Neuralgia of the trifacial or fifth nerve. One alone, more often two, but rarely all three divisions of the fifth nerve of one side of the face may be the seat of neuralgia. It is less common for the third division to suffer than the first and second.

Tic-douloureux has often been preceded or followed by neuralgia of the occipital nerve. Facial neuralgia is rare in young children, but it might occur in cases of convulsions. It always attacks the sufferer at some time during the period of bodily development. It seems the middle period of life is not so apt to the attacks of neuralgia. When a patient has a neuralgic tendency, the wear and tear of this stage tends much to recall it. Sexual changes of middle life are especially prone to reproduce facial neuralgia. It is in the period of degeneration that the worst instances occur. Formerly when malaria fever was raging in this country such afflictions were a common occurrence. But at the present day, owing to drainage and cultivation, it is very rare.

Cases do occur and are recognized by regular periodicity in the attacks of pain. Cold wind, especially with moist temperature, has an undoubted influence in starting neuralgia of the fifth nerve.

The unprotected condition of the face explains the probable liability to be attacked. There appears reason to think, however, that when damp with cold excites an attack of neuralgia there must be at the same time a peculiar condition of the system or neuralgia of the fifth nerve would be more common in this climate than it is. Such a condition is probably of a rheumatic or gouty nature, and the cold, I think, starts a subacute inflammation in the sheath of the nerve; as regards other general conditions predisposing to the affection, those common to neuralgia, injury to the nerve, foreign bodies, irritating either this or some other nerve, morbid growth of bone, especially such as to cause contraction of bony canals traversed by branches of the nerve, and syphilitic periostitis may act as exciting causes of Tic-Douloureux. The cause may be in the floor of the cranium in the form of tumors, disease of bone or membranes or abscess.

Symptoms.—Some obscure feeling of discomfort may precede the outburst of actual pain or this may occur suddenly and without warning in some part of the region supplied by the fifth nerve. The pain seems to emanate from one or more foci in swift flashes, then a dull aching remains in the intervals, and is a tiresome character very short-lived at first, then the pain comes on again, of a darting, burning, boring character which increases in severity and duration. I have seen the patient turning, twisting in every way under the violence of the agony when well pronounced. You will find a great tendency to excitement of the pain influenced by such irritants as a current of air, a sudden noise or the muscular movements in speaking, laughing, chewing, blowing the nose, or coughing.

The attack of Tic-Douloureux may vary to any degree and duration, from a short paroxysm and may never return, to a disease of obstinate character, repeated attacks, all through life.

Diagnosis.—The paroxysmal character of the pains, coupled with tenderness on pressure at various points, sufficiently indicate Tic-Douloureux. The only condition with which it is easily confounded is the pain of a tumor upon the trunk of the nerve in the cranium. The presence of pain will distinguish the spasmodic contraction of the facial muscles. Careful examination, bearing in mind the points of diagnosis described to obviate error, it must be remembered that pus in the antrum will occasion neuralgic symptoms.

Duration and Prognosis.—Tic-Douloureux occurring in youth and as an accident of exposure or as a result of faulty teeth may never recur. It is, perhaps, more common for repetitions of the attack to take place alternating. It may be with neuralgia in other quarters. Tic is not infrequently liable to recur especially under circumstances of depression through a whole lifetime, but it may never have the character of extreme severity. In certain few cases I have seen, it is not only obstinate but of terrible violence, the patient being incapacitated through many years by the constantly recurring affection. The pain in some cases has been violent enough to destroy life. As a rule, the disease, however severe, the agony entailed by it, does not seem itself to shorten the duration of the life which it fills with suffering.

Treatment.—As in neuralgia generally, the treatment of Tic-Douloureux is partly constitutional and partly local and palliative of suffering. The first care in a case should be to have the teeth accurately investigated and faulty teeth removed or treated. It may also happen that a tooth may not show any outward signs of decay. An X-ray plate should always be made which will remove all doubt.

The hypodermic injection of morphia holds the first place as a means of relief. Sometimes it requires a small dose and sometimes larger, and can be discontinued without difficulty as the pains subside.

Other indicated remedies are gelsemium, piscidia, passiflora, bryonia, hyoscyamus. Injection of alcohol is also a fine remedy.

National Eclectic Medical Association Quarterly, Vol. 26, 1934-35, was edited by Theodore Davis Adlerman, M.D.