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It's not your business by your face to show
But if your eyes should probe him over much,
Beware still further how you rudely touch.
And last, not least; in each perplexing case,
When grief and anguish crowd the anxious scene
DYSTOCIA DUE TO PELVIC TUMOR.
BY W. E. BARTLETT, M.D., KIRKMANSVILLE, KY.
On the morning of June 1, 1896, I was called to see Mrs. H., æt. 34, multipara, her two first children are living, aged respectively, 12 and 10 years, the third child was still-born. About two years after the third she was delivered of a dead fœtus between four and five months.
I found her in labor, which began eight or ten hours before my arrival, and very much exhausted. Having administered morphia,gr., with atrophia, 1-100, hypodermically, I made an examination. Digital examination disclosed a hard mass, apparently attached to the posterior wall of the pelvis. I found it impossible to pass the mass, and was compelled to satisfy myself as to the position of the child by abdominal palpation. By this means I was satisfied that the child's head was presenting, but did not believe there was room enough in the parturient canal for it to pass. I endeavored to reduce the size of the tumor by aspiration, but failed.
Feeling the need of consultation, I sent for my father and Dr. Jackson, of Hopkinsville. They arrived in about two hours, and having anesthetized the patient with chloroform, we examined her and decided that delivery could possibly be effected by forceps, but after several futile efforts this was given up. Examining further we found it possible to grasp a foot, then the other, performing pedalic version, we succeeded in delivering a nine-pound child, dead.
The mother made a slow, tedious recovery, and is now able to attend her household duties. A recent examination showed the tumor to be nearly as large as the child's head, attached to the posterior wall of the vagina.
THE TREATMENT OF TRIGEMINAL NEURALGIA.*
BY WILLIAM M. LESZYNSKY, M.D., NEW YORK. Consulting Neurologist to the Manhattan Eye and Ear Hospital; Lecturer on Mental and Nervous Diseases at the New York PostGraduate Medical School, Etc.
While deliberating upon the selection of a suitable topic which might be of interest to the general practitioner, I was consulted by a young woman who had been a sufferer from trigeminal neuralgia for a number of years, and had obtained very little or no benefit from the medical treatment she had received.
The observation of this case (which will be referred to later) hastened my decision. I shall therefore ask your attention to "The Treatment of Trigeminal Neuralgia," which I trust will prove of sufficient interest to merit your careful consideration. At the outset I should like to have it clearly understood that, as this paper is based upon the results of personal clinical experience, I shall endeavor in the limited time allotted to me to confine my remarks almost exclusively to the methods that have proved most serviceable and satisfactory in my hands. Much that I might say to you must be left unsaid, as this is neither the time nor place to indulge in a lengthy dissertation or a tedious narration of the views of others.
Trigeminal neuralgia is of comparatively frequent occurrence in the routine work of the general practitioner. It also comes within the scope of the ophthalmologist, laryngologist, and
*Read before the Harlem Medical Association, February 3, 1897, and the Practitioners' Club of Newark, N. J., March 1, 1897.
dental surgeon. The neurologist generally sees these patients after the disease has existed for a long time, and occasionally when complications are present.
The term "neuralgia," which means simply "nerve pain,' should be restricted to the cases in which the malady consists only in functional disturbance. While the usual type of this affection may be looked upon as idiopathic in the vast majority of instances, the more severe form, known as tic douloureux or epileptiform neuralgia (which generally occurs after forty years of age, and in old people), may be considered as degenerative. In order to avoid repetition, I shall discuss them as one condition, although the latter is probably dependent upon changes in the nerve itself. It is obviously unnecessary to enter into a detailed description of the symptomatology, with which you are all more or less familiar, or may read at leisure.
Of all the peripheral nerves, the trigeminus or its branches is most frequently the seat of neuralgia. We are thus reminded that it is the largest cranial nerve, that it is a nerve of special sense, of common sensation and motion, and that it is the great sensory nerve of the head and the motor nerve of the muscles of mastication.
The diagnosis of trigeminal neuralgia rests mainly upon the following points (Erb):
1. That the pain is limited to a definite nerve path, either trunk, branch, or area of distribution, and that it is usually confined to one side.
2. That the pain is, without any obvious reason, either intermitting or at least distinctly remitting in character.
3. That the pain presents very peculiar characters, and is extraordinarily acute.
4. That there are certain spots in the course of the nerve or in the area of its distribution which are very sensitive to pressure.
5. That the pain is associated with sensorimotor, and vasomotor, and secretory phenomena.
6. That the pain is unaccompanied by any inflammatory or local symptom.
Each division of the nerve or its branches may be independently affected, or all branches may be involved simultaneously. Certain diseases seem at times to possess a predilection for
certain branches. Thus, the supraorbital nerve is affected more frequently after infections such as grippe or malaria; the superior maxillary nerve from defective teeth, particularly the molars. In neuralgia of the auriculo-temporal branches, the pain is sometimes limited to a narrow stripe extending over the vertex from ear to ear, and is often occasioned by syphilis. An irritative process in the pons, involving the sensory root of the nerve, may be the cause of severe trigeminal pain. The diagnosis of such a lesion can be made only in the presence of associated symptoms of cerebral disease.
Neuralgia of a persistent character, affecting particularly the first branch, may be due to errors of refraction or other ocular defects, intra-nasal disease, or disease in the frontal sinus, or it may result from exposure to cold.
In this connection I must briefly mention a very important clinical fact not referred to in text-books. It is that the severe pain over the eye and forehead, occurring in acute inflammatory glaucoma has at times been mistaken for neuralgia, the patient treated accordingly, and the error discovered too late to save the eye from irreparable damage.
It will thus be seen that when investigating the cause of the neuralgia, our chief aim should be to ascertain as far as possible whether it arises from an affection of the nerve alone, or from an abnormal condition of the tissues or organs in immediate relation with the nerve in any part of its course, or from a morbid state of the blood and secretions generally.
The latter element is of paramount importance, and in many cases (in addition to a neuropathic heredity, which is often a predisposing factor) is the underlying constitutional cause.
It may be an autotoxæmia, resulting from constipation or other disturbances in the gastro-intestinal tract, a gouty or rheumatic diathesis, a previous syphilitic infection, or existent diabetes, or chronic renal disease, etc. Syphilis may also set up a gummatous periostitis in the narrow canals, making pressure on the nerve as well as interfering with its circulation. Overwork, constant mental strain, anxiety and worry, sexual or other excesses, or anything else which reduces the vitality and nutri. tion are more or less potent in the causation of this painful affection.