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Atypical Neuralgias and Their Treatment
372
The Journal of the American Dental Association
for a camera stand. Take a full front view of the case, a sharp profile and a picture of the lips fully distended, ex posing the teeth in occlusion. Special cases will require other views. T o eliminate undesirable background have the assistant hold a cloth back of the patient. This should be kept moving during the exposure, which is usually from one to two seconds. During the year we have had con siderable correspondence with the East man Kodak Company of Rochester, New York, on the subject of a special equip ment for dental purposes. N. B. Hodg son, manager of their medical department, very kindly offered to cooperate with us in finding a satisfactory outfit. The result of this is a part of the exhibit of the Art and Esthetics Committee. This has proved very satisfactory during the
short time we have had to try it. It con sists of a 5 by 7 view type camera fitted with a Wollensack lens, a tripod, focusing cloth, plate holders and two 300-W. flood lamps and stands. The lamps can be attached to wall brackets where there may not be enough natural light. They have the advantage of al ways giving the same amount of light from fixed positions, standardizing the length of exposure. The camera bed is graduated so that it will produce a picture that has a definite relationship to the subject, from natural size down to one-eighth natural size, thus allowing future pictures to be made on the same scale. The machine has a long bellows extension giving good detail in close up work, does excellent copying and gives good results in photo graphing casts and models.
ATYPICAL NEURALGIAS AND THEIR TREATMENT By S. L. SILVERMAN, D.D.S., F.A.C.D., Atlanta, Georgia
(R e a d bcfore thc A m erican Dental A ssociation, Clcveland, Oliio, September 10-14, 1923)
A N Y members of the medical and dental professions are wont to look on referred pain as the ex ception in disease, whereas, to the trained observer, referred pains from remote disorders are rather the rule. Moreover, when referred pains are pres ent, they usually play about the face, jaws and head, although the disorders may be in the upper or lower abdomen. As examples, note the frontal headache due to a constipated bowel. Note, too, the pain in the arms and sometimes in the jaw, due to angina pectoris. Renal colic is characterized by distant reflex pains. The swallowing of a large piece of ice produces a pain located in the
M
frontal bone. This happens when the ice is in the esophagus. The reason for lack of pain definitiveness in abdominal and other deep structures lies in the fact that Nature endowed these struc tures with little or no sensory nerves, while superficial structures are, if any thing, oversupplied, and are therefore well adapted to reflect internal dis orders. Thus, the desire to micturate is felt at the urethral meatus rather than at the distended bladder. Sore spots about the abdomen accompanying various acute abdominal infections seem to be located in the skin. An acid stomach will often make the region of the sternum feel sore, and the burning
Silverman— Atypical Neuralgias and Their Treatment sensation is located in the throat. Pages can be written enumerating instances of referred pains commonly associated with known disorders. Though it is usually conceded that tic douloureux is not only the most pain ful of all neuralgias but also more poign ant than an)- other pain in whatever part of the body, yet those of us who come in contact with the vague and minor types of neuralgias, as well as the major types, have come to look on tic douloureux as a mere bagatelle so far as securing relief is concerned, but dread the minor type of neuralgias on account of lack of success following their treatment. Everyone of us should recognize, visualize and be able to diagnose the first type that I shall mention, as it is fairly common. It is known as spheno palatine or Sluder’s neuralgia, and is characterized by him practically as fol lows : a non-excruciating pain in the upper teeth and jaw, sometimes in the lower jaw, about the eye and at the root of the nose, at the temporomandib ular joint and in the ear. The pain radiates to the mastoid region, thence to the occiput and neck and downward to the shoulder and even to the arm, hand and fingers. At times the patient will complain of an “ aching” throat, but no inflammation is to be discerned. The treatment for this complex syndrome is the injection of the sphenopalatine gang lion with 95 per cent alcohol; since adopting the new injection for the second division through the greater palatine canal, I have been successful in a greater number of these cases. A second type that is often referred back and forth between the otolaryngol ogist and the dentist is a nonexcruciat ing frontal, malar and parietal pain (less often, occipital), and it is in this type that a 35 per cent solution of cantharides in a saturated magnesium sulphate-glvcerin combination instilled into the ear has been found effective. The discovery was accidently made by
373
J. D. Thompson, an otolaryngologist of Atlanta, who, having made this applica tion for a patient suffering from otitis media, noticed that the atypical neural gia that had been present previously suddenly stopped. The prescription for this preparation is as follows: 35 % filtered tinct. cantharides.......... -....... dr. iv M agnesium sulphate .....................................oz. ii Glycerin ...............................................................oz. i (A fter this is in solution fo r five days it is ready fo r use.)
I have noticed several cases in which material benefit, if not entire cessation of pain, resulted following its use. The technic is simply this: Three or four drops are placed into the ear, and a piece of cotton is saturated with the solution and placed as near the drum as possible. The patient lies on the opposite side. Relief often occurs within thirty minutes. We are at loss to ex plain how this affects the neuralgia, as no hyperemia is to be noticed. Hygro scopic explanation is not sufficient. The result may, however, be due to the proximity of the sensory branch of the seventh cranial nerve, referred to as the intermediate nerve. Still a third type that will baffle all of us is the case in which the patient complains of a tingling or burning in the tongue (less often in the palate) and sore salivary glands, and insists on pointing to some edentulous portion of the jaw, piteously complaining that that spot “ hurts like toothache.” F. Foster Flagg no doubt had this type in mind when he referred to it as phantom odontalgia. Unfortunately, unless we can find some traumatic injury due to extraction, and a consequent healing of some nerve too near the surface, we shall often fail to help the type here described. The iodids and salvarsan, however, whether or not the Wassermann is positive, will at times clear up these cases. At this point I will remind my readers that not infrequently is this disturbance noticed in women about middle age and past. The significance
374
The Journal of the American Dental Association
is plain. During the menopause almost any disorder is likely to assert itself, especially of the reflex or referred type. When we realize that the unpleasant transitions accompanying the menopause usually last about two or three years, it is really a wonder that less neuralgias, joint troubles and mental derangements are not more often recognized. I have, however, noticed that when the change in life is complete, these neuralgic mani festations disappear as mysteriously as they came. Too much surgery has been done for this type, without benefit, in cluding the once popular operation for the removal of the ovaries; the Gasserian operations have also been performed, without benefit. And we must desist from any surgical procedures in our field unless fully warranted, remembering that when this cycle is complete, a spon taneous recovery is more than likely to assert itself. I have left the fourth and last type for final consideration because our re sults in treating this type are most gratifying. This type is characterized by sharp, severe pains that radiate, like tic douloureux, often playing around the region of the temple, though not invari ably the pains are evoked by partaking of cold or hot drinks. (In this respect it differs from dying pulp, in that with dying pulp, hot applications provoke pain, while cold applications soothe it.) This type is never present in edentulous patients; in fact, it depends on the presence of teeth to assert itself. I refer to pulp nodules and exposed den
tin at the gingival margin. Another cause for these severe pains is one that I have never seen referred to in dental literature, and I present it here for con sideration. I refer to finely split or cracked teeth— cracks so fine that the radiograph will hardly find them. A good direct light, with sometimes the improved mouth lamp, and an attentive eye will locate these fine cracks, no doubt caused by some trauma, including trau matic occlusion. Relieving the occlusion suffices in the early stages, but as is the ease with pulp nodules, the case of long standing must be treated either by pulp removal or by tooth extraction. I as sume that the picture in your mind of what I call a finely or slightly cracked crown of a tooth is not one where the broken portion of the tooth is hanging by the periodontal membrane. Differen tial diagnosis will rule out this type of fractured tooth. If we bear in mind these probable findings and diligently search for them, I venture to say that the number of pa tients that are buffeted between physi cian and dentist and who are looked on as chronic and groundless complainers would materially be decreased. In conclusion, let it not be construed that I have an unfailing remedy for neuralgic disturbances of whatever kind, because, as I have pointed out in a previous paper, there are types of neu ralgias that are apparently relieved only by time and death. But this observation does not apply to tic douloureux and to at least three types of the minor neu ralgias I have just mentioned.
The Journal of the American Dental Association
for a camera stand. Take a full front view of the case, a sharp profile and a picture of the lips fully distended, ex posing the teeth in occlusion. Special cases will require other views. T o eliminate undesirable background have the assistant hold a cloth back of the patient. This should be kept moving during the exposure, which is usually from one to two seconds. During the year we have had con siderable correspondence with the East man Kodak Company of Rochester, New York, on the subject of a special equip ment for dental purposes. N. B. Hodg son, manager of their medical department, very kindly offered to cooperate with us in finding a satisfactory outfit. The result of this is a part of the exhibit of the Art and Esthetics Committee. This has proved very satisfactory during the
short time we have had to try it. It con sists of a 5 by 7 view type camera fitted with a Wollensack lens, a tripod, focusing cloth, plate holders and two 300-W. flood lamps and stands. The lamps can be attached to wall brackets where there may not be enough natural light. They have the advantage of al ways giving the same amount of light from fixed positions, standardizing the length of exposure. The camera bed is graduated so that it will produce a picture that has a definite relationship to the subject, from natural size down to one-eighth natural size, thus allowing future pictures to be made on the same scale. The machine has a long bellows extension giving good detail in close up work, does excellent copying and gives good results in photo graphing casts and models.
ATYPICAL NEURALGIAS AND THEIR TREATMENT By S. L. SILVERMAN, D.D.S., F.A.C.D., Atlanta, Georgia
(R e a d bcfore thc A m erican Dental A ssociation, Clcveland, Oliio, September 10-14, 1923)
A N Y members of the medical and dental professions are wont to look on referred pain as the ex ception in disease, whereas, to the trained observer, referred pains from remote disorders are rather the rule. Moreover, when referred pains are pres ent, they usually play about the face, jaws and head, although the disorders may be in the upper or lower abdomen. As examples, note the frontal headache due to a constipated bowel. Note, too, the pain in the arms and sometimes in the jaw, due to angina pectoris. Renal colic is characterized by distant reflex pains. The swallowing of a large piece of ice produces a pain located in the
M
frontal bone. This happens when the ice is in the esophagus. The reason for lack of pain definitiveness in abdominal and other deep structures lies in the fact that Nature endowed these struc tures with little or no sensory nerves, while superficial structures are, if any thing, oversupplied, and are therefore well adapted to reflect internal dis orders. Thus, the desire to micturate is felt at the urethral meatus rather than at the distended bladder. Sore spots about the abdomen accompanying various acute abdominal infections seem to be located in the skin. An acid stomach will often make the region of the sternum feel sore, and the burning
Silverman— Atypical Neuralgias and Their Treatment sensation is located in the throat. Pages can be written enumerating instances of referred pains commonly associated with known disorders. Though it is usually conceded that tic douloureux is not only the most pain ful of all neuralgias but also more poign ant than an)- other pain in whatever part of the body, yet those of us who come in contact with the vague and minor types of neuralgias, as well as the major types, have come to look on tic douloureux as a mere bagatelle so far as securing relief is concerned, but dread the minor type of neuralgias on account of lack of success following their treatment. Everyone of us should recognize, visualize and be able to diagnose the first type that I shall mention, as it is fairly common. It is known as spheno palatine or Sluder’s neuralgia, and is characterized by him practically as fol lows : a non-excruciating pain in the upper teeth and jaw, sometimes in the lower jaw, about the eye and at the root of the nose, at the temporomandib ular joint and in the ear. The pain radiates to the mastoid region, thence to the occiput and neck and downward to the shoulder and even to the arm, hand and fingers. At times the patient will complain of an “ aching” throat, but no inflammation is to be discerned. The treatment for this complex syndrome is the injection of the sphenopalatine gang lion with 95 per cent alcohol; since adopting the new injection for the second division through the greater palatine canal, I have been successful in a greater number of these cases. A second type that is often referred back and forth between the otolaryngol ogist and the dentist is a nonexcruciat ing frontal, malar and parietal pain (less often, occipital), and it is in this type that a 35 per cent solution of cantharides in a saturated magnesium sulphate-glvcerin combination instilled into the ear has been found effective. The discovery was accidently made by
373
J. D. Thompson, an otolaryngologist of Atlanta, who, having made this applica tion for a patient suffering from otitis media, noticed that the atypical neural gia that had been present previously suddenly stopped. The prescription for this preparation is as follows: 35 % filtered tinct. cantharides.......... -....... dr. iv M agnesium sulphate .....................................oz. ii Glycerin ...............................................................oz. i (A fter this is in solution fo r five days it is ready fo r use.)
I have noticed several cases in which material benefit, if not entire cessation of pain, resulted following its use. The technic is simply this: Three or four drops are placed into the ear, and a piece of cotton is saturated with the solution and placed as near the drum as possible. The patient lies on the opposite side. Relief often occurs within thirty minutes. We are at loss to ex plain how this affects the neuralgia, as no hyperemia is to be noticed. Hygro scopic explanation is not sufficient. The result may, however, be due to the proximity of the sensory branch of the seventh cranial nerve, referred to as the intermediate nerve. Still a third type that will baffle all of us is the case in which the patient complains of a tingling or burning in the tongue (less often in the palate) and sore salivary glands, and insists on pointing to some edentulous portion of the jaw, piteously complaining that that spot “ hurts like toothache.” F. Foster Flagg no doubt had this type in mind when he referred to it as phantom odontalgia. Unfortunately, unless we can find some traumatic injury due to extraction, and a consequent healing of some nerve too near the surface, we shall often fail to help the type here described. The iodids and salvarsan, however, whether or not the Wassermann is positive, will at times clear up these cases. At this point I will remind my readers that not infrequently is this disturbance noticed in women about middle age and past. The significance
374
The Journal of the American Dental Association
is plain. During the menopause almost any disorder is likely to assert itself, especially of the reflex or referred type. When we realize that the unpleasant transitions accompanying the menopause usually last about two or three years, it is really a wonder that less neuralgias, joint troubles and mental derangements are not more often recognized. I have, however, noticed that when the change in life is complete, these neuralgic mani festations disappear as mysteriously as they came. Too much surgery has been done for this type, without benefit, in cluding the once popular operation for the removal of the ovaries; the Gasserian operations have also been performed, without benefit. And we must desist from any surgical procedures in our field unless fully warranted, remembering that when this cycle is complete, a spon taneous recovery is more than likely to assert itself. I have left the fourth and last type for final consideration because our re sults in treating this type are most gratifying. This type is characterized by sharp, severe pains that radiate, like tic douloureux, often playing around the region of the temple, though not invari ably the pains are evoked by partaking of cold or hot drinks. (In this respect it differs from dying pulp, in that with dying pulp, hot applications provoke pain, while cold applications soothe it.) This type is never present in edentulous patients; in fact, it depends on the presence of teeth to assert itself. I refer to pulp nodules and exposed den
tin at the gingival margin. Another cause for these severe pains is one that I have never seen referred to in dental literature, and I present it here for con sideration. I refer to finely split or cracked teeth— cracks so fine that the radiograph will hardly find them. A good direct light, with sometimes the improved mouth lamp, and an attentive eye will locate these fine cracks, no doubt caused by some trauma, including trau matic occlusion. Relieving the occlusion suffices in the early stages, but as is the ease with pulp nodules, the case of long standing must be treated either by pulp removal or by tooth extraction. I as sume that the picture in your mind of what I call a finely or slightly cracked crown of a tooth is not one where the broken portion of the tooth is hanging by the periodontal membrane. Differen tial diagnosis will rule out this type of fractured tooth. If we bear in mind these probable findings and diligently search for them, I venture to say that the number of pa tients that are buffeted between physi cian and dentist and who are looked on as chronic and groundless complainers would materially be decreased. In conclusion, let it not be construed that I have an unfailing remedy for neuralgic disturbances of whatever kind, because, as I have pointed out in a previous paper, there are types of neu ralgias that are apparently relieved only by time and death. But this observation does not apply to tic douloureux and to at least three types of the minor neu ralgias I have just mentioned.