Tic-douloureux

••'f IC-DO ULO URE UX ' '*

By

DH.

A. :B'.

80NTHEDIER, R OME ,

N. Y.

I

T GIVE 8 me great pleasure to come her e today and join you in a discussion, th e object of whi ch is th e relief of human suffering . For many years tie-doulou reaux and sphenopalatine neuralgia have robb ed many unfortunate individual s of any pleasure wh at ever in this world, and th eir existence has been one long life of pain, and paroxysms of physical torture, so great at tim es as to render them melanch oly and depressed, to suc h a degree as to welcome peaceful death in pref eren ce to living torture. Several patients have t old me that the r eassu rance that the disease was not fatal was the worst new s that they had receiv ed. l\Iy paper today dea ls with a new palliative treatm ent for the relief of this disease, whi ch ha s prov ed effec tive f or t he last t hree ye a rs in n early every case , and to my mind ha s proved by clinical results that the efficacious treatment of this dis ease lies in a n ew field of the rape utics, radicall y different than a ny employ ed at th e present time. I will divid e ti c-douloureau x and sphen opalat in e neuralgia into two separat e gr oups, for while I beli eve both of them t o have th e same etiology, th e t echni c of injection an d the pathologic sy mpto ms are different. JTh e origin of thi s disease is unknown bu t from the ear liest records availa ble it ha s always been assoc iated in on e way or anothe r wi th the t eeth. Ev en to this da y the promiscuo us extract ion of t eeth is usually r esorted t o before any true di agno sis is mad e. J Of the etiology even less is known. Patients oft en have a history of t ra uma, but in many cas es any su ch history is ofte n untrue. Due to the fact that this dis ease therapeutically resembles an asce ndin g neuritis an d sciatica, I am of the op ini on that the disease is in tr ins ic and of germ origin. Histologically th e disease resembles neuritis an d sciat ica and some cas es hav e shown atrophy and deg eneration but it has not yet been proved that in every case the microscop ic findings have been the sa me . It is better perhaps to consider this disease clinically as an upset in the electrobio chemic balan ce of the livin g cell itself, cons id er in g carefully t he properties of n eurosummation both of the ind iv id ual n euron and the assoc iated r eflex ganglion. While the v ery la t est writte n accounts of t his disease look for a t erminal origin, I believe tha t clinical evi de nce ha s no t proved t his th eory. It is true that t emperature and tactile n eurons car ry imp ulses f'r on. t he p eripher y t hat cause paro xysms of pain, probably th r ou gh summa t ion or associated · Re,u~ at the meeting of t he Seven t h D is trict Dental Soci ety of t he Stat e of N ew Y ork . A pril 6. 1926. Clinic h eld Jun e 18. 1926. a t Roch ester Dental Dispen s ary . Co m m ittee to r e port on th e r esults and follow UP of the patien ts : Clifford E . R os e, D.D. S.. Buffalo, N . Y. : Elm er W . O' Brie n, M.D ., R och ester, N. Y. ; F r ed'k. W Pros eu s, p .D.S.. R och ester. N . Y.

689

690

A. F. S oniheim er

sy mp a the tics but I h av e proved to my own sa t isfact ion t hat in many cases a complete blo ck of t he p eripher al nerves h as had no effect on the disease it self, whi ch is in trinsi c and see ms t o occupy t he n er ve en t ir ely from the gan glion to the p eriphery. Th e symptoms of tic-douloureaux are t oo well known to mention but I might sta t e that th e mandibular division is affect ed in most of the cases follow ed by the su pe rior maxillary division. Th e first di vision of the t ri geminal n erve aff ectin g t he supraorbital r egi on ha s been spoke n of by man y authorities. Patrick h as abandoned t he inj ection of this bran ch on account of the nearness to adjoi ning st r uctures of great deli ca cy. Several cases of blindness and dem entia fo llowing the inj ection of al coh ol into this bran ch , see m t o h a ve ca use d some gre a t specialists in cludin g Patrick t o abandon t his branch entire ly. While sev eral cas es that h av e come into my practice have apparently symptoms of dis ease of this branch , I have onl y found it as a sympathetic pain associat ed with th e supe r ior maxillary or mandibular n erves. After clearing up the disease in the sec ond or thi rd division the pain f ollo wing the course of the first di vision has disappeared. In describin g th e ch ar acter of the pain Blair states th at t o the paro xysmal cha racte r is la t er added an irregular p eriodicit y whi ch may be eviden ced by t he p ain being presen t on alternat e da ys, more f reque nt or more intense on alterna t e days, or present f or indefinite st retches of t ime th a t last f or weeks or mon ths alterna tin g with p er iods of comparative or complete fre ed om. A very marked r egular periodicity esp ecially in a recent case is strong eviden ce against, but d oes not abs olutely exclude t he possibility of its bein g a true ma j or tic. Su ch n euralgias are usually of t he variety known as sun pains, whi ch see m du e to some mal a r ial or cli matic influence or sinus infection. In a fe w cases the re has been a continuo us dull ache over some part of the n er ve, with r ecurri ng paroxysms of a sh ar pe r char acte r . When t he p ain r eturns it is in t he same spot in whi ch it fir st ap peared an d alt ho ug h it may radiate th e p ain is always sh ar pest in one small cer t ain pl ace. 'While usu all y confin ed t o one sid e I hav e known at least thr ee cas es to involve the other side, either simult an eously or at anothe r time. I have observed a purely sph en opalatine neuralgia to develop into a major tic in nine months. Blair describes conc isely and clea rly t he sy mpt oms as f ollo ws : " The trunks and branch es of th e n erve may or ma y not be t en d er bu t in almost all cases th er e are spots over t he d istribution of the n er ve, stimulation of whi ch ca uses a t win ge in t he pain a rea . Th e to uc h of a finger , a breath of cold air , in some cases h eat, in oth er s the takin g of f oods or liquids in the mouth , or th e ac t of swa ll owing or a sud de n movemen t or jar ri ngan y or all these may bring on th e pain. " Bl air furth er st ates , "It is pitiful to observe the extremes to whi ch sufferers will resort t o avoid the sti muli that they know will produce pa in. Some of them will t alk from, or will take food or drink into onl y one side of th e mouth. On e patient woul d go for da ys without eve n swallowing wa te r; oth ers will no t en t er a room until

Tic-Douloureux

691

they are sure all windows are closed. Some for months at a time will not wash one side of the face or brush the teeth. In older cases, though there is evidence of extreme pain during the attack, the patient seems to have become accustomed to it and seldom makes an outcry or demonstrative complaint. " The duration of the disease is one of the strongest points in the diagnosis. It is the recent cases that require the most careful differentiation. Pain due to pulpitis, malaria, malignant growths or sinusitis, will if observed long enough show some change PI' characteristic that will differentiate it from true tic, or the general health or condition of the patient will give some clue to the cause. In considering the symptoms of sphenopalatine neuralgia, Sluder gives a clear and concise description of the syndrome, therefore I will quote him as follows: "When seen from the beginning the pains of postethmoidal or sphenoidal diseases have usually preceded the development of the characteristic neuralgia picture." I have also remarked that after the neuralgic manifestations have continued for some time (approximately four weeks) they begin to run irregularly, assuming the form of migraine which may persist for years after all local inflammatory conditions have disappeared. One of the most striking manifestations of disturbance in the sphenopalatine ganglion is the wide and characteristic distribution of pain along definite lines. These neuralgic manifestations can be evoked by mechanical irritation of the ganglion by the Faradic current and by therapeutic injections of alcohol. The more recent palliative treatment which I am about to describe has proved efficacious in every case during the last three years. The neuralgia is described as a pain at the root of the nose, and sometimes in or about the eye, taking in the maxilla and teeth and extending beneath the zygoma to the ear to take on the form of earache. It is emphasized at the mastoid but nearly always severest at a point about two inches posterior to the mastoid, thence reaching backward by way of the occiput and neck and it may extend to the shoulder blade and shoulder and in severe attacks to the axilla, arm, forearm, hand and fingers. Sometimes the patient complains also of a "stiff" or aching throat without inflammation, of pain or oftener of itching in the roof of the mouth, or of pain inside the nose. Along with the pain there is also, on the affected side, slight anesthesia of the soft palate and of the pharynx as far down as the lower part of the tonsil and also in the anterior part of the nose. In a large percentage of cases the neuralgia is accompanied by motor disturbance affecting the configuration of the soft palate. The palatine arch on the affected side is often higher than on the other side and during movement the median raphe is deflected from the affected side. Taste is usually less acute on the dorsum of the tongue of the affected side. The rationale of the treatment while very successful clinically is very difficult to state as a matter of fact. We must theorize from clinical observation of the injection of which there are two great classes of drugs used.

692

A. F. Sontheimer

The first and possibly th e old er is the palliative drugs first used in 1869 and later th e escharotic dru gs of which alcohol seemed t he most popular. A bri ef hi story at t his t ime might be of interest concernin g the diffe ren t things used for injecti on. Otto 'Weiner st ates t ha t in about 1840 Rund used morphine and cre osot e and in 1857 Wood inj ected morphine only, while Bell used atropine. From this time on practically everything has been tried in the pharmacopeia with various re sults, even air and mechanical irritation of th e gan glion . The cre d it goes to Potain who in 1869 as cribed benefit to large injections of water and as f ar as I know it is the firs t palliative treatment f or' th is disease ever described. Later aqueous solu t ions of cocaine became popular. Schleich used very dilute cocaine solutions. Bock used tropacocaine and Kurzwelly used betaeucain. In 1904 Lang made intraneutral injections of physiologic saline solution and betaeucain-1 :1000. Otto Weiner made an epoch-making discovery that sciatica responded to a slight modification of the above solution. He added a small amount of calcium chloride. Last year a paper was re ad before the Philadelphia Psychiatric Soci ety and an account fully described in the New York Times st at ed, which to my mind seems a logical t r uth, that clinically an injection of . isotonic aqueous solution of sodium potassium chlor ide, calciu m chloride and magnesium sulphate into th e cerebrospinal fluid had proved succe ssf ul in a great many cases of certain forms of neuropathology. I ha ve lost th e account and do not remember the author of th at paper but I wish him cont inue d success in this field and I believe he has accomplished a decid ed advance in the study of neuropathology. My f aith in his work is in th e knowled ge that this solution, while palliative, has a d ecided effect on the nervou s ti ssu e. I had used practically the same solution minus t he magnesium sulphate as my " B " solut ion in the treatment of tic-douloureux for two ye ars previou s. In considering certain alkaloids and ptomaines whi ch have a marked effect on the nervous ti ssue a little consideration of the physiologic chemistry of certain groups and radicals is necessary. Beginning with cocaine, which is the methyl est er of benzoyl ecgonine, formula C17H21N04 , we also have hyosine and seopolamin with the same chemical formula derived from different nonvolatile alkaloids : hyoscine derived from henbane, scopolamine f rom scopola earnioliea, cocaine from erythroxylon coca. Among the nonoxygenated liquid ptomaines may be enumerat ed di ethylamine, triethylamine, propylamine. These are monamines. Th e introduction of an al cohol or ba sic radical in to the ammonia molecule, replacing one or mor e hydrogen atom s, giv es us an amin e and just as ammonia can combine with a haloid and to form an ammonium salt, so th e amine or derived ammonia can unite with the chl oride, bromide or iodide of an alcohol radical to form a derived ammonium salt in whi ch for instance th e four hydrogen atoms o{NH.CL ma y be replaced by al cohol radicals. We may have primary, secondary or tertiary amin es accor ding as one, two or three atoms of hydrogen in NHa are r eplaced. \Ve may also have

Tic-Douloureux

693

monamines, diamines or triamines, according as one, two or three molecules of ammonia are represented. 'I'hus NH 2CH3, methylamine, is a primary amine. NH-(CH3)2' dimethylarnine, is a secondary amine. The amines containing the lower alcohol radicals bear a close resemblance to ammonia. The ammonia bases are solid, very hygroscopic and exceedingly like potash in properties. When the paraamido radical is combined with benzoyldiethylamino ethanol or (butylamino propanol) we have a local anesthetic action similar to the methyl ester of benzoyl ecgonine. The hydrochloride of paraamidobenzoyldiethylaminoethanol is soluble in its own volume of water or in any other dilution. The sulphate of paraaminobenzoyl gamma di-n butylamino propanol is nearly as soluble as the former but the hydrochloride or chloride precipitate of paraaminobenzoyl gamma di-n butylamino propanol is insoluble in water or body fluids. This insolubility probably is the reason for the long lasting effects of the palliative treatment which I am about to describe, but whether this drug enters into the biologic chemistry of the protoplasm or whether it merely acts as a hygroscopic agent furnishing water to the cell by osmosis from the tissue fluids, I am unable at this time to state. The greatest mystery I believe to be solved in the world today is a knowledge of the living protoplasm. A thorough knowledge of the electrobiochemic properties of living protoplasm probably will never be understood but we have progressed clinically by empiric methods and by the studies of Koch and Ehrlich to such a degree that the results have been most gratifying. Perhaps it will not be necessary to thoroughly understand the electrobiochemic properties of living protoplasm if we continue to learn by empiricism and clinical findings. Before considering an injection into the cranial fossa, a thorough knowledge of the anatomic structures must be considered and studied in different angular relationship. The trigeminal nerve is the largest cranial nerve and is the great sensory nerve of the head and face and the motor nerve of the muscles of mastication. It emerges from the side of the pons near its upper border by a small motor and large sensory root-the former being situated in front and medial to the latter.

Motor Root.-The fibers of the motor root come from two nuclei, a superior and an inferior. The superior nucleus consists of a strand of cells occupying the whole length of the lateral portion of the gray substance of the cerebral aqueduct. The inferior or chief nucleus is situated in the upper part of the pons, close to its dorsal surface and along the line of the lateral margin of the Rhomboid fossa. The fibers from the superior nucleus constitute the mesencephalic root; they descend through the midbrain and entering the pons join with the fibers from the lower nucleus and the motor root thus

694

A. F. Sontheimer

formed, pass forward through the pons to its point of emergence. It is uncertain whether the mesencephalic root is motor or sensory. Sensory Root.-The fibers of the sensory root arise from the cells of the semilunar ganglion which lies in a cavity of the dura mater near the apex of the petrous portion of the temporal bone. They pass backward below the superior petrosal sinus and tentorium cerebelli and, entering the pons, divide into upper and lower roots. The upper root ends partly in a nucleus which is situated in the pons lateral to the lower motor nucleus and partly in the locus caeruleus; the lower root descends through the pons and medulla and ends in the upper part of the substantia gelatinosa of Rolando. This lower root is sometimes named the spinal root of the nerve. Medullation of the fibers of the sensory root begins about the fifth month of fetal life, but the whole of its fibers are not medullated until the third month after birth. The semilunar ganglion is best described anatomically by Gray and I will quote him as follows: "The semilunar or gasserian ganglion occupies a cavity in the dura mater covering the trigeminal impression near the apex of the petrous portion of the temporal bone. It is somewhat crescentic in shape with its convexity directed forward medially; it is in relation with the internal carotid artery and the posterior part of the cavernous sinus. The motor root runs in front of and medial to the sensory root and passes beneath the ganglion; it leaves the skull through the foramen ovale and immediately below this foramen joins the mandibular nerve. The great superficial petrosal nerve lies also underneath the ganglion. "The ganglion receives, on its medial side, filaments from the carotid plexus of the sympathetic. It gives off minute branches to the tentorium cerebelli and to the dura mater in the middle fossa of the cranium. From its convex border, which is directed forward and lateralward, three large nerves proceed, viz., the ophthalmic and maxillary and mandibular. "The ophthalmic and maxillary consist of sensory fibers exclusively; the mandibular is joined outside the cranium by the motor root. "Associated with the three divisions of the fifth nerve are four small ganglia. The ciliary ganglion is connected with the ophthalmic nerve; the sphenopalatine ganglion with the maxillary nerve; and the otic and submaxillary ganglia with the mandibular nerve. All four receive sensory filaments from the trigeminal and motor and sympathetic filaments from various sources; these filaments are called the roots of the ganglia." The ophthalmic nerve or first division of the trigeminal is a sensory nerve. It supplies branches to the cornea, cilium body and iris; to the lacrimal gland and conjunctiva; to the part of the mucous membrane of the nasal cavity; and to the skin of the eyelids, eyebrow, forehead and nose. It is the smallest of the three divisions of the trigeminal and from the upper part of the semilunar ganglion as a short flattened band about 2.5 mm. long which passes forward along the lateral wall of the cavernous sinus, below the oculomotor and troclear nerves; just before entering the orbit, through the sphenoidal fissure, it divides into three branches, lacrimal, frontal and nasociliary. The ophthalmic nerve is qoined by filaments from the cavernous plexus

'I'ic-Douloureux

695

of the sy mpathetic, and communicates with t he ocu lomotor, t r oclea r and a bdu cent n er ves; it gives off a r ecurrent filam en t which passes betw een the layers of the t en torum. The m axill ary nerv e, or secon d division of t he tri geminal, is a senso ry nerv e. It is interm edi at e, both in position and size, bet ween t he ophthalmic and the mandibular. It begi ns at t he middle of the semilunar gangli on as a flat t en ed pl exiform band an d, pa ssing horizo nt all y fo rwar d, it lea ves the sk ull t hr ough t he f or amen ro tun dum, wh ere it becomes mor e cylind r ica l in fo r m an d firm er in texture . It then cr osses t he ptery gopalatin e fossa, in clin es lat eralward on the back of the maxilla and ente rs the orbit through t he infer ior orbital foram en. It is the n calle d the infraor bital n erve and, p assing horizontally for ward, it leav es the skull throu gh t he infraorbital foram en. The branches gi ven off a re as follows: In t he cran ium, the middle mening eal; in the ptery gop alatin e fossa, the zygomati c, sphe n opalatin e and pos tsup erior alveolar; in th e infro a rbit al canal, th e ante r ior and the middle superi or alveolar; on the face, t he inferior palpebral and ext er nal nasal an d supe r ior labial. Th e sp henopalatine ganglion, th e largest of t he sy mpathet ic gan glia asso ciat ed wi th t he fifth n er ve, is deeply placed in the pterygo pa latine fo ssa, close to the sphe no pa la t ine fora men . It is triangular or heart sha ped, of a red dish gray colo r, and is sit uated just below the maxill ary n er ve as it crosses th e fossa . It r eceives a sensory, a moto r and a sy mpathetic r oot . Its sens ory r oot is de r ived fro m t wo sphen opal ati ne b ran ch es of t he maxillary n erve : th eir fiber s for t he most part p ass d irectly in t o the p alat ine n er ves ; a few, h owever, en te r the ga nglio n, cons t it uting its sensory roo ts . Its mot or r oot is probably deri ved from th e n ervous in t erm edium t hrough the great supe r ior petrosal n er ve and is su pp osed to cons ist in part of sy mpa thetic effere nt fiber s fro m th e medulla . In "the sp he nopalatine ganglion t hey fo rm sy na pses with neu rons whose postga n glio nic axons, vasodilato r a nd see re to ry fi bers are di stribu t ed with t he dee p branch es of t he trige mi nal t o the mu cous membrane of the n ose, soft palate, tonsils, uvula, roof of t he mouth, upper lip a nd gums, and to the uppe r pa r t of the pharynx. Its sympathetic root is de r ive d from the carotid pl exus through the d eep petrosal nerve. Th ese two ne r ves join to form th e nerve of the pterygoid ca na l before their ent rance into the ganglion. The great s1tperficial petrosa l n erve is given off from the gen icular ganglion of the fa cial n erve ; it passes thr ough the hiatus of th e fac ial can al, en te rs the cran ial cavity and runs forwar d ben eath t he dur a mat er in a gr oove on t he anter ior su rfa ce of the pet ro us p ortion of the t em poral bone . It th en en te rs the ca rtilagin ous substa nce whic h fills th e foramen lacerum and joining with the deep petrosal bran eh , fo rms the n er ve of t he ptery goid canal. The d eep petrosal n erve is give n off fr om the carotid pl exus an d runs thr ough the caro ti d cana l la t er al to the in t ern al ca ro t id arter y. It the n ente rs the cart ila gino us su bstance which fills the foramen lacerum an d j oin s with th e gr eater su perficia l pe t r osal nerve t o f or m the ne rve of the pt ery goid eanal.

696

A. F. S oniheimer

The mandibular ne rve or third division of th e trigeminal supplies th e t.eeth and gums of the mandible, the sk in of t he tempora l r egion, th e auricul a, th e lower lip , th e low er part of the face and th e muscles of mastica tion ; it also supplies th e mu cous membrane of the anterior tw o-thirds of t h e tongue. It. is th e largest of th e three divisions of the fifth nerve and is made up of two root s, a large senso ry and a small motor, which unite with the trunk of the sens ory just after its ex it fro m th e foramen oval c. Immediat ely ben eath t he base of the sk ull the nerve gi ves off from it s medi al sid e a r ecurren t branch (ner vous spinosis ) and the nerve to the pterygoid ens internus and th en divides into two bran ches. Th e anatomy at t his point is of the utmost imp ortance as all untoward seque lae are the re sult of a lack of knowledge of these structures. Th e nervous spinosus en ters the skull through the foramen spinosum with the middle meningeal ar te ry. It divides into two branches anterior and posterior and supplies the dura mater; the posterior branch also supplies the mu cous lining of th e mastoid cells; the anterior communicates with the meningeal branch of th e maxillary nerve. Th e long buc cinat or is very often involved in t ic-doulou reu x and individuall y it is next t o impossible to locate but wh en inject ed through its common trunk, viz., th e thir d division, it can r eadily be take n care of. It emerges from under the ante rior border of mas seter, ramifies on the surface of the bu ccinator and unites with the bu ccal branches of t he fa cial nerve. It su ppli es a branch to the pterygoid ens externus durin g passag e through that muscle . The bu ccinat or nerve supplies the sk in over the buccinator and t he mucus lining its surface. The lingual nerve is another branch often in vol ved in t ic-doulou r eux. It supplies the mucou s membran e of t he anterior t wo-thi r ds of the tongue. It lies at first beneath the pt erygoidens exter n us , med ial to and in front of th e infe rior alv eolar nerve and is occasionally jo in ed t o t his nerve by a bran ch which may cross th e in t ernal maxillary artery. The chorda tympany also joins it at an acute angle in this situation. Th e nerve then passes between th e pterygoidens in t ernus and the ramus of the mandible and crosses obliquely to the side of the t ongue over the constrictor pharyngis superior and styloglossus, and then between the hyloglossus and deep part of the submaxillary gland. It finally runs acr oss the duct of the submaxillary gland and along the tongue to its tip. Its branches of communica t ion are with the f acial t hrough the chorda ty mpa ni, the inferior alveolar and hypoglossal nerves, and th e submaxillary ganglion. Th e branches of the submaxill ary ganglion are two or t hree in number. 'I'hose connected wit h t he hypoglossal nerve form a pl exu s at the anterior margin of t he hyoglossu s. The inferior alveolar nerve is the largest bran ch of t he mandibular ner ve. It descends with th e inferior alve olar artery , at fir st beneath the pterygoid ens ex te rnus an d t hen betw een t he sp henomandibul ar ligam en t and the ramus of t he mandible to t he mandibular f or amen. It th en passes forward in t he man-

'I'ic-Douloureux

697

dibular canal beneath the teeth as far as the mental foramen where it divides into the incisal and mental branches. It gives off branches to the mylohyoid, teeth, incisive and mental region. Two small ganglia, the otic and submaxillary are connected with the mandibular nerve. The otic is most important from our viewpoint and it may be injured in injecting through the foramen ovale. It is a small, oval-shaped, flattened ganglion of reddish gray color, situated immediately below the foramen ovale. It lies on the medial surface of the mandibular nerve and surrounds the origin of the nerve to the pterygoidens internus. It is in relation laterally with the trunk of the mandibular nerve at the point where the motor and sensory roots join; medially with the cartilaginous part of the auditory tube and the origin of the tensor veli palatine; posteriorly with the middle meningeal artery. It is connected by two or three short filaments with the nerve to the pterygoidens internus from which it may obtain a motor and possibly a sensory root. It communicates with the glossopharyngeal and facial nerves through the lesser petrosal nerve continued from the tympanic plexus and through this nerve it probably receives a root from the glossopharyngeal and motor root from the facial; its sympathetic root consists of a filament from the plexus surrounding the middle meningeal artery. The fibers from the glossopharyngeal which pass to the otic ganglion in the small superficial petrosal are supposed to be sympathetic efferent or preganglionic fibers from the dorsal nucleus or inferior salivatory nucleus of the medulla. Postganglionic fibers from the otic ganglion, with which these form synapses, are supposed to pass to the parotid gland. A slender filament (sphenoidal) ascends from it to the nerve of the pterygoid canal and a small branch connects it with the chordea tympani. Pains referred to various branches of the trigeminal nerve are of very frequent occurrence and should always lead to a careful examination in order to discover a local cause. As a general rule the diffusion of pain over the various branches of the nerve is at first confined to one only of the main divisions and the search for the causative lesion should always commence with a thorough examination of all those parts which are supplied by that division; although in severe cases, pain may radiate over the branches of the other main divisions. The commonest example of this condition is the neuralgia which is so often associated with dental caries; although the tooth itself may not appear to be painful, the most distressing referred pains may be experienced and these are at once relieved by treatment directed to the affected tooth. Many other examples of trigeminal reflexes eould be quoted but it will be sufficient to mention the more common ones. Dealing with the ophthalmic nerve, severe supraorbital pain is commonly associated with acute glaucoma or with disease of the frontal or ethmoidal air cells . Malignant growths or empyema of the maxillary antrum, or unhealthy conditions about the inferior conchae or septum of the nose, are often found, giving rise to second division neuralgia, and should always be looked for in the absence of dental disease. It is on the mandibular nerve, however, that some of the most striking re-

698

A. F. Soniheimer

flexes are seen. It is quite common to meet with patients who complain of pain in the ear in whom there is no sign of aural disease and the cause is to be found in a carious tooth of the mandible. Moreover, with an ulcer or canker of the tongue, often the first pain to be experienced is one which radiates to the ear and temporal fossa, over the distribution of the auriculotemporal nerve. I hope that the lengthy anatomic considerations of the structures involved have not taken up too much time but the entire success of the treatments depends upon a thorough knowledge of the parts involved and the avoidance of untoward sequelae following treatment depends entirely on the operator's knowledge of the cranial anatomy. The fifth nerve becomes completely medullated three months after birth and starts at the fifth month of fetal life. Medullation, as you know, means the axis cylinder is surrounded by the sheath of Schwam or myelin. The bundles are encapsulated in a tough connective tissue sheath, the epineurium. Success of either the palliative treatment or the corrosive injection depends upon puncturing this sheath and using a comparatively small amount of fluid. The rationale of the palliative treatment, which is original and which has given me continued success for the past three years, requires a finer technic than the use of alcohol or other corrosive fluids. While almost painless and nearly free from danger, success depends entirely on an extremely delicate technic. The foramen ovale is entered (at the anterior border) and the epineurium punctured and 1 C.c. of "A" solution injected. The needle is withdrawn and is followed by the "B" solution immediately, usingB c.c. The" A" solution is a 2 per cent solution in distilled water of butyn or the paraaminobenzoyl-gamma-di-n-butylamino-propanal sulphate. This is followed by the "B" solution, which is made up as follows: Water Calcium chloride Sodium chloride Magnesium sulphate

1000.00 1.00 6.00 0.75

Perhaps the best of the corrosive liquids is Patrick's solution, viz.: Novocaine Chloroform Alcohol Water

2 5 70 23

per per per per

cent cent cent cent

The procedure of the palliative treatment which I have been using for the past three years, and which has given results in 90 per cent of the cases lasting three years plus (the shortest effect I have on record lasted eight months), is as follows: Two sterile test tubes containing the" A" and "B" solutions separately are brought to a boil and kept at boiling temperature for twenty minutes on three successive days before the operation. This assures complete sterility, which is important considering the susceptibility of the meninges to infection.

'I'ic-Douloureuo:

699

The patient is seated in a dental chair at mouth level to the operator's shoulder. The mucous membrane under the zygoma is painted with an 8 per cent tincture of iodine back to the anterior pillar of the fauces. It is immediately dried with a warm air syringe while an assistant holds the cheek away with a retractor. The patient thrusts the jaw to the side being operated upon, dropping the opposite condyle. This gives room for the operator to work. A perfectly straight steel needle 2y:!" long, with a safety disc, is used on a light weight glass syringe. The needle is 25 gauge and must be sharp. Dull needles cannot be used as they will not puncture the epineureum but will cause considerable pain and thrust aside the nerve trunk. Being parallel with the inferior border of the mandible the needle is inserted as high as possible, just posterior to the tuberosity. It is necessary to pierce the substance of the internal pterygoid muscle and a feeling like a rubber resistance is conveyed to the syringe; the needle is pointed slightly medially and continued up until the internal pterygoid fossa is struck. Very little areolar tissue will be met with and as soon as the bone is struck carry the point of the needle downward, feeling with short jabs until the anterior border of the foramen ovale is reached. Now a twinge will be felt by the patient and a few drops of "A" solution are deposited. Wait a few seconds and then firmly push the needle 5 mm. further, emptying the rest of the 1 c.c. of "A" solution. The "B" solution is injected in the same way; only 3 c.c. are used. It is best in using the palliative treatment to follow it up once or twice at intervals of one week apart. In old persons having osteoporosis it is possible to inject into the wrong place unless painstaking care is used to get the necessary twinge. The untoward sequelae following the palliative treatment are small. If infection is guarded against nothing but a passing trauma need be experienced; however, the possibilities of untoward sequelae following an escharotic fluid are great and may be summed up as follows: 1. Injection into the internal carotid artery happened in Germany, causing instant death. 2. Injection into the eustachian tube caused intense agony and permanent Joss of hearing on the affected side. 3. Injection of the foramen spinosum caused cerebral shock and convulsions. 4. Paralysis of the seventh and eighth nerves by using too much alcohol which followed the course of the great superficial petrosal nerve to the aqueductus fallopii. 5. Terrific shock, convulsions and complete motor paralysis of the opposite side of the body caused by too much alcohol or opening an artery communicating to the substantia gelatinosa of Rolando. 6. Violent dementia due to circulatory communication with the cells of Purkinje in the cortex.

A. F. Sontheimer

700 INJECTION

m'

THE SPHENOPALATINE GANGLION

The needle used for this injection is slightly shorter than for the gasserian ganglion but otherwise has the same gauge and safety disc. A slightly obtuse right angle to the barrel of the syringe gives about the proper form for convenience of injection. The preliminary preparation of the mouth is the same as for the injection of the gasserian. The needle is inserted close behind the maxillary tuberosity, usually just above the roots at the point above the second and third molar. Bone should be felt and followed for ly:! inches to insure the entrance of the needle into the pterygopalatine fossa and mesially to the petrygoid plate of the sphenoid. At this point the needle is slightly withdrawn and tipped distally until the mesial surface of the pterygoid plate is felt. This gives the landmarks of the fossa mesially and distally and when by the sense of touch the approximate center is found the ganglion can be reached by a 10 mm. thrust. The danger of using an escharotic fluid at this point lies chiefly in the nearness to the optic nerve, which lies about 15 mm. above. I have never found occasion to use alcohol or like preparations for this ganglion. The palliative treatment has given a permanent relief in every case without exception for the past three years. I must say, however, that the technic of injection for the palliative treatment is more exact than that for alcohol as far as results are concerned. Unless a puncture of the epineurium is secured the results will not be lasting. While a bathing of the ganglion or nerve trunks with alcohol will give immediate results, and a 5 or 10 mm. proximity often reaches the nerve, the palliative treatment will not give results unless a direct hit is made. The customary procedure for injection of the foramen ovale is to inject from the outside cheek 5 or 10 mm. below the middle of the zygoma and half way between the posterior border of the condyle of the jaw and the angle formed by the temporal and zygomatic border of the malar bone. The needle penetrates to a depth of 40 to 50 mm. and then comes in contact with the external plate of the pterygoid process. This depth varies in proportion to the width of the skull and the prominence of the cheek bones. When the bone is felt the point of the needle is worked upward repeatedly, withdrawing slightly and then reinserting it, the point each time coming in contact with the bony plate until the under surface of the great wing of the sphenoid is felt. This surface is rather perpendicular to the pterygoid process and the needle is felt to slide obliquely along the bone. In this way the sulcus between the pterygoid process and the under side of the sphenoid wing is located. When this sulcus is recognized the point of the needle is, by the same process of withdrawing and reinserting, made to step backward until it is felt to slip off into space at the posterior border of the process, when it will be right at the foramen ovale, which gives exit to the whole of the third division of the fifth nerve.

Ti c-Douloureux

701

In working t he poin t of t he needle backwards, it is k ept more in con tact with th e u nder surface of t he sp he noid wing than wit h the extern al plate of t he process. The sulcus betw een these t wo is rounded an d the needle mu st work alon g the up per pa rt of th e gr oove . Otherwise, wh en the post erior border of the process is r each ed , the point will be bel ow t he foramen ovale and a back ward proj ecti on of the exter n al ptery goid plate might separ at.e it from the nerve. When from t he feel of the n eedle or the sensation of the 'pa tien t it is thought that the needl e is in contact with th e n er ve, the fluid is lib erated a few drops at a time, th e p oin t of th e n eedl e being shi fte d slight ly until an an esthesia and a pa resthesia pr oclaim success of the operati on. Blair advises 4 c.c. of alcoh ol mixture be used but to me this seems just fou r t imes too mu ch. Such a quantity injected accidentall y into the internal ca r ot id or with a skull hav ing ost.eoporosis, int.o th e meninges, probably would cause instant death. Th e sh ock following the inj ect ion of such an amount of alcohol might also cause de ath. Terrific pajn and shock are to be consid er ed and, due to the capillary at tract ion of alcohol in the ti ssu es, it. is apt t o extend t o d elicate areas, produc in g untoward sequelae (to pu t it mildly ). Due t.o the fact t hat the forame n ova le extends la tterly and the n er ve tr unk is flatt en ed in t he sa me direction , a direct hit an d puncture of the p eri n eurium is eas ier to mak e in tra orally. One is more apt, ho wever, to b e suc cessfully gu ided by th e ex te r n al zygomatic inj ecti on on account of the ac cura t e landmarks to f oll ow than by t he in tr ao ra l in j ect ion whi ch mu st b e gui ded mainly by a long stu dy of various sk ulls. Bl air uses a thick , h eavy gauge n eedle rather blu nt. I use a fin e, 25-gau ge n eedl e wit h a ra ther sha r p p oin t . The n eedl e must penetra t e t he subs tance of the ptery goid. mu scle and puncture the p erineurium ' and t his can be d one almost p ainlessly by a sharp fin e n eedle in cont rast t o a blunt h eavy one. Success at this work r equires long hard stu dy an d exper ienc e, for some ti mes it is necessary t.o try sever al times before success is attained. But I believe, if we can give a patient t.reatment pract ically without pain and obt ain results of long duration by the palliative treatm ent, it is far better than using alcohol, which is ac compan ied by excru ciating pain an d always the ri sk of accident. The cases I ha ve on record show sphe n op alliative neural gia 100 per cent successful ; tim e, three years plus. Major tic-douloureux-t ime: sh or t est, eigh t mon th s ; longest , three y ears plus. R esults obtained in eve ry case without except ion . REP ORT S OF P ATIE NTS

CASE I.-June 17, 1926. C. W. Y., m ale , Amer ican , a ged 58 years, married, childre n. Th er e are no t eeth on th e maxill a. Radiogram s wer e t ak en which showed n o troubl e. Dr. Welcher cut the g um an d scraped th e j aw bone twi ce, but th is did not help. P atient went to Dr. G. Kirby Colli er, who diagnosed it as Tic-Doulour eux. H e sa id poison f ormed in lower b owel. P a tient took cat hartics an d f ound th at when bowels wer e kep t open t he p ain was not nearly so severe. At tim es he could not eat, drink or ta lk, th e pain was so severe. Dr. Collie r di agn osed it by to uchin g face . wit h stee l in st rument, th e pa t ien t felt every t ouch.

702

A. F. Soniheimer

Patient has two, three and four bowel movements a day. After first treatment by Dr. Collier, patient was free from pain for six months. When pain first started three years ago, he felt it first when shaving. Patient takes 1 teaspoon Kerns Tea every night, steeping it in water. The past four months, while taking this, has had pain only a little. Before this at times he was miserable-the longest the pain ever lasted was forty minutes. This tea is to keep the bowels open. It seems to be in the first and second division. Sometimes it would disappear by swallowing. The pain is always on the right side, at times it feels like fire. Now, while he is talking, the pain comes and goes, but is not severe. Dr. Collier did not advise operation. When pain would be severe, Dr. Collier would give him pills, advise him to take salts and get the intestinal tract open. Patient would then feel some better. Patient had injection at Dispensary at Clinic June 18, 1926. June 24, 1926. Patient felt no effects after the treatment otherwise than a sore gum and a swollen cheek for about 48 hours. The pains have been the same with the exception of the pain near the ear-that seems to be better. Have felt no other effects of the treatment. July 1, 1926. Patient went to Rome, N. Y., Sunday, June 27 and had treatment (injection) by Dr. Sontheimer-has had no pain of any kind since, had no pain from treatment. Patient is freer from pain than he has been for three years. After the first treatment at the Dispensary patient had some pain all the while but since second treatment there has been no pain of any kind. There is some swelling on the right side. Dr. Sontheimer gave patient four injections-there was immediate relief after this. He said he would probably have to come for another treatment. When the injection was made, Dr. Sontheimer said patient might have some severe pains within a couple of hours after the treatment and advised him to consult a physician and take an aspirin tablet. This was not necessary as there was no pain. There has been numbness since inj ection but feeling seems to be coming back. July 28, 1926. There has been a soreness and a decisive swelling up to July 24. At present it is considerably down-the soreness has left and patient has had no pains of any kind since the injection. The swelling interferes somewhat with eating. Patient can now wash face and shave. There is a numbness at the end of the nose, the upper right lip and right side of the face under the eye. Once in a while there is a little burning sensation, but no pain. At Rome, N. Y. patient had four injections, one right after the other, all within about half an hour. It took a little longer between the second and third. First twofirst and second again. August 12, 1926. Patient has had no pains since treatment. Occasionally he has a burning sensation over the parts which are still numb. The numbness has not disappeared since the treatment. Patient feels fine. December 31, 1926. C. W. Y., was in the office today and reported the following: From June 27, the day of the treatment, until December 25, 1926 when there was a slight twitch on the right side of the face, similar to those he was having previous to the treatment, but not so severe. He has had the same twitch now and then. It comes mostly when he draws a towel over' the face in wiping it or when taking something cold. The tic usually comes directly over the right eye, in the supraorbital area. Between Dec. 31 and next report Feb. 14, 1927 patient had bad attack of la grippe. February 14, 1927, he was in the office and reported that the pain was better, and that he was feeling good again, only when using a towel in wiping the face the pressure will bring on a quick pain but this does not last. This is the only time patient has any pain of any kind. CASE 2.-J. M., June 18, 1926, widower, aged 82 years. Pain started about four years ago. All teeth were extracted at the time pain started. Went to three doctors at Caledonia. They did not discover what was wrong. He was then taken to Dr. Conner of Rochester. He ordered an x-ray taken by Dr. Palmer. Dr. Palmer then diagnosed it as tic-douloureux. He had Dr. Roy Bryant inject alcohol three times" at intervals of a year or more apart. This stopped the pain entirely for a while. After alcohol is injected there is severe pain for a while (a couple of days). The pain is in the lower right. Gum has not healed since last 'This was injected at the mental foramin.

Tic-Doulou reux

70B

injectio n. At tim es he ca nnot ta lk with th e pain. H e can a lways te ll when th ere is a change of the wea th er, th e p ain bein g worse. It is over a year si nce last inj ectio n. P ain is as ba d in th e night as in th e day, sometimes it is so bad th at it wakes him up with a start. H as had pain a gain since J anuary but has n ot been as ba d since alcohol was at first in j ecte d. Patient had inj ectio n at Dispensary at Clinic June 18, 1926. On June 21, 1926, patient wr ot e t he following : " Dr . P . \V. P rose us, Dear Sir : In regard to t r eat ment June 18, will say I have f elt very good- no pain to speak of . Gums fire very sor e an d f eel dizzy at times. Cheek swolle n, but I certa inly f eel mu ch r elieved. Very t r uly, J. M . " On A ug ust 24, 1926, J . 1\1. 's son called a t office and gave r epor t : A little over a week a fter patient had in j ecti on at Dispensary ( J une 18) patient went t o R ome and had t wo inj ecti ons. Dr. Sontheimer sai d pati ent would probably have severe pain f our hours afte r injection, but he did not. Two or t hr ee day s a f te rwar d, he would ha ve a shooting pain once in a while and be both ered wit h a growling p ain all t he while. T he gums have been very sore and patient did not f eel as well sinc e second i nj ecti on, as he did after first. P ati ent is to go to Rom e Sun day , August 29. Will r eport a week or so after this. On October 14, 1926, J . M. 's son called at office an d ga ve following report: Patient went to Rome on August 29, a nd had two injections, poss ibl y three. That night there was It blackness under the eye, sor t of bl ack and blue, which last ed f or a bout three days. Patient ha d some pain for three or f our days but not as bad as a fte r second visit to Rome. Finally pain clear ed up and he has not suff ere d any pain f or three weeks. Pat ient feels fine. Ma r ch 8, 1927. it was qu it e severe. in J anuary-h e sa id ag o the pain st opped now is th at t he gum s

Du ri ng N ovember a nd December J . M. had consta nt pain-at tim es H is gums have been sore right along . T hey wrote Dr. Sontheimer he th ough t he might need a nother treatment but two or th ree weeks a nd he has been f ree from pain ever since. Th e only trouble he has a r e sore, t he same as th ey have been r ight along. H e is feeling good.

CASE 3.-Mrs. O. H. F . consulted Dr. Proseus r egarding having ti c-douloureux May 1, 1926. He r eferred her t o Dr. Flyn n who to ok a r adiogram of sinuses and r eported clea r . Advised her to see Dr. Sont heimer, when a clinic was arra nge d her e in Rochester. A dvise d her to come and ha ve radiograms taken. Th e x-ray exami nation showed acc essory sinuses , fr ontal s clear. Ethmoids clear, Maxillary si nuses clear. N o diff ere nce in .density between r ight and left. Sphenoi ds clear. Impress ion- f rom an x-ray standpoint- all sinuses clea r . P ain star ted a bout two and a hal f yea rs a go. D oes not have it when sleepi ng but as soon as she begi ns t o move a round, it starts . T he more ti re d th e pa ti en t is, th e worse t he pain is- also any little excite ment mak es it wor se. Teet h on righ t side wer e extracted before pain star te d excepting ca nin e, U. R. This was ext racted a bout tw o month s afte r patient felt a cr awli ng sensa t ion bel ow the eye. An x-ray was taken but showed n o trouble where tooth had been. Pat ient is troubled with cons t ipation and takes salts r egularly, th at is, once a week. P atient ha s ha d trouble with right sid e of nose and piece of bon e was removed by Dr. Hoyt two years ago just before the troubl e sta rted. Patient also went t o Dr. Honis. Patient had injection at Di spensary at Clinic June 18, 1926. On June 28, 1926 she wr ot e as follows: " Dear Dr. Proseus : I waited until" after the second in j ect ion before writing you. We went t o Rome yesterday fo r t hat . I st ill have quite a bi t of pain in my face but not as much as a f te r th e first injec t ion. It does n ot come along quit e as fas t as I had hoped but I think Dr. Sonthe imer sincer e and mea ns to do th e f air thing, so I am going t o g ive him a fa ir trial. I go t o Rome July 10 f or a third injecti on an d he hopes that will be th e last . My tongue and lip s are quit e numb sin ce the inj ect ion yest erday and quite a burning sensation but the pain is not quite as severe ." On July 30 patien t called at office and gave f ollowing r eport: After the injection at the Disp ens ary patient suffered severe pai n f or a week in th e upper right part of th e f ace. Th en went to Rome an d had injecti on in mandible. H a d severe pain all th e way home. Pain g ra dually left. F a ce swelled t erribly after second vis it. Th en wait ed t wo weeks and went aga in to Rome and had in j ect ion in right maxill a under eye. Dr . Sont heimer ex pect ed t hat f ace would swell but patient kept ice bag on it a ll th e way home and it did not swell.

704

A. F . Soniheimer

Patie nt had pra cti call y no pai n-only t he sa me pain she al ways has. Dr. Sontheimer suid he had done all he could do. H e said if pa ti ent wan ted to have operation to go eit her to P hilad elphia or Boston. Cold ai r does not a ffec t th e pain. P ati en t ha s had cata rrh since she was a little child. Dr . Sonthe imer sai d case was a li t tl e diffe rent th an other cases he has had , as patient has pain constantly but it is n ot as severe as man y oth ers. It is very tiring and wearing. P E R~ON AL

COMMU NICA T ION

My dear Dr . Proseus : After seei ng yo u with Dr. Sont heimer in Rochest er, I ca me home quite ela te d over th is new solution. I had some solut ion mad e up , according to Dr. Sont heimer's formula, a nd nsed it on tw o cases. Th e first case I used it on was one which I had inject ed two years a ge with alcohol, but a t t he fo ramen ovale. H owever, I decid ed t o use t he Sont heimer solution at th e f oram en ovale. He gave th e patient some anodyne after the in j ection, and told her she would probably have some pain fo r a few days. The patien t r eturned in a few days and would not let us use the Sontheimer solution again, as she ha d had so much relief from th e ot her alcohol injection. The r esult was that we injected with alcohol. The second ease was Dr. McCoy from Smethport, P a. , and who coul d only stay in th e City two or three days. We t ri ed th e Sont heimer solution with him but th e patient was un abl e to get an y relief, a nd as his stay was so sho r t, we j ust inj ect ed with th e alc ohol, t o mak e . him comfo rtable. After reading th e r esults which you sent me, I have come to th e conclus ion t ha t we should not exp ect r elief as soon as I had th ough t we might, and a mor e caref ul under stan ding of th e Sont hei mer proced ure, would, I'm sure, bring more gratifying result~. I believe that I will t ak e a trip down t o Rome in th e near fu ture when it might be convenient f or Dr. Sontheimer to ha ve me, an d watch him do a f ew cases in his own cli nic. I am not a s yet satisfied to believe this solution will t ake th e pla ce of alcohol. If you are in a position t o gi ye me further r ep orts on these cases you have, I would be ver y gl ad to receive th em, and would be very glad t o cooperate with you in any way. Sincerely yours, Oliffor d E. Rose.