig. 490 (Gray's Anatomy, p. 731, edition of 1887, edited 
by Keen), is found to correspond quite closely to the distribution of 
the second branch of the fifth nerve, leaving the distribution of the 
first branch intact and impinging slightly on that of the third. Along 
the border of the anaesthetic area a pin-point is felt as dull pressure. 
Within the area the anaesthesia is complete, except that pressure causes 
a displacement of the parts pressed upon, and affects the surrounding 
sensitive tissues, and is perceived in this way. 
"No sensation is felt on the inside of the right cheek, and the right 
side of the tongue is almost anaesthetic, but not entirely so. Sensation 
at the back of the mouth on the right side is impaired. 
"According to his statements, the saliva escapes at times from the 10 
KEEN, SPILLER: GASSERIAN GANGLION. 
right corner of the mouth, and at night the lower jaw hangs somewhat. 
He can open his mouth only to about the width of one and a half inches, 
and is obliged to cut his food into small pieces in order to get it into 
his mouth. In opening his mouth the lower jaw goes somewhat to the 
right, and this is probably due to more vigorous action of the external 
pterygoid muscle of the left side. No contraction of the right masseter 
is felt, and none of the right temporal muscle. 
"Salt and acid are tasted a little on the right side of the tongue and 
quite well at the point on the right side. 
" No loss of vision has occurred, but he complains of impairment of 
sight, which, most probably, is a result of old age. No trophic lesions 
of the eye are noticed. As the first branch is probably not destroyed, 
judging from the distribution of the anaesthesia, trophic lesions of the 
eye could hardly be expected." 
Case VIII. Removal of the Gasserian ganglion as a primary opera- 
tion; possible tear of the cavernous sinus, controlled by packing; unevent- 
ful recovery; cure for one year and eight months.-Mrs. A. W. S., aged 
sixty-nine years, first consulted me January 11, 1895. Her present 
trouble began eighteen years ago, with pain in the left face. In a few 
years all her teeth were removed. The pain is chiefly felt in the second 
and third divisions, but is also felt in the area supplied by the first divi- 
sion. Free purgation by sulphate of magnesium and later by castor 
oil was tried for ten days without result. 
Fig. 6. 
Gasserian ganglion, from Case VIII. 
Operation, January 24, 1896. The usual Hartley-Krause flap was 
turned down. The anterior branch of the middle meningeal ran in a 
complete canal, the posterior in excessively deep grooves practically 
equivalent to canals. All of these branches were torn, therefore, in 
turning down the flap, but were rapidly secured. The ganglion was 
seized, the second and third divisions severed, and the ganglion twisted 
out. (Fig. 6.) In doing so the second division tore loose from the 
ganglion, and was lost in the rush of blood which followed its avulsion. 
The hemorrhage was so severe that I was inclined to think that the 
cavernous sinus was torn, though this was uncertain. Packing by gauze 
controlled it readily. The highest temperature, on the third day, was 
100.6° F. The gauze was removed on this day without hemorrhage. 
For three days the eyelids were closed by a bit of sterilized cotton and 
a bandage and by the Buller shield afterward. I kept her under ob- 
servation for three weeks, lest trouble should ensue with the cornea, 
but when she went home the cornea was perfectly normal. She has 
had no return of pain for a year and eight months. For report on 
specimen, see Case VIII. of Dr. Spiller's notes. 
Case IX. Removal of the Gasserian ganglion after one prior opera- 
tion ; wound of cerebral vessels while making flap; rupture of the cavern- KEEN, SPILLER: GASSERIAN GANGLION. 
11 
ous sinus, packing with gauze; coma and hemorrhage, followed by death 
in three days.-Mr. G. K., aged forty-nine years ; father and mother 
died of okl age. In his personal history the only thing of importance 
is that he had smallpox at sixteen years of age. Seventeen years ago 
the pain began in the right upper jaw near the canine tooth, gradually 
extending over the cheek. A number of his teeth were extracted, 
without relief. Seven years ago, at the Jefferson Hospital, the infra- 
orbital nerve was removed, giving relief for two and a half years on the 
cheek, but the pain in the forehead still remained. His pain has become 
entirely unbearable. It extends over the right forehead and sweeps 
down to the cheek. The lower jaw is not involved. When he is quiet 
a touch on the cheek does not cause pain, but the slightest touch on 
the forehead is followed by intense pain. For the last six or eight 
weeks the pain has been increasing greatly in severity. 
Operation, April 21, 1896. The Hartley-Krause osteoplastic flap 
was made by means of Dr. Cryer's drill. In making the first small 
trephine opening, in spite of the utmost care, the trephine slipped in- 
side the skull. This was followed by copious hemorrhage, showing that 
a large vessel had been divided. The flap was then quickly turned 
down. As soon as the dura was exposed an extensive clot was found 
Fig. 7. 
Gasserian ganglion, Case IX. 
under it, having resulted from the mishap in the first small trephine open- 
ing. About an ounce of clot was removed ; the source of the bleeding 
was a branch of the middle cerebral. The dura was then closed. The 
anterior branch of the middle meningeal ran through a canal and had 
been torn. This was ligated. The temporo-sphenoidal lobe was then 
lifted, the second and third divisions readily found, and the middle 
meningeal avoided. The ganglion was seized with a pair of haemostatic 
forceps, the second and third divisions were separated, and I then 
attempted to twist out the ganglion. (Fig. 7.) In this I found two 
difficulties : one that the forceps did not grasp the ganglion with suffi- 
cient tightness to twist it, and the other that the third division had been 
only partly divided. The third division was then completely divided, 
and I removed the major part of the ganglion. A portion of the 
ganglion still escaped the jaws of the forceps. They were reapplied so 
as to get a good hold on the ganglion, but the moment that I began to 
twist it out a copious gush of venous blood convinced me that I had 
probably pushed the forceps too far inward and torn a rent in the 
cavernous sinus. The wound was packed with iodoform gauze imme- 
diately and the wound closed, leaving the packing in place. He reacted 
well; at the end of an hour his temperature was 97.4° F., but he was 
not yet conscious, and his puffing respiration made me suspect that the 
pressure of the gauze had produced what I hoped to be a temporary 
hemiplegia. He remained, however, hemiplegic and unconscious till 
his death, at 1.20 A.M., on April 24th, almost three days after the oper- 
ation. The temperature rose very little till about forty-eight hours 12 
KEEN, SPILLER: GASSERIAN GANGLION. 
after the operation, when it fluctuated between 103° and 104° F. The 
gauze (two hundred and sixty-seven square inches) was removed after 
forty-eight hours, without hemorrhage. 
Post-mortem examination was refused. For the histological exam- 
ination of the specimen, see Dr. Spiller's report of Case IX. 
Case X. Removal of the Gasserian ganglion; death from shock in ten 
hours.-Mrs. M. S., aged sixty-three years, first consulted me about the 
middle of October, 1896. She had suffered with neuralgia for over 
thirty years. A few years ago Dr. W. J. Hearn removed the second 
and third divisions, with relief for a considerable time. The pain has 
now returned not only in these two divisions, but also in the first. Un- 
fortunately, the notes of the earlier history were lost by one of my 
assistants, and these are the only facts which I can give. (Fig. 8.) 
Fig. 8. 
Gasserian ganglion (A) and second and third divisions (B and C) respectively, 
from Case X. 
Operation, October 31, 1896. The ordinary osteoplastic flap was 
turned down. The anterior branch of the middle meningeal divided 
into three large branches, all running in very deep grooves in the bones, 
and all were lacerated in turning down the flap. After some little 
trouble they were secured. The second and third divisions were readily 
found and traced back to the ganglion. In uncovering the ganglion I 
met with such profuse hemorrhage that I divided the second and third 
divisions and endeavored to remove the ganglion by traction instead of 
seizing the ganglion itself. I decided upon this procedure not so much 
because of the amount of blood lost, which constantly recurred upon 
the slightest manipulation in the effort to uncover the ganglion, as 
because of the amount of time lost. Avulsion of the third division 
brought a considerable quantity of the ganglion with it. When the 
second was avulsed no ganglion tissue could be recognized. The gan- 
glion was broken up and wiped away by the small sponges which we 
used to check the hemorrhage. The operation lasted an hour and a 
half; the patient's pulse kept up very well, but the respiration was 
very poor. During the operation three doses of one-twentieth of a 
grain of strychnine and one one-hundredth of a grain of atropine were 
administered. In one hour after the operation she seemed to be react- 
ing very nicely. Soon after that, however, she began to fail, and died 
ten hours after the operation. No post-mortem examination could 
be obtained. For a full report of the specimen in this case, see Dr. 
Spiller's notes of Case X. KEEN, SPILLER: GASSERIAN GANGLION. 
13 
Case XI. Removal of the Gasserian ganglion after six prior operations; 
recovery; cure for sixteen months; eyesight lost from secondary corneal 
ulcer caused by his neglect.-F. W. P., aged fifty-six years. Neuralgia 
began six years ago in the right lower jaw. At different times he has 
had six peripheral operations by Dr. Parmenter, of Buffalo. He has 
•operated on the inferior dental both in the dental canal and finally at 
the foramen ovale. On November 8, 1895, Dr. Parmenter operated on 
the Gasserian ganglion, but the pain returned within a month. When 
I first saw him the conjunctiva and cornea had norma] sensibility, as also 
the skin of the entire face and the tongue. 
Operation, January 22, 1897. Owing to the former Hartley-Krause 
operation, great difficulty was found in turning down the flap on ac- 
count of adhesions to the dura mater. The anterior branch of the 
middle meningeal was ligated, as it had been torn during the removal 
of the flap. Temporary packing and heat were applied, which checked 
the hemorrhage very readily. The third and, later, the second divisions 
Fig. 9. 
•Gasserian ganglion and second and third divisions, from Case XI. The ganglion is the mass to 
the right; the left portion is the second division, and the detached mass is the third division. 
were then readily found, and later the ganglion laid bare. (Fig. 9.) It 
was seized with a pair of hemostatic forceps', and the second and third 
divisions of the nerve severed at their foramina. The foramen ovale, 
instead of being oval, was distinctly triangular, and the nerve only 
partly filled it. The foramen was much larger than I had ever seen it 
before. The second division tore loose from the ganglion. Removal of 
the ganglion was followed by moderate hemorrhage. The operation was 
unusually long, two and a quarter hours, on account of the adhesions 
to the bone and also the difficulty of determining when I had reached 
the dura. The eyelids were stitched together at the close of the opera- 
tion. Thirteen days after the operation he went home, his highest tem- 
perature having been 100° F. The stitches were removed on the third 
day and the eye covered by a Buller shield. When he went home the 
eye was in good condition and he was beginning to dispense with the 
shield. Later, through his negligence in covering the eye with a hand- 
kerchief without the shield, friction on the cornea produced a corneal 
ulcer, from which I learned later that he ultimately lost his eyesight. 
He has been now entirely free from pain for sixteen months. His gen- 
eral health is excellent. For a fuller report of the specimen in this 
case, see Dr. Spiller's notes of Case XI. 14 
KEEN, SPILLER: GASSERIAN GANGLION. 
To sum up the results of Dr. Spiller's researches, we may say that in 
a general way the pathological changes which he has found are : 
1. That the medullary substance of the nerve fibres within the gan- 
glion and its branches is much swollen, atrophied, or entirely gone, 
depending on the intensity of the disease. 
2. That the axis cylinders similarly are markedly degenerated or en- 
tirely destroyed. 
3. That the cells of the- ganglion itself, in at least one case, are so 
degenerated or atrophied that there would be even doubts whether we 
were dealing with ganglionic tissue in certain parts of the field, were it 
not for the occasional nerve cells seen. 
4. That the vessels are very distinctly sclerotic. In some instances 
the lumen is even entirely obliterated. 
5. There is, in at Dast one case, a decided amount of increase in the 
connective tissue of the ganglion, which is enough to call the alteration 
a distinct sclerosis. 
I propose now to consider four points : 
1. Should the Gasserian ganglion be removed ? 
2. The answer being in the affirmative, to what extent shall it be 
removed-i. e., shall we remove the entire ganglion, or only its outer 
two-thirds? or shall we be satisfied with simply " breaking it up " by 
blunt instruments or a curette? 
3. Should the ganglion be removed as a primary operation, or should 
its removal be reserved till the very last operation for tic douloureux ? 
4. A few points in the technique. 
1. The removal of the Gasserian ganglion is in some respects rather 
peculiarly American. The first deliberate proposal to remove the Gas- 
serian ganglion was made by Dr. J. Ewing Mears, of Philadelphia 
(Transactions American M&Hcal Association, 1884, vol. ii. p. 469). An- 
drews, of Chicago (Chicago Medical Record, 1891, vol. i. p. 322), had 
been at work for eighteen months devising practically the same opera- 
tion as Rose, but the latter preceded him both in publication and per- 
formance (Lancet, 1890, vol. ii. p. 914). Similarly, Hartley, of New 
York, and Krause, of Altoona, almost at the same time devised the 
method of operating which has been most used and is, on the whole, 
perhaps the best method. 
Of the 108 cases of intracranial operations on the fifth nerve, col- 
lected by Tiffany (Transactions American Surgical Association, 1896, 
vol. xiv. p. 1, and Annals of Surgery, 1896, vol. xxiv. p. 575), seventy- 
nine were done by American surgeons and twenty-nine by European 
surgeons. 
Whether we ought still to resect the ganglion depends, in my opinion, 
on three conditions : (a) The mortality of the operation ; (6) its efficiency 
as a means of permanent cure ; and (c) whether its disadvantages, KEEN, SPILLER: GASSERIAN GANGLION. 
15 
especially the possibility of the loss of the eye on the operated side, can 
be avoided. 
(а) The mortality of the operation may be taken as that shown by 
Tiffany's table (108 cases, twenty-four deaths), a mortality of 22.2 per 
cent. For an operation done by modern antiseptic or aseptic methods, 
a mortality of over one-fifth is very large. I have no doubt it will be 
diminished in the future, as we learn by experience to deal with the 
vicissitudes and emergencies. In fact, surgically speaking, we must 
master and overcome so large a mortality. No one who has ever 
resected a Gasserian ganglion will speak lightly of the operation. Even 
now, after having operated on eleven, I always approach the operation 
with a certain amount of hesitation. The mortality alone would cause 
me to answer the third question positively in favor of the resection 
being reserved for the last of the series of operations instead of the first. 
(б) What has been the history of the cases as to cure ? So far as I 
know, there have been four cases in which the pain has returned ; one 
of Rose's, one reported by Dana, and two by myself. But I especially 
desire to call attention to the fact that my own two cases of recurring 
pain were my first two operations; that in Case I. no microscopical 
examination of the fragment removed was made, and in Case II. the 
examination revealed no ganglionic cells or nerve fibres. As I now 
look at it, Case I. was imperfectly done, and Case II. still more so. 
Therefore the recurrence of pain in these two cases cannot be used as 
an argument against the removal of the ganglion. The facts as to 
recurrence of pain in these two cases have been given earlier in this 
paper. 
In addition to this, Krause has reported one case in which the sen- 
sory root was found diseased, and the pain returned on the other side of 
the face. We can conclude, therefore, in general, as a result of expe- 
rience in over one hundred cases of intracranial operation on the fifth 
nerve that, practically, the pain will return in not over 1 or 2 per 
cent, with any such severity as to liken it to the original disease, 
and that it will return to any degree in not more than 4 or 5 per 
cent. Perhaps, if we consider the uncertainty of total excision of the 
ganglion in the reported cases in which pain did return, this per- 
centage is too high. As Dr. Spiller has shown, there are only two 
cases known to him in which the sensory root has been examined 
(although it may be that Krause examined the sensory root in some of 
his other cases); one of these was by Krause and one by himself. In 
Krause's case the root was diseased, and the pain returned upon the 
opposite side. In my own case (Case VI.), though the lesions of the 
ganglion were very intense, and the disease had existed for five years, 
yet Dr. Spiller found the sensory root entirely free in longitudinal as 
well as transverse sections. We must expect, as a result of both the 16 
KEEN, SPILLER: GASSERIAN GANGLION. 
clinical history and the pathological examination of Krause's case, that 
the disease may not only reach, but may pass beyond, the ganglion to 
the sensory root, and that, therefore, even the removal of the ganglion 
will not always absolutely prevent a return. 
(c) Apart from the mortality the chief danger is the loss of vision, if 
not of the eyeball. This, I think, I now know how to master. I shall 
consider it under the question of technique. All other disadvantages, 
such as the possible necrosis of a piece of the bone, the sinking in of 
the flap, or the possible uselessness in a certain number of cases of the 
muscles of deglutition, are very slight as compared with the immense 
relief from the horrible pain. My conclusion, therefore, is that the 
removal of the Gasserian ganglion should still be done, but that we 
should especially strive to lessen the mortality of the operation. 
2. To what extent shall the ganglion be removed ? Tiffany has ex- 
pressed the opinion (1) that the motor root can be saved, and (2) that 
it ought to be saved. In some of my cases, though I have made no 
attempt to save the motor root, the muscles of mastication on the oper- 
ated side were not wholly paralzyed. In Case VI., in which the motor 
root was certainly removed, the muscles of mastication on the operated 
side are atrophied and useless, but the patient can readily masticate 
meats, the lower jaw being easily moved by the muscles of the opposite 
side. I do not, however, believe that the motor root can be preserved. 
In the first place, I do not think that, from an operative point of view, 
it is possible to do so, and, secondly, the very careful dissection of the 
ganglion made by Jouvara (Chipault's Travaux Neurol. Chir., 1897, vol. 
ii. p. 205) makes me sure that this is even anatomically quite impossible. 
He says (pp. 209-210), " the masticatory nerve [by which I take it he 
means the motor root] and its branches are very adherent to the trunk 
of the inferior maxillary division and are contained in the same sheath 
of connective tissue; the separation of these two nerves is difficult even 
by the most careful dissection, and to avulse the inferior maxillary 
without at the same time avulsing the masticatory nerve is veritably 
impossible." If this cannot be done on the dead body by the most 
careful dissection, it cannot be done on the living during the exigencies 
of an operation. 
In the microscopical examination of Case VI. the motor root was 
found to form an intimate part of the third branch so near the ganglion 
that it would have been very difficult or even impossible to separate it 
from the ganglion at the time of operation. Another point is worthy 
of mention ; the peripheral sensory branches must degenerate after 
resection of the ganglion, and it may be that in the sclerosis which 
follows the destruction of the sensory fibres in the third branch the 
motor fibres would be at least partly affected even if they had not 
been cut. The only possible absolute necessity for preserving the nerve KEEN, SPILLER: GASSERIAN GANGLION. 
17 
would be the need for preserving it in case of a bilateral resection of the 
Gasserian ganglion. This has never yet been necessary, and will surely 
be extremely rare. If, after destruction of the ganglion, the muscles 
of mastication on the sound side are sufficient for the purposes of 
mastication, I see no reason to trouble ourselves to preserve the motor 
root. 
A much more important question as to the extent of the removal of 
the ganglion is whether the entire ganglion shall be avulsed, such, for 
example, as is seen in Fig. 3 from Case VI. of my own series and in 
several of Krause's photographs (JNeuralgie des Trigeminus), or whether 
we should follow the recommendation of Tiffany, that only the outer 
two-thirds of the ganglion, together with the second and third divisions, 
should be removed and the inner third left. The only object in leaving 
the inner third is the conservation of vision. But, as shown below, I 
believe that our methods of dealing with the eye are so improved that 
we can positively now remove the ganglion and yet conserve the eye. 
In addition to this we must remember that the ganglion is not divided 
into thirds physically or physiologically. It is not true that the inner 
third of the ganglion is connected exclusively with the first division 
and supplies the eye, the middle third with the second division, and the 
outer third with the third division ; but the cells of the ganglion in 
every part are more or less connected, so far as we know, with any or 
all of the three divisions. 
An arbitrary line, therefore, removing the outer two-thirds and 
leaving the inner third will leave undoubtedly diseased ganglionic cells 
if the ganglion is affected. If these cells are diseased, any stimulus 
from the first division will excite sensation in them, and thus may bring 
about a return of the pain. 
As the only objection to removing the whole ganglion-the effect 
upon the eye-can now, I think, be overcome, we ought, I believe, 
distinctly to aim at the removal of the entire ganglion. 
3. Shall the ganglion be removed as a primary operation-the very first 
after the disease has set in-or shall it be left till the last operation ?- 
that is to say, shall we perform as many peripheral operations as can 
be done first, and only remove the ganglion when we are driven to it ? 
I believe that this last is the proper position to take. 
While Dr. Spiller, from his investigations of the pathology, is not able 
to say positively whether the ganglion becomes diseased primarily or 
secondarily, yet, as he points out, the clinical evidence would lead us 
to believe that the ganglion is the last of all to suffer. Of course, 
after any peripheral operation, just as after an amputation of an arm, 
atrophic changes will set in which will go direct to the Gasserian gan- 
glion, and may, so far as we know, reach to the pons, or even possibly 
the cortex, just as after an amputation of an arm atrophic changes 
2 18 
KEEN, SPILLER: GASSERIAN GANGLION. 
can be traced into the central nervous system, yet these are very differ- 
ent from anything like an ascending neuritis which would involve the 
ganglion in inflammatory troubles as a result of the preceding disease 
of the nerve branches. 
The effect on the ganglion, even after eighteen years of suffering, in 
Case VIII., was very slight. This, so far as I know, is the only exami- 
nation of a ganglion in which no peripheral operation had been done, 
and in which the examination is, therefore, free from any suspicions of 
alteration in the ganglion other than that due to a possible ascending 
neuritis. It must be stated, however, that the entire ganglion could 
not be examined microscopically. If the ganglion is not diseased, 
therefore, primarily I believe that we ought to attack the disease where 
we know it exists-namely, in the peripheral branches. If the ganglion 
is primarily diseased, we cannot understand how it is that relief is 
afforded for one, two, three, or more years by a peripheral operation. 
The simple shock of the operation would not keep a diseased ganglion 
quiescent for months or years. My own conviction, based on examina- 
tions so far made, is that the disease, in many cases at least, is primarily 
peripheral and that the ganglion is involved by extension upward. In 
those cases in which some local growth is found on the branches of the 
fifth nerve the cause of the pain must, of course, be peripheral, and 
we have no means of detecting the presence of such a lesion previous 
to operation. I would, therefore, urge not only that the removal of the 
Gasserian ganglion should be the last operation, but I would specially 
urge that peripheral operations be done early. Most operations for tic 
douloureux are made two, three, five, ten, or even twenty years after 
the disease began and after vain attempts have been made to cure by 
drugs. My own view decidedly is that, if the disease has positively 
existed for so long a period as three or four months, and if during this 
time, while drugs may have relieved, they have not cured it, I would 
wait no longer, but instantly do the peripheral operation in the hope of 
arresting the peripheral disease and preventing its upward course, which 
in time will result in its involving the ganglion. 
When we remember the fact that all the peripheral operations are 
virtually without danger to life, and that they relieve for a considerable 
time, and that we are in a position now to state that the mortality of 
Gasserian operations is over 20 per cent., and that in a small percent- 
age of cases even the removal of the Gasserian ganglion may not surely 
and permanently cure, I think we are in a position to say that the 
removal of the ganglion should not be done till we have exhausted 
our resources in peripheral operations, or till a larger surgical expe- 
rience shows that the removal of the entire ganglion will cure per- 
manently and a better surgical technique greatly lessens the present 
mortality. KEEN, SPILLER: GASSERIAN GANGLION. 
19 
4. A few points in technique : 
(а) Access to the cranial cavity. There is no question in my mind that 
either the Hartley-Krause operation, or the operation of Doyen (which 
I have never yet attempted), or an operation somewhat analogous to it, 
described by Poirier in Chipault's Travaux de Neurologie Chirurgicale, 
1897, vol. ii. p. 213, is the preferable one. All of these approach the 
ganglion from the side and by lifting the temporo-sphenoidal lobe. By 
no possibility can one work with the same advantage either as to light 
or facility of manipulation by Bose's method. Whether the flap shall 
be raised by chisel or drill or saw I think is a matter largely of prefer- 
ence of each individual operator. 
(б) Hemorrhage. In three instances I have done the operation in 
two stages on account of hemorrhage, packing iodoform gauze into the 
skull in these cases. The amount of gauze which I have used has 
surprised me very much. In one case it was 37 by 6 inches, or 222 
square inches of gauze ; in a second, 23 by 14 inches, or 322 square 
inches ; in a third, 267 square inches ; and in a fourth a piece 16 by 6, 
or 96 square inches. I mention this to show what an amount of pressure 
the brain will stand, but I also mention it to condemn the procedure if 
it is possible to avoid it. The danger of infection is always considerable 
in any case in which the skull cavity has to be reopened. Moreover, I 
think we ought always to avoid testing the power of the brain to stand 
pressure, if we can. I join, therefore, heartily with Krause in urging 
that the operation shall be completed in a single sitting, if possible. 
Hemorrhage from the middle meningeal has almost invariably taken 
place in all of my operations, either by unavoidable tearing of the 
vessel in turning down the flap, or, as happened three times, by the 
tearing of the vessel at the foramen spinosum. In the latter case the 
simple use of the Allis blunt dissector, to block up the vessel for a 
moment by the curved end, and later the substitution first of the left 
forefinger and then of a small bit of iodoform gauze, will overcome the 
difficulty, if the vessel cannot be ligated. On no account, in my opinion, 
should the external carotid be ligated as a preliminary measure. In 
one case in this city (Philadelphia) in which it was done,'necrosis of the 
temporal flap took place, and the patient's death from sepsis followed as 
a result. 
(c) The removal of the ganglion itself is best done by Krause's method 
-namely, uncovering the ganglion and then seizing it and twisting 
it out after dividing the second and third divisions at their foramina. 
This method of removal should be employed instead of the uncertain 
method of "breaking up" the ganglion when we act blindly and 
unscientifically. 
(d) The preservation of the eye. The method which experience has 
taught me now definitely to adopt is as follows : Either immediately 20 
KEEN, SPILLER: GASSERIAN GANGLION. 
before or at the close of the operation I disinfect the eye and sew the 
two lids together by two or three stitches, near the margins, drawing 
together only the middle of the lids. This leaves the two ends open 
sufficiently, first, for washing the space between the lids and the eye- 
ball with a warm boric-acid solution, to wash away any mucus, and also 
leaves enough space for us to observe the cornea when the patient looks 
strongly to one side. This occlusion of the lids should last for not less 
than four or five days. The stitches may then be cut and the eye 
immediately covered by a Buller shield-i. e., a watch-glass held in 
place by means of either a circular fenestrated disk of rubber plaster or 
by four separate pieces of plaster. I prefer the circular plaster. 
The reason for the corneal ulceration and loss of vision or loss of the 
eye is undoubtedly, first, the drying of the cornea, due to the want of 
appreciation of its drying and, therefore, to want of winking, by which 
the cornea is kept moist; and, secondly, as another result of the want 
of sensitiveness of the cornea, either foreign bodies get into the eye, or, 
as in one of my cases, a bandage over the eye may rub the cornea and 
thus produce ulceration and the destruction of the cornea. The use 
of the Buller shield is so thoroughly satisfactory both in protecting the 
eye and in keeping it moist that I think any one who has tried it will 
be unwilling to dispense with it afterward. Its use should be continued 
for from ten to thirty days after the operation. 
Pathological Report, by Dr. Spiller. 
{From the Wistar Institute of Anatomy and Biology.) 
Little attention has been paid to the microscopical examination of 
the Gasserian ganglia removed from patients suffering from tic doulou- 
reux ; indeed, with the exception of a few cases, we have had almost no 
information furnished us on the pathological condition of these structures 
in the disease. It was, therefore, with a feeling of deepest interest 
that I undertook the examination of the ganglia removed by Dr. 
Keen from seven cases of prosopalgia. 
This report is based on a study of several hundred sections. The 
stains employed have been carmine, hsematoxylin (Delafield's and 
Weigert's), osmic acid (methods of Azoulay and of Marchi), thionin, 
acid fuchsin, and eosin. The method of Rosin has given most satis- 
factory results for a study of the nerve fibres, and in some cases, in 
which the material did not stain readily with carmine, Delafield's 
hiematoxylin, with an after-stain of acid fuchsin, presented beautifully 
colored specimens. Unfortunately, the method of Nissl could not be 
employed, as all the ganglia had been placed in Muller's fluid. The 
method of Azoulay proved to be of great service, for in some cases in FIG. 11. 
FIG. IO. 
FIG. 12. 
FIG. 18. 
FIG. 14. KEEN, SPILLER: GASSERIAN GANGLION. 
21 
which the method of Weigert did not give thoroughly satisfactory 
results, the former yielded sections well stained. 
Case V.-The nerve fibres are greatly altered ; in many the medullary 
sheaths are much swollen, and no traces of axis cylinders can be seen ; 
in others the latter are represented by irregular and separate masses of 
a hyaline-like red substance, which have little resemblance to normal 
axis cylinders. Many nerve sheaths are entirely empty. The vessels 
are sclerotic, and some of the smaller ones are entirely closed. The 
ganglion cells are in different stages of degeneration ; some are faintly 
stained and have very indistinct outlines, and there are numerous spaces 
in which the cells have entirely disappeared. Some of the nerve cells 
are very small and without nuclei and nucleoli, though possibly this 
may be due to the fact that superficial portions of these cells were 
obtained in the sections, and the connective tissue between them is 
increased in amount. The pericellular spaces seem to be somewhat 
larger than in normal ganglia, and appear as if the cells had shrunken 
away from their capsules. No very great difference can be noticed in 
the condition of the second and third branches of the nerve, for they 
seem to be nearly equally diseased. 
Case VI.-The ganglion removed from Case VI. presents, on micro- 
scopical examination, most distinct evidences of degeneration. The 
medullary sheaths of many of the intraganglionic fibres are greatly 
swollen, and the fibres have an irregular, beaded appearance in longi- 
tudinal sections. (Fig. 10.) Some bundles, cut transversely, contain 
masses of medullary substance varying greatly in size and of most 
irregular form, and without a trace of axis cylinders. Stained by the 
method of Azoulay or Weigert, these masses of medullary substance 
stand out prominently, and it is noticed that frequently they are not 
continuous with one another, but that they are connected by empty and 
contracted nerve sheaths. There is no great increase in the number of 
the nuclei of the sheaths of Schwann. Normal bundles of fibres are 
found lying close to fibres very greatly degenerated. It is impossible 
to find any greater alteration of the fibres belonging to the second 
than of those belonging to the third branch of the trifacial nerve. 
Description of Plates. 
Fig. 10. Portion of the Gasserian ganglion at the entrance of the third branch of the trifacial 
nerve, from Case VI. The medullary sheaths are most irregularly swollen, and at the right of 
the field empty nerve sheaths are seen (method of Azoulay). 
Fig. 11. Portion of the second branch of the trigeminal nerve near the Gasserian ganglion, 
from Case VI. The axis cylinders have entirely disappeared, and the medullary sheaths are 
greatly swollen. In many places the medullary substance of two or more nerve fibres 
has united into irregularly shaped masses. 
Fig. 12. One of the nerve bundles within the Gasserian ganglion, from Case VI. Numerous 
swollen and irregularly formed axis cylinders may be seen. In most portions of the field these 
appear as drops of a red, hyaline-like substance, but in one portion an axis cylinder of con- 
siderable length may be seen. 
Fig 13. Bloodvessels from the Gasserian ganglion in Case IX. The walls are greatly thick- 
ened, and the lumen of the large vessel has been almost entirely obliterated. In one place the 
innermost layers of the vessel have contracted from the outer during the process of hardening. 
Smaller vessels in the upper part of the field are entirely closed. 
Fig. 14. A nerve bundle of the trigeminus close to the Gasserian ganglion, from Case X. 
Only a few nerve fibres are present, and everywhere an abundance of connective tissue is seen. 
Three much swollen medullary sheaths are in the field. 22 
KEEN, SPILLER: GASSERIAN GANGLION. 
The sensory and motor roots are normal; the nerve fibres in these 
roots present medullary sheaths which stain well and have normal out- 
lines. Longitudinal and transverse sections of the motor and sensory 
roots, and of the second and third branches of the nerve, have been 
obtained ; the first branch had been broken off close to the ganglion at 
the time of the operation. 
Transverse sections of the motor and sensory roots present the usual 
number of nerve fibres, each with an axis cylinder surrounded by a 
medullary sheath and separated from the other by a moderate amount 
of connective tissue. The contrast afforded by the transverse sections 
of the second and third branches with those of the sensory and motor 
roots is most striking. In the second branch, especially, the irregular 
and large masses of medullary substance are very distinct (Fig. 11), and 
in many bundles it is impossible to detect axis cylinders. Atrophied 
fibres seem to predominate in the transverse sections of the third branch, 
though in longitudinal sections a little nearer the ganglion the swollen 
medullary sheaths are as visible as in the second branch. The ganglion 
was cut longitudinally in such a manner that its relation to the second and 
third branches and the sensory root are shown in a single -section. In 
some intraganglionic nerve bundles axis cylinders may be found greatly 
swollen and occurring in irregular masses of a pinkish hue when the 
carmine is employed as stain, but these masses are more numerous 
in certain bundles. (Fig. 12.) The process has evidently reached a 
stage in which the swollen axis cylinders have in large part been re- 
moved. The connective tissue about and between the bundles of nerve 
fibres is not very excessive, but is increased to some extent between the 
individual fibres. 
The ganglion cells are somewhat more irregular in outline, the smaller 
cells are more numerous, and the pericellular spaces are larger than in 
normal ganglia. Many cells contain vacuoles, but the nuclei are not 
eccentric and the nucleolus can usually be seen. The pigmentation of 
the cells is not excessive, and the capsules of the cells do not appear to 
be much thickened, nor are their nuclei unusually numerous. The in- 
tercellular tissue is not notably increased. In some places the cells are 
very small and faintly stained, though a few appear unusually large 
and swollen, but these are comparatively rare. The most striking 
alteration of the cells is the atrophy with the enlargement of the peri- 
cellular spaces, of which the latter may be due to changes which have 
occurred after removal of the ganglion. 
The small vessels in many parts of the ganglion are greatly altered ; 
some are completely closed by the proliferation of the tissue in the 
walls of the vessels, while others show only a slight alteration. 
Case VII.-The ganglion cells are most irregular in shape, and 
appear to be somewhat more separated than normally from one another 
by overgrowth of the intercellular connective tissue. Some of the cells 
are not sharply defined from the surrounding tissue, and some do not 
contain distinct nuclei or nucleoli. In some places the ganglion cells 
have been destroyed and removed ; in others the cells contain much 
pigment and some vacuoles. The cellular changes are greater than in 
the preceding case, in which they are not especially striking. The 
medullary sheaths of the nerve fibres in many places are greatly swollen. 
Many nerve bundles contain very small nerve fibres ; many are entirely 
deprived of nerve fibres and contain merely connective tissue ; and KEEN, SPILLER: GASSERIAN GANGLION. 
23 
many contain swollen medullary sheaths without axis cylinders. The 
small vessels have thickened walls, and some are entirely closed by 
proliferated tissue. 
Case VIII.-Some of the vessels are sclerotic, but there is little 
change in the nerve fibres. The smaller ganglion cells are abnor- 
mally abundant. In some places the medullary sheaths are somewhat 
swollen. 
Case IX.-The findings in this case consist of swollen medullary 
sheaths, diseased axis cylinders, proliferated connective tissue in the 
nerve bundles, with destruction of nerve fibres, and altered ganglion 
cells. Only a portion of the ganglion has been obtained, but it is suffi- 
cient for the purposes of microscopical study. The cells and their cap- 
sules in certain parts can be distinguished with difficulty from the sur- 
rounding tissue ; in other parts they are much more distinct; it is 
frequently impossible to detect nuclei or nucleoli, and one might well 
doubt whether he were examining ganglionic tissue were it not for the 
fact that here and there a nerve cell is detected. The intercellular 
tissue has replaced the ganglion cells. 
The bloodvessels are much altered, as may be seen in Fig. 13. In 
the vessel represented here the media and intima are much thickened, 
and the latter has almost entirely filled the lumen of the vessel, leav- 
ing several smaller passages for the current of blood. In the process 
of hardening the inner coats at one portion have contracted and with- 
drawn from the outer, leaving an open space. 
Case X.-The medullary sheaths in certain parts of the sections 
are greatly swollen, and the axis cylinders have been almost entirely 
destroyed (Fig. 14) and removed, leaving small lumps of pinkish hyaline 
substance here and there. Many nerve sheaths may be found in which 
the medullary substance and axis cylinders have entirely disappeared. 
The vessels seem to be less affected than in the other cases in which 
evidences of intense degeneration have been noted. The ganglion 
cells have indistinct outlines, and some stain very faintly. The in- 
tercellular tissue is increased in amount, and throughout the sections 
in which the ganglion cells are found numerous granular corpuscles 
are noticed. 
Case XI.-The ganglion cells are vacuolated, but do not appear to 
be greatly altered, nor are the cell capsules notably thickened. In one 
portion of certain sections nerve bundles are found in a high degree of 
degeneration ; the medullary sheaths have almost entirely disappeared, 
leaving only granular masses here and there ; the axis cylinders are 
swollen, and the connective tissue and empty nerve sheaths occupy a 
large portion of the fields. The vessels are somewhat altered. 
In six of the cases just described the lesions are of an intense degree 
and unquestionable. In a seventh case (Case VIII.) they are much 
less distinct. 
The lesions in the Gasserian ganglion in the more advanced cases of 
tic douloureux consist of much-swollen medullary sheaths, swollen axis 
cylinders, atrophied fibres, empty nerve sheaths, nerve bundles in which 
the nerve elements have been destroyed and only connective tissue is 
left, atrophied ganglion cells, cells faintly stained, and sclerosed blood- 24 
KEEN, SPILLER: GASSERIAN GANGLION. 
vessels, in some cases even without a lumen. In all the specimens ex- 
amined numerous red blood-corpuscles are observed, which doubtless 
owe their position within the tissues to the surgical interference. 
The pathology of tic douloureux has not been well known. Some 
have held that it is a neurosis ; others that it is a neuralgia, though 
this distinction is not very clear ; and still others that it is a neuritis. 
Some have believed that the disease is a peripheral one, and others 
that the primary lesion is within the ganglion. There is always a pos- 
sibility that in some cases the lesion may be a central one. 
Putnam1 says that, as a rule, neuritis is present in trifacial neuralgia, 
and probably exists far oftener than we think. This seems to me ex- 
ceedingly probable, for the dividing line between neuralgia and neuritis 
cannot be sharply drawn. One, we are told, is a functional, the other 
an organic process ; but "functional" is a very comprehensive term. 
Putnam states that of late years physicians have been more favorable to 
the view that, in chronic forms of neuralgia, at least, the pain is simply 
the expression of the inflammation of a nerve. 
Dana2 placed much more value on the condition of the bloodvessels 
than on inflammatory changes in the nerve fibres. 
In a recent communication to the writer he expresses the opinion 
that trifacial neuralgia is due to degenerative neuritis of the peripheral 
sensory neurons of the fifth nerve, depending on or associated with 
obliterating arteritis. 
The investigations by Thoma3 of the bloodvessels from the painful 
area in supra-orbital neuralgia, and his explanation for their sclerotic 
condition, are most interesting. 
Rose4 also has remarked on the size of the vessels and the thickness 
of their walls in some of the cases on which he operated. He found 
great alteration of the peripheral nerves in trifacial neuralgia. The 
appearances were those of chronic neuritis, and were often more marked 
at the peripheral than at the central end of the nerves. 
Microscopical alterations of the peripheral branches of the fifth nerve 
in cases of tic douloureux have also been noticed by Tuflier,5 
De Schweinitz,6 Horsley,7 Tripier,8 Putnam,9 Krause,10 Spiller,11 and 
1 Putnam : Boston Medical and Surgical Journal, 1891, vol. ii. pp. 157, 186. 
2 Dana : Medical News, May 16, 1891. 
3 Thoma: Deutsches Archiv filr klinische Medicin, 1888, vol. Ixiii. p. 409. 
4 Rose: Transactions of the Medical Society of London, 1892, vol. xv. p. 157. 
5 Tuffier: La France medicale, 1881, vol. I. p. 672. 
6 De Schweinitz: In paper by Mears, Transactions of the American Surgical Association, 
1885, vol. ii. p. 469. 
7 Horsley . Transactions Odontological Society, 1887, vol. xix. p. 270. Cited by Rose. 
3 Tripier : Revue de Chirurgie, 1889, vol ix. p. 453. 
9 Putnam : Boston Medical and Surgical Journal, 1892, vol. ii. pp 157, 186. 
10 Krause: Die Neuralgie des Trigeminus Leipzig, 1896. 
11 Spiller: Journal of Nervous and Mental Disease, June, 1898, p. 400. (In a paper by J. 
K. Mitchell.) KEEN, SPILLER: GASSERIAN GANGLION. 
25 
others, and macroscopical changes have been detected by Tuffier,1 
Mears,2 Tripier,3 Keen,4 and others. 
Krause's5 book is the most thorough which has as yet appeared on 
trifacial neuralgia. Though he found alterations in branches of the 
fifth nerve which had been slowly twisted out, he was unable to detect 
changes in the vessels. Krause observed marked lesions in the Gasse- 
rian ganglion in cases of tic douloureux, but only in one ease could he 
demonstrate changes in the sensory fifth root, and in this case after the 
pain had disappeared on one side of the face, as a result of excision of 
the ganglion, it recurred on the other. 
Krause could not find the sclerosis of the ganglion which other writers 
describe, and which certainly exists in one of Dr. Keen's cases (Case IX.). 
In six of Krause's seven cases resection of the nerves had preceded 
by some years the excision of the ganglion, and he justly compares his 
findings with those seen after amputation, but he regards them as too 
intense to be merely secondary. He thinks the question cannot be 
positively settled until a ganglion is examined the peripheral nerves of 
which have never been resected. This examination has been made in 
Case VIII. of this paper. In none of Krause's cases did the neuralgia 
return after excision of the ganglion, even within three and a half years 
after the operation, and as the peripheral operations did not give per- 
manent relief, and extirpation of the ganglion did do so, he thinks it is 
allowable to conclude that the cause is to be sought in the Gasserian 
ganglion. 
It seems to me quite possible that the trouble may first be peripheral, 
and as resection gives only temporary relief, the recurrence of the pain 
may be due to extension of the morbid process to the ganglion. 
Krause is disposed to regard the changes in the ganglion partly as 
primary and partly as secondary from the resection. 
The fact that nerve degeneration may extend beyond the spinal 
ganglia and affect the posterior roots must make us prepared for the 
possibility of an extension of a similar process after extirpation of the 
Gasserian ganglion. 
Other investigators who have found lesions of the Gasserian gan- 
glion are Wedl, Rose, Podrazky and Laveran, Horsley, Putnam, and 
Antonino d'Antona (all cited by Krause). 
The possibility of the changes in the ganglion being secondary, as 
Krause suggests, is not to be lightly passed over. Lugaro6 has shown 
1 Tuffier: La France mSdicale, 1881, vol. i. p. 672. 
2 Mears: Transactions of the American Surgical Association, 1885, vol. ii. p. 469. 
3 Tripier. Revue de Chirurgie, 1889, vol. ix. p. 453. 
4 Keen : The American Journal of the Medical Sciences, 1896, vol. i. 
6 Krause: Die Neuralgie des Trigeminus. Leipzig, 1896. 
6 Lugaro: Rivista di Patologia nervosa e mentale, 1896. Cited by Schaffer in Monatsschrift 
filr Psychiatrie und Neurologic, July, 1897. 26 
KEEN, SPILLER: GASSERIAN GANGLION. 
that the nerve cells of the spinal ganglia undergo marked alteration 
after lesions of the peripheral fibres, and the spinal ganglia are so 
similar to the Gasserian that the results of these experiments may be 
applied to the latter. 
Fleming has noticed that the cells of the ganglia on the posterior 
nerve roots in rabbits and dogs undergo definite changes as the result 
of nerve section or of ligature, and do so at a much earlier period than 
do the multipolar cells in the cord, beginning probably as early as the 
fourth day, and certainly by the seventh day. The nucleus, and some- 
times the nucleolus also, become small, and the nucleus may be excentric 
and even bulge the cell wall. The chromophilic granules are altered, 
the cells atrophy, and the pericellular lymph spaces become enlarged. 
Just here we may mention, however, that Lanhossek's1 recent studies 
on fresh spinal ganglia, obtained from an executed man, have taught 
us that when the ganglia are properly hardened such pericellular 
lymph spaces do not exist. Fleming2 also says that large vacuoles 
are found in some cells. He thinks it is quite comprehensible that the 
cells of the ganglia should suffer before the cells of the anterior horns, 
inasmuch as nerve impulses pass normally to them from the site of the 
lesion. 
Kowalewsky3 cut the sciatic nerve in animals, and injected a few 
drops of a 5 per cent, chromic acid solution into the central end. The 
animals were killed two to four days later, and the chromophilic bodies 
of the cells of the spinal ganglia were found much altered. 
If, therefore, such alterations of the ganglion cells occur within a few 
days after resection of the nerve we may expect greater changes when 
the time which has elapsed since the operation is reckoned by years 
instead of days. And yet it is probable that some of the lesions of the 
ganglion cells which have been described are only of a temporary 
character. 
Neuritis may ascend ; it seems that the possibility of this, though 
often disputed, must be acknowledged. Mlle, de Majewska4 has 
recently written a thesis on the subject. She states that the lesions of 
ascending neuritis are the same as those of ordinary peripheral neuritis ; 
viz., fragmentation of the myelin, multiplication of the nuclei, and 
alteration of the axis cylinders. There is no reason why this neuritis 
should not extend to the cells of the Gasserian ganglion. 
It is well, of course, to examine an entire Gasserian ganglion in a 
case in which resection had never been performed, but the examination 
of the motor root in a case in which the third branch of the fifth nerve 
1 Lanhossek : Archiv filr Psychiatric, vol. xxix. No. 2. 
2 Fleming : Brain, parts Ixxvii. and Ixxviii. 
3 Kowalewsky : Abstract in Monatsschrift fiir Psychiatrie und Neurologie, vol. ii. No. 2, p. 147. 
•* Mlle, de Majewska : Abstract in Revue Neurologique, 1897, No. 15. KEEN, SPILLER: GASSERIAN GANGLION. 
27 
had been resected in the portion which contains this root, would also be 
of value, if done some years after the operation. Should no degenera- 
tion of the motor root be found there would be some evidence that the 
ascending degeneration had not been important, for this ascending 
degeneration is not limited to sensory fibres. 
Krause could demonstrate changes in the sensory fifth root only in 
one case. In Case VI., which I have examined, the sensory root is 
perfectly normal. The cells of the Gasserian ganglion have each a 
single axis cylinder, which, at a short distance from the cell body, 
divides, and one branch passes centrally and the other peripherally. 
If, therefore, the lesion is primarily within the ganglion cells, we cannot 
understand why only the peripheral branches of the axis cylinders are 
diseased, while the central branches remain normal. The same objec- 
tion has been raised against the ganglionic theory for the commence- 
ment of tabes in the spinal ganglia, only in the latter case the central 
branches of the axis cylinders are diseased and the peripheral, as a 
rule, are intact. 
The great and durable improvement occurring in many cases of tri- 
facial neuralgia after removal of the Gasserian ganglion would seem to 
indicate that the cause of the suffering is to be sought, at least in many 
cases, in the Gasserian ganglion ; but it by no means follows that we 
may expect to find lesions of the ganglion in every case, any more than 
we may hope to find lesions of the spinal ganglia in every case of tabes 
in which there has been pain, unless the employment of the method 
of Nissl changes our views, which Schaffer's1 recent studies make 
improbable. 
We know that a lesion within the cerebrum may produce intense 
pain, as Edinger,2 Biernacki,3 and Kirchhoff1 have shown, and Gowers5 
states that in a case known to him irritation of the sensory nucleus of 
the fifth nerve in the pons seemed to be the cause of the suffering in 
the face. Indeed, Gowers says distinctly that we know nothing of the 
sensory function of the posterior ganglia, and are justified in looking 
to the nerve cells within the cerebro-spinal axis as the seat of the 
morbid process. 
In a case of trifacial neuralgia, therefore, attention should be directed 
not only to the condition of the Gasserian ganglion, but also, if possi- 
ble, to that of the sensory nucleus of the fifth nerve, and to the spinal 
root of this nerve-i. e., the descending branch. 
We must acknowledge, it seems to me, that pain is not the usual 
manifestation of a lesion confined to the brain or cord, and, indeed, the 
1 Schaffer : Nenrologisches Centralblatt, 1893. 
2 Edinger : Deutsche Zeitschrift fiir Nervenheilkunde, 1891, vol. 1. 
3 Biernacki: Deutsche med. Wochenschrift, 1893, No. 52, p. 1372. 
4 Kirchhoff: Archiv fiir Psychiatrie, vol. xxix. No. 3. 
6 Gowers : A Manual of Diseases of the Nervous System, vol. ii. p. 803. English edition. 28 
KEEN, SPILLER: GASSERIAN GANGLION. 
presence of pain in cases of suspected hjematomyelia leads one to 
diagnosticate hjematorrhachis. We do not, as a rule, find pain in 
chronic degenerative processes of the cord which respect the posterior 
roots and meninges, as, for instance, in syringomyelia, but we find it 
as an early symptom of tabes, which is also a chronic process, but one 
which affects the posterior roots. 
As Gowers states, vascular dilatation attends functional activity, and 
it is probably also true that vascular dilatation, if not excessive and 
too prolonged, causes functional activity. Excessive functional activity 
of sensory cells may be manifested as pain, but it is possibly equally 
true that diminution or imperfect quality of the blood-supply may be 
a cause of pain. How can we better explain the frequent headache of 
anaemia? If, therefore, we find alteration of the bloodvessels within 
the ganglia, we may with reasonable suspicion look upon the condition, 
in part at least, as the cause of the pain, and may believe that peripheral 
irritation which under normal conditions would not be perceived would 
be sufficient to produce painful sensation. 
As yet, as far as I am able to judge from my researches in the litera- 
ture, the Gasserian ganglion excised from a case of trifacial neuralgia 
has never been examined by the method of Nissl. 
This method is so important for a study of degenerative changes in 
nerve cells that no one can say that such changes are absent until he 
has used the method. Nissl1 teaches that the employment of the older 
methods of technique, especially the hardening of the tissue in the 
chromic salts and the staining with carmine, are not only unsuitable, 
but likely to be most misleading, a view which most neuropathologists 
accept. 
I am unable, therefore, from a study of these seven cases and from 
an examination of the literature, to state whether the lesions of the 
ganglia are primary or secondary, and, if secondary, whether of the 
nature of ascending neuritis or not. The possibility of the secondary 
nature of the process within the ganglia in some cases, it seems to me, 
should not be overlooked. I base the opinion of a possible peripheral 
involvement, in certain cases, chiefly on the clinical evidence afforded 
by the relief of pain during two or more years in some patients by 
nerve resection, though, unfortunately, such cases are in the minority; 
on the normal condition of the sensory root in Case VI., and on the 
examination of Case VIII. of this paper, in which the lesions are very 
slight in comparison with those in the other cases, though the pain had 
existed for eighteen years. It is true that only a part of the ganglion 
was obtained in this case, and it is possible that this portion was the 
least diseased, but it is remarkable that in all the other cases intense 
1 Nissl: Allgemeine Zeitschrift fiir Psychiatric, vol. liv. Nos. 1 and 2, pp. 26-27. KEEN, SPILLER: GASSERIAN GANGLION. 
29 
alteration was found, and in some of these the parts of the ganglia 
obtained were not larger than in Case VIII. 
Case VIII. is the only one of the seven in which a primary resection 
of the peripheral branches was not done. The pain involved all three 
branches of the fifth nerve, and Professor Keen therefore attacked the 
ganglion at once. The possibility of an ascending neuritis in this case, 
due to nerve resection, is excluded, inasmuch as no operation on the 
peripheral branches had been performed. 
The clinical evidence is of importance, for an absence of pain for two 
or three years seems to indicate that during the respite the ganglion 
cannot be greatly diseased. No branch of the fifth nerve is sharply 
limited to any one portion of the Gasserian ganglion, and were the 
ganglion primarily diseased the resection of one branch would not 
remove the peripheral irritation transmitted by the other branches to 
the hypersensitive cells. 
There can be no doubt that intense alteration of a chronic inflamma- 
tory character may be found in the Gasserian ganglion in certain cases 
of tic douloureux, and also that the sensory root may be intact. This, 
it seems to me, is a satisfactory explanation for the relief of pain expe- 
rienced by many patients in whom the ganglia have been excised. 
The removal of the diseased cells within the Gasserian ganglion, which 
are capable of responding abnormally to every peripheral irritation, 
may well be attended with the relief of pain. Excision of the ganglion 
destroys at once the paths of painful sensation from a large area. 
The integrity of the sensory root, in the case in which the whole 
ganglion was removed by Professor Keen, is a fact of considerable im- 
portance. It teaches that though the ganglion may be greatly diseased, 
the process may be arrested at this point. In the other case in which 
the sensory root was examined-the only other case (Krause) with such 
an examination which seems to have been reported, though possibly 
Krause examined the sensory roots of some of the other ganglia, and if 
so, he probably found them normal-the fibres were found diseased, and 
the process extended to the other side of the face. This report, and 
the four cases (one reported by Rose, two by Keen, and one by Dana) 
in which the pain returned after removal of the ganglion, though we 
are not sure that all portions of the ganglia were excised in these cases, 
must make us prepared for the possibility of a renewal of the suffering 
in some instances, even after the excision of the Gasserian ganglion. 
I feel more than ever inclined to believe, from a study of these cases, 
that neuralgia cannot be sharply distinguished from neuritis, and in 
some cases of so-called chronic neuralgia, such as obstinate sciatica, I 
believe we may frequently be able by the microscope to detect evidences 
of chronic inflammation. At the same time we should not forget that 
neuritis may assume different clinical forms. 30 
KEEN, SPILLER: GASSERION GANGLION. 
If it could be shown that the sensory root of the Gasserian ganglion 
does not unite after its fibres are divided, we should have a fact of great 
importance. Division of this root would probably be a less serious 
operation than the removal of the entire ganglion, and might have the 
same effect in the relief of pain, but the surgical difficulties might be 
insurmountable. Experiments on animals to determine whether or not 
the sensory root of the Gasserian ganglion unites after section of its 
fibres might result in a lessening of the great mortality now existing in 
operations on the ganglion. The Medical News. 
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