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dreths of a grain, and while taking this dose every three hours he felt very much better. Later, as it became necessary to increase the dose, pills of one-one-hundreth of a grain were ordered, four of which were to be taken daily. Having followed my instructions, he returned in four weeks, asking for a new prescription, so that he could more conveniently get the medicine in his own neighborhood. In order to be more certain that he should receive the genuine preparation, I wrote for pills of one-two-hundredth of a grain, and directed him to take two at a dose. He did not begin the latter until the following morn. ing. At noon I was hastily summoned, and found him in bed, profoundly collapsed and apparently about to expire, with alarming symptoms of aconite poisoning. He had taken one dose at 7 A.M., and another at 11 A.M. With difficulty his life was saved. Upon investigation I discovered that the first druggist had substituted one-one-hundreth of a grain pills of Merck's aconitine, and these the patient had been taking for nearly four weeks, without any improvement in his condition. The last druggist had furnished what was ordered, and his symptom was at once overwhelmed by the doses of one-one-hundreth of a grain of Duquesnel's aconitia. Further comment on the subsequent events in this case is obviously unnecessary.
Cocaine has been injected into the tissue of the alveolar process, and also into the face, but its toxic effects are occasionally so rapid and alarming that I have discarded its use in this manner. In certain individuals it seems to possess some special langer when injected about the head. In some patients the pain is temporarily relieved by the use of cocaine introduced into the tissues of the face by the aid of the galvanic current. This procedure is known as anodal diffusion or electric cataphoresis.
A small electrode, connected with the positive pole of the battery, is either dipped into a solution of cocaine, or a small disc of white filter paper saturated with the desired dose is attached to the electrode and applied over the seat of pain. The skin should previously be washed with a little alcohol or chloroform, in order to remove any sebaceous matter. The current is then used in the manner described in the paragraph on the use of the galvanic current. A special electrode has
been constructed for this purpose, and other drugs have also been similarly used.
Nitroglycerin, either in solution or in the form of tablets, has often been serviceable, particularly in patients who are over forty years of age, without any marked evidence of increased arterial tension, as indicated by the radial pulse. When the latter condition is present, it is always valuable as an adjunct in the management of these cases, due recognition being given to the cause of the increased blood pressure.
In intractable cases that have resisted other forms of medication, the injection of sulphate or muriate of strychnine into the tissue of the face on the affected side has met with considerable success in a few instances. A daily injection is given, the dose at first being one-thirtieth of a grain. This is gradually augmented to about one-fifth of a grain, or until intolerable physiological symptoms are produced. One of my patients recently received one-sixth to one fifth of a grain daily for a week, which resulted in temporary relief, but was discontinued on account of rigidity and cramp in the cervical and calf muscles. This form of treatment should always be accompanied by rest and the administration of abundance of nutritious food.
Iodide of potassium in increasing doses, in conjunction with the administration of aconitia, has been the means of relieving and also curing quite a number of otherwise intractable cases. Just as large doses of quinine are sometimes effectual in nonmalarial cases, so iodide of potassium has proved remedial in the absence of all evidence of syphilis.
I have often found galvanism exceedingly serviceable in diminishing or abolishing the pain, especially in early cases. The current strength may range from five to ten milliapères, and the seance last from five to ten minutes daily, or twice a day if indicated. It is essential that a rheostat and meter be included in the circuit. The current should be very slowly increased from zero to the amount desired, and allowed to flow at the same degree without interruption, until the time for cessation, when it should be gradually decreased until zero is reached, before the electrodes are removed from the skin. I have been accustomed to apply the positive pole over the painful area. The induction current from a static battery, applied directly to the face, has in wo or three cases produced considerable amelioration,
If a local cause of the pain is discovered and seems removable, this should be accomplished without unnecessary delay. Consequently it often becomes imperative to seek the counsel and assistance of the ophthalmologist, laryngologist, or dental surgeon, whose special qualifications make their services of inestimable value, both to the attending physician and the patient.
The Importance of studying the habits and constitutional condition has already been referred to, but is deserving of emphasis. Whatever is ascertained must receive the careful and methodical attention that its nature demands. I shall not dwell any further upon this matter, as such details in general management may usually be left to the good judgment and discretion of the prac titioner. In this connection let me call to your notice the case which prompted the writing of this paper:
Miss J. L., 27 years of age, consulted me for the first time on the 20th of last October. Four years ago, she began to have pain in the right side of the face, with intervals of abatement for three or four weeks. Within the last two years and up to the present time, it has been constant. The pain is limited to the distribution of the second and third branches of the right trigeminus, extending to the tip of the tongue and the chin. Paroxysms occur every ten or fifteen minutes, and accompanied by a profuse flow 'of saliva, which terminates the attack. The pain is excited and increased by taking, eating, blowing the nose, etc. It also occurs during the night and disturbs the sleep. She complains of constipation and flatulent dyspepsia. Menses are regular. Although six teeth have been extracted from the right lower jaw, the pain has persisted. There is no history of rheumatism, syphilis, etc., traumatism, or exposure to cold, to account for the origin of her trouble. She had been advised to have the nerves removed by surgical operation.
Upon examination the paroxysm is produced when pressure is made over the toothless alveolar processes. There are no other painful points. The tongue, which is protruded well, is tremulous, thickly coated, and a few superficial ulcers are seen on the border of the right side. The breath is very offensive. Stomatitis, which has existed for many months, is quite pronounced. The gums are tender and soft, and bleed readily upon the slightest touch, the condition being very suggestive of
a scorbutic gingivitis. The saliva shows a distinctly acid reactjon. Pupils and ocular fundi normal. Pulse 76 and regular, but somewhat weak. Heart's action and other organs normal. Examinations of urine negative.
The mouth was cleansed and a one-per-cent. solution of nitrate of silver applied daily. An alkaline, antiseptic mouth wash was used every half hour, and absolute cleanliness enjoined. Subsequently peroxide of hydrogen was applied, and later an astringent solution. She was instructed to avoid unnecessary talking and to have fluid diet only, consisting of milk, eggs, meat juice and pulp, and the juice of two lemons daily. She also received maltine with cascara sagrada, and later this was changed to one drachm of phosphate of sodium in solution on arising. The galvanic current was applied daily. After three days she slept well every night, and at the end of a week she had only occasional pain during the day. The tongue gradually cleared and the stomatitis subsided. She is still under observation, and is very much improved.
This case, it seems to me, clearly illustrates the advantage of careful and systematic treatment. Such prompt relief without the use of anodyne drugs is not at all unusual, when local measures are supplemented by judicious management of the general health. This young woman had previously obtained no relief from symptomatic remedies, and her physician had consequently advised surgical intervention.
Just here let me say a few words regarding recklessness and unwarranted haste in advising surgical operation upon the nerve. I regret to admit that within a few weeks several cases have come to my notice, and many others in recent years, in which, the patient demanding relief and the physician either becoming impatient or discouraged, surgical measures have been recommended, although the duration of the affection was but six or eight weeks.
There seems to be a deeply rooted opinion that in all cases that have resisted the canonical forms of medicinal treatment, recourse must be had either to operation upon the deep branches of the nerve, or excision of Meckel's or the Gasserian ganglion, or to the systematic use of morphine to make life endurable. Before advising or consenting to surgical operation, I must feel
satisfied that suitable thorough and persistent treatment has proved ineffectual under competent observers. As there is possibility, nay, even great probability of relief in most cases of tic douloureux and chronic trigeminal neuralgia without surgical operation, the latter should be seriously considered only as a dernier ressort or after all available resources have been exhausted. -Medical Record.
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