NEURALGIA OF THE FIFTH PAIR.— Neuralgia of the fifth pair of cranial nerves is also known as trifacial neural gia, facial neuralgia, tic douloureux, etc.
Neuralgia of the fifth pair is more fre quent than all other forms of neuralgia combined, and is, from a clinical stand point, the most important of the forms of neuralgia with which the physician has to deal, this nerve seeming peculiarly susceptible to functional and organic disorders as a consequence of the com plexity and highly differentiated charac ter of its structure and connections.
All three of the branches are seldom affected simultaneously. The ophthal mic branch is that most often involved, giving rise to neuralgic pain in eye and brow ("brow-ague") with an especially painful point at the supra-orbital notch. In some cases the pain is especially in tense in the eyeball. When the infra orbital branch is involved there is the usual pain in the area of distribution of the nerve, and a marked tender point at infra-orbital foramen. A toothache-like pain in upper teeth is common. In neuralgia of the inferior dental branch the pain is often diffuse, extending from temporal region over the side of the face to the chin, with pain in lower teeth and side of the tongue, the last mentioned being, in some cases, the situation of greatest intensity. In severe forms of pain involving any branch of the fifth nerve the pain may in lesser degree ex tend to the other branches. fn all forms of facial neuralgia trophic disorders, in particular herpes, may occur. When the pain in facial neuralgia is very intense and markedly- paroxysmal, with reflex facial muscular spasm accompanying, we have the form known as "tic doulou reux": the most distressing and intract able form of nerve-pain. The general sy-mptomatology and causation, as well as therapeutic indications of neuralgia in general apply- to the facial form.
Neuralgias of the fifth nerve differ in history, course, and treatment from migraine. True cases occur in groups, but this is due to season ot the year.
Occasionally it begins in youth and con tinues at intervals for years. The pain is deep, sometimes over the entire area of the supra-orbithl nerve; sometimes most at one spot, as on the brow; occa sionally associated with pains in other parts of the head. Usually there is an attack in the morning, a lighter one in the afternoon, perhaps a slight one at night. Some persons have 2 attacks
every year, spring and autumn. Some times there is a family history of this or migrainous affection. J. J. Putnam (Med. Rec., May 9, '99).
Trealment.—In treatment, improve ment in general health is first to be sought.
For the relief of the acute pain opium, of course, is most reliable, but it should not be employed -until aconite, coal-tar remedies, and other analgesics have been given a trial. Galvanic electricity seems especially valuable. The cataphoric ad ministration of cocaine, chloroform, aconite, and other shnilar drugs gives in many cases complete and entire re lief for many hours. The continued hypodermic use of strychnine at the seat of the pain has given excellent results in preventing the return of the parox ysms.
A certain number of eases of tic doll loureux believed to be caused by ciea trization of the peripheral portion of the nerve. These eicatricial lesions arc pro duced chiefly by alveolar dental perios titis, and also by the periostitis (-aimed by eruption of the wisdom teeth. The first desideratum is, therefore, to cause the disappearance of the cicatrices by mg the bone mid freeing the mu cous membrane of the glints. Jarrc Oka Press and Circ., Sept. 13, '93).
in tie donloureux injections of strych 11111V are aluable made once a day, thc do4e being gradually increased from Vic, tt, ' , or ' , grain: ten to twenty days are required to reach this maximum. As adjuvants to the injections potassimn iodide and iron, re.,t in bed, light diet, and diluents are to be used. Dana (Lios ton Med. and Surg. Jour., July.2, '96).
Se% ere case of tic doulourcux success fully treated ‘‘ith nitroglycerin. Tab lets of '/),„ grain were prescribed, at first thrice daily, gradually increased until the patient sx as taking seven or eight tablets daily, and, if necessary, one every hour. The face was also treated with a mild galvanic current, and slte was given a laxative tonic. She began to im prove after the second week, and the im provement steadily continued.
The dose of nitroglycerin should be in creased until the physiological effects are produced, even if enormous quantities must be administered. Krauss (BufTalo Med. Jour., Oct., '97).
Treatment of neural,gia, of the fifth nerve is quinine in large dose four hours before attack, arsenic, and attention to nasal passages. J. J. Putnam (Med. flee., May 9, '99).