The Surgery of the Skull and Brain

by Louis Bathe Rawling

The onset of pain may be preceded by premonitory symptoms such as tinglings, throbbings, and burning sensations in the parts subsequently involved, whilst, in the earlier stages of the disease, the pain may be more or less localized to the site of emergence of the nerve from an osseous foramen.

In the earlier stages also the attacks, though severe, are paroxysmal, of short duration, perhaps not lasting more than half a minute, and definitely localized to some special nerve-trunk. During the periods of remission the patient feels quite well. Gradually the pain increases in severity, the periods of remission shorten, and the pain in its distribution becomes more widespread, the neuritis—or whatever the process may be—spreading centrally and radiating along the course and distribution of such branches of the nerve as shall be encountered.

Paroxysms are a marked feature, occasionally of so severe a nature that the patient falls to the ground as if struck by lightning, recovering after a variable period of time.

In the later stages of the disease the pain may be almost continuous, and the condition of the patient is truly miserable.

The attacks are often ushered in by the slightest stimulus—talking, mastication of food, draughts, emotion, &c.—and, in order to avoid the occurrence as far as possible, the patient abstains from talking, dreads eating, &c. Dribbling from the mouth may be observed in those cases in which the patient finds some relief in keeping the mouth open. It is also frequently seen during the height of the paroxysm. At such stages the patient is collapsed, with feeble pulse, shallow respiration, the temperature subnormal, and the skin clammy. The attacks occur both during the day and the night, sleep fails, and the body nutrition suffers.

The site at which the pain originates can often be fixed by the patient himself. Occasionally relief may be attained by pressure applied over some particular part, by heat or by cold, or by some other method discovered by the patient himself.

The attacks are often accompanied by twitchings of the muscles supplied by the facial nerve, and, according to some investigators, by fibrillary twitchings of the muscles of the region affected.

In the later stages, wasting of the muscles may be observed.

Vaso-motor and trophic changes.

The skin and mucous membrane supplied by the nerve involved become hyperæmic and hyperæsthetic, and, in the more chronic cases, these changes may be associated with œdema of the subcutaneous tissues—the clinical picture now closely resembling that observed in some cases of angio-neurotic œdema.