tions of the nerves about the head and face which have been variously denominated, as clavus hystericus, hemicrania, tic douloureux, &c. "appearing to be all the same disease, only varying in situation and degree." The symptomatology of this class of affections is unfortunately too well known. The pain, though sometimes attacking the whole, or great part of the head, is generally confined to one side only, and frequently to but a part of that, as one eye, the upper lip and nose, the gums, &c. varying in different people, from a common headach to the most exquisite anguish which human nature can possibly suffer without destroying life. "Volat enim angor per nervi surculos fulgure ociùs, desinitque sensu vibrante, ægrotum miserimum attonitumque subitò relinquente."* "When the pain is confined principally to the head, and has become almost continual, it may be suspected that there is some disease within the cranium; on the contrary, if there is a perfect intermission in the twenty-four hours at about the same time, or if the pain, though constant, becomes more violent once in twenty-four hours at about the same hour, and continues so for some time, and then somewhat abates; if it strikes down the face, and wine does not increase it, and if the patient has been bled from the arm, and has experienced no relief; in all these cases, it may be judged to be an affection of the nerves without the cranium." 43. Anatomy has done but little, as yet, in explaining the exact nature of tic douloureux; for, although it generally happens that this complaint, especially in its progress, is attended with an increase of heat, and also of vascularity in the part affected, yet it appears to Mr. Swan that these are the effects of the nervous irritation, which, however, may tend to increase and keep up their cause. The nerves may become enlarged from irritation, in the same way the muscles are from continued action; but dissection, our author observes, has not shown those depositions of coagulable lymph, and changes of structure produced by continued inflammations of other parts of the body, and of the nerves themselves in stumps and portions along the seat of inflammatory action. This is also the opinion of Dr. Kerrison, as expressed at page 6 of his able thesis. "Sometimes it is produced by irritation, as from an ulcer connected with a branch of a nerve; sometimes from a decayed tooth, from the anastomosis between the affected nerve and those of the teeth, but most frequently from some disorder of the constitution.” P. 45. Dr. Kerrison's Thesis, page 9. Tic douloureux appears to Mr. Swan a diametrically opposite affection to that of paralysis. "We find that debility of the body is a state the most fitted for keeping up an irritation of the nervous system; and when any part of it has once become irritated in a subject to which we might suppose there was a predisposition, a habit is formed so as to continue the irritation, which generally becomes stronger and more obstinate, the longer it is unopposed by such remedies as have the power of breaking through it." 46. Sometimes the complaint terminates spontaneously, sometimes by the supervention of another disease, of which Mr. Swan relates an instance at page 46 of his work. The patient was 43 years of age, and had received a blow on the right eye, which produced a great extravasation of blood between the conjunctiva and sclerotica. At first he complained of very violent pains in the eye, for which he was bled, purged, and had cooling washes. Shortly afterward he complained of stabbing or darting pains, which went from the temple down the face, and sometimes to the ear, coming on in violent paroxysms, and always confined to the nerve. His complaint continued ten weeks, at first almost constant, then twice or thrice a day. At length an erup-. tion, resembling the nettle rash, came all over his body, when the pains instantly ceased, and returned no more. "During all the time before the eruption his spirits were much depressed. Much anxiety always increased the paroxysms, as did likewise any thing that caused him to be angry; much stooping, or motion of the head, likewise brought them on. During the paroxysms there was a great pulsation of the temporal arteries." 47. There appears to Mr. Swan two principal indications of treatment in this disease-1st, to strengthen the constitution, and thereby enable it to counteract the habit which favours the continuance of the irritation-the 2d indication is to allay the local irritation. "The first is best fulfilled by the exhibition of tonic remedies in doses, which must be repeated frequently, and at regular intervals, so as to produce new and regular actions: and when the diseased action is very violent, sedatives must be given, both with a view of alleviating the pain, and assisting the constitution to overcome the morbid actions. The best tonic remedy for affecting this change is bark, which should be taken regularly in doses, from half a drachm to a drachm every three or four hours day and night wine and malt liquor should be allowed rather freely. In this complaint the digestive organs are frequently disordered, but I have often known them restored during this plan of treatment." 48. : Mr. S. thinks arsenic a doubtful remedy, and that mer cury should be used very sparingly. In addition to remedies the patient should take regular and gentle exercise, and endeavour to tranquillize the mind, an endeavour, by the by, that is generally fruitless, for few can call in the precepts of philosophy, or even of religion, to their aid, when labouring under severe corporeal pain! The following case is related by our author to show that tic douloureux and periodical face-ach are the same affection of the nerves; and also for the purpose of showing the manner in which the bark should be administered to produce its beneficial effect. "Mrs. P., forty-eight years of age, had complained of a violent pain in her face, which extended up the head, and was supposed to proceed from the stump of a tooth. On the eighth day after its first attack I saw her; she complained of very excruciating pain, which came on at nine every evening: it was not the continued pain of the toothach, but came on in excruciating paroxysms, which lasted two or three minutes, and then abated. She would continue easy for a few minutes, and then again the pain would recur; and in this manner she passed her time until seven in the morning, when she became quite easy, though the pain would return occasionally at different times in the day. It seemed to be confined to the upper branches of the portio dura of the seventh pair of nerves. As it was supposed to proceed from a tooth, the tooth was extracted; and as her mouth was inflamed, she took four grains of submuriate of mercury and some purging medicine. On the tenth day I saw her again, when she had received no benefit from what I had done for her. I ordered her the following draught, to be taken half an hour before the pain came on, and the powders to be taken regularly every three hours through the day and night. "R. Tinct. Opii. gtt. xl. R. Pulv. Cinchon. Cordifol. 3ss. -Zingib. gr. iij. Mf. Pulv. "On the eleventh day I saw her again; the medicines had been taken regularly, and she had passed, upon the whole, a better night." 50. The pain gradually subsided, and in three or four days more it was removed. In cases, however, where the disease has been of long duration, much more time will be required before the salutary effects of the bark are perceptible. "But it must be persevered in, and taken regularly through the day and night, or it will not be found often to succeed." Here Mr. Swan states a case where the disease was brought on by a blow on the face, which broke one of the incisor teeth. In this instance, two scruples of the bark, with an infusion of the same and cloves, were exhibited every three hours. These remedies removed the disease in a short time. A subsequent relapse was also cured by the same means. The next case brought forward by Mr. Swan is to show how debility produces a morbid sensibility of the nervous system, in general, and thus disposes to local complaints of particular nerves. The patient had eaten some hashed hare, which had stood in a brass pan covered with verdigris, in consequence of which his health was much impaired. When Mr. Swan saw him, some months after the accident, he had an affection of the nerves at the back of the head, that caused excruciating pain. He had become weak and much emaciated, and had used a variety of means without any abatement of the complaint. Mr. S. ordered him half a drachm of the powdered cinchona every three hours, and a blister to the back of the neck. As the paroxysm was always most severe in the mornings, a draught with 30 drops of laudanum was ordered at that time, while wine and malt liquors were recommended for drink. Soon after this plan was adopted, the pain began to be less severe, and it gradually diminished till it ceased entirely. As the pain diminished, his bodily health improved. When the complaint has resisted bark, and the various other methods that have been recommended, as arsenic, belladonna, steel, mercury, &c. then our author considers the division of the nerve as our last hope, though too often a fallacious one. "Nonne verisimile sit," says Dr. Kerrison, "signis aliorum morborum perspectis, quod dolor hic originem ducat a quavis corporis parte longè distante, propter nervorum consensum." Thesis, p. 3. Dr. K. illustrates this by adverting to the irregular action of the voluntary muscles in chorea, where the cause of the disease is often unequivocally seated in the abdomen--to the pruritus narium from ascarides in the rectum, and also in the infantile remittent fever, where children will frequently continue to pick the nose and checks while any sordes remain in the bowels-the facial irritation immediately subsiding when the cause is removed by cathartics. Dr. Kerrison here asks if it be unlikely that depraved gastric or intestinal secretions should excite painful affections of the fifth pair of nerves from their consent, or rather connexion with the great visceral nerves. In the next sentence, the Doctor asks what is this connexion? This question is answered by himself in a subsequent part of his Thesis. "The connexion of the second branch of the fifth pair with the great sympathetic, by means of the spheno-palatine or vidian nerve, is capable of being demonstrated." Hence, says he, we see the reason why dividing the facial nerves, where tic douloureux is sym pathetic of visceral irritation, fails to procure relief, since the vidian junction of the fifth and great sympathetic, " profundior est quam scalpellus chirurgi peritissimi pertingere queat:" 37. Dr. Kerrison seems persuaded that tic douloureux is not local disease-but depending on a constitutional origin" sedantium medicamentorum fere omnium applicatio jam dicta, atque multimodis repetita, æque ac nervorum sectiones quas videram, absque fructu quam minimo, mihi persuaserunt neuralgiam facialem spasmodicam a causa generali pendere." Dr. K. from attentive observation and experience, has been led to conclude, that depraved secretions in the primæ viæ are the grand causes of this disease, and that although purgation may prove an auxiliary, it will not cure tic douloureux. His principal reliance is on the cinchona judiciously administered, with attention to regimen, open bowels, and other juvantia. He is unable to account for the ratio agendi of this valuable medicine; otherwise than that it changes or corrects the habit of mal-secretion in the stomach and other chylopoietic viscera. "Absentia doloris capitis, remissio frequens, ademptio etiam totalis cruciatûs, absque remediis topicis, et non rarò sine opio aut quovis pharmaco narcotico, probant, ni fallor, neuralgiam facialem spasmodicam nec a cerebro, cerebello, neque a nervo faciali quocunque originem trahere; ergo, probabile ratus sum, ut cinchona, vi quâdam astringente prædita, superficieique purgatæ intestinorum admota, aliquid mutationis efficiat, quo facto, munus eorum magis salubriter perficiatur, ita ut liquor, gasve excitans, haud amplius secernatur, aut conficiatur, et Irritatio Faciei symptomatica quiescat." Thesis, 44. Dr. Kerrison states, that he has used the following means in tic douloureux with very little effect, viz. repeated leeching of the part, cupping,* applications of ice, pouring cold water from a height, extract of belladonna externally, opium, plumbi carbonas, in form of ointment with oil, superacetas plumbi, fomentations of tobacco infusion, blisters, issues, (with some relief,) electricity, prussic acid. In respect to the treatment, Dr. K. lays down the following therapeutical indications, viz. 1st, to cleanse the intestinal canal; 2d, to meliorate the intestinal secretions. He properly considers it superfluous to dwell upon forms or prescriptions, since every one acquainted with physiology, pathology, and thera * General bleeding he has never tried, but in a note it appears that Dr. Pemberton had recourse to this measure in his own person, every second day till he could scarcely walk, without making the least impres sion on the complaint! |