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+The Project Gutenberg EBook of Neuralgia and the Diseases that Resemble it, by 
+Francis E. Anstie
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Neuralgia and the Diseases that Resemble it
+
+Author: Francis E. Anstie
+
+Release Date: October 1, 2011 [EBook #37592]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT ***
+
+
+
+
+Produced by Bryan Ness, JoAnn Greenwood and the Online
+Distributed Proofreading Team at https://www.pgdp.net (This
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+
+
+                 NEURALGIA
+                    AND
+       THE DISEASES THAT RESEMBLE IT.
+
+                    BY
+
+      FRANCIS E. ANSTIE, M.D., LONDON,
+
+FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S
+COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER HOSPITAL;
+LECTURER ON MEDICINE IN WESTMINSTER HOSPITAL SCHOOL; PHYSICIAN TO THE
+BELGRAVE HOSPITAL FOR CHILDREN.
+
+              [Illustration]
+
+                NEW YORK:
+      BERMINGHAM & CO., UNION SQUARE.
+                  1882.
+
+           W. L. MERSHON & CO.,
+   _Printers, Electrotypers and Binders_,
+              RAHWAY, N. J.
+
+
+
+
+PREFACE.
+
+
+I believe it will not be disputed that there was considerable need for
+an English treatise dealing rather fully with the subject of Neuralgia,
+and therefore I hope that the profession will be willing to give me a
+hearing. The present work, moreover, does not profess to be a mere
+compilation of standard authorities corrected down to the present time,
+but puts forward a substantially new view of the subject--at least, a
+view that has been only briefly sketched by me in an article that
+appeared, three years ago, in Reynolds's "System of Medicine." My
+principal object, in writing this volume, was to vindicate for Neuralgia
+that distinct and independent position which I have long been convinced
+it really holds, and to prove that it is not a mere offshoot of the
+Gouty or Rheumatic diatheses, still less a mere chance symptom of a
+score of different and incongruous diseases. In order to set the
+diagnosis of true Neuralgia from its counterfeits in the clearest light,
+it seemed advisable to draw separate pictures of each of the latter (at
+least of as many as are of real importance) and present them separately,
+as a kind of gallery of spurious neuralgias, and this I have done in the
+second part of the volume. No one who had not tried to do it would
+imagine how difficult this latter kind of work is. It was necessary for
+the sketches to be very brief (unless my book was to become unmanageably
+large), and yet to be as truthfully characteristic as possible; and it
+was necessary also that only those diseases which so much resemble
+Neuralgia as practically to lead medical men astray in diagnosis, should
+be dealt with. The selection of the subjects, and the execution of this
+part, took a long time, though it only covers about fifty pages. Then,
+as regards Neuralgia itself, it became necessary to completely recast
+the chapters on "Pathology" and on "Complications," on account of some
+of the polite criticisms which Dr. Eulenburg directed (in his recent
+"Lehrbuch der Nervenkrankheiten") to my argument in the article above
+referred to, since it was obvious that a too brief statement of my views
+had caused them to be partially misunderstood by the German physician.
+These chapters (Part I., Chapters II. and III.) are certainly the most
+important portion of my book, and I would particularly direct attention
+to them, in order that their contents may be affirmed or corrected: the
+reader will at any time find that they contain a kind of investigation
+never before systematically carried out with regard to Neuralgia. The
+causes above mentioned, together with others over which I had no
+control, have kept back the appearance of this work so long beyond the
+date for which it was originally announced, that I feel I ought to
+apologize for an amount of delay that would seem hardly justified by the
+moderate size of the volume.
+
+16 WIMPOLE STREET, LONDON, _October_ 1, 1871.
+
+
+
+
+CONTENTS.
+
+
+    INTRODUCTION--ON PAIN IN GENERAL                7
+
+
+                 PART I.
+
+             _ON NEURALGIA._
+
+    CHAP.                                        PAGE
+
+       I.--CLINICAL HISTORY                        12
+
+      II.--COMPLICATIONS OF NEURALGIA              79
+
+     III.--PATHOLOGY AND ETIOLOGY OF NEURALGIA     96
+
+      IV.--DIAGNOSIS AND PROGNOSIS OF NEURALGIA   142
+
+       V.--TREATMENT OF NEURALGIA                 149
+
+
+                 PART II.
+
+     _DISEASES THAT RESEMBLE NEURALGIA._
+
+    CHAP.
+
+       I.--MYALGIA                                196
+
+      II.--SPINAL IRRITATION                      200
+
+     III.--THE PAINS OF HYPOCHONDRIASIS           207
+
+      IV.--THE PAINS OF LOCOMOTOR ATAXY           210
+
+       V.--THE PAINS OF CEREBRAL ABSCESS          213
+
+      VI.--THE PAINS OF ALCOHOLISM                215
+
+     VII.--THE PAINS OF SYPHILIS                  218
+
+    VIII.--THE PAINS OF SUBACUTE AND CHRONIC
+              RHEUMATISM                          225
+
+      IX.--THE PAINS OF LATENT GOUT               227
+
+       X.--COLIC, AND OTHER PAINS OF PERIPHERAL
+              IRRITATION                          229
+
+      XI.--DYSPEPTIC HEADACHE                     231
+
+
+
+
+INTRODUCTION.
+
+ON PAIN IN GENERAL.
+
+
+Although it is, in a general way, unadvisable to introduce abstract
+discussions into a treatise which should be strictly practical, it is
+almost impossible to avoid some few general reflections on the
+physiological import of Pain, as a preliminary to the discussion of the
+maladies which form the subject of this volume. This whole group of
+disorders is linked together by the fact that pain is their most
+prominent feature; and, with regard to most of them, the relief of the
+pain is the one thing required of the physician. It seems, therefore,
+very important that we should ascertain, at least approximately, in what
+the immediate state consists, which consciousness interprets as pain. It
+is not necessary to enter at this stage into any inquiry as to the
+pathological causes of the phenomenon; what we know of these, and it is
+unfortunately too little, will be discussed in detail under the headings
+of the several affections which I shall have to describe.
+
+The question before us now is this: What is that functional state of the
+nerves which consciousness interprets as pain? Is it, or is it not, an
+exaltation of the ordinary function of sensation?
+
+The latter question is generally answered affirmatively, without much
+thought, by those to whom it casually occurs; but indeed there is plenty
+of prescriptive authority for so dealing with it. Pain has been
+described by some of the most distinguished writers on nervous diseases
+as a hyperęsthesia. Yet there is really little difficulty in convincing
+ourselves, if we institute a thorough inquiry into the matter, that pain
+is certainly not a hyperęsthesia, or excess of ordinary sensory
+function, but something which, if not the exact opposite of this, is
+very nearly so.
+
+The leading fallacy in the common view is the confusion which is
+perpetually being made between function and action. Now, the function of
+individual nerves is very nearly a constant quantity, at least, it
+varies only within narrow limits; while the action of the same nerves
+may be almost any thing. The function of the nerve is that kind of work
+for which it is fit when its molecular structure is healthy; it is the
+series of dynamic reactions which are necessarily produced in
+nerve-tissue by the external influences which surround and impinge upon
+it in the conditions of ordinary existence. The action of nerves, under
+the pressure of extraordinary influences, may include all manner of
+vagaries which really have nothing in common with the effects of
+ordinary functional stimulation; which are, in fact, nothing but
+perturbation. No one can suppose, for instance, that the explosive
+disturbances of nerve-force which give rise to the convulsions of
+tetanus are any mere exaggerated degree of the orderly and symmetrical
+action by which the healthy nerve responds to the stimulus of volition
+ordering a given set of muscles to contract; they are something quite
+different in kind. And so it is with the sensory nerves. The functions
+of these conductors, in health, is to convey to the perceptive centres
+the sensations, varying only within a most limited range, which
+correspond to a state of well-being of the organs, and which excite only
+those reflex actions that are necessary to life. Thus the large surface
+of sensitive nerve terminals which is represented by the collective
+peripheral branches of the fifth cranial conveys to the medulla
+oblongata an impression, derived from the temperature and movement of
+the surrounding air, when the latter is neither too hot nor too cold,
+which imparts to the brain a perception of comfortable sensations, and
+excites in return the reflex action of breathing, which is necessary to
+life. But the impression produced on this same peripheral expanse of
+nerve-branches by prolonged exposure to cold wind may, and often does,
+convey to the centres sensations which are quite different and provokes
+reflex movements which are altogether abnormal. Pain is the product in
+one direction; sneezing, perhaps, in the other. It seems absurd to say
+that sneezing is any part of the function of those motor nerves whose
+action regulates the performance of expiration. And it appears to me not
+less absurd to say that pain is the function of the sensitive fibres of
+the trigeminus. But the best way, perhaps, to illustrate the looseness
+and incorrectness of applying the term "hyperęsthesia" (implying exalted
+function) to the state of sensitive nerves when suffering pain, is to
+examine the condition of distinctive perception in the very same parts
+to which the painful nerves are distributed. It will invariably be
+found, as we shall have occasion to see more fully proved hereafter,
+that, in parts which are acutely painful, a marked bluntness of the
+tactile perceptions can be detected. The tactile perceptions are, no
+doubt, conveyed by an independent set of fibres from those which convey
+the sense of pain.[1] Yet it is surely impossible to believe the effect
+of the same influence, in functional power can be different--much more
+than it can be exactly opposite--in the two cases.
+
+If pain be not a heightening of ordinary sensation, then we seem to be
+shut up to the idea that it is a perversion owing to a molecular change
+of some part of the machinery of sensation which frustrates function.
+For it is to be observed that, while the sensations conveyed by the
+healthy nerve are correct in the indications which they afford to the
+percipient brain, the indications given by pain are vague and
+untrustworthy, and often seriously misleading. Not to speak of the
+nerves of special sense, or of the fibres which convey the sensations of
+muscular movement, even the nerves of common sensation do carry to the
+internal perception, in health, a distinct impression of the well-being
+of the organs to which they are distributed. Mr. Bain[2] has well
+pointed out the positive character of this feeling, which is so often
+incorrectly referred to as if it were a mere negation of feeling. It is
+a sensation of equable and diffused comfort, if I may be allowed to use
+the expression, which streams in from all parts of the organism; and
+there is no possibility of comparing it, in any scale of less or more,
+with the sensation of pain; for the latter commonly conveys no correct
+information as to the organ from which it proceeds, or appears to
+proceed. Especially is this the case in the neuralgias, for more
+commonly than not the apparent seat of the pain is widely removed from
+the actual seat of the mischief which causes it.
+
+If we inquire a little further into the circumstances under which
+various kinds of pain occur, we gain some fresh suggestions. Among the
+neuralgias, those are the most acutely agonizing which occur under
+circumstances of impaired nutrition incident to the period of bodily
+decay, and strong reasons will be hereafter adduced for the belief that
+there is especial impairment of the nutrition of the central end of the
+painful nerves. To find a parallel to the severity of this kind of pains
+we must turn to the case of organic tumors, which, from their position,
+structure, and mode of growth, necessarily exercise continuous and
+severe pressure on the branches or the trunk of a nerve; or to the class
+of pains which attend severe cramp, or tonic contraction of muscles.
+Now, it can scarcely be doubted that in the latter instance there is an
+abnormally rapid and violent destruction of tissue going on; at the very
+least there is an extraordinarily violent and irregular manifestation of
+motor force. In any case the patent fact here is dynamic perturbation
+of a severe kind; and, in the instance of organic tumors exercising
+steady and continuously increasing pressure on nerves, one can scarcely
+doubt that a similar perturbation, less intense but more enduring, is
+necessarily set up. That which can be done in the way of producing
+severe pain by these severe affections of the peripheral portions of
+nerves, or of tissues lying outside them, we might _a priori_ expect
+would be effected by slighter but continuous changes in the nutrition of
+the more important portion of the nerve itself--its central gray
+nucleus. One would say that a pathological process which continuously
+and progressively lowered the standard of nutrition here must interfere
+from hour to hour, certainly from day to day, with that regular and
+equable distribution of force which is the essence of unimpeded
+function.
+
+Take, again, the case of the very severe pain which frequently attends
+inflammation of the pleura and of the peritoneum. Whatever theory of the
+causation of these pains we may adopt, it is certain that one most
+important element in their production and maintenance is the continual
+movement and friction of the affected parts. But there is little doubt
+that the moving muscles are involved in the inflammatory process, as Dr.
+Inman has correctly observed. It would seem plain that under these
+circumstances--an inflamed muscular structure forced to perform its
+ordinary contractions as well as it can--there must be powerful dynamic
+perturbation going on.
+
+If perturbation of nerve-function--a disturbance quite different from
+mere exaltation of the normal development of nerve-force--be the essence
+of pain, how comes it that pains of the severest type may be produced by
+changes in structures which are usually described, for practical
+purposes, as lying outside the nervous system? We must, in the first
+place, remark that the externality of any bodily tissue to the nervous
+system is more apparent than real. Microscopic researches are constantly
+revealing nerve-fibres, in ever-increasing profusion, which penetrate to
+parts seemingly the least vitalized in the organism. But, in any case,
+the nerves are certainly the ultimate channel of communication between
+the suffering part and the sentient centre. It seems, therefore, the
+inevitable conclusion that a dynamic perturbation going on in the
+non-nervous tissue is continued along the nerves themselves: and that
+the severity of the pain perceived by the conscious centres is
+proportionate to the tumultuousness, the want of coordination, and the
+waste with which force is being evolved in the cramped muscle, or
+whatever structure it may be, in which the pain takes its source.
+
+Not to pursue these topics further, we may sum up the considerations
+which have now been adduced, in the following general propositions,
+which will tend to simplify the examination of the various painful
+disorders which we are about to discuss:
+
+1. Pain is not a true hyperęsthesia; on the contrary, it involves a
+lowering of true function.
+
+2. Pain is due to a perturbation of nerve-force, originating in dynamic
+disturbance either within or without the nervous system.
+
+3. The susceptibility to this perturbation is great in proportion to the
+physical imperfection of the nervous tissue, until this imperfection
+reaches to the extent of cutting off nervous communications
+(paralysis).
+
+FOOTNOTES:
+
+[1] See, on this subject, some remarks, in my work on "Stimulants and
+Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception
+and Common Sensation."
+
+A very distinct and careful statement of the distinction between pain
+and hyperęsthesia will be found in a prize essay "On Neuralgia" by M. C.
+Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.
+
+[2] "Senses and Intellect."
+
+
+
+
+PART I.
+
+ON NEURALGIA.
+
+
+
+
+CHAPTER I.
+
+CLINICAL HISTORY.
+
+
+Neuralgia may be defined as a disease of the nervous system, manifesting
+itself by pains which, in the great majority of cases, are unilateral,
+and which appear to follow accurately the course of particular nerves,
+and ramify, sometimes into a few, sometimes into all, the terminal
+branches of those nerves. These pains are usually sudden in their onset,
+and of a darting, stabbing, boring, or burning character; they are at
+first unattended with any local change, or any general febrile
+excitement. They are always markedly intermittent, at any rate at first;
+the intermissions are sometimes regular, and sometimes irregular; the
+attacks commonly go on increasing in severity on each successive
+occasion. The intermissions are distinguished by complete, or almost
+complete, freedom from suffering, and in recent cases the patient
+appears to be quite well at these times; except that, for some short
+time after the attack, the parts through which the painful nerves ramify
+remain sore, and tender to the touch. In old-standing cases, however,
+persistent tenderness, and other signs of local mischief, are apt to be
+developed in the tissues around the peripheral twigs. Severe neuralgias
+are usually complicated with secondary affections of other nerves which
+are intimately connected with those that are the original seat of pain;
+and in this way congestions of blood vessels, hypersecretion or arrested
+secretion from glands, inflammation and ulceration of tissues, etc., are
+sometimes brought about.
+
+The above is a general description of neuralgia which will identify the
+disease sufficiently for the purpose of introducing it the attention of
+the reader. We must now proceed to give a more accurate account of its
+
+_Clinical History and Symptoms._--These vary so greatly in different
+kinds of neuralgia that it will be necessary to discuss the greater part
+of this subject under the headings of the special varieties of the
+disease. There are certain common features, however, in all true
+neuralgias.
+
+I. In the first place, it is universally the case that the condition of
+the patient, at the time of the first attack, is one of debility, either
+general or special. I make this assertion with confidence,
+notwithstanding that Valleix, and some other very able observers, have
+made a contrary statement. In the first place, it is certainly the case
+that the larger half of the total number of cases of neuralgia which
+come under my care are either decidedly anęmic, or else have recently
+undergone some exhausting illness or fatigue; and if other writers have
+failed to see so many neuralgic patients in whom these conditions were
+present, it must certainly be because they have limited the application
+of the term "neuralgia" within bounds which are too narrow to be
+justified by any logical argument; as will, indeed, be shown at a later
+stage. On the other hand, although a considerable number of neuralgic
+patients have an externally healthy appearance, as indicated by a ruddy
+complexion and a fair amount of muscular development, it cannot be
+admitted that these appearances exclude the possibility of debility,
+either structional or functional, of the nervous system. The commonest
+experience might teach us that, so far from the nervous system being
+invariably developed with a corresponding completeness and maintained
+with a corresponding vigor to those which distinguish the muscular
+system and the organs of vegetative life, there is often a very striking
+contrast between these in the same individual. What physician is there
+who has not seen epileptic patients, in whom mental habitude, a low
+cranial development, imperfect cutaneous sensibility, and other obvious
+marks of deficient innervation, were marked and striking features at, or
+even before, the first occurrence of convulsive symptoms, while the body
+was robust, the face well colored, and the muscular power up to or
+beyond the average? Now, it will invariably be found, on carefully
+sifting the history of apparently robust neuralgic patients, that they,
+too, have given previous indications of weakness of the nervous system:
+thus, women, who, after a severe confinement attended with great loss of
+blood, are attached with _clavus hystericus_ or with _migraine_; will
+inform us that whenever, in earlier life, they suffered from headache,
+the pain was on the same side as that now affected, and chiefly or
+altogether confined to the site of the present neuralgia. In a
+considerable number of cases, also, in which I have been able to observe
+accurately the events which preceded an attack of neuralgia, it has been
+found that the skin supplied by the nerves about to become painful was
+anęsthesic to a remarkable degree; and it is very often the case that a
+more moderate amount of blunted sensation was perceptible in these parts
+during the intervals between attacks of pain. A somewhat delusive
+appearance of general nervous vigor is often conveyed to the observer of
+neuralgic patients, by reason of the intellectual and emotional
+characteristics of the latter. Both ideation and emotion are, indeed,
+very often quick and active in the victims of neuralgia, who in this
+respect differ strikingly from the majority of epileptics. But this
+mobility of the higher centres of the nervous system is itself no sign
+of general nervous strength; which last can never be possessed except by
+those in whom a certain balance of the various nervous functions is
+maintained. Much more will be said on this topic when we come to discuss
+the etiology of neuralgia. Meantime I may content myself with repeating
+the fact which is indubitably taught by careful observation--that
+neuralgics are invariably marked by some original weakness of the
+nervous system; though in some cases this defect is confined strictly to
+that part of the sensory system which ultimately becomes the seat of
+neuralgic pain.
+
+Another circumstance is common to all neuralgias of superficial nerves;
+and, as a large majority of all neuralgias are superficial in situation,
+this is, for practical purposes, a general characteristic of the
+disease. I refer to the gradual formation of tender spots at various
+points where the affected nerves pass from a deeper to a more
+superficial level, and particularly where they emerge from bony canals,
+or pierce fibrous fascię. So general is this characteristic of
+inveterate neuralgias, that Valleix founded his diagnosis of the genuine
+neuralgias on the presence of these painful points. Herein he appears to
+me to be decidedly in error. I have watched a great many cases (of all
+sorts of varieties as to the situation of the pain), and I have
+uniformly observed that in the early stages firm pressure may be made on
+the painful nerve without any aggravation of the pain; indeed, very
+often with the effect of assuaging it. The formation of tender spots is
+a subsequent affair: they develop in those situations which have been
+the foci, or severest points, of the neuralgic pain. There is however, a
+point which, though not always, nor often, the seat of spontaneous pain,
+is nevertheless very generally tender. Trousseau, who criticises
+unfavorably the statement of Valleix as to the situation of the points
+douloureux, insists that this tender spot, which is over the spinous
+processes of the vertebrę corresponding to the origin of the painful
+nerve, and which he calls the points apophysaire, is more universally
+present than any of those pointed out by Valleix. I shall hereafter
+endeavor to show that these spinal points are by no means characteristic
+of neuralgia; they are present in a variety of affections which were
+ably described, under the heading of "Spinal Irritation," many years
+ago, by the brothers Griffin. ["Observations on the Functional
+Affections of the Spinal Cord," by William and Daniel Griffin. London,
+1834] and they are also present with misleading frequency in cases of
+mere myalgia, such as I shall have to describe at a later stage.
+
+Another characteristic of neuralgic patients in general is, I believe,
+a certain mobility of the vaso-motor nervous system and of the cardiac
+motor nerves; but I insist less on this than on the above-named
+features, because a more extended experience is necessary to establish
+the fact with certainty. Within my own experience it has always seemed
+to be the case that persons who are liable to neuralgia are specially
+prone to sudden changes of vascular tension, under emotional and other
+influences which operate strongly on the nervous system. The observation
+of this fact has been made accidentally, without any previous bias on my
+part, in the course of a large number of experiments made upon
+individuals free from manifest disease at the time, with Marey's
+sphygmograph.
+
+Neuralgic attacks are always intermittent, or at the least remittent, in
+every stage of the disease.
+
+The manner in which neuralgic pain commences is characteristic and
+important. There is always a degree of suddenness in its outset. When
+produced by a violent shock, it may, and often does, spring into full
+development and severity at once, of which, perhaps, the most striking
+example is the sudden and violent neuralgic pain of the eyebrow which
+some persons experience from swallowing a lump of undissolved ice.
+Usually, however, the first warning is a sudden, not very severe, and
+altogether transient dart of pain. The patient has probably been
+suffering from some degree of general fatigue and malaise, and the skin
+of the affected part has been somewhat numb, when a sudden slight stitch
+of pain darts into the nerve at some point which corresponds to one of
+the foci hereafter to be particularized. It ceases immediately, but in a
+few seconds or minutes returns; and these darts of pain recur more and
+more frequently, till at last they blend themselves together in such a
+manner that the patient suffers continuous and violent pain for a minute
+or so, then experiences a short intermission, and then the pain returns
+again, and so on. These intermittent spasms of pain go on recurring for
+one or several hours; then the intermissions become longer, the pain
+slighter, and at last the attack wears itself out. Such is generally the
+history of first attacks, especially in subjects who are not past the
+middle age, nor particularly debilitated from any special cause.
+
+A point of interest in connection with the natural history of the
+neuralgic access is the condition of the circulation. The commencement
+of pain is generally preceded by paleness of skin and sensations of
+chilliness. At the commencement of the painful paroxysm, sphygmographic
+observation shows that the arterial tension is much increased, owing, in
+all probability, to spasm of the small vessels. This condition is
+gradually replaced by an opposite state, the pulse becoming large, soft,
+and bounding, though very unresisting, and giving a sphygmographic trace
+which exhibits marked dicrotism. Simultaneously with this the skin
+becomes warmer, sometimes even uncomfortably warm, and there is
+frequently considerable flushing of the face.
+
+The final characteristic common to all neuralgias is that fatigue, and
+every other depressing influence, directly predispose to an attack, and
+aggravate it when already existing.
+
+_Varieties._--It is possible to classify neuralgias upon either of two
+systems: first (_a_), according to the constitutional state of the
+patient; and, secondly (_b_), according to the situation of the affected
+nerves. It will be necessary to follow both these lines of
+classification, avoiding all needless repetition.
+
+(_a_) In considering the influence of constitutional states upon the
+typical development of neuralgia, it will be convenient to commence with
+the group of cases in which the general condition of the organism
+produces the least effect. This is the case when the pain is the result
+of direct injury to a nerve-trunk, whether by external violence, by the
+mechanical pressure of a tumor, or by the involvement of a nerve in
+inflammatory or ulcerative processes originating in a neighboring part.
+As regards the development of symptoms, the important matters are, that
+the pain in these cases commences comparatively gradually, that the
+intermissions are usually more or less complete, and that the pain is
+far less amenable to relief from remedies, than in other forms of
+neuralgia. The little that can be said about the form which is dependent
+upon progressively increasing pressure, or involvement of a nerve in
+malignant ulcerations, caries of bones or teeth, etc., falls under the
+heads of Diagnosis and Treatment, and need not detain us here. The
+clinical history of neuralgia from external violence, however, requires
+separate discussion:
+
+1. Neuralgia from external shock may be produced by a physical cause (as
+by a fall, a railway collision, etc.), which gives a jar to the central
+nervous system; or by severe mental emotion, operating upon the same
+part of the organism. Under either of these circumstances the
+development of the affection may occur at once, but by far the most
+frequently it ensues after a variable interval, during which the patient
+shows signs of general depression, with loss of appetite and strength.
+Sometimes vomiting, and in other instances paralysis, of a partial and
+temporary kind, occur. When once developed, the neuralgic attacks do not
+differ from those which proceed from causes internal to the organism. In
+the greater number of instances, so far as my experience goes, it is the
+fifth cranial nerve which becomes neuralgic from the effects of central
+shock. Illustrative cases will be given in the section on Local
+Classification. Meantime the important facts to note, in relation to the
+influence of constitutional states, are these: In the first place, the
+tendency of such accidents to excite neuralgia varies directly with the
+hereditary predisposition evinced by the liability of the sufferer's
+family to neuralgic affections and to the more serious neuroses.
+Secondly, the likelihood of a neuralgic attack is indefinitely increased
+if he has already had neuralgia. Thirdly, although debility from
+temporary and special causes can rarely be sufficient to insure a true
+neuralgic access after a severe shock, it probably heightens,
+indefinitely, the tendency in a person otherwise predisposed. Delicate
+women are many times more liable to experience such consequences, from a
+physical or mental shock, than men of tolerably robust constitution.
+
+2. Neuralgia from direct violence to superficial nerves is produced by
+cutting or, more rarely, by bruising wounds. Cutting wounds may divide a
+nerve-trunk (_a_) partially, or (_b_) completely.
+
+(_a_) When a nerve-trunk is partially cut through, neuralgic pain
+occurs, if at all, immediately, or almost immediately, on the receipt of
+the injury. One such instance only has come under my own care, but many
+others are recorded. In my case the ulnar nerve was partly cut through,
+with a tolerably sharp bread-knife, not far above the wrist; partial
+anęsthesia of the little and ring fingers was induced, but at the same
+time violent neuralgic pains in the little finger came on, in fits
+recurring several times a day, and lasting about half a minute.
+Treatment was of little apparent effect in promoting a cure; though
+opiates and the local use of chloroform afforded temporary relief. The
+attacks recurred for more than a month, long after the original wound
+had healed soundly; and, for a long time after this, pressure on the
+cicatrix would reproduce the attacks. A slight amount of anęsthesia
+still remained, when I saw the patient more than a year after the
+injury.
+
+(_b_) Complete severance of a nerve-trunk is a sufficiently common
+accident, far more common then is neuralgia produced by such a cause;
+indeed, so marked is this disproportion between the injury and the
+special result, that I have been led to infer that a necessary factor in
+the chain of morbid events must be the existence of some antecedent
+peculiarity in the central origin of the injured nerve. This opinion is
+rendered the more probable because the consecutive neuralgia is in some
+cases situated, not in the injured nerve itself, but in some other nerve
+with which it has central connections. Two such cases are recorded in my
+Lettsomian Lectures, [_Lancet_, 1866], in which the ulnar nerve, and one
+in which the cervico-occipital, were completely divided; in all three
+the resulting neuralgia was developed in the branches of the fifth
+cranial. Here we may suppose that the weak point existed in the central
+nucleus of the fifth; and that the irritation, or rather depression,
+communicated to the whole spinal centres by the wound of a distant
+nerve, first found, on reaching this weak point, the necessary
+conditions for the development of the neuralgic form of pain, which
+therefore would be represented to the mental perception as present in
+the peripheral branches of the fifth nerve. In all the cases which have
+come under my notice, the neuralgia set in at a particular period,
+namely, after complete cicatrization of the wound, and while the
+functions of the branches on the peripheral side of the wound were
+partly, but not completely, restored. The same obstinacy and
+rebelliousness to treatment are observed as in other instances of
+neuralgia from injury.
+
+One of the cases above referred to may here be briefly detailed, as it
+shows very completely the clinical history of such affections. C. B.,
+aged twenty-four, an agricultural laborer, applied for relief in the
+out-patient room of Westminster Hospital, suffering from severe
+neuralgic pains of the forehead and face of the left side. Then pains
+were felt in the course of the supra-orbital, ocular, nasal, and
+supra-trochlear branches, and also in the cheek, appearing, there, to
+radiate from the infra-orbital foramen. They had commenced about three
+weeks previously to the patient's first visit to the hospital, and about
+six weeks after the accident which appeared to have started the whole
+train of symptoms. This was a cutting wound, evidently of considerable
+depth as well as external size, toward the back of the neck, and so
+situated that it must have divided the great occipital nerve of the left
+side: and, from the man's account of the numbness of the parts supplied
+by the nerve which immediately followed the wound, there could be no
+doubt that this had occurred. There was no acute nerve-pain, either
+during the healing of the wound, which was rapid, or subsequently, until
+more than three weeks from the date of the injury; at this time there
+was still a considerable sense of numbness in the skin of the occipital
+and upper cervical region; but there now commenced a series of short
+paroxysms of pain in the forehead of the same side. These at first
+occurred only about twice daily, at regular intervals; the pain was not
+very sharp, and only lasted a minute or two. The attacks rapidly
+increased in frequency and duration, however, and extended their area.
+At the time when I first saw the case the pain was very formidable, it
+recurred with great frequency during the day, but would sometimes leave
+the patient free for several hours together. The site of the wound was
+occupied by a firm cicatrix of about a line in breadth and an inch and a
+quarter in length; pressure on this excited only a vague and slightly
+painful tingling in the part itself, but severely aggravated the
+trigeminal pains, or reproduced them if they happened to be absent. The
+regions supplied by the great occipital nerve were still very
+imperfectly sensitive. This patient gave me a great deal of trouble. He
+continued for many weeks under my care, and I can scarcely flatter
+myself that any of the numerous remedies which I administered
+internally, or applied locally, had any serious effect in checking the
+disorder. The subcutaneous injection of morphia gave some relief, as it
+always does, but this seemed to be perfectly transitory; and, although
+when the patient ceased to attend the hospital he was decidedly better,
+I cannot imagine that there was anything in it except the slow wearing
+out of the neuralgic tendency, very much without reference to the
+administration of any remedies.
+
+The description of neuralgia from injury would be incomplete without
+some special words on a variety of this affection which has only very
+recently been described with that fulness which it deserves. I refer to
+the pains which are produced by gunshot injuries of nerves, received in
+battle, of which no sufficient account had been given until the
+publication of the experience of Messrs. Mitchell, Moorehouse, and Keen,
+in the late American civil war.[3]
+
+From the interesting treatise of the above-named writers it appears that
+not merely is neuralgia of an ordinary type a frequent after-consequence
+of wounds, but that certain special pains are not unfrequently produced.
+In the more ordinary instances, pain is of the darting, or of the aching
+kind; and all writers on military surgery, who have recorded their
+experience of the results of wounds received in battle, have spoken of
+affections of this kind, for the most part singularly severe and
+obstinate, and in not a few recorded instances clinging to the patient
+during the remainder of his life. These pains may at times leave the
+sufferer, but they infallibly recur when from any cause his health is
+depressed, and it is an especially common thing for them to be evoked in
+full severity under the influence of exposure to cold, and particularly
+to damp cold.
+
+But the American writers introduce us to another and more terrible
+neuralgia which is a, fortunately, less frequent result of serious
+injuries to nerves. They speak of it as a burning pain of intense and
+often intolerable severity; they believe that it seldom if ever
+originates at the moment of the injury, but rather at some time during
+the healing process; and it is especially noteworthy that it is
+sometimes felt not in the nerve actually wounded, but in some other
+nerve with which it has connections. After it has lasted a certain time,
+an exquisite tenderness of the skin is developed, and a peculiar
+physical change of skin-tissue occurs; it becomes thin, smooth, and
+glossy. It is a remarkable fact that these burning pains which are so
+definitely linked with a nutrition-change of skin are never felt in the
+trunk, and rarely in the arm or thigh, not often in the forearm or leg,
+but commonly in the foot or hand; and the nutrition changes of the skin
+are generally observed on the palm of the hand, the palmar surface of
+the fingers, or the dorsum of the foot; rarely on the sole of the foot
+or the back of the hand. It is very interesting to remark that these
+skin-lesions correspond very nearly, not only to those observed in the
+cases of nerve-injury reported by Mr. Paget,[4] in which actual
+neuralgia was present (though the kind of pain is not exactly
+specified), but also very nearly with the nutritive changes observed by
+Mr. Jonathan Hutchinson in a number of cases of surgical injuries of
+nerves.[5] The tendency of neuralgic pain accompanied by nutritive
+lesions of the skin and nails to seat itself in the hands and feet will
+be hereafter noted in connection with the subject of the pains of
+locomotor ataxy and of those produced by profound mercurial poisoning.
+And it will be seen in the section on Pathology, that very important
+conclusions are suggested by the coincidence.
+
+Joined with the burning pains, and the altered skin-nutrition, in the
+cases of gunshot injury of nerves which we are considering, there is
+nearly always a marked alteration in the temperature of the parts,
+either in one direction or the other. In the great majority of instances
+of ordinary neuralgia after wounds, this alteration is a very
+considerable reduction of the temperature of the parts supplied by the
+painful nerves; a change which corresponds with what appears in the vast
+majority of all cases of division of sensitive nerves, whether pain be
+set up or not. But, in all examples of the burning pain after injury,
+Messrs. Mitchell, Moorehouse, and Keen found the temperature of the
+painful parts notably elevated.
+
+It would appear that there is no form of neuralgia more dreadful, and
+scarcely any so hopeless, as this burning pain coming on as a sequel to
+severe nerve injuries. It exercises a profoundly depressing effect upon
+the whole nervous tone; the most robust men become timid and broken
+down, and their condition is compared by the American writers to that of
+hysterical women.
+
+There is another peculiar nutritive affection, first recognized as an
+occasional consequence of nerve injuries by Messrs. Mitchell,
+Moorehouse, and Keen, namely, an inflammation of joints, and, although
+we have no concern here with this symptom, it will be referred to
+hereafter as throwing interesting light on certain questions of
+pathology. Certain lesions of secretion will also be specially referred
+to under the heading of Diagnosis.
+
+II. NEURALGIAS OF INTRA-NERVOUS ORIGIN.--As regards the constitutional
+conditions with which the several varieties of neuralgia that arise
+independently of external violence, or disease of extra-nervous tissues,
+are respectively allied, the following preliminary subdivisions may be
+made:
+
+    1. Neuralgias of malarious origin.
+    2. Neuralgias of the period of bodily development.
+    3. Neuralgias of the middle period of life.
+    4. Neuralgias of the period of bodily decay.
+    5. Neuralgias associated with anęmia and mal-nutrition.
+
+1. _Neuralgias of malarious origin_ were formerly far more prevalent
+than they are at present, within the sphere of the English practitioner
+of medicine; with the general decline of malarial fevers, consequent on
+improved drainage and cultivation of lands, they have become constantly
+more scarce. The districts in which they still are found to prevail with
+any frequency are carefully specified in the interesting report of Dr.
+Whitley to the Medical Officer of the Privy Council, in the Blue-Book
+for 1863.
+
+Of course, however, there are a considerable number of persons
+continually returning to England from countries where malarious diseases
+are common; and these often bear about with them the effects of paludal
+poisoning which occasionally exhibits itself in the form of neuralgia.
+Till very lately, however, I had not happened to come across such cases,
+although at one time and another I have seen and treated a good many
+persons returned from India and Africa, whence I judge that neuralgia
+with this special history is less common than many seem to think. In
+former times, on the contrary, malarioid neuralgias were so common that
+they forced themselves on the notice of every practitioner. The term
+"brow-ague," to this day applied by many medical men to every variety of
+supra-orbital neuralgia, is a relic of the older experience on this
+point, as is also the very common mistake of expecting all neuralgic
+affections to present a distinctly rhythmic recurrence of symptoms.
+
+In the year 1864 I published the statement[6] that, "in a fair
+sprinkling" of the cases of neuralgia which present themselves in
+hospital out-patient rooms, ague-poisoning may be suspected; but I was
+then speaking rather from hearsay than from my own experience, which, in
+fact, had yielded no clear cases of this sort of neuralgia, and was till
+just recently unable to reckon up more than two undoubted and one
+doubtful case of the affection, in all of which the fifth cranial nerve
+was unattacked. The periodicity in one of the genuine cases was regular
+tertian, in the other regular quotidian. A semi-algide condition always
+ushered in the attacks; but this was gradually exchanged, as the pain
+continued, for a condition in which the pulse was rapid and locomotive,
+but compressible, and the strength was further depressed. In both these
+cases there was unilateral flushing of the face, and congestion of the
+conjunctiva, to a slight degree, during the attack of pain. The pain
+became duller and more diffused contemporaneously with the lowering of
+arterial pressure; and, after the disappearance of active pain, moderate
+tenderness over a considerable tract round the course of the painful
+nerves remain for some time. There was no distinct development of
+painful points in the situations described by Valleix; but it should be
+remarked that the cases were rapidly cured with quinine, which very
+probably accounts for this circumstance.
+
+Till lately I had not witnessed neuralgia as an after-consequence of
+tropical malaria-poisoning, although I have had many cases of other
+diseases, the relics of hot climates, under my care; but within the last
+year I have seen a case of extremely severe intercostal neuralgia of a
+perfectly periodic type occurring in a patient whose constitution had
+been thoroughly saturated with tropical marsh poison, and in whom the
+spleen was still much enlarged. The neuralgia was so terrible, and
+accompanied by such severe algide phenomena at the beginning of the
+attacks, and such a sense of throbbing as the pain developed, as to lead
+to serious suspicions of hepatic abscess, for the moment; but the course
+of events soon corrected this idea.
+
+2. _Neuralgias of the Period of Bodily Development._--By the "period of
+bodily development" is here understood the whole time from birth up to
+the twenty-fifth year, or there-abouts. This is the period during which
+the organs of vegetative and of the lower animal life are growing and
+consolidating. The central nervous system is more slow in reaching its
+fullest development, and the brain especially is many years later in
+acquiring its maximum of organic consistency and functional power.
+
+That portion of the period of development which precedes puberty is
+comparatively free from neuralgic affections. At any rate, it is rare to
+meet in young children with well-defined unilateral neuralgia, except
+from some very special cause, such as the pressure of tumors, etc. Such
+neuralgias as do occur are commonly bilateral, and are connected either
+with the fifth cranial or the occipital nerves.
+
+I must here mention an affection which was quite unknown to my
+experience, but was brought under my notice by the late Dr. Hillier, who
+kindly called my attention to the notes of two cases which were
+published in his interesting work on "Diseases of Children." The cases
+are those of two female children, aged nine and eleven respectively, in
+whom the principal symptom was violent and paroxysmal neuralgic
+headache. In both of these children the existence of cerebral tubercle
+was suspected, but this proved to be a mistake. In both there were
+intolerance of light, vomiting, tonic contraction of the muscles of the
+neck, and occasional double vision; but no impairment of intelligence,
+no amaurosis, and no paralysis or rigidity of the limbs. Each of these
+children died rather suddenly, after a violent paroxysm of pain. The
+main, indeed almost the only characteristic post-mortem change was a
+marked loss of consistence of tissue, in one case in the pons varolii,
+in the other in the pons, the medulla oblongata, and the cerebellum.
+These cases are of the highest possible interest, as are also several
+other instances of headache in children recorded by Dr. Hillier; notably
+one in which severe paroxysmal pains were attended with general
+impairment of brain-power, and, on the occurrence of death from
+exhaustion, the autopsy revealed an amount of degeneration in the
+cerebral arteries (as also in the general arterial system) which was
+astonishing, considering that the child was only ten and a half years
+old. This case, the full significance and interest of which will be
+better seen when we come to discuss the subject of pathology, is an
+example of physical changes in the nervous system, which are usually
+delayed to an advanced period of life, occurring altogether prematurely,
+and bringing with them a kind of neuralgic pain which is far more common
+in the decline than in morning of life. It will be seen presently that
+functional derangements may be in like manner precociously induced, with
+the parallel effect of inducing such pains as are ordinarily the product
+of a later epoch.
+
+From the moment that puberty arrives all is changed in the status of the
+nervous system. In the stir and tumult which pervade the organism, and
+especially in the enormous diversion of its nutritive and formative
+energy to the evolution of the generative organs and the correlative
+sexual instincts, the delicate apparatus of the nervous system is apt to
+be overwhelmed, or left behind, in the race of development. Under these
+circumstances, the tendency to neuralgic affections rapidly increases.
+It will, however, be seen later that there is a great preponderance of
+particular varieties of the disease during this time. This period is
+above all things fruitful in trigeminal neuralgias, especially migraine.
+
+There remains to be noticed the fact that sexual precocity sometimes
+very much anticipates the peculiar characteristics of the period after
+puberty. It is well known that in too many instances children are led,
+by the almost irresistible influence of bad example, to indulge in
+thoughts and practices which are thoroughly unchildish, and which
+exercise a powerfully disturbing influence upon the nervous system. A
+child before the age of puberty ought to be distinguished (if moderately
+healthy in other respects) by the absence of any tendency to dwell upon
+his own bodily health. Under the influence of precocious sexual
+irritation he becomes hypochondriacal and self-centred, and often
+suffers, not merely from fanciful fears and fanciful pains, but from
+actual neuralgia, which is sometimes severe. The attacks of migraine
+which are a frequent affection of delicate children whose puberty
+occurs at the normal time, are a much earlier torment with children who
+have early become addicted to bad practices. It is an anticipatory
+effect upon the constitution, strictly analogous to the production of
+the so-called "hysteria" in little girls under similar circumstances;
+and I suppose there is no physician who has not once or twice, at least,
+met with cases of the latter kind. The existence of any severe neuralgic
+affection in a young child, if it cannot be traced to tuburcle or other
+recognizable or organic brain-disease is _prima-facie_ ground for
+suspicion of precocious sexual irritation; though, as Dr. Hillier's
+cases show, it is occasionally produced otherwise. Usually, there are
+other features which assist in the discovery of precocious sexualism,
+when it exists; there is a morbid tendency to solitary moping, and a
+moral change in which untruthfulness is conspicuous.
+
+3. _Neuralgias of the Middle Period of Life._--By this period is meant
+the time included between the twenty-fifth and about the fortieth or
+forty-fifth year. It is the time of life during which the individual is
+subjected to the most serious pressure from external influences. The
+men, if poor, are engaged in the absorbing struggle for existence, and
+for the maintenance of their families; or, if rich and idle, are
+immersed in dissipation, or haunted by the mental disgust which is
+generated by _ennui_. The women are going through the exhausting process
+of child-bearing, and supporting the numerous cares of a poor household,
+in some cases; or are devoured with anxiety for a certain position in
+fashionable society for themselves and their children; or again, they
+are idle and heart-weary, or condemned to an unnatural celibacy. Very
+often they are both idle and anxious.
+
+It must not be supposed that there is a sharp line of demarcation
+between this period and the last; nevertheless, there are certain
+well-marked differences, both in their general tendencies, and as
+regards the local varieties which are commonest in each. We shall
+discuss the latter point farther on. At present, it is interesting to
+remark on the general freedom of the busy middle period of life from
+first attacks of neuralgia. A person who has had neuralgia previously
+may, and very likely will, during this epoch, be subject to recurrence
+of the old affection under stress of exhaustion of any kind. But it is
+very rare, in my experience, for busy house-mothers or fathers of
+families to get first attacks of neuralgia during this period of life.
+It is not the way in which a still vigorous man's nervous system breaks
+down, if it breaks down at all. Men frequently do break down, of course,
+at an age when their tissues generally are sound enough, and there is no
+reason, except on the side of their nervous system, why they should not
+remain in vigorous health for years. But it is greatly more common for
+the nervous collapse to take the form of insanity, or hypochondriasis,
+or paralysis, then that of neuralgia. If a man has escaped the latter
+disease during the period when the growth of his tissues was active, it
+is not very often that he falls a victim to it till he begins,
+physiologically speaking, to grow old.
+
+4. _Neuralgias of Declining Bodily Vigor._--The period here referred to
+is that which commences with the first indications of general physical
+decay, of which the earliest which we can recognize (in persons who are
+not cut off by special diseases) is perhaps the tendency to atheromatous
+change in the arteries. The first development of this change varies very
+considerably in date; but whenever it occurs it is a plain warning that
+a new set of vital conditions has arisen, and especially notable is its
+connection with the characters of the neuralgic affections which take
+their rise after its commencement. The period of declining life is
+pre-eminently the time for severe and intractable neuralgias.
+Comparatively few patients are ever permanently cured who are first
+attacked with neuralgia after they have entered upon what may be termed
+the "degenerative" period of existence. I mentioned the existence of
+commencing arterial degeneration as the special and most trustworthy
+sign of the initiation of bodily decay; but it is needless to say that
+this change is often not to be detected in its earliest stage. Something
+has been done of late years, however, to render its diagnosis more easy.
+Not to dwell upon the phenomenon of the arcus senilis, which though of a
+certain value is confessedly only very partially reliable, we may
+mention the sphygmographic character of the pulse as possessing a real
+value in deciding the physiological status of the arterial system. There
+is a well-known form of pulse-curve, square-headed, with marked
+lengthening of the first or systolic portion of the wave, and with an
+almost total absence of dicrotism, even when the circulation is rapid,
+which will often seem to assure us that atheromatous change of the
+arterial system has commenced, even when the physical characters of
+inelastic artery are not to be recognized with the finger in any of the
+superficial vessels by the touch of the finger. Indeed, the latter test
+is in all cases far less reliable than the sphygmographic trace, except
+when the arterial change has proceeded to a very marked degree of
+development.
+
+To a certain extent, the presence or absence of gray hair is of value in
+deciding whether physiological degeneration has begun. Like the arcus
+senilis, however, this is only reliable when joined with other
+indications, for it may be a purely local and separate change, having
+nothing to do with the general vital status of the body.
+
+5. _Neuralgias which are immediately excited by Anęmia or
+Mal-nutrition._--Of the neuralgic affections which can be reckoned in
+this class, the sole characteristic worthy of note is the circumstances
+in which they arise. It would seem that anęmia and mal-nutrition simply
+aggravate the tendency of existing weak portions of the nervous system
+to be affected with pain; just as they notoriously do aggravate lurking
+tendencies to convulsion and spasm. It is very common, for instance, for
+women to suffer severely from migraine, and other forms of neuralgia,
+after a confinement in which they have lost much blood. According to my
+own experience, however, those patients are generally, if not
+invariably, found to have previously suffered more or less severe
+neuralgic pain, at some time or other in their history, in the same
+nerves which now, under the depressing influence of hęmorrhage, have
+become neuralgic. One of the very worst cases of clavus which I ever saw
+happened after hęmorrhage in labor; the pain was so severe and
+prostrating that it appeared likely the patient would become insane. I
+discovered, on inquiry, that this woman had been liable for many years
+to headache affecting precisely the same region, on the occasion of any
+unusual fatigue or excitement.
+
+There is, however, one variety of neuralgia from mal-nutrition which
+deserves special consideration, viz., that which is occasionally
+produced as an after-effect of mercurial salivation. I have only seen
+one instance of this affection, but several are recorded. [Such, at
+least, is my impression, but I have not been able to find the reports of
+them.] My patient was a woman of somewhat advanced years when she first
+came under my notice, but her malady had (though with long
+intermissions) existed ever since she was a young girl in service. At
+that early date she was severely salivated by some energetic but
+misguided practitioner, for an affection which was called pleurisy, but
+(according to her description) might well have been only pleurodynia, to
+which servant girls are so very subject. At any rate, the consequences
+of the medication were most disastrous. Not only did she then and there
+lose every tooth in her head and suffer extensive exfoliations from the
+maxillę, but after this process was over she began to suffer frightfully
+from neuralgic pains in both arms and in both legs. Tonic medicines and
+a change to sea-air brought about a tardy and temporary cure; but from
+that moment her nervous system never recovered itself. Whenever she took
+cold, or was over-fatigued, or depressed from any bodily or mental
+cause, she was certain to experience a recurrence of the pains. At the
+time of her application to me she was suffering from an attack of more
+than ordinary severity, and which had lasted a long time without showing
+any signs of yielding. She apparently could not find words to express
+the acuteness of her sufferings. All along the course of the sciatic
+nerve in the thigh, all down the course of the middle cutaneous and long
+saphenous branches of the anterior crural, in the musculo-spiral,
+radial, and the course of the ulnar nerves, and also, in a more
+generalized way, in the gastrocnemii, in the soles of the feet, and in
+the palms of the hands, the pains were of a tearing character, which she
+described as resembling "iron teeth" tearing the flesh. The pains
+recurred many times daily; her life was a perfect burden to her, and
+always had been during these attacks. This patient was under my
+observation, on various occasions, during several years, and I
+established the fact that cod-liver oil always did very great good. But
+it was evident that nothing would remove the tendency to the recurrence
+of the pains. I should mention, as additional proof of the extent to
+which the mercurial poison had shattered the nervous system of this
+woman, that she had violent muscular tremors at the time of her first
+attack, and on several subsequent occasions. A more completely ruined
+life was never seen; the poor woman had been on the highway to promotion
+in the service of a nobleman when she was mercurialized, but her whole
+prospects were blighted by the serious danger to her health which was
+caused by the preposterous antiphlogisticism of her medical attendant.
+
+I do not know that the poisonous action of any other metallic poison
+than mercury has been distinctly shown to produce neuralgic pains of
+superficial nerves. The action of lead is well known to produce colic, a
+disease which will be specially dwelt on elsewhere. And undoubtedly a
+certain amount of aching pain sometimes attends certain stages of
+lead-palsy of the extensor muscles of the forearm. But I know of no
+facts pointing to a true saturnine neuralgia. And the chronic poisonous
+effects of arsenic on the nervous system seem to produce sensory
+paralysis, rather than pain.
+
+We come now to the consideration of the local varieties of neuralgia.
+The primary subdivision of them may be made as follows:
+
+I. Superficial Neuralgias. II. Visceral Neuralgias.
+
+I. SUPERFICIAL NEURALGIAS.
+
+Of superficial neuralgias a further classification may be made:
+
+    (_a_) Neuralgia of the fifth (trigeminal, or trifacial).
+    (_b_) Cervico-occipital neuralgia.
+    (_c_) Cervico-brachial neuralgia.
+    (_d_) Intercostal neuralgia.
+    (_e_) Lumbo-abdominal neuralgia.
+    (_f_) Crural neuralgia.
+    (_g_) Sciatic neuralgia.
+
+This arrangement is that of Valleix, and appears to me substantially
+correct.
+
+(_a_) _Neuralgia of the Fifth._--The most important group of neuralgias
+are those of the fifth cranial nerve.
+
+Neuralgia of the fifth nerve always exhibits itself in the especial
+violence in certain foci, which Valleix was the first to define with
+accuracy. These foci are always in points where the nerve becomes more
+superficial, either in turning out of a bony canal, or in penetrating
+fascię. In the ophthalmic division of the nerve the following possible
+foci are noticeable: (1) The supra-orbital, at the notch of that name,
+or a little higher, in the course of the frontal nerve; (2) the
+palpebral, in the upper eyelid; (3) the nasal, at the point of emergence
+of the long nasal branch, at the junction of the nasal bone with the
+cartilage; (4) the ocular, a somewhat indefinite focus within the globe
+of the eye; (5) the trochlear, at the inner angle of the orbit.
+
+In the superior maxillary division the following foci may be found: (1)
+The infra-orbital, corresponding to the emergence of the nerve of that
+name from its bony canal; (2) the malar, on the most prominent portion
+of the malar bone; (3) a vague and indeterminate focus, somewhere on the
+line of the gums of the upper jaw; (4) the superior labial, a vague and
+not often important focus; (5) the palatine point, rarely observed, but
+occasionally the seat of intolerable pain.
+
+In the inferior maxillary division the foci are: (1) The temporal, a
+point on the auriculo-temporal branch, a little in front of the ear; (2)
+the inferior dental point, opposite the emergence of the nerve of that
+name; (3) the lingual point, not a common one, on the side of the
+tongue; (4) the inferior labial point, only rarely met with.
+
+Besides these foci in relation with distinct branches of the trigeminus,
+there is one of especial frequency which corresponds to the inosculation
+of various branches. This is the parietal point, situated a little above
+the parietal eminence. It is small in size--the point of the little
+finger would cover it. It is the commonest focus of all.
+
+Neuralgia may attack any one, or all, of the three divisions of the
+nerve; the latter event is comparatively rare. Valleix, indeed, holds a
+different opinion; but this seems to me to arise from the fact that his
+definition of neuralgia was too narrow to include a large number of the
+milder cases of neuralgia, which are, nevertheless I believe, decidedly
+of the same essential character with the severer affections. The most
+frequent occurrence is the limitation of the pain to the ophthalmic
+division, and incomparably the most frequent foci of pain are the
+supra-orbital and the parietal.
+
+The most common variety of trigeminal neuralgia is migraine, or
+sick-headache, as it is often called. This is an affection which is
+entirely independent of digestive disturbances, in its primary origin,
+though it may be aggravated by their occurrence. It almost always first
+attacks individuals at some time during the period of bodily
+development. Under the influences proper to this vital epoch, and often
+of a further debility produced by a premature straining of the mental
+powers, the patient begins to suffer headache after any unusual fatigue
+or excitement, sometimes without any distinct cause of this kind. The
+unilateral character of this pain is not always detected at first; but,
+as the attacks increase in frequency and severity, it becomes obvious
+that the pain is limited to the supra-orbital and its twigs, with
+sometimes also the ocular branches. In rare cases, as in all forms of
+neuralgia, the nerves of both sides may be affected; I have already
+observed that this seems to be relatively more common in young children.
+If the pain lasts for any considerable length of time, nausea, and at
+length vomiting, are induced. This is followed at the moment by an
+increase in the severity of the pain, apparently from the shock of the
+mechanical effect; but from this point the violence of the affection
+begins to subside, and the patient usually falls asleep. The history of
+the attacks negatives the idea that the vomiting is ordinarily remedial.
+This symptom merely indicates the lowest point of nervous depression;
+but it may happen that a quantity of food which has been injudiciously
+taken, lying as it does undigested in the stomach, may of itself greatly
+aggravate the neuralgia, by irritation transmitted to the medulla
+oblongata. In such a case vomiting may directly relieve the nerve-pain.
+When the patient awakes from sleep, the active pain is gone. But it is a
+common occurrence--indeed it always happens when the neuralgia has
+lasted a long time--that a tender condition of the superficial parts
+remains for some hours, perhaps for a day or two. This tenderness is
+usually somewhat diffused, and not limited with accuracy to the foci of
+greatest pain during the attacks.
+
+Sick headache is not uncommonly ushered in by sighings, yawning, and
+shuddering--symptoms which remind us of the prodromata of certain graver
+neuroses, to which, as we shall hereafter see, it is probably related by
+hereditary descent. In its severer forms, migraine is a terrible
+infliction; the pain gradually spreads to every twig of the ophthalmic
+division; the eye of the affected side is deeply bloodshot, and streams
+with tears; the eyelid droops, or jerks convulsively; the sight is
+clouded, or even fails almost altogether for the time, and the darts of
+agony which shoot up to the vertex seem as if the head were being split
+down with an axe. The patient cannot bear the least glimmer of light,
+nor the least motion, but lies quite helpless, intensely chilly and
+depressed, the pulse at first slow, small and wiry, afterward more rapid
+and larger, but very compressible. The feet are generally actually, as
+well as subjectively, cold. Very often, toward the end of the attack,
+there is a large excretion of pale, limpid urine.
+
+Another variety of trigeminal neuralgia which infests the period of
+bodily development is that known as clavus hystericus: clavus, from the
+fact that the pain is at once severe, and limited to one or two small
+definite points, as if a nail or nails were being driven into the skull.
+These points correspond either to the supra-orbital or the parietal, or,
+as often happens, to both at once. But for the greater limitation of the
+area of pain in clavus, that affection would have little to distinguish
+it from migraine, for the former is also accompanied with nausea and
+vomiting when the pain continues long enough; and in both instances it
+is obvious that there is a reflex irritation propagated from the painful
+nerve. The adjective hystericus is an improper and inadequate definition
+of the circumstances under which clavus arises. The truth is, that the
+subjects of it are chiefly females who are passing through the trying
+period of bodily development; but there is no evidence to show that
+uterine disorders give any special bias toward this complaint. Both
+migraine and clavus are often met with in persons who have long passed
+their youth; but their first attacks have nearly always occurred during
+the period of development.
+
+One circumstance in connection with well-marked clavus appears worth
+noting, as somewhat differentiating it from migraine. It is, I think,
+decidedly more frequently the immediate consequence of anęmia than they;
+but it does not appear, from my experience, that the chlorotic form of
+anęmia is any more provocative of it than is anęmia from any other
+cause. Some of the worst cases of clavus, probably, that have ever been
+seen were developed in the old days of phlebotomy. It was then very
+common for a delicate girl, on complaint of some stitch of neuralgia or
+muscular pain in the side, to be immediately bled to a large extent,
+with the idea of checking an imaginary commencing pleurisy. The
+treatment, so far from curing the pain and the dyspepsia (which it
+produced), often aggravated them; whereupon the signs of inflammation
+were thought to be still more manifest, and more blood was taken. Under
+such circumstances the most complete anęmia was developed, and very
+often the patient became a martyr to clavus in its severest forms. One
+does not now very frequently meet with the victims of such mistaken
+practice; but I have seen one [since writing this I have seen another
+case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus
+produced by loss of blood (in a subject who was doubtless predisposed to
+neuralgic affections, to judge from his family history). The case was
+that of a boy who accidentally divided his radial.
+
+The middle period of life is not, according to my experience, fruitful
+in first attacks of trigeminal neuralgia. But, when the neuralgic
+tendency has once declared itself, there are many circumstances of
+middle adult life which tend to recall it. Over-exertion of the mind is
+one of the most frequent causes, especially when this is accompanied by
+anxiety and worry; indeed, the latter has a worse influence than the
+former. In women, the exhaustion of hęmorrhageal parturition, or of
+menorrhagia, and also the depression produced by over-suckling, are
+frequent causes of the recurrence of a migraine or clavus to which the
+patient had been subject when young. The middle period of life is very
+obnoxious to severe mental shocks, which are more injurious than in
+youth, because of the diminished elasticity of mind which now exists;
+and the same may be said of the influence of severe bodily accident of a
+kind to inflict damage on the central nervous system. Special mention
+ought to be made, in the case of women, of the disturbing influence of
+the series of changes which close the middle portion of their life,
+viz., the involution of the sexual organs. It would seem as if every
+evil impression which has ever been made on the nervous system hastens
+to revive, with all its disastrous effects, at this crisis. Latent
+tendencies to facial neuralgia are particularly apt to reassert their
+existence, and they are usually accompanied and aggravated by a tendency
+to vaso-motor disturbance, which not unfrequently seems to be the most
+distressing part of the malady. I have several times been consulted by
+women undergoing the "change," whose chief complaint was of disagreeable
+flushings and chills, especially of the face; and, on inquiring further,
+one has found that they were suffering from severe facial neuralgia,
+which, however, alarmed and distressed them less than did the vaso-motor
+disturbance, and the giddiness, etc., which were an evident consequence
+of it.
+
+It is, however, the final or degenerative period of life which produces
+the most formidable varieties of facial neuralgia. Neuralgia of the
+fifth, which have previously attacked an individual, may recur at this
+time of life without any special character, except a certain increase of
+severity and obstinacy. But trigeminal neuralgias, which now appear for
+the first time, are usually intensely severe, and nearly or quite
+incurable. These cases correspond with the affection named by Trousseau
+tic epileptiforme, and it is of them, doubtless, that Romberg is
+speaking, when he says that the true neuralgias of the fifth rarely
+occur before the fortieth year of life. These neuralgias are
+distinguished by the intense severity of the pain, the lightning-like
+suddenness of its onset, and the almost total impossibility of effecting
+more than a temporary palliation of the symptoms. But they are also
+distinguished by another circumstance which too often escapes attention,
+namely, they are almost invariably connected with a strong family taint
+of insanity, and very often with strong melancholy and suicidal
+tendencies in the patient himself, which do not depend on, and are not
+commensurate with, the severity of the pain which he suffers. It may
+seem a strong view to take, but I must say that I regard a
+well-developed and typical neuralgia, of the type we are now speaking
+of, as an affection in which the mental centres are almost as deeply
+involved as in the fifth nerve itself; though, whether this is an
+original part of the disease, or a mere reflex effect of the affection
+of the trigeminal nerve, I am not prepared to say. Other reflex
+affections are common enough in this kind of facial neuralgia, and
+especially spasmodic contractions of the facial muscles, which, indeed,
+often form one of the most striking features of the malady, the attacks
+of pain being accompanied by hideous involuntary grimaces. Even in the
+earlier stages of the disease there is usually some degree of the same
+thing, as, for instance, spasmodic winking. In the great majority of
+cases, after a little time, exquisitely tender points are formed in the
+chief foci of pain; in the intervals between the spasms the least
+pressure on these points is sufficient to cause agony, and a mere breath
+of wind impinging on them will often reproduce the spasm. Yet, in the
+height of the acute paroxysm itself, the patient will often frantically
+rub these very parts in the vain attempt to produce ease; and it has
+often been noticed that such friction has completely rubbed off the hair
+or whisker on the affected side: this happens the more easily, because
+the neuralgic affection itself impairs the nutrition of the hair and
+makes it more brittle, as we shall have occasion to show more fully
+hereafter. The general appearance of a confirmed neuralgic of the type
+now described is very distressing, and the history of his case fully
+corresponds to it. He is moody and depressed, he dreads the least
+movement, and the least current of air; he hardly dares masticate food
+at all, more especially if the inferior maxillary division of the nerve
+be implicated (as is generally the case sooner or later), for this
+movement re-excites the pain with great violence. Nutrition is very
+commonly kept up by slops, and is thus very insufficiently maintained:
+this failure of nutrition is itself a decidedly powerful influence in
+aggravating the disease. And there is a still further calamity which is
+not unlikely to occur. The patient may fly to the stupefaction of drink
+as a relief to his sufferings, and, if he has once experienced the
+temporary comfort of drunken anęsthesia, is excessively likely to repeat
+the experiment. But this is another and one of the most fatally certain
+methods of hastening degeneration of nerve-centres, and the ultimate
+effect, therefore, is disastrous in every way.
+
+Although the neuralgias of the degenerative period are thus fatally
+progressive, on the whole, there are some curious occasional anomalies.
+Many cases are recorded, and I have myself seen such, in which the
+attacks of pain, after reaching a very considerable degree of intensity,
+have ceased for many months, whether under the influence of remedies or
+not it is difficult to say with certainty, but probably far more from
+independent causes. Whatever may be the reason of these sudden arrests,
+however, certain it is that they are very seldom permanent, the pain
+returning sooner or later, like an inexorable fate.
+
+(_b_) _Cervico-occipital Neuralgia._--As Valleix has remarked, there are
+several nerves (in fact, the posterior branches of all the first four
+spinal pairs) which are more or less frequently the seat of this
+affection. But among them all there is none comparable to the great
+occipital, which arises from the second spinal pair, for the frequency
+and importance of its neuralgic affections. This nerve sends branches to
+the whole occipital and the posterior parietal region. On the other
+hand, the second and third spinal nerves help to make up the superficial
+cervical branch of the cervical plexus which is distributed to the
+triangle between the jaw, the median line of the neck, and the edge of
+the sterno-mastoid, and those to the lower part of the cheek. Then there
+is the auricular branch, which starts from the same two pairs, and
+supplies the face, the parotid region, and the back of the external ear.
+Then the small occipital, distributed to the ear and to the occiput.
+And, finally, superficial descending branches of the plexus. These,
+altogether, are the nerves which at various points, where they become
+more superficial, form the foci of cervico-occipital neuralgia.
+
+The most typical example of this form of neuralgia which has fallen
+under my notice occurred (after exposure to cold wind) in a lady about
+sixty years of age, who had all her life been subject to neuralgic
+headache approaching the type of migraine, and who came of a family in
+which insanity, apoplexy, and other grave neuroses, had been frequent.
+The pain centred very decidedly in a focus corresponding to the
+occipital triangle of the neck; it recurred at irregular intervals, and
+in very severe paroxysms, lasting about a minute. It was interesting to
+follow the history of this case in one respect. It afforded a clear
+illustration of the manner in which local tenderness is developed; for
+during the first three or four days the patient, so far from complaining
+that the painful part was tender on pressure, experienced decided relief
+from pressure, although she experienced none from mere rest, however
+carefully the neck might be supported. But in the course of a few days
+an intensely painful spot developed itself in the occipital triangle,
+and the back of the ear became excessively tender. All manner of
+remedies had been tried in this case, without the slightest success and
+especially there was a large amount of speculative medication, on the
+theory of the probably "rheumatic" or "gouty" nature of the affection.
+Nothing was doing the least good to the pain, and meantime the old
+lady's digestion and general health and spirits were suffering very
+severely. Blistering was now suggested, and the affection yielded at
+once. The relief afforded must have been very complete, to judge by the
+warm gratitude which the patient expressed. The subsequent history of
+this patient illustrates several points which will engage our attention
+under the section of Pathology. It may be just mentioned here, that she
+suffered, twelve months later, from a hemiplegic attack of paralysis.
+
+The tendency of cervico-occipital neuralgias is to spread toward the
+lower portions of the face, as observed by Valleix; in this case they
+become, sometimes, undistinguishable from neuralgias of the third
+division of the trigeminus. In the early stages of the disease, if the
+physician had been lucky enough to witness them, the true place of the
+origin of the pain would have been easily recognizable; at a later date
+it sometimes needs great care, and a very strict interrogation of the
+patient, to discover the true history of the disease. Sometimes, even, a
+cervico-occipital neuralgia which spreads in this way causes great
+irritation and swelling of the submaxillary and cervical glands; and I
+have known a case of this kind mistaken for commencing glandular
+abscess. The pain and tension were so great in this case, and the
+constitutional disturbance was so considerable, that the presence of
+deep-seated pus was strongly suspected, and the propriety of an incision
+(which would have been a hazardous proceeding) was seriously canvassed.
+
+Experience is too limited, to judge by what I have personally seen, and
+the recorded cases with which I am acquainted, to enable us to say
+anything with confidence of the conditions, as to age and general
+nutrition of the body, which specially favor the occurrence of
+cervico-occipital neuralgia. Apparently, however, there is much reason
+for thinking that the immediately exciting cause of it is most
+frequently external cold. I have known it produced several times in the
+same person, by sitting in a draught which blew strongly on the back of
+the neck. And I am inclined to think that it is seldom the first form of
+neuralgia which attacks a patient, but usually occurs in those who have
+previously suffered from neuralgic pains either of the trigeminus or of
+some other superficial nerve. I have known it once to occur in a person,
+thus predisposed to neuralgic affections, in consequence of reflex
+irritation from a carious tooth, as was proved by its cessation on the
+extraction of the latter, although there was no facial pain.
+
+(_c_) _Cervico-brachial Neuralgia._--This group includes all the
+neuralgias which occur in nerves originating from the brachial plexus,
+or from the posterior branches of the four lower cervical nerves. The
+most important characteristic of the neuralgias of the upper extremity
+is the frequency, indeed almost constancy, with which they invade,
+simultaneously or successively, several of the nerves which are derived
+from the lower cervical pairs. The neuralgic affections of the small
+posterior branches (distributed to the skin of the lower and back part
+of the neck) are comparatively of small importance. But the
+"solidarite," which Valleix so well remarked, between the various
+branches of the brachial plexus, causes the neuralgias of the shoulder,
+arm, forearm, and hand to be extremely troublesome and severe, owing to
+the numerous foci of pain which usually exist. Perhaps Valleix's
+description of these foci is somewhat over-fanciful and minute; but the
+following among them which he mentions I have repeatedly identified; (1)
+An axillary point, corresponding to the brachial plexus itself; (2) a
+scapular point, corresponding to the angle of the scapula. (It is
+difficult to identify the peccant nerve here; the one to which it
+apparently corresponds, and to which Valleix refers it, is the
+subscapular; but we are accustomed to think of this as a motor nerve.
+Still, it is certain that pressure on a painful point existing here will
+often cause acute pain in the nerves of the arm and forearm.); (3) A
+shoulder point, which corresponds to the emergence, through the deltoid
+muscle, of the cutaneous filets of the circumflex; (4) a median-cephalic
+point, at the bend of the elbow, where a branch of the musculo-cutaneous
+nerve lies immediately behind the median-cephalic vein; (5) an external
+humeral point, about three inches above the elbow, on the outer side,
+corresponding to the emergence of the cutaneous branches which the
+musculo-spiral nerve gives off as it lies in the groove of the humerus;
+(6) a superior ulnar point, corresponding to the course of the ulnar
+nerve between the olecranon and the epitrochlea; (7) an inferior ulnar
+point, where the ulnar nerve passes in front of the annular ligament of
+the wrist; (8) a radial point, marking the place where the radial nerve
+becomes superficial, at the lower and external aspect of the forearm.
+Besides these foci, there are sometimes, but more rarely, painful points
+developed by the side of the lower cervical vertebrę, corresponding to
+the posterior branches of the lower cervical pairs.
+
+The most common seat of cervico-brachial neuralgia has been, in my
+experience, the ulnar nerve, the superior and inferior points above
+mentioned being the foci of greatest intensity; an axillary point has
+also been developed in one or two cases which I have seen. Rarely,
+however, does the neuralgia remain limited to the ulnar nerve; in the
+majority of cases it soon spreads to other nerves which emanate from the
+brachial plexus. A very common seat of neuralgia is also the shoulder,
+the affected nerves being the cutaneous branches of the circumflex. I am
+inclined to think, also, that affections of the musculo-spiral, and of
+the radial near the wrist, are rather common, and have found them very
+obstinate and difficult to deal with. One case has recently been under
+my care in which the foci of greatest intensity of the pain were an
+external humeral and a radial point; but besides these there was an
+exquisitely painful scapular point. In another case the pain commenced
+in an external humeral and a radial point, but subsequently the shoulder
+branches of the circumflex became involved. A most plentiful crop of
+herpes was an intercurrent phenomenon in this case, or rather, was
+plainly dependent on the same cause which produced the neuralgia.
+
+Median cephalic neuralgia is an affection which used to be comparatively
+common in the days when phlebotomy was in fashion, the nerves being
+occasionally wounded in the operation. I have only seen it in connection
+with this cause, that is to say, as an independent affection. One such
+case has been under my care. But a slight degree of it is not uncommon,
+as a secondary symptom, in neuralgia affecting other nerves. The
+traumatic form is excessively obstinate and intractable.
+
+In the neuralgias of the arm we begin to recognize the etiological
+characteristic which distinguishes most of the neuralgic affections of
+the limbs, namely, the frequency with which they are aggravated, and
+especially with which they are kept up and revived when apparently dying
+out, the muscular movements. In the case above referred to, of neuralgia
+of the subscapular, musculo-spiral (cutaneous branches), and radial, the
+act of playing on the piano for half an hour immediately revived the
+pains, in their fullest force, when convalescence had apparently been
+almost established.
+
+There is a special cause of cervico-brachial neuralgias which is of more
+importance than, till quite lately, has ever been recognized, namely,
+reflex irritation from diseased teeth. The subject of these reflex
+affections from carious teeth has been specially brought forward by Mr.
+James Salter, in a very able and interesting paper in the "Guy's
+Hospital Reports" for 1867; and Mr. Salter informs me that he has been
+surprised by the number of cases of reflex affections, both paralytic
+and neuralgic, of the cervico-brachial nerves, produced by this kind of
+irritation, and that he agrees with me in thinking that a peculiar
+organization or disposition of the spinal centres of these nerves must
+be assumed in order to account for the fact.
+
+The liability of particular nerves in the upper extremity to neuralgia
+from external injuries requires a few words. The nerve which is probably
+most exposed to this is the ulnar. Blows on what is vulgarly called the
+funny-bone are not uncommon exciting causes of neuralgia in predisposed
+persons, and cutting wounds of the ulnar a little above the wrist are
+rather frequent causes. The deltoid branches of the circumflex and the
+humeral cutaneous branches of the musculo-spiral are much exposed to
+bruises and to cutting wounds. So far as I know, it is only when a nerve
+trunk of some size has been wounded that neuralgia is a probable result.
+Wounds of the small nervous branches in the fingers, for instance, are
+very seldom followed by neuralgia. I have no statistics to guide me as
+to the effect of long-continued irritation applied to one of these small
+peripheral branches, but it is probable that that might be more capable
+of inducing neuralgia. As far as my own experience goes, however, it
+would appear that a more common result is convulsion of some kind, from
+reflex irritation of the cord.
+
+(_d_) _Dorso-intercostal Neuralgia._--This is one of the commonest
+varieties of neuralgia, and yet it is very likely to be confounded with
+other affections not neuralgic in their nature. The disorder with which
+it is especially liable to be confounded is myalgia, which will be fully
+described in another chapter, and which, when developed in the region of
+the body to which we are now referring, is commonly spoken of as
+pleurodynia, or lumbago (according as it affects the muscles of the back
+or of the side), or muscular rheumatism. It must be owned that the
+severer forms of this affection can scarcely be distinguished from true
+intercostal neuralgia by anything in the character or situation of the
+pains. It will be seen, hereafter, however, that myalgia has its own
+specific history, which is very characteristic; at present, it is
+sufficient to remember that it is often extremely like neuralgia when
+situated in the dorso-intercostal region.
+
+Dorso-intercostal neuralgia is an affection of certain of the dorsal
+nerves. These nerves divide, immediately after their emergence from the
+intervertebral foramina, into an interior and a posterior branch. The
+latter sends filaments which pierce the muscles to be distributed to the
+skin of the back; the former, which are the intercostal nerves, follow
+the intercostal spaces. Immediately after their commencement they
+communicate with the corresponding ganglia of the sympathetic.
+Proceeding outward, they at first lie between two layers of intercostal
+muscles, and, after giving off branches to the latter, give off their
+large superficial branch. In the case of the seventh, eighth and ninth
+intercostal nerves, which are those most liable to intercostal
+neuralgia, the superficial branch is given off about midway between the
+spine and the sternum. The final point of division, at which superficial
+filets come off, in all the eight lower intercostal nerves, is nearer to
+the sternum; and is progressively nearer to the latter in each
+successive space downward. There are thus, as Valleix observes, three
+points of division: (1) At the intervertebral foramen; (2) midway in the
+intercostal space; (3) near to the sternum. And there are three sets of
+branches (reckoning the posterior division) which respectively make
+their way to the surface near to these points.
+
+In one of its forms, intercostal neuralgia is one of the commonest of
+all neuralgic affections. I refer to the pain beneath the left mamma,
+which women with neuralgic tendencies so often experience, chiefly in
+consequence of over-suckling, but also from exhaustion caused by
+menorrhagia or leucorrhoea, and especially from the concurrence of one
+of the latter affections with excessive lactation. It is especially
+necessary, however, to guard against mistaking for this affection a mere
+myalgic state of the intercostal or pectoral muscles, which often
+arises in similar circumstances with the addition of excessive or too
+long continued exertions of these muscles. "Hysteric" tenderness also
+sometimes bears a considerable resemblance, superficially, to true
+intercostal neuralgia, in cases where the genuine disease does not
+exist.
+
+A less common but very remarkable variety of intercostal neuralgia than
+that just mentioned, is the kind of pain which attends a good many cases
+of herpes zoster, or shingles. It is only of recent years that any
+essential connection between zoster and neuralgia has been suspected.
+The occurrence of neuralgia as a sequel to zoster had indeed been
+mentioned by Rayer, Recamier, and Piorry, but the essential nature of
+the connection between the two diseases was evidently not suspected by
+Lecadre, when, as late as 1855, he published his valuable essay on
+intercostal neuralgia. M. Notta was one of the first to present
+connected observations on the subject. But it was much more fully
+discussed in a paper published by M. Barensprung, in 1861. [_Ann. der
+Charite-Krakenhauser zer Berlin, ix._, 2, p. 40. _Brit. and For. Med.
+Rev._, January, 1862.] This author showed the absolute universality with
+which unilateral herpes, wherever developed, closely followed the course
+of some superficial sensory nerve, and gave reasons, which will be
+discussed hereafter, for supposing that the disease originates in the
+ganglia of the posterior roots, and that the irritation spreads thence
+to the posterior roots in the cord, causing reflex neuralgia. We shall
+have more to say on this matter. Meantime, it seems to be established,
+by multiplied researches, that, though unilateral herpes may and often
+does occur without neuralgia, and neuralgia without herpes, the
+concurrence of the two is due to a mere extension of the original
+disease, which is a nervous one.
+
+In young persons, zoster is not attended with severe neuralgia, but a
+curious half-paretic condition of the skin, in which numbness is mixed
+with formication, or with a sensation as of boiling water under the
+skin, precedes the outbreak of the eruption by some hours, or by a day
+or two. Painless herpes is commonest in youth. I remember, for instance,
+that, in an attack of shingles which I suffered about the age of eleven,
+there was at no stage any acute pain; only, in the pre-eruptive period,
+for a short time, I had the curious sensations referred to above: and
+the same thing has occurred in all the patients below puberty that I
+have seen, if they complained at all. From the age of puberty to the end
+of life, the tendency of herpes to be complicated with neuralgia becomes
+progressively stronger. The course of events varies much in different
+cases, however. In adult and later life the symptoms usually commence
+with a more or less violent attack of neuralgic pain, which is
+succeeded, and generally, though not always, displaced by the herpetic
+eruption. The latter runs its course, and after its disappearance the
+neuralgia may return, or not. In old people it almost always does
+return, and often with distressing severity and pertinacity. Six weeks
+or two months is a very common period for it to last, and in some aged
+persons it has been known to fix itself permanently, and cease only with
+life. In these subjects a further complication sometimes occurs. The
+herpetic vesicles leave obstinate and painful ulcers behind them, which
+refuse to heal, and which worry the patient frightfully, the merest
+breath of air upon them sufficing to produce agonizing darts of
+neuralgic pain. I have known one patient, a woman over seventy years of
+age, absolutely killed by the exhaustion produced by protracted
+suffering of this kind.
+
+The foci of pain in intercostal neuralgia are always found in one or
+more of the points, already enumerated, at which sensory nerves become
+superficial. In long-standing cases acutely tender points are developed
+in one or more of these situations; not unfrequently the most decided of
+these spots is where it gets overlooked, namely, opposite the
+intervertebral foramen. H. G., a young woman aged twenty-six, who
+applied to me at Westminster Hospital, had suffered for twelve months
+from an irregularly intermitting but very severe neuralgia at the level
+of the seventh intercostal space of the left side. The violence of the
+pain was sometimes excessive, and when the paroxysm lasted longer than
+usual it generally produced faintness and vomiting. This patient had no
+sign of tenderness anywhere in the anterior or lateral regions, though
+the pain seemed to gird round the left half of the chest as with an iron
+chain, but an exquisitely tender spot, as large as a shilling, was found
+close to the spine; pressure on this always induced a strong feeling of
+nausea.
+
+As an illustration of the herpetic variety of dorso-intercostal
+neuralgia, running a severe but not protracted course, I may relate the
+case of a medical man whom I formerly attended. This gentleman was about
+thirty-two years of age, and a highly neurotic subject: inter alia, he
+had already suffered from a severe and protracted sciatica; and, very
+shortly before the herpetic attack, had been jaundiced from purely
+nervous causes. His nervous maladies were undoubtedly caused by
+over-brain-work. In this case the neuralgia developed itself during the
+latter half of the eruptive period, which was rather unusually
+lengthened. It occupied the seventh, eighth, and ninth intercostal
+spaces of the side affected with herpes, and was very violent and acute,
+so that the patient expressed himself as almost "cut in two" with it.
+The pain ceased even before the vesicles had perfectly healed; a rather
+unusual occurrence in my experience. I shall refer to this case
+hereafter, as an example of what I believe to be the effect of a
+particular method of treatment in lessening the tendency to
+after-neuralgia. The result of my experience is certainly this--that if
+a case of herpes in an adult, or still more in an aged person, be left
+to itself, the amount of after-neuralgia will very closely correspond
+with the severity of the eruptive symptoms.
+
+There is a variety of intercostal neuralgia which is of more importance
+than the commoner kinds. Occurring mostly in persons who have passed the
+middle age, it possesses the characters of obstinacy and severity which
+belong to the neuralgias of the period of bodily decay. It is at first
+unattended with any special cardiac disturbance. By-and-by, however, it
+begins to attract more careful attention from the fact that the severer
+paroxysms extend into the nerves of the brachial plexus of the affected
+side, so that pain is felt down the arm. In the midst of a paroxysm of
+intercostal and brachial pain, it may happen that the patient is
+suddenly seized with an inexpressible and deadly feeling of cardiac
+oppression, and, in fact, the symptoms of angina pectoris, such as they
+will be described in a future chapter, become developed. A case of this
+kind is at present under my care at the Westminster Hospital. The
+patient is a man only fifty-six years of age, but whose extreme
+intemperance has produced an amount of general degeneration of his
+tissues such as is rarely seen except in the very aged; he has the most
+rigid radial arteries, and the largest arcus senilis, I think, that I
+ever saw. This man has long been subject to attacks of violent
+intercostal neuralgia, and a recent access assumed the type of
+unmistakable angina. It is very probable that his coronary arteries have
+now become involved in the degenerative process. In this case, before
+the development of any marked anginal symptoms, the paroxysmal pain,
+from being merely intercostal, had come to extend itself into the left
+shoulder and arm.
+
+Intercostal neuralgia not unfrequently accompanies, and is sometimes a
+valuable indication of, phthisis. I do not mean to say that the vague
+pains in the chest-walls, which are so very common in phthisis, are to
+be indiscriminately accounted neuralgia; on the contrary, they are, in
+the large majority of instances, merely myalgic, and arise from the
+participation of the pectorals, or intercostals, or both, in the
+mal-nutrition which prevails in the organism generally. But it happens,
+sometimes that a distinctly intermitting neuralgia occurs as an early
+symptom of phthisis; in fact, where there is a predisposition to
+neurotic affections, I believe that this is not very uncommon. The
+subjects are generally women; they are mostly of that class of
+phthisical patients who have a quick intelligence, fine soft hair, and a
+sanguine temperament. I have had one male patient under my care: this
+was a young gentleman aged eighteen, in whom a neuralgic access came on
+with so much severity, and caused so much constitutional disturbance,
+that the idea of pleurisy was strongly suggested. The paroxysms returned
+at irregular intervals for a considerable period: they were quite
+unlike myalgic pains, not only in their character, but more especially
+with respect to the circumstances which were found to provoke their
+recurrence. They were the first symptoms which lead to any careful
+examination of the chest; it was then found that there were prolonged
+expiration and slight dulness, at one apex. At this period, wasting had
+not seriously commenced; but, on the other hand, there was an
+extraordinary degree of debility for so early a stage of phthisis. I am
+inclined to think that self-abuse was the principal cause both of the
+phthisis and the neuralgia, acting doubtless on a predisposed organism,
+for his family was rather specially beset with tendencies to
+consumption. I may add here, that it has appeared to me that young
+persons with phthisical tendencies are specially liable to neuralgic
+affections as a consequence of self-abuse.
+
+A special variety of intercostal neuralgia is that which attacks the
+female breast. The nerves of the mammę are the anterior and middle
+cutaneous branches of the intercostals; and they are not unfrequently
+affected with neuralgia, which is sometimes very severe and intractable.
+Dr. Inman has very properly pointed out that a large number of the cases
+of so-called "hysterical breast" are really myalgic, and are directly
+traceable to the specific causes of myalgia; but there is no question in
+my mind that true neuralgia of the breast does occur, and indeed is
+frequent, relatively to the frequency of neuralgias generally. There are
+several kinds of circumstances under which it is apt to occur. In
+highly-neurotic patients it may come on with the first development of
+the breasts at puberty; and it may be added that this is especially apt
+to occur where puberty has been previously induced by the unfortunate
+and mischievous influences to which we had occasion to refer in speaking
+of certain other neuralgię. A neuralgia of the left breast occurred in a
+patient of mine, who attended the Westminster Hospital. She was only
+twelve years of age, and small of stature, but the mammę were
+considerably developed. The face was haggard, there was an almost
+choreic fidgetiness about the child, and a very unprepossessing
+expression of countenance; the result of inquiries left no doubt that
+the patient was much addicted to self-abuse; and it seemed probable that
+to this was due the fact that menstruation had come on, and was actually
+menorrhagic in amount.
+
+A very painful kind of mammary neuralgia is experienced by some women
+during pregnancy; but more commonly the mammary pains felt at this
+period are mere throbbings, not markedly intermittent in character, and
+plainly dependent on mechanical distention of the breast: such
+affections are not to be reckoned among true neuralgię. A true neuralgia
+of a very severe character is sometimes provoked by the irritation of
+cracked nipples. I have seen a delicate lady, of highly-neurotic
+temperament, and liable to facial neuralgia, most violently affected in
+this way. Vain attempts had been made for several consecutive days to
+suckle the infant from the chapped breast; when suddenly the most severe
+dorso-intercostal neuralgia set in. The attacks lasted only a few
+seconds each, but they recurred almost regularly every hour, and were
+attended with intense prostration, and sometimes with vomiting.
+Discontinuance of suckling was found necessary, for even the application
+of the child to the sound breast now sufficed to arouse a paroxysm of
+pain. Complete rest, protection of the breast from air and friction, and
+the hypodermic injection of morphia, rapidly relieved the sufferer.
+
+(_e_) _Dorso-lumbar Neuralgia._--The superficial branches of the spinal
+nerves emanating from the lumbar plexus are considerably less liable to
+be affected with severe and well-marked neuralgia than are the
+dorso-intercostal nerves. Pains in the abdominal walls, which are a good
+deal like neuralgia, are not uncommon; but the majority of them will be
+found, on careful observation, to be myalgia. At least, this has been
+the case in my own experience.
+
+When true neuralgia of the superficial branches of the lumbo-abdominal
+nerves occurs, it develops itself in one or more of the following foci:
+(1) Vertebral points, corresponding to the posterior branches of the
+respective nerves; (2) an iliac point, about the middle of the crista
+ilii; (3) an abdominal point, in the hypogastric region; (4) an inguinal
+point, in the groin, near the issue of the spermatic cord, whence the
+pain radiates along the latter; (5) a scrotal or labial point, situated
+in the scrotum or in the labium majus.
+
+Such is the description given by Valleix; for my own part, I cannot say
+that I have seen enough cases to test its accuracy. I believe it to be
+generally correct, yet it may fairly be doubted whether the author might
+not have revised his description had the natural history of myalgic
+affections been as carefully investigated as it has since been. The
+hypogastric foci of pain of which he speaks are at least open to
+considerable suspicion, as it will be shown, in the chapter on Myalgia,
+that an extremely common variety of the latter affection is situated in
+this region, and the severity of the pain which it often produces might
+well cause it to be mistaken for a genuine neuralgia.
+
+I have, however, seen three or four cases in which the very complete
+intermittence of the paroxysms, without any perceptible relation to the
+question of muscular fatigue, left no doubt in my mind of the really
+neuralgic character of the malady. In one of these instances, oddly
+enough, the exciting cause appeared to be fright; and this was as severe
+a case as one often sees. The patient was a woman of middle age, and
+much depressed by the long continuance of a profuse leucorrhoea. As
+she was walking along the street, a herd of cattle, in a somewhat
+irritable and disorderly condition, came suddenly toward her; she
+immediately began to suffer pain just above the crest of the ilium, and
+at the lumber region, and, most acutely, in the labium majus of one
+side; and then pain returned daily, about 10 A. M., lasting for half an
+hour with great severity. This woman's family history was remarkable:
+her mother had been paraplegic, her sister was a confirmed epileptic,
+and two of her children had suffered from chorea.
+
+In two other cases of lumbo-abdominal neuralgia which were under my
+care, there were also very painful points in the spermatic cord and in
+the testicle. One of these cases will be referred to under the head of
+Visceral Neuralgia. Another case, in which severe quasi-neuralgic pain
+was referred to the groin, will be described in the chapter on the Pains
+of Hypochondriasis.
+
+(_f_) _Crural Neuralgia._--This appears to be rare as an independent
+affection occurring primarily in the crural nerve. Valleix had only seen
+it twice in all his large experience, and I have never seen it myself.
+Neuralgic pain of the crural nerve is almost always a secondary
+affection arising in the course of a neuralgia, which first shows itself
+in the external pudic branch of the sacral plexus; or else occurring as
+a complication of sciatica. A remarkably severe example of the latter
+occurrence was observed in an old man who still occasionally attends the
+Westminster Hospital. He has been a martyr to the most inveterate
+bilateral sciatica for between two and three years; and, within the last
+three months, it has extended itself into the cutaneous branches of the
+curval nerves of both thighs. So great an aggravation of the pain is
+produced by any muscular movement, that the patient can only walk at the
+slowest possible pace, moving each foot forward only a few inches at a
+time. The bilateral distribution of the pain is remarkable in this case;
+but there can be no doubt of its really neuralgic character, from the
+truly intermittent way in which it recurs, and the absence of any
+history whatever to point in the direction of rheumatism, gout, or
+syphilis.
+
+The nervous supply to the skin of the anterior and external portion of
+the thigh includes: (1) The middle cutaneous, (2) the internal
+cutaneous, and (3) the long saphenous branch of the anterior crural
+nerve; (4) the cutaneous branch of the obturator; and (5) the external
+cutaneous nerve, derived from the loop formed between the second and
+third lumbar nerve. The sensitive twigs derived from the two latter
+sources, equally with the branches of the anterior crural, are liable to
+be secondarily affected by neuralgia, which commences in the
+lumbo-abdominal nerves; but it must be a rare event for them to be the
+seat of a primary neuralgia. The only occasion on which I have seen
+anything which looked like the latter was in the case of a porter, who,
+in straining to lift a very heavy load, ruptured some part of the
+attachment of the tensor vaginę femoris. But the susceptibility of all
+the nerves of the front of the thigh to secondary or reflex neuralgia
+receives numerous illustrations. The extremely severe pain at the
+internal aspect of the knee-joint, which is such a common symptom in
+morbus coxę, is evidently a reflex neuralgia of the long saphenous
+nerve, the ultimate irritation being situated in the branches of the
+obturator nerve which supply the hip-joints. For some reason
+unexplained, it happens that this saphenous nerve is specially liable to
+be affected in a reflex manner: for instance, this happens in a
+considerable number of cases of sciatica. I have a lady now under my
+observation, in whom the secondary neuralgia of the saphenous nerve has
+become even more intolerable than the pain in the sciatic, which was the
+nerve primarily affected. The pain in these cases very frequently runs
+down the inner and anterior surface of the leg to the internal ankle.
+Sometimes the branches of the anterior crural become the seat of
+intensely painful points in the course of a long-persisting sciatica. A
+patient at present under my care has a spot, about the size of a
+shilling, just at the emergence of the middle cutaneous branch from the
+fascia lata, which is intensely and persistently tender to the touch,
+and the skin here is so exquisitely sensitive to the continuous galvanic
+current that the application of moistened sponge-conductors, with a
+current of only fifteen Daniell's cells, causes intolerable burning
+pain; whereas at every other part of the limb the current from
+twenty-five cells can be borne without much inconvenience.
+
+(_g_) _Femoro-popliteal Neuralgia, or Sciatica._--This is one of the
+most numerous and important groups of neuralgia; but, notwithstanding
+that there are plenty of opportunities for studying it, I venture to
+think it is very commonly mistaken for different and non-neuralgic
+diseases, and they for it. The rules of diagnosis which will be laid
+down for all the neuralgię would nevertheless prevent these errors, if
+carefully attended to.
+
+Sciatica is a disease from which youth is comparatively exempt. Valleix
+had collected one hundred and twenty-four cases, and in not one was the
+patient below the age of seventeen, only four were below twenty. In the
+next decade there were twenty-two; in the next, thirty; and the largest
+number of cases, thirty-five, occurred between the ages of forty and
+fifty. This completely tallies with my own experience, and appears to
+afford some support to a suspicion I have formed, that the chief
+exciting cause of sciatica is the pressure exercised on the nerve in
+locomotion, and that this cause exercises its maximum influence when the
+period of bodily degeneration commences. It is further remarkable that,
+in elderly persons (whose habits of locomotion are of course more
+limited), the proportion of fresh cases rapidly diminishes; and also
+that above the age of thirty the number of male patients greatly exceeds
+that of female patients attacked. All this seems to point in the same
+direction.
+
+According to my observation, there are three distinct varieties of
+sciatica. The first of these is obscure in its origin, but may be said,
+in general terms, to be connected with a nervous temperament of the
+highly impressible kind, which is more or less like what we call
+"hysteric," not only in the female, but also in male patients. The
+subjects of this kind of sciatica are mostly young persons, and hardly
+ever more than middle-aged; they are generally found to be liable to
+other forms of neuralgia; and the actual attack of sciatica is produced
+by some fatigue or mental distress, which at other times might have
+brought on sick headache, or intracostal neuralgia, etc. Very many of
+these patients are anęmic; and chlorotic anęmia seems specially to favor
+the occurrence of the affection. The greater number of the victims are
+females, and in very many, whether as cause or effect, there is impeded,
+or at least imperfect, menstruation. This kind of sciatic pain is not
+usually of the highest degree of intensity, but it generally spreads
+into a great many branches, both in a direct and a reflex manner. It is
+probable that this variety of the disease is, at least very often,
+dependent upon, or much aggravated by, an excited condition of the
+sexual organs; certainly, I have observed it with special frequency in
+women who have remained single long after the marriageable age, and in
+several male patients there has been either the certainty or a strong
+suspicion of venereal excess. Sciatica of this kind also occurred in the
+case of a single woman aged about thirty, who to my knowledge was
+excessively addicted to self-abuse.
+
+The second variety of sciatica occurs for the most part in middle-aged
+or old persons who have long been subject to excessive muscular
+exertion, or have been much exposed to damp and cold, or who have been
+subject to the combined influence of both these kinds of evil influence.
+One must also include, I think, in this group a considerable number of
+cases where the age is not so advanced, but the patient has been
+obliged, by the nature of his business, to maintain the sitting posture
+daily, for hours together, exercising pressure on the nerve; this is
+especially liable to happen in these persons.
+
+The sufferers from this variety of sciatica are mostly, as already said,
+of middle age or more; but this statement must be understood to be made
+in the comparative sense, which refers rather to the vital status of the
+individual than to the mere lapse of years. Many of these people have
+hair which is prematurely gray, and in some the existence of rigid
+arteries, together with arcus senilis, completes the picture of organic
+involution, or senile degeneration. In particular cases, where
+depressing influences have been at work for a long time, or unusually
+active, these appearances rectify the false impression we should
+otherwise derive from learning the mere nominal age of the person; this
+is especially often the case with regard to patients who have for a long
+time drunk to excess. The prematurely and permanently gray hair (it will
+be seen hereafter that permanency of grayness is an important point),
+together with well-marked inelasticity of arteries, very often tells a
+tale which is most useful in informing us, not only of the vital status
+of the patient, but of the kind of sciatica under which he labors; and
+also influences our prognosis seriously. There is otherwise a somewhat
+deceptive air about the appearance of many of these degenerative cases;
+for instance, a ruddy complexion is not uncommon, nor the retention of
+considerable, or even great, muscular strength. It is probable that
+these appearances deceived Valleix and many others, or they could hardly
+have failed, as they have, to observe the frequency of the degenerative
+type among the most numerous group of sciatic patients, namely, those
+between thirty and fifty years of age. These persons are not truly
+"robust," although at a hasty glance they might at first seem to be so.
+It would be a serious mistake to omit the search for the important vital
+evidences which have been referred to, since these therapeutic and
+prognostic indications are of the highest value.
+
+A prominent feature in this kind of sciatica is its great obstinacy and
+intractability. Another, equally marked, is the tendency to the
+development of spots around the foci of severest pain which are
+intensely and permanently tender, and the slightest pressure on which is
+sufficient to set up acute pain. This is a symptom much less developed,
+if developed at all, in the variety of sciatica which we first
+discussed. The places which are especially apt to present this
+phenomenon of tenderness are as follows: (1) A series, or line of
+points, representing the cutaneous emergence of the posterior branches,
+which reaches from the lower end of the sacrum up to the crista ilii;
+(2) a point opposite the emergence of the great and small sciatic nerves
+from the pelvis; (3) a point opposite the cutaneous emergence of the
+ascending branches of the small sciatic, which run up toward the crista
+ilii; (4) several points at the posterior aspect of the thigh,
+corresponding to the cutaneous emergence of the filets of the crural
+branch; (5) a fibular point, at the head of the fibula, corresponding to
+the division of the external popliteal; (6) an external malleolar,
+behind the outer ankle; (7) an internal malleolar.
+
+I have already mentioned that in sciatica the pain frequently spreads in
+a reflex manner to nerves which are connected, by their origin from the
+plexus, with the sciatic. It will be remembered, also, that I related
+cases in which the formation of tender points, in the course of the
+nerves thus secondarily affected, was even more distinct and remarkable
+than anywhere in the branches of the sciatic itself.
+
+Another circumstance which distinguishes the form of sciatica which we
+are now describing is, the degree in which (above all other forms of
+neuralgia) it involves paralysis of motion. [The subject of the
+complication of neuralgia will be treated in a general manner farther
+on; but it seems necessary to note here the special liability of sciatic
+patients to this and to the most material complications]. By far the
+largest part of the motor nervous supply for the whole lower limb passes
+through the trunk of the great sciatic; it might therefore be naturally
+expected that a strong affection of the sensory portion of the nerve
+would produce, in a reflex manner, some powerful effect upon the motor
+element. This effect is most frequently in the direction of paralysis.
+Complete palsy is rare, but in a large proportion of cases which have
+lasted some time there will be found, independently of any wasting of
+muscles, a positive and considerable loss of motor power. It is of
+course necessary to avoid the fallacy which might be produced by
+neglecting to observe whether movement was restricted merely in
+consequence of its painfulness. Not long since, I had occasion to test
+the electric sensibility in a case of sciatica, in which there was
+extremely severe pain, affecting chiefly the peroneal region of the leg,
+and great weakness of the leg, amounting to inability for walking. The
+gastrocnemius could hardly be got to contract at all, when the most
+powerful Faradic current was directed upon the nerve in the popliteal
+space of the affected limb, though the muscle of the sound side reacted
+with great vigor.
+
+_Anęsthesia_ is also a common complication of sciatica, far commoner, I
+venture to think, than it has been represented either by Valleix, or
+Notta. It is necessary, however, to be explicit on this point. In the
+early stages, both of this form of sciatica, and of the milder variety
+previously described, there is almost always partial numbness of the
+skin previous to the first outbreak of the neuralgic pain, and during
+the intervals between the attacks. By degrees this is exchanged, in the
+milder form, for a generally diffused tenderness around the foci of
+neuralgic pain, while other portions of the limb remain more or less
+anęsthetic. In the severer forms it sometimes happens that, besides an
+intense tenderness of the skin over the painful foci, there is diffused
+tenderness over the greater part or the whole of the surface of the
+limb. But it is important to remark that both in the anęsthetic and the
+hyperęsthetic conditions (so called) the tactile sensibility is very
+much diminished. I have made a great many examinations of painful limbs,
+in sciatica, and have never failed to find (with the compass points)
+that the power of distinctive perception was decidedly lowered.
+
+_Convulsive movements of muscles_ are met with in a moderate proportion
+of cases of sciatica in middle and advanced life, in which affection
+they are entirely involuntary. They differ from certain spasmodic
+movements not unfrequently observed in the milder form (and especially
+in hysteric women), for these are more connected with morbid volition,
+and are in truth, not perfectly involuntary. In several cases of
+inveterate sciatica I have seen violent spasmodic flexures of the leg
+upon the thigh. Cramps of particular muscles are occasionally met with.
+I have seen the flexors of the toes of the affected limb violently
+cramped, and in one case there was agonizing cramp of the gastrocnemius.
+It is chiefly at night, and especially when the patient is falling
+asleep, that this kind of affection is apt to occur.
+
+A third variety of sciatica is the rather uncommon one so far as my
+experience goes, in which inflammation of the tissues around the nerve
+is the primary affection, and the neuralgia is mere secondary effect,
+from mechanical pressure on the nerve, which, however, is not apparently
+itself inflamed. I believe that these cases are sometimes caused by
+syphilis, and sometimes by rheumatism. One of the most violent attacks
+of sciatic pain which ever came under my notice was in a syphilized
+subject, a discharged soldier, who had been the victim of severe
+tertiary affections, and had been mercilessly salivated into the
+bargain. This unfortunate man suffered dreadful agony, which was
+aggravated every night, but was never totally absent. The pain started
+from a point not far behind the great trochanter: pressure here caused
+intolerable darts of pain, which ramified into every offshoot of the
+sciatic nerve, as it seemed, and made the man quite faint and sick.
+Large doses of iodide of potassium, together with the prolonged use of
+cod-liver oil, completely removed the pain and tenderness. It need
+hardly be said that cases of this kind are essentially different, and
+require perfectly different principles of treatment from neuralgias in
+which the disturbance originates within the nervous tissues themselves.
+
+The chronic rheumatism does also, occasionally, affect the sheath of the
+nerve in such a manner as to produce a deposit which sets up neuralgic
+pain, must also be admitted, although I believe the number of such cases
+to be preposterously over-estimated by careless observers. It has
+several times happened that a patient has come under my care with
+so-called "rheumatic affection of the nerves" of the thigh and leg, and
+that on examination one has found all the symptoms and clinical history
+of a neurosis, but not the slightest valid argument for a diagnosis of
+the rheumatic diathesis. Indeed, upon this point, I think it is time
+that a decided opinion should be expressed. I firmly believe that a
+large number of sciatic patients have their health ruined by treatment
+directed to a supposed rheumatic taint which is purely imaginary. The
+state of medical reasoning, suggested by the way in which too many
+practitioners decide that such and such pains are rheumatic in their
+origin, is a melancholy subject for reflection. Nearly always it will be
+found, on cross-examination, that the state of the urine has been made
+the basis of a confident diagnosis; the practitioner will tell you that
+the urine was loaded, _i. e._, with lithtaes. He ignores the fact that
+nothing is more common, in neurotic patients who are perfectly guiltless
+of rheumatic propensities, than a fluctuation between lithiasis and
+oxaluria, neither of which phenomena, under the circumstances, indicates
+any more than a temporary defect of secondary assimilation of food,
+produced by nervous commotion. I may perhaps find room, on a future
+page, for a few further remarks on the subject; at present I only put in
+a caution against too ready an acceptance of the rheumatic hypothesis.
+
+II. VISCERAL NEURALGIAS.
+
+_Uterine and Ovarian Neuralgia._--This is an important group of
+neuralgic affections, and one which I cannot help thinking is strangely
+misappreciated, very often, in a therapeutic point of view. In one
+aspect these affections possess a special interest, namely this, that
+they are more frequently dependent on peripheral irritation for their
+immediate causation than any other group of neuralgias. If we consider
+the great copiousness of the nervous supply to the uterus and ovaries,
+and the powerfully disturbing character of the functional processes
+which are periodically occurring in these organs, we shall be at no loss
+to understand how this may be. The amount force of the peripheral
+influence and which are brought to bear upon the central nervous system
+by the functions of the uterus and ovaries are greater than any that
+emanate from the diseases and functional disturbances of any other organ
+in the body.
+
+The most common variety of peri-uterine neuralgia is that which attends
+certain kinds of difficult menstruation. It would be hardly correct to
+give the name of neuralgia to the pain existing in these very numerous
+cases of dysmenorrhoea in which the suffering is apparently altogether
+dependent on the mere retention or difficult escape of the menstrual
+fluid, although the character of the pain often resembles the neuralgic
+type. There is another group of dysmenorrhoeal affections however, in
+which the pain may fairly be called neuralgic, since it is apparently
+independent of the circumstances of the discharge of menstrual fluid,
+and simply attends the process, seemingly on account of a
+naturally-exaggerated irritability of the organs concerned. There is a
+large class of young women in whom, and more especially before marriage,
+the time of menstruation is always marked by the occurrence of more or
+less severe pain. Formerly I used to believe that this pain was relieved
+on the occurrence of the discharge, but I have seen too many cases of a
+contrary nature to retain this opinion. I now believe that the subjects
+of the kind of menstrual pain to which I am referring are naturally
+endowed with a very irritable nervous apparatus of the pelvic organs,
+and that there is a certain character at once of immaturity and
+excitability in their sexual organs, especially in the virgin condition.
+So far from these females being disposed to sterility, as is too often
+the case with those dysmenorrhoeal subjects whose troubles depend upon
+occlusion, distortion, or narrowing of the outlets, they are often
+extremely apt to the generative function; and, what is more, the full
+and natural exercise of the sexual function appears necessary to the
+health of their organs, as is shown by the fact that these menstrual
+pains lose their abnormal character, completely or in great part, after
+marriage, and especially after child-bearing. The contrast between the
+two types of dysmenorrhoeal patients is sharply brought out by the two
+following cases:
+
+CASE I.--S. M., a housemaid, aged twenty-three when first under my
+notice, was the picture of physical health and strength, very
+intelligent, and a girl of excellent character and most industrious
+habits. At every menstrual period, however, she suffered, for some hours
+previously to the occurrence of the flow, from severe pain in the
+uterine region, which was tumefied and tender. Hot hip-baths gave some
+relief, apparently by hastening the discharge; as soon as the latter was
+established, the pain rapidly subsided. This young woman married a
+healthy and vigorous young man, but has never had any children, and at
+the date of my last inquiries still suffered periodically from her old
+troubles.
+
+CASE II.--Mrs. B. was married at the age of twenty-six. Up to the date
+of her marriage she used to suffer the most severe pain at every
+menstrual period; the pain, however, bore no relation to the freedom of
+the discharge, but always lasted about the same length of time, under
+any circumstances, or was only less or more according as the general
+bodily vigor was greater or less at the moment. From the date of
+marriage these troubles steadily declined; a child was born at the end
+of twelve months, and the menstrual troubles have never resumed a
+serious shape up to the present time, a period of nearly nine years.
+This lady is herself a neuralgic subject, liable to migraine in
+circumstances of fatigue, and suffering horribly from it during her
+pregnancies; and she comes of a family in whom the nervous temperament
+is strongly developed.
+
+It must not always be concluded, because the menstrual pain is very
+severe before the discharge and is relieved at or soon after its
+appearance, that the case is one of occlusion, and not of neuralgia.
+There is a class of cases in which the affection appears to be a very
+severe ovarian neuralgia, attended with a vaso-motor paralysis which
+causes great engorgement of the ovary and consequent difficulty of
+"ovulation." I have seen several instances which I could not explain in
+any other way.
+
+CASE III.--One patient I particularly remember, from the fact that she
+was always attacked with dreadful pain, which was sometimes seated in
+one groin and sometimes in the other, but was regularly attended with
+large and palpable tumefaction of the ovary, which began to subside when
+the discharge commenced. This woman married rather late, but her
+menstrual troubles immediately became less, and she became pregnant and
+was happily delivered, nearly as soon as was possible. She, too, was a
+decidedly neuralgic subject, independently of her tendency to
+dysmenorrhoeal ovarian pain.
+
+In some women who remain single long after the marriageable age, ovarian
+or uterine neuralgia becomes a constantly-recurring torment, not only at
+the menstrual period, but at various other times when they are depressed
+or fatigued in body or mind. As might be expected, this tendency is
+greatly aggravated in the rarer cases where the patient's mind dwells in
+a conscious manner on sexual matters, especially if by an evil chance
+she becomes addicted to self-abuse. Among the many reproaches that have
+been thrown upon the indiscriminate use of the speculum in examining
+unmarried women, it has often been urged that it tends to excite sexual
+feelings. I do not for a moment doubt that this is the case, or that the
+indiscriminate use of the instrument is altogether indefensible. But I
+expect that neuralgic pain of the uterus or ovaries, in unmarried women,
+connected with an already irritable condition of the sexual organs, has
+often been the reason why such women have applied for advice and have
+consequently been examined with the speculum; and that the same thing
+has frequently happened in the case of women who have been left widows
+at a time of life when the sexual powers were still in full vigor. These
+patients deserve great pity.
+
+The peripheral irritation which gives rise to peri-uterine neuralgia is
+not always originally seated in the organs of generation. The following
+are various sources of external irritation which I have known to produce
+the affection:
+
+1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman,
+aged thirty-four, single, was under my care in King's College Hospital
+many years ago, under suspicions of ulcerated cervix. On examination, no
+lesion could be detected. It was discovered that the rectum was infested
+with ascarides, and, after the use of appropriate vermifuges and tonics,
+the patient entirely lost the uterine pains and also a tormenting
+pruritus vaginę, from which she suffered. This woman had at various
+times suffered from neuralgic headache a good deal.
+
+2. Profuse and intractable leucorrhoea, whether associated or not with
+ulceration of the cervix, may produce peri-uterine neuralgia, even of
+great severity, when there are strongly-marked neurotic tendencies. It
+must be noted, however, that many cases of pain in leucorrhoeal
+subjects, which superficially bear the aspect of neuralgia, turn out on
+closer investigation to be merely examples of myalgia of the abdominal
+muscles or aponeuroses.
+
+3. Calculus in the kidney, or in the ureter, sometimes causes
+intolerable ovarian neuralgia. In the case of a woman who was under my
+care at the Chelsea Dispensary, some years ago, this was the unsuspected
+origin of severe neuralgic pains in the left ovary, which recurred
+several times a day, and which certainly contributed to the patient's
+death by the exhaustion which they produced. A calculus was found
+tightly impacted in the ureter, near the kidney.
+
+4. Prolapsus uteri sometimes gives rise to severe peri-uterine
+neuralgia, or what appears to be such; though it is difficult here to
+draw the line between neuralgia and myalgia. The commonest kind of pains
+from prolapsus uteri are not neuralgic in their nature at all, but are
+of a "bearing down" character, and probably depend upon actual
+contractile movement of the walls of the uterus.
+
+5. The presence of tumors, either cancerous or fibroid, in the uterus or
+its appendages, gives rise, frequently, to severe and indeed almost
+intolerable pains of a distinctly intermittent character. In the early
+stages of cancerous diseases these pains are usually felt at the lower
+part of the back; in the later stages they are felt also in the
+hypogastric region, and are then much more severe.
+
+6. Ulcer of the cervix, of a non-malignant kind, probably sometimes
+gives rise to neuralgic pain of the uterus, though this is not so severe
+as in cancer.
+
+7. Large masses of scybalous fęces, impacted in the rectum, will
+occasionally, by the pressure which they exert on nerves, set up violent
+neuralgia of uterus or ovaries, the true nature of which is accidentally
+discovered by the use of aperients which unload the intestine and put an
+end to the suffering. No doubt it is chiefly in persons with neuralgic
+predisposition that this effect is produced; for, common as is the
+occurrence of extreme constipation in women, it is comparatively very
+rare for us to hear of distinctly neuralgic pain being caused by it.
+
+8. The condition known as "irritable uterus," ever since Gooch's
+classical description of it, is always attended with uterine pain, which
+is continuous, but is liable to periodical exacerbations of great
+severity. In this disorder there is no recognizable physical disease of
+the pelvic organs, and the patient will generally be found to have
+suffered neuralgia in other parts of the body on previous occasions.
+[There is some difference of opinion about this affection: some authors
+(_e. g._, Hanfield Jones) considering it as distinct from the true
+neuralgias.]
+
+9. Reflex irritation, the source of which is in some quite distant part
+of the body, has in many recorded instances occasioned uterine
+neuralgia, in highly-predisposed persons. I have seen one case in which
+severe pain of this kind was clearly proved to have been excited by the
+presence of a carious tooth which was itself little, if at all, painful,
+but the removal of which at once cured the pelvic pain.
+
+Neuralgia of the urethra is an affection which is occasionally seen,
+both in males and females. I have observed it three times; all these
+cases were apparently traceable to the effects of excessive self-abuse.
+The male subject was an unmarried man, aged forty-two, of cadaverous
+appearance, much emaciated, with clammy, perspiring skin, and habitual
+coldness of the extremities; he suffered much from dyspepsia and
+palpitation of the heart. The pain ran along the under side of the
+penis, which was very large, with an elongated prepuce. The paroxysms
+were severe, and came on chiefly in the morning, soon after he awoke. No
+remedies did this man any permanent good, and he passed out of my sight,
+being at that time in a condition of wretched feebleness, and with
+symptoms of threatened dementia. Of the female subjects, one was a
+married woman, who accused her husband of impotence, and from her
+account it would certainly appear that effective connection had never
+taken place; the hymen was completely destroyed, however. The neuralgic
+pains recurred nightly in several paroxysms, and were especially severe
+about the time of the monthly periods. In this case the patient was, she
+stated, induced to give up her malpractices; at any rate, the pain
+subsided in a manner which could not be well accounted for by any direct
+influence of the medicinal treatment. The other female patient was a
+widow in whom the morbid habit was suspected from her general
+appearance, and from the existence of enlarged clitoris and other signs
+of irritation about the external parts: she became rather rapidly
+phthisical, and suffered severely from neuralgic headaches.
+
+Neuralgia of the bladder has been specially described by various
+writers; the pain is usually spoken of as seated at the neck of the
+bladder, and as accompanied by frequent desire to micturate. I have seen
+two cases, both in women: the first was eventually discovered to be an
+instance of malignant disease of the fundus of the bladder; the other
+was apparently the result of a long-continued menorrhoeal flux, which
+had greatly impaired the health, and produced extreme anęmia. In neither
+of these instances was the pain referred to the external meatus, as in
+the female patients above mentioned who were suffering from urethral
+neuralgia. I have never seen the extreme examples of vesical neuralgia
+described by some writers, in which actual paralysis of the coats of the
+bladder was secondarily produced; but the reflex influence of the
+neuralgic affection in both the examples just mentioned appeared to
+produce great weakening of the muscular power of the rectum, occasioning
+most obstinate and troublesome constipation.
+
+It would appear, from recorded cases, that both the bladder and the
+uterus are liable to be affected with neuralgia from malarious
+influences; but I have never chanced to see any such cases.
+
+Neuralgia of the kidney is spoken of by several writers, and I suppose
+there is no doubt that it may exist as a special neurotic disease with
+obvious organic cause. For my own part, I cannot say that I have ever
+seen it except in instances where there was either the certainty, or a
+very strong suspicion, that the cause was the mechanical pressure and
+irritation of a calculus within the kidney. The diagnosis of the simple
+functional disorder must be excessively perplexing; for in the first
+place there is the greatest difficulty in making sure that the pain is
+not external, and seated either in the muscles of the back, or in the
+superficial dorsal or lumbar nerves, and certainly I am strongly
+inclined to suspect that this has been really the case in many examples
+of so-called renal neuralgia. That neuralgia of the kidney may arise
+secondarily, as a reflex extension of pelvic neuralgia, does, however,
+appear probable enough; for it is almost certain that in the latter
+affection at least, the vaso-motor nerves of the kidneys must be
+strongly influenced in a reflex manner; since the crisis or acme of a
+paroxysm of pelvic pain is not unfrequently attended with a copious
+secretion of pale urine.
+
+Neuralgia of the rectum has been carefully described by Mr. Ashton, but
+is probably not often seen except by practitioners who possess special
+opportunities of observing rectal diseases. In the one pure case which
+has fallen under my notice the patient complained of acute paroxysmal
+cutting pains extending about one inch within the anus, and, as these
+were greatly increased by defecation I suspected the existence of
+fissure. Nothing of the kind, however, was found on examination; and the
+pain ultimately yielded to repeated subcutaneous injections of atropine.
+This patient had got wet through, and had sat in his damp clothes,
+getting thoroughly chilled; the pain came on with great suddenness and
+severity, and the tenderness which has been mentioned was developed very
+quickly. Probably the influence of cold and wet is among the commonest
+causes of the complaint. Mr. Ashton also reckons as causes, reflex
+irritation from other parts of the alimentary canal, and the influence
+of malaria. He observes that the subjects of the affection are most
+frequently anęmic, and of a generally excitable and deranged
+susceptibility, and that females, who, from menorrhagia, or frequent
+child-bearing with much hęmorrhage, have lost a great deal of blood, are
+specially predisposed.
+
+Neuralgia of the testis (as an independent affection and not a mere
+extension of lumbo-abdominal neuralgia) is fortunately a much less
+common malady than the corresponding affection of the ovary; as might
+indeed be expected, from the much less degree of functional perturbation
+to which, in ordinary physiological circumstances, the former organ is
+exposed than the latter. Except from actual growths within the testis,
+of which it was a mere symptom, I have never seen neuralgia of the
+testis save from one of three causes. In one remarkable example it was
+produced as a reflex effect of severe herpes preputialis. Secondly, it is
+sometimes observed as a symptom of calculus descending the ureter. And,
+thirdly, I have seen it several times undoubtedly produced by excessive
+self abuse.
+
+The occurrence of testicular neuralgia, in one case of epilepsy, as to
+the cause of which I had been previously much puzzled, led to the
+discovery of the real origin of the fits. I should observe here that I
+do not believe that self-abuse is ever more than an immediately exciting
+cause of epilepsy, a predisposition to the disease having previously
+existed in all cases. In the patient just referred to, there was a
+family history of epilepsy, but it was difficult to explain the exciting
+cause until this was suggested by the occurrence of neuralgic pain in
+the testicle. The patient relinquished his habit, and both the pain and
+the epilepsy ceased, and, for some twelve months during which I had him
+under observation, had not recurred at all. A medical friend has
+informed me of an instance in which the same habit had produced a
+neuralgia of the testis so severe as to strongly tempt the patient to
+castrate himself, and he would probably have done so but that he was too
+much of a coward with regard to physical pain. The attacks of pain were
+so severe as frequently to produce vomiting and the greatest
+prostration.
+
+_Hepatic Neuralgia._--It must be allowed that the evidence even for the
+existence of neuralgia of the liver is at present in an unsatisfactory
+state. At the same time, there are carefully-recorded cases, by
+Trousseau and other[7] writers of unquestionable authority, which leave
+no doubt in my mind, corroborated as they are by a certain amount of
+experience of my own, that such a form of neuralgia really exists. I
+must, of course, be understood to refer to something altogether
+different from the spasmodic pain which is produced by the difficult
+passage of a gall-stone toward the bowel. I have now seen several cases
+in which, as it appeared to me, there was sufficient evidence of
+neuralgic pain seated in the liver itself, and not dependent either on
+gall-stone or any so-called organic diseases of the viscus.
+
+The subjects of hepatalgia are probably never troubled only by pain in
+the liver; they are persons of a nervous temperament, in whom a slight
+shock to, or fatigue of, the nervous system, habitually provokes
+neuralgic attacks; the pain localizing itself sometimes in the branches
+of the trigeminal, sometimes in those of the sciatic, sometimes in the
+intercostal nerves, etc. In one instance which has been under my
+observation, the attacks of hepatalgia alternated with cardiac neuralgia
+assuming the type of a rather severe angina pectoris. In another case
+the patient, a man aged sixty-seven, was very liable to attacks of
+intermittent abdominal agony, in which one could hardly doubt that the
+pain was located in the colon, and was attended with paralytic
+distention of the bowel; the peculiar feature of the case being the
+sudden way in which the symptoms would appear and depart, independently
+of any recognizable provocation or the use of any remedies. On two
+separate occasions this patient was attacked with pain of a precisely
+similar kind, but limited to the right hypochondrium, attended with
+great depression of spirits, and followed by a well-pronounced jaundice.
+So remarkable was the conjunction of symptoms in these two attacks that
+a strong suspicion of biliary calculus was raised, but not the slightest
+confirmation of this idea could be obtained; and indeed one
+symptom--vomiting--which nearly always attends the painful passage of a
+biliary calculus, was altogether absent.
+
+Putting aside a considerable number of cases in which "pain in the
+liver" was vaguely complained of by patients who were plainly
+hypochondriacal, and whose account of their own sufferings could not be
+relied on, I have altogether seen five instances of what I regard as
+genuine hepatalgia. The first of these was very remarkable in its
+history and in all its features. The patient was a respectable girl of
+eighteen, subject to migraine, who had reason to fear that she had
+become pregnant, though this proved, ultimately, not to be the case.
+Under these circumstances she was attacked with intermittent pains, in
+the right hypochondrium, of intolerable severity; resembling, in fact,
+the pain of biliary calculus, but without the sense of abdominal
+constriction, and without any vomiting. These recurred daily at about
+the same hour in the morning, for about ten days; when rather
+suddenly, a jaundiced tint appeared upon the face, and very shortly the
+whole skin was colored bright yellow; there was intense mental apathy;
+the urine was loaded with bile-pigment, and the fęces clay-colored. This
+state of things lasted only about a week and then very rapidly
+disappeared; but as the jaundice subsided there was a partial recurrence
+of the neuralgic pains, which, for a day or two, were as severe as they
+had ever been; The other four cases of hepatalgia which I have seen,
+including that of the man above mentioned, have all been in persons in
+advanced life; but, except the latter, neither of them displayed any
+symptoms of disordered biliary secretion; and the diagnosis (as to
+situation, for the character of the attacks was manifestly neuralgic)
+rested mainly on the fact that the pain radiated to the shoulder.
+
+There remains to be noticed one clinical feature of the disease, which,
+I believe, is characteristic; namely, the peculiar mental depression
+which attended all the cases I have seen, but was most marked in the two
+in which jaundice occurred. In the girl above referred to, the apathy,
+during the period when there was jaundice but no pain, was even
+alarming; it reminded one of the mental state in commencing catalepsy;
+during the painful stages it was more like the gloom of suicidal
+melancholia. Of course, the acute mental anxiety which this patient had
+suffered would account for a good deal of this; but the symptom was as
+distinct, though less severe, in the case of an elderly lady, whom I
+have attended on another occasion for migraine; here there was no
+recognizable source of anxiety; and, on the other hand, there was no
+reason to suspect the retention of bile-elements in the blood. It seems,
+therefore, as if an essentially depressing influence on the mind was
+excited by hepatic neuralgia; or else, that emotional causes are the
+chief source of the malady.
+
+_Neuralgia of the Heart._--If there be any hesitation in treating this
+disease as exactly conterminous with angina pectoris, it can, I think,
+be only reasonably justified on two grounds: In the first place, it may
+be urged that acute pain of the neuralgic type is not always present in
+angina pectoris; and, secondly, it may be urged that many cases of
+painful neurosis of the heart have been observed, in which the
+recurrence of pain with some amount of cardiac embarrassment has gone on
+for years, whereas the popular conception of true angina almost
+necessarily involves rapid fatality.
+
+There is doubtless some force in these objections, especially in the
+second, for it does seem rather inconvenient to call by the same name so
+deadly a disorder as the worst form of angina, and so comparatively
+harmless a malady as some of those instances of chronic tendency to
+spasmodic pain of the heart which are not very uncommon, and in which
+the patient survives, perhaps, to an old age. Yet, after all, there is
+the greatest difficulty in drawing any rational line of distinction; for
+the basis of the affection seems the same in every case, whether pain or
+spasm be the predominant feature, and whether the course of the disease
+be long or short. All that appears to be necessary for its production is
+a certain originally neurotic temperament (with possibly some congenital
+weakness or some post-natal disease of that part of the spinal-cord
+centres which Von Bezold has described as furnishing three-fourths of
+the propulsive power of the heart) and the presence of almost any kind
+of difficulty or embarrassment of the action of the heart. The most
+common source of this embarrassment is perhaps failure of nutrition in
+the muscular walls of the heart, from disease of the coronary arteries.
+Indeed, it is not known that any organic change of the heart or great
+vessels, even of the slightest kind, is necessary to the production of
+angina; on the contrary, there is every reason to think that mere
+fatigue and depression may bring on the attacks in persons of a strongly
+nervous temperament. For my own part, I am inclined to believe, however
+that there really always is disease somewhere in the cardiac centre of
+the spinal cord, though that disease may consist in no more than a
+disposition to minute interstitial atrophy. But we shall say more about
+this presently.
+
+It is at any rate certain that cardiac neuralgia is always a most grave
+complaint, from the almost total uncertainty whether succeeding attacks
+will not involve a fatal amount of spasm. As for the expression angina
+pectoris, it is just one of those mischievous terms which, arising out
+of the mystified ignorance in which the elder physicians found
+themselves as to the pathology of internal diseases, have since been
+attached in turn to various definite organic changes, with none of which
+they had any essential connection; and it is therefore much to be wished
+that it could be altogether done away with. At the same time, there is
+so much that is peculiar in the case of cardiac neuralgia, owing to the
+importance of the organ affected, that it will be necessary here to
+treat not merely its symptoms, but also its diagnosis, prognosis,
+etiology, pathology, and treatment, in a separate and continuous manner.
+
+_Clinical History and Symptoms._--Cardiac neuralgia usually shows itself
+for the first time with considerable abruptness. The patient may or may
+not have been consciously ill before the actual seizure, but it rarely
+happens, even when the heart has notoriously been the subject of some
+organic disease, that there has been any thing to lead him to expect the
+kind of attack from which he now suffers. In the midst of some little
+unusual effort, or even without this kind of provocation, suddenly the
+patient is attacked with severe pain, usually at the lower part of the
+sternum; this pain darts through to the back and left shoulder, and
+nearly always runs down the left arm. Sometimes, indeed, it is felt
+acutely over a large area of the chest, and runs down both arms; this is
+the case in a patient now under my care, in whom the affection is more
+obviously a neurosis, and less attended with coarse organic changes,
+than is usually the case. Along with the pain, which is always very
+distressing, but varies greatly in severity in different cases, there is
+a variable amount of another sensation which can be compared to nothing
+but cramp, or rather compression; the patient usually describes it as
+feeling as if some one were grasping the heart in his hands, and, when
+this sensation is at all prominent, the idea of impending death is most
+strongly impressed on the sufferer's mind. His outward appearance seems
+to confirm the idea. In cases where the sense of compression is great,
+the face is of an ashen gray; the lips white, with a faint livid tinge;
+the pulse small, feeble, and unrhythmical, or imperceptible, at the
+wrist; cold perspiration breaks out upon the face; in short, all the
+signs of approaching dissolution are present. In cases where the
+suffering is chiefly or entirely confined to severe pain, of a darting
+or burning character, the state of the circulation is often different.
+The heart bounds against the ribs, in rapid and painful palpitation, the
+face is flushed deep crimson, the pulse at the wrist is large, bounding,
+but very compressible; in fact, the outward appearance of the patient is
+so different from that of one who suffers from the more depressing kind
+of angina, that it is difficult to consider the two affections as
+essentially similar. But there can be no question, if we carefully
+examine the matter, that they are mere varieties of the same disorder,
+especially as they both may successively occur in the same person.
+
+The course of cardiac neuralgia varies extremely. Supposing the malady
+to be purely neurotic, and not complicated with organic disease, which
+forms a constant source of cardiac embarrassment, then the patient may
+only experience one or two attacks, under some special circumstances of
+exhaustion, which may never recur; or, on the other hand, he may develop
+a strong tendency to cardiac neuralgia which may beset him during almost
+any number of years. In the latter case, it is an even chance whether
+the patient will at last sink from the anginal affection; for, even
+supposing him to escape any fatal intercurrent disease of an independent
+nature, the fatal event may be at last produced by cerebral softening,
+or by apoplexy, or other central nervous disease. In fact, the frequency
+with which the latter kind of termination occurs is very significant of
+the essential nature of the disease.
+
+The manner in which cardiac neuralgia commences varies very greatly. In
+the celebrated case of Dr. Arnold, the first attack did not occur till
+he was forty-seven years of age; it at once assumed full intensity, and
+proved fatal in two hours and a half. There is also reason to believe
+that Dr. Arnold's father died in a first attack of angina. I have myself
+known a first attack prove fatal in the course of an hour; there was
+very considerable ossification of the coronary arteries and fatty
+degeneration of the heart-walls. Again, there are many cases which
+commence gradually, and with great mildness, and with little appearance
+of danger to life in the first attacks; but the subsequent attacks are
+progressively more severe and dangerous up to a fatal result, after
+weeks, months, or years. On the other hand, I have known three instances
+in which the first attacks of spasmodic heart-pain very nearly proved
+fatal, but the subsequent fits were milder (in one there was no second
+attack): all those patients are living, six, eight, and three years
+respectively, after their first attacks.
+
+It can hardly be doubted that neuralgic spasm is the true cause of
+sudden death in some cases of stenosis of the aortic orifice, which, but
+for some accidental circumstances, would not have died suddenly at all,
+but would have gone through a long and gradual course of deterioration.
+I particularly remember an instance in which extreme and calcareous
+constriction of the aortic orifice, in a boy not yet come to puberty,
+was entirely unsuspected, until one day, in running fast, he screamed
+out and fell down, and was almost instantaneously dead. I remember
+another case very similar, in which extreme mitral constriction produced
+almost as sudden death, apparently from painful spasm, under the same
+kind of exertion. On the other hand, sudden death, when produced by the
+form of heart-disease which (as Dr. Walshe points out) is most likely to
+cause such a catastrophe, viz., aortic regurgitation pure, without
+hypertrophy, does not seem to be due to painful spasm, but to simple and
+complete failure of the muscular power, and is perhaps partly of the
+nature of paralysis from a syncopal condition of the brain, the
+unhypertrophied heart having become for the moment unable to supply
+blood enough to the brain to carry on nervous function at all.
+
+A good instance of the form which angina takes, when the element of
+organic cardiac change is well pronounced, was afforded by the case of a
+young gentleman recently under my care. He was twenty-one years of age,
+and from early boyhood had been accustomed to a great deal of muscular
+exercise; in fact, it is probable that he had undermined his health by
+the frequent and extraordinarily long walks which he took, for his frame
+was particularly small and slight, and the muscles small and soft. He
+came of a family in whom the tendency to neurotic disorders is obviously
+very strong; both his father and his brother are subject to bad attacks
+of migraine, and he had himself repeatedly suffered from the same thing.
+The family disposition, altogether, is highly nervous and excitable. The
+remarkable circumstance in this young gentleman's case is, that although
+he had taken for years an extraordinary amount of pedestrian exercise
+(including mountain-climbing), and latterly had exchanged this for the
+even more trying exertion of rowing, he had never suffered from any
+noticeable symptom of cardiac distress up to the very day of his anginal
+attack. For some months, however, he had been growing thin and pale, and
+I had given him certain cautions, and had made him take cod-liver oil
+and steel, as I entertained some fears of his becoming phthisical. On
+the day of the attack there was nothing particular in his appearance,
+but he complained of a slight cold, and had no appetite for his six
+o'clock dinner. He retired to rest at eleven o'clock, having taken a
+small dose of laudanum and chloric ether for his cold. In less than half
+an hour he awoke out of his sleep in fearful agony; so severe and
+prostrating was the anginoid pain that he had the greatest difficulty in
+crawling out of bed to unlock his door. I found him bathed in cold
+sweat, pale as a sheet, and with livid lips. He groaned with pain, which
+he described as "cutting him across" from the sternal notch to the
+nipple, and going down the left arm; and there was so marked a catching
+of the breath as to make it almost certain that there was diaphragmatic
+spasm; in fact, it was this which alarmed him, and made him say that he
+was certainly dying. The heart, however, appeared to be pushed up
+somewhat, and it was thought that this might be partly due to stomachic
+distention, but a mustard emetic produced little effect. The
+heart-sounds were so weak that the presence or absence of bruit could
+not be safely predicated; meantime, the pulsations intermitted in a most
+alarming manner. Large doses of brandy and sulphuric ether at length
+(after several relapses) seemed to subdue the pain and spasm, and in an
+hour and a half from the commencement of the attack the patient, though
+utterly worn out, sank into a tolerably quiet sleep. The spasms did not
+recur, but for the next three or four days he was in a state of great
+exhaustion. When his tranquillity of mind had been somewhat restored, a
+careful physical examination was made, and it was discovered that there
+was a moderately loud and somewhat thrilling systolic bruit at the site
+of the aortic valves, and extending some distance into the vessels. The
+pulse still remained strikingly intermittent, and, though of fair
+volume, was very compressible. Percussion indicated considerable
+enlargement of the heart, and the physical signs pointed, on the whole,
+to dilatation without hypertrophy. Some doubtful signs of consolidation
+were observed at both apices of the lungs.
+
+It is remarkable that, notwithstanding the serious degree of cardiac
+mischief indicated by the above signs, the patient, a very few days
+later, took a walk of some ten miles, and, though much exhausted,
+suffered no recurrence of his formidable spasmodic symptoms in
+consequence of this imprudence. He was sent to the mild climate of
+Mentone, and subsequently to Nice; the angina never recurred, but the
+patient remained weak, and liable to more or less dyspnoea for fifteen
+or sixteen months; now he lives an ordinary life, doing his duty as a
+Swiss citizen and officer. The cure of some hęmorrhoids, about twelve
+months after the anginal attack, seemed greatly to benefit him. What the
+future of this case may be it is impossible to say, but of course there
+is no security against the angina recurring on extraordinary excitement
+or over-exertion.
+
+Of the purely neurotic variety of angina it is impossible to determine
+the frequency; but it seems certain that the affection is common, and I
+suspect that it occurs more often than is supposed, as a sequel to
+asthma. The probable relationship between the two affections was long
+ago indicated by Kneeland.[8] I have certainly seen several cases of
+asthma in which spasmodic pain of the heart has occurred on various
+occasions after or during a very severe asthmatic paroxysm. One case was
+that of a gentleman, of a highly delicate and neurotic temperament, who
+had suffered for fifteen or sixteen years from well-marked spasmodic
+asthma: this case is remarkable as an illustration of several points
+which will be dwelt upon in other parts of this volume. For some time
+before the outbreak of cardiac neuralgia, he had suffered repeatedly
+from severe facial neuralgia, and these attacks on more than one
+occasion culminated in facial erysipelas, or what was entirely
+indistinguishable from that affection. He then began to suffer from
+cardiac pain and spasm after his asthmatic paroxysms, and these new
+symptoms speedily assumed the form of a very severe intermittent angina:
+in several of the attacks he appeared about to die. The pain in these
+attacks is very severe; it occupies a large area in the centre of the
+chest, and runs down both arms; and, what is strange, the arms become
+remarkably swollen and hot after an unusually long bout of pain, I
+presume from vaso-motor paralysis. At present (nearly five years from
+the commencement of the cardiac neuralgia) the cardiac attacks, though
+of frequent occurrence, are decidedly more tolerable than they were at
+first, and the sense of squeezing or pressure, though never quite
+absent, does not amount to the dreadful sort of feeling which used to
+convince the patient that he was at the point of death. In this case,
+the heart has been repeatedly explored without any positive result, and
+the pulse has been frequently tested by the sphygmograph. The latter
+instrument is the only mode of examining by which I have been able to
+elicit even suspicious evidence that there is any organic change of the
+heart; by means of it I have lately obtained some grounds for suspecting
+that there is slight dilatation of the heart, but it is uncertain
+whether anything of the kind existed at the commencement of the anginal
+symptoms. In this case I am inclined, on the whole, to doubt whether the
+angina will ever prove fatal, unless the bronchitis, with which the
+patient's asthma has for some time past been liable to be complicated,
+should occur in a severe form; in that case it is likely that the
+additional embarrassment of the heart's action may bring on fatal
+spasms.
+
+One of the best examples I ever saw of cardiac neuralgia (ultimately
+proving fatal) was one of which the origin was entirely nervous. It
+occurred in a gentleman in the prime of life, and naturally of a
+powerful physique, whose very active and capacious mind had been greatly
+overwrought. The whole weight of responsibility for an undertaking of
+national importance, and which involved great difficulties and much
+anxiety, for a long time rested on his shoulders. Under these influences
+he broke down, and never effectually recovered himself. At first, the
+symptoms were those of mere ordinary nervous exhaustion, but after a
+time he became subject to frequently recurring attacks of agonizing
+spasmodic heart-pain, with a sense of impending dissolution; from these
+he was invariably relieved by the inhalation of a small amount of
+chloroform. Not the slightest organic heart mischief could be detected,
+either during life or after death.
+
+_Pathology._--Angina stands in so peculiar a position that I deem it
+well to discuss it as a whole, and not merely its clinical history, in
+this place. As I have already said, there is nothing in the morbid
+appearances found after death which is characteristic of fatal angina,
+and in the milder kinds of cardiac neuralgia we are driven back upon the
+general probabilities which we deal with in reasoning as to the origin
+of neuralgias in general. As to morbid changes, it is impossible to say
+any thing more exhaustive of the facts known than the following words of
+Dr. Walshe:[9] "First, there are few, if any, structural diseases either
+of the heart, its orifices, and its nutrient arteries, or of the aorta,
+found recorded in the narratives of the post-mortem examination of
+different victims of angina pectoris. Secondly, there is no conceivable
+disease of these structures and parts which has not in various
+individuals reached the highest point of development, without anginal
+paroxysms, even of a slight kind, having occurred during life; to this
+proposition extensive calcification of the coronary arteries perhaps
+furnishes a solitary exception. Thirdly, the organic changes most
+frequently met with have been fatty atrophy and flabby dilatation of the
+heart; obstructive disease of the coronary arteries by atheroma and
+calcification of the orifice and arch of the aorta. Fourthly, the rarest
+have been hypertrophy and hypertrophy with dilatation. In truth, it may
+be doubted whether these conditions in their genuine form, without any
+combination of fatty atrophy, have ever been the sole morbid states
+present." From all this Dr. Walshe concludes that the fundamental
+mischief of angina is neurotic; and, while he believes that some
+textural change in the heart is necessary as an irritant to generate
+this neurotic susceptibility to dynamic disturbance from slight causes,
+he recognizes only one common quality in these various cardiac lesions,
+viz., that they indicate mal-nutrition and weakened power. Dr. Walshe
+does not appear to believe the neurotic disturbance can arise without
+the kind of irritation which is kept up by such cardiac changes. In
+spite, however of the great authority of this author, it certainly seems
+very probable that organic cardiac change is by no means necessary to
+the occurrence of angina, and this for two reasons: In the first place,
+though full reliance may be placed on the details of the post-mortem
+examinations made by Dr. Walshe himself, they are very few (twelve or
+fourteen) in number; and other observers who have recorded cases are as
+little trustworthy, considering their evident tendency to find some
+disease where none exists, as the older narratives which Dr. Walshe
+naturally distrusts were unreliable when they declared that no morbid
+change was present. And, secondly, his view hardly takes it into account
+that there are still two other alternatives, even supposing that one or
+other of the above changes is always present: (_a_) it is possible that
+the neurotic disturbance and the cardiac lesions might both be the
+result of a common cause; and (_b_) it is even possible that the
+alterations of tissue in the heart and vessels are due to a morbid
+influence proceeding from a diseased nervous centre, either spinal or
+sympathetic.
+
+As for the state of the muscular fibre which immediately causes death,
+Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and
+he urges in favor of this view the fact that in his large experience he
+has never known the pulse to intermit during the attack--it was always
+regular, however feeble. In this respect he is in opposition to some
+distinguished authors, however, and, as he allows that he has not seen
+original attacks in their height, but only when they were subsiding, it
+would be possible that the spasm stage had subsided. However Dr. Walshe
+admits that there may be exceptional cases in which spasm, or cramp (_i.
+e._, spasm with rupture or dislocation of fibre), really occurs, and
+suggests that this is very probable in the rare cases where death is
+attended by general tetanic spasm of the muscles. As far as my own
+opinion is worth anything, I could insist that at least Dr. Walshe must
+be right as against Dr. Latham and Dr. Inman, in affirming that cardiac
+cramp, if it occurs, is the consequence and not the cause of the
+neuralgic pain.
+
+_Causes._--In some respects it is impossible to deal with the etiology
+of angina apart from the pathology, just as we remarked with regard to
+neuralgias in general. But there are certain special features in the
+causation of angina pectoris which require separate notice, just as
+there are special features in its pathology.
+
+Of predisposing causes, the majority are the same as those of which we
+have spoken in our general remarks on the etiology of neuralgia. A
+family history of a tendency to the graver neuroses is I believe
+universal, and, indeed, direct inheritance of angina from father to
+son, as in Arnold's case, has happened in many recorded instances. A
+very remarkable fact is the time of life at which the disease originally
+appears: Walshe says it is rare before the age of fifty, but excessively
+rare before forty. This is very interesting, as placing angina in the
+same category with the severe and intractable forms of facial and other
+neuralgias which are so highly characteristic of the period of bodily
+degeneration. One may even gather a suspicion, though it goes but a
+short way toward proof, that the essence of angina is an atrophy either
+of the cardiac plexus or of the nucleus of the vagus, or of that part of
+the spinal cord, already mentioned, which seems to be the centre of the
+major part of the propulsive force of the heart.
+
+On the other hand, there is a fact, even more remarkable than the
+influence of age, which tells somewhat in a contrary direction. There is
+a most extraordinary preponderance of males among the victims of angina.
+Sir John Forbes found eighty males among eighty-eight patients suffering
+from this disease. On the first blush it would seem natural, indeed
+almost necessary, to explain this by supposing that, as men take a much
+larger amount of strong physical exercise than women, they will furnish
+a much larger proportion of subjects in whom an ill-nourished heart will
+break down under its work and be seized either with paralysis or cramp
+(for the two states are, after all, not opposed to each other, but only
+varying shades of debility.) Upon this theory one would have to believe
+that the origin of angina was far more peripheral than central, if we
+are to suppose that spasm is the ordinary condition of the heart during
+the anginal paroxysm. But we do not know that this is the case; indeed,
+there are many arguments against it; and at any rate we must suppose
+that in a considerable number of cases the muscular state is one of
+relaxation from want of power. And certainly it is infinitely more
+probable that paralysis or spasm of a muscular viscus should occur as a
+reflex consequence of neuralgia occurring in a nerve whose central
+nucleus was closely connected with the motor centre of the organ, than
+that mere paralysis of the viscus should convey a reflex impression to
+sensitive nerves which should express itself in the form of acute pain.
+It must be confessed that the matter hangs in doubt; but the evidence
+is, on the whole, very strong for the belief that central nervous
+mischief is the most important element in angina.
+
+Another very important class of predisposing causes of angina is the
+mental emotions. It is notorious that the disease is one not common in
+humble life; it chiefly assails the more cultivated class, and
+especially men who are much engaged in affairs in which great mental
+anxiety or emotion is mingled with severe toil of intellect. Thus the
+professional class has always shown a sad predominance in tendency to
+this disease; a large number of the victims have been found among
+overworked clergymen, lawyers, doctors, engineers, etc. The various
+forms of heart-lesion which have been already mentioned must doubtless
+be considered highly predisposing, when there is already a neurotic
+susceptibility, more especially those which, like fatty degeneration of
+the muscular structure, greatly enfeeble the heart's action. I do not
+believe that these diseases will cause angina in a person who is free
+from the peculiar nervous susceptibility.
+
+The immediately exciting causes are very various. The most common of all
+is doubtless some exertion of body, or distress of mind, which at once
+agitates and embarrasses the heart's action; and, where the tendency to
+cardiac neuralgia has once declared itself by an actual attack, very
+slight excesses of this kind will usually suffice to re-excite the
+paroxysm. Sexual excitement is particularly provocative of the attacks,
+in the predisposed. But much slighter causes suffice, in those cases
+where the irritability of the cardiac nerves has become very intense:
+thus a mere puff of cold air upon the face, and other similar slight
+peripheral impressions, by acting in a reflex manner, have frequently
+produced the paroxysm. I have seen an extremely severe anginal attack
+brought on by the slight shock of the sudden slamming of a door. And it
+would even appear that some peripheral excitements of a powerful kind
+may operate with such force as to generate angina in persons who are
+merely in weak health, but who cannot be supposed to be specially
+predisposed to angina; it is in this way, I presume, that we must
+explain the extraordinary occurrence, reported by Guelineau,[10] of an
+epidemic outbreak of angina, in which numbers of men, belonging to a
+ship's crew, were simultaneously affected. The men had been badly fed,
+and their quarters were very unhealthy; but the powerful exciting cause
+seemed to be the rapid change from a very hot to a very cold climate.
+Not only were there many cases of severe angina, but other forms of
+neuralgia, and severe colics, were observed in others of the crew. Among
+the sources of peripheral irritation which ought to be particularly
+considered, in relation to angina, are the diseases and injuries which
+produce powerful irritation of the branches of the trigeminus. Lederer's
+cases[11] of violent vomiting and cardiac pain, from the operation of
+pivoting teeth, and Remak's instances[12] of violent palpitation and
+cardiac distress, produced by disease of the last molar tooth, seem to
+show that, both through the vagus and the sympathetic, the most
+powerful reflex action may be produced in the heart and stomach by
+irritation of the fifth cranial.
+
+Another occasional excitant of angina is an interesting link in the
+chain of proof that angina is _au fond_ a neuralgia, namely, the
+malarial poison, which has in a good many well-observed cases distinctly
+induced the disease.[13] Finally, the occasional influence of excessive
+tobacco-smoking in producing anginal attacks, in persons not affected
+with any discoverable organic heart-disease, affords the strongest
+corroborative evidence of the essentially neurotic character of angina
+pectoris. M. Beau[14] has recorded many serious, and some fatal, cases
+from this cause. Probably in both the malarial cases and those induced
+by tobacco-poisoning the special neurotic tendency existed already.
+
+_Diagnosis._--The diagnosis of angina pectoris, in those severe forms
+with which the popular idea of the disease is chiefly connected, can
+hardly be a matter of much difficulty. When we see an elderly man lying
+in a state of deathly collapse, which has suddenly come on, with cold
+sweats and nearly extinguished pulse, gasping for breath, and
+complaining of intolerable pain in the chest and arm, and a sense of
+oppression more dreadful, even, than the pain, we can hardly doubt that
+the case is angina in its worst form. On the other hand, when a young
+person, especially a young female, complains even of very severe pain in
+the cardiac region, together with breathlessness, especially if the
+heart be palpitating and the face flushed, the diagnosis, though not
+immediately certain, already very strongly indicates the probability
+that the case is not one of primary cardiac neuralgia at all. These are
+extreme instances, however. In more doubtful cases, the following are
+the principal materials for decision:
+
+        _Affirmative Signs._                  _Negative Signs._
+
+  1. Age over forty.                  1. Age under forty.
+
+  2. Male sex.                        2. Female sex.
+
+  3. Nervous temperament (personal    3. Temperament either not nervous
+      and family) without marked          at all, or markedly hysterical
+      hysteria or hypochondriasis.        or hypochondriacal.
+
+
+  4. Existence of arterial            4. No signs of arterial
+      degeneration.                       degeneration.
+
+  5. Existence of valvular disease    5. No discernible valvular
+      of the heart.                       disease.
+
+  6. Extension of the pain to         6. Heart sounds clear and strong.
+      one or both arms.
+
+  7. Vivid sense of approaching       7. Pain fixed to one spot and
+      dissolution.                        increased or relieved by
+                                          muscular movements of the
+                                          painful parts.
+
+                                      8. Pain running round one side,
+                                          but not extending to shoulder
+                                          or arm.
+
+It is scarcely necessary to say that no single one of the above signs is
+individually of positive worth for the decision, which must be made
+after a careful review of the comparative arguments, _pro_ and _con_.
+The disorders with which angina is most likely to be confused are (1)
+Myalgia of the intercostal or pectoral muscles; (2) intercostal
+neuralgia; (3) acute commencing pleurisy. Either of these may very
+perfectly simulate the more formidable disease, as regards the two
+elements of acute pain and catching of the breath; but the condition of
+the circulation, taken together with the consideration of the above
+named points, will generally decide the question. Especially important
+is the deep persuasion of impending dissolution, when present, as a
+positively affirmative symptom.
+
+It should be born in mind that, if we are summoned to a patient's
+assistance, and have no previous history to guide us, our diagnosis, to
+be useful, must be rapid; and it is always better to err on the side of
+angina than in other directions, and to employ remedies boldly in that
+sense, if there be any reasonable ground for believing the case to be of
+that nature. A more mature and careful diagnosis may be made when the
+patient has recovered from the severe symptoms of the paroxysm.
+
+_Prognosis._--The prognosis of cardiac neuralgia is at best doubtful,
+and, in many cases, positively bad in the highest degree. If the attacks
+occur for the first time in a patient who has passed middle life, and is
+physiologically old for his age, _i. e._, shows tendency to degenerative
+changes of vessels, arcus senilis, gray hair etc., they are of very
+gloomy import; more especially if any signs exist which make a fatty
+change in the ventricle probable, or if there be serious valvular
+lesions. The probability here is greatly in favor of a speedy fatal
+termination; if the first attack does not kill, a second or third very
+probably will; at any rate, the patient is not likely to survive any
+considerable number. If the attack occurs in a younger person, in whom
+there is not much likelihood that arterial degeneration has seriously
+commenced, or the heart-muscles become fatty, more especially if the
+attacks have been brought on by such an accidental circumstance as a
+very exhausting bout of mental or physical toil, then there is
+considerable reason to hope that the disease may soon wear itself out.
+Even patients who have serious valvular lesions may, with young and
+undegenerated tissues in their favor, quiet down again into a regular
+habit of semi-health, in which they may live for a long time without
+any recurrence of cardiac neuralgia. The more purely neurotic form,
+again, especially when it develops gradually out of some pre-existing
+chronic neurosis, such as asthma, is usually slow in its progress; and
+it may well happen, in such cases, that the danger to life is more on
+the side of serious nervous lesions than from the anginal attacks
+themselves. At the same time, it must be remembered that, even in the
+milder cases, any very unusual excitement, bringing on an unwontedly
+severe attack, may produce fatal results at any period of the disease.
+
+There is some reason to believe that cardiac neuralgia is occasionally
+produced in a reflex manner in consequence of a severe existing
+intercostal neuralgia. I cannot say that I have witnessed any thing
+which can be considered as completely proving this; but it certainly
+seems likely that, in some of the few cases of excessively painful
+herpes zoster which have proved fatal (of which I have given one
+example), cardiac spasm or paralysis may have been secondarily induced,
+and may have occasioned the catastrophe. It is likely enough that, if
+this was the case, the reflex irritation operated upon motor centres
+which themselves were predisposed to take on the morbid action; but this
+again is a fresh illustration of the uncertainties to which prognosis is
+liable in a disease like angina, the very fundamental character of which
+is that, upon increase of the irritation, the gravity of the resulting
+functional affection is liable to be indefinitely and most rapidly
+increased.
+
+_Treatment._--The treatment of cardiac neuralgia is (1) prophylactic,
+and (2) palliative of the attacks.
+
+As regards the prophylactic treatment, it is unnecessary to repeat the
+remarks which we have made elsewhere upon the general principles of
+tonic and nutritive medication in neuralgias of every kind. One especial
+prophylaxis, in the case of this formidable variety of neuralgia, is
+concerned with the preservation of the heart from certain disturbing
+influences which would render the occurrence of the fit more probable.
+All violent emotions and all strong physical exercise (but especially
+such forms of it as, like boating, are well known to "pump" the heart
+severely) are to be carefully avoided. Even indigestion and flatulence
+are to be carefully guarded against since these are quite capable of
+embarrassing the action of the heart to a degree which, though it might
+be trivial in the case of ordinary health, may prove fatal by exciting a
+flabby ventricle to irregular and embarrassing contraction. It is even
+possible that the strong irritation set up by some varieties of
+indigestible food might propagate an irritation to the spinal cord which
+would produce an interbitory paralysis at once.
+
+But besides these obvious precautions against interference with the
+regular and tranquil action of the heart, there are some special
+medicinal remedies which deserve particular notice. Whether we really
+possess any means of so influencing the nutrition of the muscular tissue
+of the heart as to prevent its lapsing into a fatty degeneration, it is
+impossible to say; but this may be affirmed with some confidence, that,
+in cases where awkward threatenings of cardiac neuralgia have occurred,
+and simultaneously it has been noticed that the heart-sounds become weak
+and the circulation languid, a most marked improvement has been produced
+in all respects by the administration of iron and strychnia. I usually
+give tincture of sesquichloride of iron, ten minims, and strychnia,
+one-fortieth of a grain, three times a day. Still better, where it can
+be borne, is the syrup of the triple phosphate of quinine, iron, and
+strychnia, which undoubtedly has an extraordinary influence upon tissue
+nutrition, as exemplified in its remarkable effects in many cases of
+phthisis. It must be observed, however, that it is not every neuralgic
+patient who will bear the combination of quinine with iron; it has
+occurred to me to meet with several in whom the union of these two
+remedies proved violently disturbing to the nervous system, causing
+distressing headache and palpitation of the heart, which could not be
+attributed to any want of care in the apportioning of the dose, or in
+the mode of administration. Iron is more especially indicated, of
+course, in cases where there is anęmia; but there are some cases in
+which strychnia given alone seems to produce a very beneficial
+influence. (_vide_ Chapter V., on "Treatment.")
+
+By far the most important prophylactic tonic against cardiac neuralgia,
+however, is arsenic. That this drug should prove useful in cardiac
+neuroses might readily be anticipated from its very great utility in
+many cases of asthma, a disease which, as already remarked, has a close
+relationship to the former. Dr. Philipp has recently recorded a case
+which is perhaps an extreme instance of this beneficial influence of
+arsenic, but is none the less encouraging, especially as it only
+corroborates what has been advanced by other observers. Given in doses
+of from three to five minims of Fowler's solution, twice or thrice
+daily, arsenic is an invaluable remedy in cardiac neuralgia; the one
+objection to it being that some neurotic patients possess such an
+irritable intestinal canal that the remedy cannot be borne, as it
+produces diarrhoea. Even here we may sometimes succeed by combining it
+with very small doses of opium. It is more especially with regard to
+those cases in which the neurotic character of the disease is very
+prominent--_i. e._, in which the nervous temperament of the patient
+betrays itself in other ways besides the tendency to spasmodic
+embarrassment of the heart's action, that arsenic holds such a very high
+place as a remedy. And it should be carefully remarked that the
+prophylaxis of angina extends itself, in such cases, beyond the limits
+of actually-declared and well-defined angina, which is, of course, an
+uncommon disease. This remedy is important, and may be most usefully
+employed in the far larger group of cases in which a marked tendency to
+spasmodic pain in the chest, on the occurrence of some comparatively
+trifling excitement, is observed in patients who either have some
+organic heart-disease, or who are liable to severe attacks of asthma. It
+cannot be too often repeated that there is no intelligible separation,
+except one of degree, between these cases and the malignant forms of
+angina. It may be added that, in my experience, I have found the whole
+group of cases to be bound together in a singular way by the tolerance
+of arsenic which, with certain exceptions already referred to, they
+display. Commencing with the small doses above mentioned, I have found
+it possible, in many cases, to advance to the administration of twice or
+thrice the quantity, and to continue this medication for months
+together, not only with no evil effect, but with the best results.
+
+Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but
+little. Truth to say, it is a nervine tonic of occasional great value,
+but which, on the whole, I have found so unreliable that I am somewhat
+prejudiced against it; and perhaps have not given it a fair trial in
+those milder cases of cardiac pain to which it might be suited. It does
+appear, however, to have some preferential action on the vagus, and
+might therefore be possibly more useful than I am at present inclined to
+think it.
+
+The treatment of the acute neuralgic stage itself is a matter in which
+we are sadly limited by the exigencies of the case. Relief must be
+excessively rapid if we are to save life in the most threatening cases,
+or to deliver the patient from a most prostrating agony, which might
+have lasted for hours, in other instances.
+
+The remedy which the highest authority, Dr. Walshe, seems to put first
+in efficacy is opium; and he directs the dose to be measured by the
+intensity of the pain, as much as forty to sixty drops of laudanum being
+given in a severe case. He says, however, that it should be given with
+an antispasmodic, such as brandy, or ether, or sal-volatile; and I
+confess that I believe the antispasmodic treatment to be by far the most
+important. Indeed, so marked is the success which I have found to attend
+the use of ether in the paroxysm, that till lately I scarcely cared to
+make further experiments, with drugs, for the relief of the patient at
+this stage. One teaspoonful of ether in two ounces of thickish mucilage
+should be given at once, and repeated in a short time if the patient
+does not rally.
+
+In a few instances, angina seems to be provoked by the irritation of
+indigestible food, and when there is good reason to suspect this an
+emetic should be given. I strongly recommend that mustard should be
+used for this purpose, for the effect of a mustard-emetic is by no means
+merely to empty the stomach, it has a powerfully rousing influence on
+the heart.
+
+Upon the subject of the inhalation of chloroform for cardiac neuralgia,
+I have only to say that, though I have seen it usefully employed, I
+should not, with my present experience, ever think of employing it
+myself. Every possible advantage which it could give is obtained by the
+internal use of ether, and many serious dangers are avoided, which would
+attend the use of chloroform. For it must be remembered that the only
+kind of chloroform inhalation which would be useful would be that in
+which a carefully measured small dose of a weakly impregnated atmosphere
+should be inhaled, and, without large experience in the administration
+of chloroform, the practitioner will be unable to secure this effect
+with certainty. And the effect of a powerfully-charged atmosphere,
+breathed only once or twice even, would be instantaneously fatal.
+
+Hot epithems to the epigastrium are probably of some use, and besides
+this the temperature of the body should be carefully kept up by hot
+bottles to the feet, hot tins to the epigastrium, etc. Brandy should be
+freely administered during the attack, if we cannot immediately obtain
+either ether or a remedy now to be mentioned. I refer to the nitrite of
+amyl, which, at the time when the first part of this chapter was
+written, I had not had the opportunity of testing.
+
+Nitrite of amyl is a highly-vaporizable fluid, which possesses the
+following remarkable physiological action: the inhalation even of a very
+small quantity is followed, after a minute or so, by a sudden
+acceleration of the heart's action, accompanied by intense crimson
+congestion of the vessels of the face and conjunctiva, and a sense of
+enormous fulness in the head; these phenomena are extremely fugitive,
+passing away completely in two or three minutes, unless the inhalation
+is renewed. These characteristic effects had for some years been
+experimentally exhibited by Dr. Fraser and others, but the practical
+application of amyl to the treatment of angina was first suggested, I
+believe, by Dr. Brunton, in the case of a patient under the treatment of
+Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The
+angina was in this case symptomatic, there being advanced valvular
+disease of the heart. Comparative examinations with the sphygmograph,
+during the intervals and during the paroxysms, made strikingly manifest
+the fact that, during the attacks, there was an increase of arterial
+tension which was directly proportionate to the severity of the pain and
+cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that
+nitrite of amyl, by relaxing the systemic arteries, might remove the
+unnatural tension, and give relief to the pain; and the result confirmed
+this hope. Doses of five and ten drops were inhaled from a towel, with
+the uniform result of at once quieting the pain; it might return in a
+few minutes, but a second dose usually removed it entirely for many
+hours. Various other cases have since been reported, in which similar
+relief was obtained, and I had occasion to employ it myself in one
+instance. The gentleman whose case has been related above (see page
+101), as an example of the relief obtainable by the use of ether began
+to suffer rather more severely from his attacks than had been the case
+for some time, toward the end of the year 1869. I now determined to try
+the amyl, and accordingly left a small bottle containing half an ounce
+of it in his possession, with exact instructions to the following
+effect: On the first symptoms of a paroxysm of angina, he was to get the
+bottle open, and as soon as their character was fully declared he was to
+put the bottle to one nostril (closing the other with the finger, and
+keeping the mouth shut) and take one long, powerful inspiration. The
+result of his first experiment was very remarkable: the first sniff
+produced, after an interval of a few seconds, the characteristic
+flushing of the face and sense of fulness of the head; the heart gave
+one strong beat, and then at once he passed from the state of agony to
+one of perfect repose and peace, and at his usual bedtime slept
+naturally. This experience was repeated on several occasions, and for a
+considerable time the patient retained such full confidence in the
+remedy that he discarded all use of ether, and greatly reduced his
+allowance of stimulants, with very marked benefit to his appetite and
+general health. The new remedy did not lose any of its power by
+repetition, but unfortunately the patient at last conceived a horror of
+it, which caused him to abandon its use. So distressing and alarming to
+him was the sense of fulness in the head produced by the amyl, that,
+notwithstanding his certain knowledge that he could at once cut short a
+paroxysm, he could not persuade himself to continue its use, and for
+some time past he has returned to the use of the ether and (though in
+less quantities than previously) of the brandy, for this purpose. And
+here it must be remarked that this objection, although probably needless
+in the case of this particular patient, may have real importance in
+certain circumstances. The admirable physiological researches of Dr.
+Brunton leave no doubt that the effect of inhalation of amyl is to
+relax, very suddenly, the tonic contraction of the systemic arteries,
+and in the case of the brain it would appear that a serious strain must
+be suddenly thrown upon the capillary net-work. This being the case, it
+appears likely that, where the atheromatous change has considerably
+invaded these delicate vessels, they might prove too brittle to stand
+the sudden distention, and a rupture and consequent cerebral hęmorrhage
+might ensue. This suspicion, then, that such pathological changes exist,
+ought to seriously affect our judgment as to the administration of
+amyl; and this suspicion ought to be always entertained, _prima facie_,
+in the case of patients who have much passed the age of fifty, more
+especially if they have gray hair and an arcus senilis, or if the
+sphygmograph yields a pulse-trace of the decidedly square-headed type,
+or if they have been long addicted to alcoholic intemperance. In such
+patients I should be disinclined to allow the use of amyl.
+
+[Although I have thought fit here to give an outline of angina pectoris
+as a connected whole, I shall have occasion to recur to the subject
+again under the heads of Pathology and Treatment of Neuralgias in
+General.]
+
+_Gastralgia._--Neuralgia seated in the stomach itself is not to be
+distinguished with accuracy from neuralgic pains occupying one or other
+of the neighboring nervous plexuses. It must be remembered that not
+merely is the stomach itself copiously supplied by the pneumogastric
+nerves with afferent fibres, but the great solar plexus is close behind
+it, the coeliac plexus springs from the fore part of the latter, and
+these, with the coronary and superior mesenteric plexus, may all be said
+to be well within the region in which "gastralgic" pain is felt. It is
+not particularly important, however, in my opinion, to make any very
+exact diagnosis here, as to the site of the pain, since all these
+neuralgias must be considered to belong to the pneumogastric nerve, the
+branches supplied from which are probably the sole means by which these
+plexuses become the seat of neuralgia.
+
+Abdominal pneumogastric neuralgia is an extremely distressing and
+occasionally a very intractable disorder. The subjects of it are almost
+invariably in a state of marked and evident debility, and inquiry
+generally elicits the fact that they have suffered at other times from
+neuralgia elsewhere than in its present seat. By far the most common
+history of previous affections of this kind is that of trigeminal
+neuralgia, especially of the supra-orbital branch; and it has several
+times occurred to me to observe the direct sequence of a gastralgia upon
+a unilateral browache. Anęmia is a specially frequent attendant of
+gastralgia, more so than of other neuralgias. Women are, by the general
+consent of authors, more liable to gastralgia than men.
+
+The special mark of true neuralgic pain in the abdominal pneumogastric,
+as distinguished from other deep-seated pains in the epigastrium, is the
+remarkably direct relation of its severity to the patient's exhaustion,
+particularly in regard to the weakness induced by want of food. While
+the great majority of dyspeptic pains are increased by filling the
+stomach, gastralgia, on the contrary, is invariably relieved by food,
+often most strikingly and completely. Pressure from without, also, while
+it aggravates most pains dependent on local organic mischief, nearly
+always more or less relieves gastralgia. Equally striking is the comfort
+given by stimulants, especially by hot brandy-and-water; in this respect
+gastralgia resembles colic. There is something special in the degree of
+mental depression which attends gastralgic pain. In this it resembles
+the pains of hypochondriasis, but there is a resilience of the spirits
+when the pain has been relieved which is not seen in the latter
+affection. A very frequent complication of gastralgia is severe
+palpitation of the heart, but during the paroxysm itself the pulse,
+whether rapid or not, is commonly small, at first tense, and afterward
+soft, but not acquiring any considerable volume till the pain has
+ceased.
+
+So severe is the pain, and so complete the mental and physical
+prostration in bad attacks of gastralgia, that the first aspect of the
+patient might suggest--indeed often has suggested--the occurrence of
+gastric or duodenal perforation; but, as soon as the paroxysm is over
+all the alarming appearances vanish, leaving only a certain amount of
+tenderness on deep pressure. In the more typical cases there are no
+signs of dyspepsia whatever, no fulness nor excessive redness of the
+tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the
+neuralgic affection is complicated with more or less gastric catarrh;
+but this is a much rarer occurrence, in my experience, than some writers
+would lead one to believe; and, moreover, where a certain amount of
+organic disorder of the stomach is observed, it is usually a mere
+secondary result of the neuralgia. The most severe example of gastralgia
+which I ever saw was entirely unaccompanied by dyspepsia; this patient
+absolutely attempted suicide to escape from his agonizing pains, which
+recurred with the greatest frequency and obstinacy, but were at last
+entirely removed by strychnia. In another patient whose very interesting
+case will be again alluded to under the head of Complications of
+Neuralgia, violent abdominal pneumogastric pain was succeeded by a
+severe attack of trigeminal neuralgia, accompanied by inflammation of
+the eye, which inflicted irreparable damage; here, too, the gastralgia
+was entirely uncomplicated by any other stomach-symptoms.
+
+_Cerebral Neuralgia._--We enter, here, on an extremely obscure and
+doubtful subject: Can there be pain in the central masses of the
+encephalon? There are undoubtedly a not inconsiderable number of cases
+of pain, neuralgic in type on the whole, in which the suffering cannot
+be referred to any recognizable superficial nerve. It seems deeply
+situated within the cranium. I have also quoted cases of Dr. Hillier's
+in which not merely was there deep-seated headache in children, but
+there was something like a characteristic general change observed in the
+brain-tissues after death, viz., a great moisture and softness of
+texture. Notwithstanding all this, I am not convinced, nor indeed much
+disposed to believe, that pain is ever felt in the structure of the
+brain; I rather believe that, in the cases where this seems to occur,
+the pain is either in the intracranial portion of the nerve trunks, or,
+far more probably, in the twigs of nerves that are distributed to the
+cerebral membranes. In that case they are, strictly speaking, only
+varieties of neuralgia of the fifth nerve, and might have been properly
+discussed under that heading; but it is more convenient to speak of them
+apart, since their phenomena present considerable differences from those
+of the external neuralgias of the head and face.
+
+I have now seen several of these cases of intracranial neuralgias, and
+very perplexing and (at first sight) alarming they certainly are. The
+first of these cases came under my care in 1868. The patient was a
+single lady who had greatly over-tasked an intellect that was not,
+perhaps, originally very strong, by trying to do hack literature on
+conscientious principles; insisting, for instance, on knowing something
+about every subject she wrote upon. Her age was thirty-eight when she
+applied to me; menstruation was scanty but regular; and, on the whole,
+she could not be said to have passed an unhealthy life, although
+"nervous-headaches" and "sick-headaches" had occasionally beset her.
+This time the trouble seemed to be more serious. Ten days before
+applying to me, she had awaked in the morning with a feeling that
+something was very wrong in her head; there was not so much pain as a
+dull, brooding sort of weight, felt deeply within the cranium, and
+rather anteriorly. This had not lasted many hours when she was seized
+with a sensation of intense cold, amounting almost to rigors, and then
+before long was suddenly attacked with acute splitting pain in the same
+situation as the feeling of weight already mentioned had occupied. This
+pain, which came and went, or rather intensified and remitted, without
+ever completely ceasing, lasted about two hours, and then rather
+suddenly disappeared, leaving the patient with a deep "bruised and sore
+feeling in her brains." The pain recurred about the middle of the next
+day, lasting for several hours, and again leaving behind it the sore
+feeling. Day by day the paroxysms returned, and, on the day before her
+visit to me, the patient had, she told me, been driven frantic by her
+sufferings and had become actually delirious. Her appearance, when I
+first saw her, was wretched; the face haggard, both eyes sunken and
+surrounded with deep rings of dusky pigment, both conjunctivę bloodshot,
+the whole face almost earthy in its pallor. At that hour (11 A. M.) the
+pain had not positively recommenced, but she was in momentary dread of
+its recurrence. She complained of giddiness, muscę volitantes, and great
+feebleness of vision, and dreaded attempting to read, as the mere effort
+of fixing her eyes on anything intently caused flashes of fire before
+them. It was difficult at first to believe that there was not some
+serious organic brain-mischief; but on the whole I concluded that there
+was an absence of any genuine symptoms of such disease. At the same
+time, the pain was decidedly not referred to any cutaneous sensory
+nerve; and on the whole it appeared probable that the affection was
+intracranial. There remained the diagnosis of meningeal neuralgia, and
+to this I provisionally made up my mind. The opinion that the pain did
+not depend on any fixed organic disease was decisively justified by the
+results of treatment. One-sixth of a grain of morphia was injected on
+the occasion of the first visit, and this was repeated every day, and
+sometimes twice a day, for a fortnight; by this sole means, with rest,
+quietude, and light nourishing food, the patient was brought to
+comparative convalescence. The injections were then gradually
+discontinued, and she got quite well.
+
+In a second case, which presented itself in the out-patient room at
+Westminster Hospital, a young man of markedly-nervous temperament, who
+had been somewhat given to drink, complained of similarly deep-seated
+intermittent pain, which he referred, however, to a point nearer the
+back of the head. He suffered, also, from vertigo, especially after
+unusually long paroxysms. Blisters to the nape of the neck, and a few
+subcutaneous injections of morphia, removed the pain and the vertigo
+completely.
+
+A third example was that of a gentleman, aged thirty-four, who was sent
+over from the neighborhood of Sydney, Australia, to see me. Here, also,
+there was deep-seated intracranial neuralgic pain of the most severe
+kind, which greatly alarmed his local medical attendants; and it was
+only after a great many remedies had been tried that one medical man
+gave the opinion that the disease was "neuralgia of the membranes of the
+brain," and employed the hypodermic injection of morphia. This treatment
+at once gave great relief, though the pain had been so severe as to
+cause delirium on several occasions. In order to get thoroughly
+re-established, he was sent to England, and desired to consult me. As
+was expected, the voyage proved of the greatest service, as he hardly
+suffered at all while on the water. On arriving in England he was at
+first well, but in a week or two began to feel somewhat below par, and
+one morning, feeling an attack of pain coming on, he came to me. He was
+a tall and strongly-built man, with nothing peculiar in his appearance
+except a certain languor and heaviness of the eyes. He appeared to have
+lived somewhat freely and to have smoked decidedly to excess. His
+description of the attacks left no doubt of their neuralgic character,
+and in other respects they seemed quite analogous to the other cases
+mentioned above, except in one thing, that there seemed a good deal of
+evidence tending to show a bad local influence in the air of that part
+of Australia where he usually resided. Almost any change from that had
+always done him good, though nothing had done anything like so much as
+the voyage to England. On the occasion of his first visit to me I
+injected him with one-sixth grain acetate of morphia, thereby stopping
+the pain. I prescribed muriate of iron and minute doses of strychnia,
+which he took for some little time, but the pain never recurred during
+his stay in England and on the Continent. Unfortunately, as he was
+anxious to return to Australia, I permitted him to do so, after a stay
+in the Old World of only three or four months; but, very shortly indeed
+after his return to Sydney, his old complaint attacked him. This time,
+unhappily, the hypodermic morphia has proved merely palliative, and I
+have latterly heard very bad accounts from him; still, there has been
+nothing to throw doubt on the neuralgic character of the disease.
+
+In reflecting upon the anatomy of the nervous branches to the dura
+mater, I have formed the opinion that there are two situations, one
+anterior and the other posterior, in which intracranial neuralgia may
+occur; the former at the giving off of Arnold's recurrent branch from
+the ophthalmic division, near the sella turcica, the other in the
+peripheral twigs of this same branch, distributed to the tentorium
+cerebelli.
+
+_Pharyngeal Neuralgia._--A rather common and extremely troublesome form
+of neuralgia is that which attacks the pharynx. It is very much more
+common in women than in men, and especially in hysterical persons. The
+pain commonly commences in a not very acute manner; it may be felt for
+some days, or even weeks, as a dull aching, coming and going pretty much
+in accordance with the patient's state of fatigue, or of reinvigoration
+after meals, etc. Some trivial circumstance, such as a slightly extra
+degree of exhaustion, or the influence of some depressing emotion, will
+then change the type to that of decided neuralgia, which may become
+extremely severe. Nothing is more annoying, and even distressing, than
+the suffering itself, besides which there are abnormal sensations in the
+throat which almost irresistibly compel the patient to believe that
+there are severe inflammation and ulceration, and that the throat is in
+danger of being closed up. Although the pain is usually one-sided, it
+sometimes affects both sides, and is felt also at the back of the
+pharynx. The act of swallowing being painful, there is the greater
+suspicion of inflammation or ulceration, but careful observation shows
+that a large bolus of food is swallowed with as little, if not less,
+pain than a small mouthful of solids or even liquids.
+
+Pharyngeal neuralgia must, I think, be considered mainly an affection of
+the glosso-pharyngeal nerve; the evidence for this is found in the
+distribution of the pain. A slight degree of the neuralgia will only
+involve some one or two points in or behind the tonsil; but, when the
+pain is strongly developed, it will be found to radiate into the tongue,
+in one direction, and into the neck (following the course of the
+carotid) in another, besides spreading well into the region occupied by
+the pharyngeal plexus. One disagreeable reflex effect of severe
+pharyngeal neuralgia consists in involuntary movements of the muscles of
+deglutition, another is seen in the copious outpouring of thick mucus
+similar to that which collects in the pharynx and oesophagus when a
+foreign substance has become impacted.
+
+_Laryngeal neuralgia_ concentrates itself mainly in the twigs of the
+superior laryngeal branch of the pneumogastric which are distributed to
+the arytęno-epiglottidean folds, the epiglottis, and the chordę vocales;
+more rarely a neuralgia is developed lower down, within the cavity of
+the larynx, apparently in one or more of the scanty twigs to the mucous
+membrane supplied by the recurrent laryngeal.
+
+Pure neuralgias of the larynx, like those of the pharynx, are more
+common in women, and especially in weakly hysterical women, than in men.
+They are easily excited and greatly aggravated by movements of the
+parts, and thus it happens that, among men, by far the most numerous
+subjects of laryngeal neuralgia are found among clergymen, professional
+singers, and others whose occupation compels them to strenuous and
+fatiguing employment of the laryngeal muscles. It is rather a singular
+and striking fact, however, that the so-called "clergyman's
+sore-throat," which is characterized by most unpleasant sensations, and
+by a more or less complete loss of voice, is not, in the majority of
+cases, attended with any distinct laryngeal neuralgia. It seems that a
+predisposition to neuralgia is a necessary element in the latter
+affection.
+
+FOOTNOTES:
+
+[3] "Gunshot Wounds and other Injuries to Nerves." Philadelphia:
+Lippincott & Co., 1864.
+
+[4] _Med. Times and Gazette_, March 26, 1864.
+
+[5] "London Hosp. Reports," 1866.
+
+[6] "Stimulants and Narcotics," Macmillan, 1854, p. 86.
+
+[7] Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du
+Nevralgies," Journ de Med. de Bruxelles, tome xl.
+
+[8] Amer. Jour. Med. Science. Jan. 1850.
+
+[9] "Diseases of the Heart and Great Vessels." Third edition, 1862.
+
+[10] _Gaz. des Hop._, 114, 117, 120. 1862.
+
+[11] _Wien Med. Presse_, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p.
+120.
+
+[12] Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120.
+
+[13] See Wahn, _Journ. de Med. et Chir. Prat._ 1854. Also several
+original and quoted cases in Dr. Handfield Jones's "Functional Nervous
+Disorders," second edition, 1870.
+
+[14] _Journ. de Med. et Chir. Prat._, July, 1862.
+
+
+
+
+CHAPTER II.
+
+COMPLICATIONS OF NEURALGIA.
+
+
+The secondary affections which may arise as complications of neuralgia
+form a deeply interesting chapter in nervous pathology, and one which
+has only been explored in quite recent years. The excellent treatises of
+Valleix and Romberg, written only thirty years ago, make but most
+cursory and superficial mention of these complications, and do not
+attempt to group them in a scientific manner. The reflex convulsive
+movement of the facial muscles in severe tic-douloureux had of course
+been long observed; and Valleix added the correct observation that
+gastric disturbance was often secondarily provoked in facial neuralgia,
+thus improving greatly on the old view, which supposed that, where
+trigeminal neuralgia and stomach disorder coexisted, the latter must
+have been the antecedent and the cause of the former. Still, he did not
+explain the pathological connection. And as regards certain other most
+interesting results of neuralgia, which he could not avoid meeting with
+from time to time, _e. g._, lachrymation, flux from the nostril,
+salivation, altered nutrition of the hair, he only speaks of these as
+occasional phenomena, and in no way classifies them, or explains their
+relation to the neuralgia itself.
+
+There did exist, however, one too little known work of some years
+earlier date, which, though not dealing specifically with neuralgia, and
+though based upon the necessarily very imperfect knowledge of the
+functions of the nervous system prevalent in its day, had nevertheless
+done much to lay the foundation of a comprehensive view of the
+complications of neuralgia; we refer to the work of the brothers
+Griffin, on "Functional Affections of the Spinal Cord and Ganglionic
+System," published in 1834. In this most interesting treatise, the
+record of acute and extensive observations made in a quiet and
+unpretending way by two Irish practitioners, numerous examples are cited
+in which neuralgic affections were seen to be inseparably united with
+secondary affections of the most various organs, with which the
+neuralgic nerves could have no connection except through the centres, by
+reflex action. The authors, while firmly grasping the fact of the common
+connection of the nerve-pain and the other phenomena (convulsions,
+paralysis, altered special sensation, changes in secretion, changes even
+in the nutrition of particular tissues) with the central nerve system,
+were doubtless in error in thinking that they could detect the precise
+seat of the original malady, by discovering certain points of tenderness
+over the spinal column. But their facts were observed with the greatest
+care, and can now be interpreted more intelligently than was possible at
+the time. Here, for example, is a case which forestalls one of the most
+interesting pieces of information which more recent research has made
+generally known:
+
+"CASE XXIV.--Kitty Hanley, aged fourteen years, catamenia never
+appeared; about six months ago was attacked with pain in the right eye
+and brow, occurring only at night, and then so violently as to make her
+scream out and disturb every one in the house; it afterward occurred in
+the infra-orbital nerve, and along the lower jaw in the teeth, and there
+was inflammation of the cornea, with superficial ulceration and slight
+muddiness. Tenderness was found at the upper cervical vertebrę, pressure
+on any of them exciting severe pain in the vertex and brow; but none in
+the eye or jaws, where it is never felt except at night."
+
+The above is a well-marked example of neuralgia of the trigeminus
+causing secondary inflammation and ulceration of the eye of a precisely
+similar kind to that which had been experimentally produced by Magendie
+by section of the fifth, at or posterior to its Gasserian ganglion. We
+shall see, hereafter, how extremely important are this and similar
+facts, not only in regard to the clinical history, but also to the
+pathology of neuralgia in general.
+
+The first regular attempt, I believe, to classify the complications of
+neuralgia, was made by M. Notta, in a series of elaborate papers in the
+"Archives Generales de Medecine" for 1854. We may specially mention his
+analysis of a hundred and twenty-eight cases of trigeminal neuralgia,
+which is well fitted to impress on the mind the frequency, though, as we
+shall presently see, it does not adequately represent the seriousness,
+of these secondary disorders. As regards special senses, Notta says that
+the retina was completely or almost completely paralyzed in ten cases,
+and in nine others vision was interfered with, partly, probably, from
+impaired function of the retina, but partly, also, from dilatation of
+the pupil or other functional derangement independent of the optic
+nerve. The sense of hearing was impaired in four cases. The sense of
+taste was perverted in one case, and abolished in another. As regards
+secretion, lachrymation was observed in sixty-one cases, or nearly half
+the total number. Nasal secretion was repressed in one case, in ten
+others it was increased on the affected side. Unilateral sweating is
+spoken of more doubtfully, but is said to have been probably present in
+a considerable number of cases. In eight instances there was decided
+unilateral redness of the face, and five times this was attended with
+noticeable tumefaction. In one case the unilateral tumefaction and
+redness persisted, and were, in fact, accompanied by a general
+hypertrophy of the tissues. Dilatation of the conjunctival vessels was
+observed in thirty-four cases. Nutrition was affected as follows: In
+four cases there was unilateral hypertrophy of the tissues; in two, the
+hair was hypertrophied at the ends, and in several others it was
+observed to fall out or to turn gray. The tongue was greatly tumefied in
+one case. Muscular contractions, on the affected side, were noted in
+fifty-two cases. Permanent tonic spasm, not due to photophobia, was
+observed in the eyelid in four cases, in the muscles of mastication four
+times, in the muscles of the external ear once. Paralysis affected the
+motor oculi, causing prolapse of the upper eyelid, in six cases; in half
+of these there was also outward squint. In two instances the facial
+muscles were paralyzed in a purely reflex manner. The pupil was dilated
+in three cases, and contracted in two others, without any impairment of
+sight; in three others it was dilated, with considerable diminution of
+the visual power. Finally, with regard to common sensibility, M. Notta
+reports three cases in which anęsthesia was observed. Hyperęsthesia of
+the surface only occurred in the latter stages of the disease.
+
+To Notta's list of complications of trigeminal neuralgia must be added
+the following, all of which have been witnessed, and several of them in
+a large number of instances: Iritis, glaucoma, corneal clouding, and
+even ulceration; periostitis, unilateral furring of the tongue, herpes
+unilateralis, etc. In writing on this subject three or four years ago, I
+mentioned that all these secondary affections had been seen by myself,
+except glaucoma. That is now no longer an exception; indeed, my
+attention has been so forcibly called to the connection between glaucoma
+and facial neuralgia, that I shall presently examine it at some length.
+
+The trigeminus is, of all nerves in the body, that one whose affections
+are likely to cause secondary disturbances of wide extent and various
+nature, owing to its large peripheral expanse, the complex nature of its
+functions, and its extensive and close connections with other nerves.
+Moreover, its relations to so important and noticeable an organ as the
+eye tends to call our attention strongly to the phenomena that attend
+its perturbations. But there is every reason to think that all secondary
+complications which may attend trigeminal neuralgia are represented by
+analogous secondary affections in neuralgias in all kinds of situations;
+and we may classify them in the principal groups which correspond to
+disturbance of large sets of functions:
+
+1. First, and on the whole, probably, the most common of all secondary
+affections, we may rank some degree of vaso-motor paralysis. It may be
+doubted if neuralgia ever reaches more than a very slight degree without
+involving more or less of this; for so-called points douloureux are
+themselves pretty certainly, for the most part, a phenomenon of
+vaso-motor palsy; and the more widely-diffused soreness, such as remains
+in the scalp, for instance, after attacks of pain, even at an earlier
+stage of trigeminal neuralgia than that in which permanently tender
+points are formed, is probably entirely due to a temporary
+skin-congestion. The phenomenon presents itself in a much more striking
+way in the condition of the conjunctiva seen in intense attacks of
+neuralgia affecting the ocular and peri-ocular branches of the fifth;
+one sometimes finds the whole conjunctiva deeply crimson; and, in one
+remarkable instance that I observed, the same shade of intense red
+colored the mucous membrane of the nostril of the same side. In several
+instances, I have seen a more than usually violent attack of sciatic
+pain followed by the development of a pale, rosy blush over the thinner
+parts of the skin of the leg, especially of the calf, which were then
+extremely tender, in a diffuse manner, for some time after spontaneous
+pain had ceased.
+
+2. Not merely the circulation, however, but the nutrition of tissues,
+becomes positively affected, in a considerable number of cases. It is
+difficult to judge, with any exactness, in what proportion of neuralgic
+cases this occurs, but its slighter degrees must be very common. It has
+very frequently happened to me, quite accidentally, in examining with
+some care the fixed painful points, which are so important in diagnosis,
+to be struck with the decided evidence to the finger of solid
+thickening, evidently dependent on hypertrophic development of
+tissue-elements; in severe and long-standing cases, I believe this
+condition will always be found. Probably the change is, more usually
+than not, sub-inflammatory; but it is certain, on the other hand, that
+there are great variations in the kind of tissue-changes complicating
+neuralgia, and that inflammation is no necessary element in them. This
+subject has greatly engaged my attention, and I find myself able to give
+what is probably a fuller account of the matter than any yet published
+connectedly.
+
+The following tissues have been seen by myself to become altered under
+the influence of neuralgia in nerves distributed to them, or to the
+parts in their immediate neighborhood.
+
+(_a_) The hair has changed in color in many cases. Of twenty-seven
+patients suffering from neuralgia of the ophthalmic division of the
+fifth, eleven had more or less decided localized grayness of hair on
+that side. The amount of this varied greatly, from mere patches of gray
+near the roots of the hair to decided grayness of the majority of the
+hairs over the larger part of half the head, nearly to the vertex; but
+in each case it was a change of color that did not exist on the other
+side of the head. In four of these cases there was also grayness of part
+of the eyebrow on the affected side. A very remarkable phenomenon, which
+I have sometimes identified, is fluctuation of the color, the grayness
+notably increasing during, and for some time after, an acute attack of
+pain, and the same hairs returning afterward more or less to their
+original color. My attention was first called to this curious occurrence
+in my own case. I have so often related this case [see, for instance, my
+article on Neuralgia in "Reynolds's System of Medicine," vol. ii.] that
+I shall merely recall the fact that, when pain attacks me severely, the
+hair of the eyebrow on the affected side displays a very distinct patch
+of gray (on some occasions it has been quite white) opposite the tissue
+of the supra-orbital nerve, and that the same hairs (which can be easily
+identified) return almost to the natural color when I am free from
+neuralgia. I must, however, add the very curious fact, which I observed
+accidentally in experimenting (as regards urinary elimination) on the
+effects of large doses of alcohol, that a dose sufficiently large to
+produce uncomfortably narcotic effects invariably caused the same
+temporary change of color in the hair of the same eyebrow, even when no
+decided pain was produced, but only general malaise. The subject will
+be again referred to under the heading of Pathology.
+
+Change in the size and texture of the hairs, in neuralgia, has been
+noted by Romberg and Notta, and has been several times observed by
+myself. Occasionally the individual hairs near the distribution of the
+painful nerve become coarsely hypertrophied; at times the number of
+hairs appears to multiply, but I imagine this is only a case of more
+rapid and exuberant development of hairs that would be otherwise weak
+and small. In one very remarkable instance of sciatica this came under
+my observation; the whole front of the painful leg, from the knee nearly
+to the ankle, became clothed, in the course of about six months, with a
+dense fell of hair, which strongly reminded me of similar abnormal
+hair-growths that have been occasionally seen in connection with
+traumatic injuries to the spinal cord. More commonly, the effect of
+neuralgia upon hair is to make it brittle, and to cause it to fall out
+in considerable quantities; one young lady, who consulted me for a
+severe migraine, was seriously afraid of having a good head of hair
+completely ruined in this way, but the hair gradually grew again after
+the neuralgia had disappeared.
+
+(_b_) The periosteum of bone and the fibrous fascię in the neighborhood
+of the painful points of neuralgic nerves not unfrequently take on a
+condition of subacute inflammation, with marked thickening and
+tenderness on pressure. The most striking instance of this that I have
+seen was in a lady suffering from severe cervico-brachial neuralgia. In
+the neighborhood of the emergence of the musculo-spiral nerve at the
+outer side of the arm, there was developed what looked for all the world
+like a large syphilitic node, except that the skin was brightly reddened
+over it; this disappeared altogether some little time after the
+neuralgia had been relieved by ordinary treatment. I must say that, but
+for the peculiar circumstances of the case, putting syphilis out of the
+question, I could not have avoided the suspicion, at first, that the
+swelling was specific. But I have several times seen similar, though
+less developed, swellings in neuralgia, and in one case I noticed the
+occurrence of such a swelling on the malar bone, in an old woman in whom
+the neuralgic pain was limited to the auriculo-temporal and the
+supra-orbital branches of the fifth.
+
+A very important point is to be noted in connection with these
+sub-inflammatory swellings in connection with neuralgia. Pressure on
+them will, frequently, not merely excite the neuralgic pains in the
+branches of the affected nerve, but send a powerful reflex influence
+through the cord to distant organs, causing vomiting, for instance, or
+affecting the action of the heart in a very perceptible manner. I shall
+show, when I come to speak of the phenomena of so-called spinal
+irritation, that this circumstance has led to erroneous influences in
+many cases. These exquisitely tender points are often found where
+Trousseau places his neuralgic _point apophysaire_, namely, over, or
+very near, the spinous processes of the vertebrę. The tenderness is
+quite unlike that which is known as hysterical hyperęsthesia; it is much
+severer, and is limited to one, two, or three points, corresponding, in
+fact, to the superficial part of the posterior branches of as many
+spinal nerves.
+
+(_c_) The nutrition of the skin over neuralgic nerves is sometimes
+notably affected even when the process does not reach the truly
+inflammatory stage, which will be more particularly mentioned presently.
+A certain coarseness of texture of the skin has struck me much, in
+several cases of long-standing facial neuralgia. And there is a most
+curious phenomenon (which will be especially considered hereafter in
+regard to the singular influence of the constant galvanic current upon
+it), the distribution of a greater or less amount of dark pigment to the
+skin near the painful part. This phenomenon is much more marked during
+the paroxysms, and in the slighter cases entirely disappears in the
+intervals, but in old-standing severe cases it becomes more or less
+permanent.
+
+(_d_) The mucous membranes, in situations where we can observe them, not
+unfrequently show interesting changes, the nutrition of the epithelium
+of parts covering the painful nerve being exaggerated. It has been noted
+by various observers, in neuralgia affecting the second and third
+divisions of the trigeminus, that the half of the tongue corresponding
+to the painful nerve was covered with a dense fur. This is by no means
+universally the case, but I have seen it occur several times. In my own
+case, in which the neuralgia is limited for the most part to the
+ophthalmic division, and only rarely spreads even to the second division
+of the nerve, this does not usually occur, but I have noticed it on one
+or two occasions. And I once made the still more singular observation
+that a large narcotic dose of alcohol, which was sufficient to cause
+comparatively free elimination of unchanged alcohol in the urine, caused
+furring of the tongue, which was decidedly thicker on the side of the
+affected nerve than on the other half of the tongue.
+
+(_e_) We come now to a group of complications of neuralgia which are
+exceedingly important, and by no means adequately appreciated as yet,
+viz., the acute inflammations which directly result from neuralgic
+affections in a certain percentage of cases, probably much larger than
+has been at all generally suspected.
+
+The most familiar of the inflammatory complications of neuralgia is
+herpes zoster, the favorite seat of which is the skin which covers one
+or more of the intercostal spaces: the eruption, as occurring in this
+situation, is so well known that it would be waste of time to describe
+it. In young subjects zoster is commonly painless, at least the
+sensations are those of heat, pricking, and irritation, rather than of
+acute pain; but from puberty onward there is an increasing tendency,
+especially in those otherwise predisposed to neuralgia, for zoster to be
+preceded, accompanied, or followed by neuralgia of the intercostal
+nerves corresponding to the distribution of the eruption. Most commonly,
+the eruptive period is, in my experience, nearly or quite free from
+neuralgia, but it often recurs, or breaks out for the first time, when
+the vesicles are drying up, but more especially if, as is sometimes the
+case, especially in elderly people, the scabs fall off and leave
+superficial ulcers. Neuralgia may last, after herpes zoster, for any
+time from a few days to many weeks, and I have known it so agonizingly
+severe and so persistent as actually to kill an aged woman from sheer
+exhaustion. In spite of sundry objections that have been raised to the
+theory of the nervous origin of zoster, it appears to me that the
+evidence in favor of it is overwhelming, more especially now that it is
+proved that the disease, with all the same characteristics presented by
+it when seen on the chest or abdomen, may occur on the face (following
+the branches of the trigeminus), or on the forearm (following the course
+of nerves from the brachial plexus). Two of the severest cases of
+neuralgia attending herpes that I have ever seen were in private
+patients (whose family history, unfortunately, I had no means of
+ascertaining) who were affected, respectively, in the facial and in the
+brachial nerve-territories.
+
+A far more formidable occasional complication of neuralgia is
+inflammation affecting the eye. Mr. Jonathan Hutchinson records several
+cases in which neuralgic herpes zoster of the face was attended with
+iritis, with serious or even irremediable damage to the organ. For my
+own part, I have witnessed several instances in which neuralgia of the
+first and second divisions of the fifth has been attended with
+skin-inflammation, but only in one of these (just alluded to) did the
+inflammation present the characteristic appearances of herpes: in all
+the rest it far more closely resembled erysipelas. The skin was
+excessively reddened in an almost or quite continuous patch over the
+whole territory through which ran the painful nerves; by no means only
+linearly in the course of the nerves, though accurately limited to the
+district of the first or first and second divisions of the fifth. In the
+first case I saw (a woman, aged thirty-two), nothing could be more
+startling than the rapidity with which an irregular patch of the skin,
+including half of one cheek, the side of the nose, and a large part of
+the forehead and scalp on the same side, became converted into the
+dense, fiery-red, brawny tissue, with minute vesicles scattered over its
+surface, which looks so characteristic of erysipelas; this commenced
+immediately on the subsidence of severe neuralgic pain. During the
+erysipelatoid inflammation, though there was no spontaneous pain, the
+neuralgia could be instantly lighted up for a moment by pressure on the
+infra-orbital foramen, on the supra-orbital notch, or upon the malar
+bone, about its centre. Since that time I have seen several cases of a
+similar character; two of these, which were reported in the _Lancet_ for
+1866, I shall here reproduce: [Extensive inquiries convinced me that the
+tendency to erysipelatous complication of facial neuralgia is
+exceedingly common. Eulenburg expressly confirms my original statement
+to this effect, and extends it to all neuralgias.]
+
+CASE I.--A woman, aged sixty-three, presented herself in the out-patient
+room at Westminster Hospital, suffering from neuralgia of ten days'
+standing (which for the present, however, seemed to have abated
+considerably), but asking advice chiefly for an erysipelatoid
+inflammation which had come on a day or two before, and occupied the
+area of the painful nerve-district. The neuralgia had affected the
+supra-orbital nerve, running up toward the vortex, and the
+auriculo-temporal branch of the third division of the fifth; although
+there was no very acute pain present at this time, pressure over the
+supra-orbital notch, or at a point just in front of the ear, would at
+once cause a brief paroxysm of pain. It was curious to find that there
+was a thickened and tender spot over the malar bone (and corresponding
+to the exit of some nerve filaments from the bone) which had never been
+the seat of spontaneous neuralgia, but pressure here sent a dart of pain
+into the auriculo-temporal and supra-orbital nerves. The inflammation
+was markedly limited to the general area of distribution of the twigs of
+the auriculo-temporal and of the ophthalmic division; it was of a
+continuous deep-red color, and attended with much thickening of the
+skin. The conjunctiva was intensely congested, and there were
+lachrymation and very marked photophobia, but there were no signs of
+iritis, and no corneal clouding.
+
+CASE II.--M. W., a woman, aged forty-two, well-nourished and
+healthy-looking, married and had one child; had never suffered any
+serious ailment except once, about five years previously. She then had a
+decided attack of "erysipelas," very accurately limited to the right
+half of the face. Five months before coming to me she sustained a severe
+shock from being thrown out of a chaise, without suffering any external
+or visible damage. An hysterical tendency, which she had always
+possessed, became more marked; it revealed itself by palpitations,
+occasional dysphagia, and a disposition to weep causelessly. The menses
+were flowing at the time of the accident; they ceased abruptly soon
+after (they had been scanty for some time previously), and did not recur
+till four months later. The hysteric disturbance progressively increased
+during a fortnight, and then the patient was attacked with violent
+intermittent neuralgia, commencing in the eyeball and spreading over
+the district supplied by the branches of the first and second divisions
+of the trigeminus. The pain was accompanied by intense conjunctival
+congestion and photophobia [Dr. Handfield Jones remarks that
+photophobia, in his experience, is only a rare accompaniment of facial
+neuralgia. I have latterly come to the same opinion. Redness of the eye
+and lachrymation are very common; true photophobia uncommon. Notta's
+experience would seem to have been similar]. It lasted on the first day
+fourteen hours, and returned daily for the next fifteen or sixteen days.
+An attack of erysipelas, strictly limited to the district of the painful
+nervous branches, then set in. From that moment the neuralgic attacks
+became less frequent and severe. A second similar onset of erysipelas
+occurred some three or four weeks after the first. Finally, the
+neuralgia disappeared about four months after its first occurrence, and
+the menses reappeared in tolerable abundance about the same time. About
+a fortnight before this the patient had discovered that her right eye
+was dim; as the photophobia had previously disabled her from opening the
+eye, she could not be sure how long this dimness had existed. At the
+time of her visit to me the cornea was blurred with a large patch of
+interstitial lymph, with the remains of a superficial ulcer in the
+centre; the iris was turbid and discolored, showing the traces of recent
+but past iritis; the pupil was regular in form and active to light; the
+conjunctiva was slightly congested. Ophthalmoscopic observation was
+attempted by a skilled observer, but could not be satisfactorily carried
+out, from the turbid state of the media. The conjunctiva was slightly
+congested. In place of the lachrymation that had prevailed during the
+neuralgic period, there was a remarkable insensibility of the lachrymal
+apparatus, for the patient had noticed that the smell of onions, which
+would make the other eye weep profusely, had no influence on the
+affected one.
+
+The family history of this patient is a most remarkable one. All the
+members of her mother's family, for two generations back, had died at
+middle age, either from apoplexy or some disease involving hemiplegia.
+This case has, by a mistake, not been added to the list of twenty-two
+private cases in which the family history was carefully investigated,
+that will be found in the chapter on Pathology; this arose from the fact
+that the patient was not properly under my care, but was sent to me as a
+medical curiosity; the notes of her case were therefore taken in a
+different book from the others. The case certainly ought to be taken as
+a counterpoise to such a one as No. XVI. in the list, which is that of a
+gentleman who suffered from the most complicated neurotic maladies
+(asthma, angina pectoris, facial neuralgia, more than once attended with
+erysipelas), but whose family history, so far as it was known, presented
+no traces of tendency to neurotic disease.
+
+To these two cases of inflammation, secondary to neuralgia, I shall add
+a third, which is even more interesting, and which came under my notice
+not long since.
+
+CASE III.--H. T., watchmaker's assistant, aged forty-two, suffered for
+about three weeks with very severe remittent abdominal pain, entirely
+unconnected with dyspepsia, constipation, or diarrhoea. It was
+intermittent in character, but observation soon showed that the times at
+which it came on were simply those at which the stomach had gone longest
+without food, especially the early morning, and that nourishment never
+failed to relieve it. The suffering was great, and the man failed
+considerably in general health, notwithstanding that his appetite and
+digestion were unimpaired. He had only been under my care about ten days
+when he presented himself one day at the hospital, and stated that the
+pains in the stomach had entirely left him, but that he suffered the
+most frightful pains in and around the right eye. I found a well-marked
+conjunctival congestion and lachrymation, but there were as yet no
+tender points; the neuralgia was felt most severely in the globe of the
+eye and in one tolerably straight line, darting up toward the vertex
+from the brow. The iris seemed clear and free, and the cornea was not
+cloudy. I gave the man a subcutaneous injection of one-sixth grain
+acetate of morphia, for present ease, and ordered him muriate of iron
+and small doses of strychnia three times a day. When he next appeared,
+four days later, I was alarmed to perceive that unmistakable iritis had
+fully developed itself, the iris was already turbid and discolored and
+the pupil irregular, from a serious amount of adhesions. By this time
+there were fully-developed tender points, supra-orbital and parietal;
+besides this, pressure on the globe caused paroxysms of pain, in all the
+branches of the ophthalmic division, but there was not much spontaneous
+pain. I dropped atropine in the eye, applied blistering fluid to the
+back of the neck, [the nape of the neck is the point most suitable for
+blistering which is intended to affect the eye, and the ophthalmic
+division of the fifth, generally,] and desired the man to come to see me
+at my own house next day, intending to take him to an ophthalmic
+surgeon. Unfortunately he failed to do this, and three days later, when
+he came to see me at the hospital, the cornea was studded with
+opacities, the pupil was almost closed with effused lymph, there was
+violent ocular pain, and a great and increasing sense of tension. I
+begged him to go without loss of time to the Eye Hospital, as my own
+ophthalmic colleague was not at Westminster that day; and I have never
+heard any more of the patient.
+
+Glaucoma is a still more serious disease of the eye, which I think there
+is now sufficient evidence to show is sometimes entirely, and very often
+in considerable part, neuralgic in its origin. Since my attention was
+directed, some six years ago, to the frequent connection between the
+so-called rheumatic iritis and neuralgia, I have taken much interest in
+the subject of acute eye-affections; and the occurrence of one or two
+cases of glaucoma in personal friends of my own has made this interest
+even painfully strong. I am necessarily without the means of personally
+observing glaucoma on the large scale, but I have now seen two cases in
+which, if I possess any faculty of clinical observation whatever, the
+whole genesis of the disease was a neuralgic disorder of the trigeminus;
+and it was to me a melancholy reflection that nothing better than
+iridectomy in one case, and excision of the eyeball in the other, could
+be done in the present state of ophthalmic science. There are now a good
+many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell
+Carter, of St. George's, and the South London Ophthalmic Hospital,
+recently assured me that nervous aspect of some form of glaucoma
+presents itself the strongly to his mind, though he does not commit
+himself to any theory. Two cases were reported by Mr. Hutchinson, in
+Ophthalmic Hospital Reports IV. and V.; but the most complete and
+interesting cases that I have met with are recorded by Dr. Wegner;[15]
+they are two out of four that occurred within a very short time in the
+clinic of Prof. Horner at Zurich, and they form the basis of some
+researches by Wegner into the nature of the influence of the trigeminus
+upon ocular tension, which will be referred to, along with others, in
+the chapter on Pathology. The second of these cases is so important that
+I shall reproduce it in full.
+
+A. Hediger, aged twenty-four, a moderately strongly-built young woman,
+seen first in August, 1860. From her own and her mother's account, it
+seemed she had long suffered from convulsive attacks that did not appear
+to have been truly epileptic. Some days previously her left eye became
+very painful, and the sight failed, without any inflammatory symptoms.
+On inspection the pupil was somewhat dilated, the eye somewhat
+hypermetropic, fundus normal; No. 5, Jager's type, was read with
+difficulty. Wegner could not explain the condition. At the end of
+October the eye was much worse; after severe paroxysms of pain, No. 16
+type was the smallest legible, the field of vision was decidedly limited
+in all directions, but especially on the inner and upper portions. An
+unusually long hysteric attack was now observed. The patient was for
+twenty-four hours in a half-sleep, the extremities, meantime, were much
+jerked, the speech sometimes coherent and sometimes incoherent; she
+cried out to her friends, etc., but had no severe convulsion-fit with
+spasm of glottis. She was removed to the hospital, where she stayed six
+weeks. The hysteria improved under treatment with valerian and morphia
+(Prof. Greisinger had confirmed the opinion that there was no true
+lesion of the centres), but the neuralgia of the globe was
+extraordinarily severe, both day and night. From January to June, 1861,
+Wegner saw her occasionally. The visual power of the left eye fluctuated
+between 15 and 19 Jager. Field of vision very limited. Pupil very
+dilated and insensitive, the globe painful to the touch, and injected.
+The right eye weakly hypermetropic; normal field of vision, normal
+pupil, no pain. The scene suddenly changed on the 29th of June. She was
+attacked with fearful pain, and an enormous mydriasis with extreme
+amblyopia of the right eye; the fingers could hardly be counted when
+placed quite close. The optic disc appeared somewhat cloudy, with very
+evident venous pulsation. The mydriasis, amblyopia, and neuralgia lasted
+some time, while simultaneously the left eye could only read 19-17 type,
+but was painless. The pathology seemed quite obscure, and the surgeon
+remained almost passive till August, when he performed paracentesis on
+the left eye. The patient could distinguish fingers at that time at a
+foot's distance with the right eye; with the left read No. 11, but
+suffered fearful pains. These diminished after the puncture; the eye
+could read No. 20 next day, and improved after that to 19; the pains
+recurred in the next day, but for the first time ceased to disturb
+sleep. The scene again changed in the most surprising manner on the 27th
+of August. The most frightful pain again attacked the left eye. The
+pupil was dilated to the maximum (far beyond what occurs in oculo-motor
+paralysis); the globe was extremely painful on touch, visual power
+fallen to 19 Jager. On the other hand, the right eye had a normal pupil,
+was painless, and could read No. 12. Paracentesis of the left eye
+improved its vision and diminished pain, but only temporarily, so that
+it had to be repeated at short intervals. The condition was so far
+stationary toward the end of October that the right eye continually
+gained visual power, but the left stood still and fluctuated from worse
+to better, with the greater or less severity of the neuralgic paroxysms.
+Pupils always in extreme dilatation. In the end of October and beginning
+of November (the patient had worn a large seton for a month) remarkable
+changes occurred; the neuralgia of the left globe diminished steadily,
+the pupil got smaller, the visual power increased, the neuralgia now was
+only on the lower lid, which was slightly red and painful to the touch,
+and had continual spontaneous pain. Visual power of right eye No. 3, of
+left eye No. 5. Visual field intact; with full illumination by weak
+light there is a peripheral torpor, but only in a narrow zone. The
+hyperęmia now extended more and more over the lower lid and the upper
+part of the cheek; this was apparent during the paroxysms, which were
+very severe, and destroyed sleep; it did not allow the skin to be
+touched; the color was deep (with high temperature) and extended to the
+angle of the mouth. This phenomenon lasted till the beginning of
+December, when neuralgia again attacked the left globe, with strong
+mydriasis and diminution of visual power (15 to 20 Jager), till at last
+the movements of the hand could hardly be distinguished, and this state
+of things continued with fluctuations up to the end of the month. The
+seton had been taken off just before the new outbreak; it was put in
+again on December 31st. In January the pains continued severe in the
+eye, with only one remission (from the 17th to the 20th), when the
+hyperęmia recurred in the cheek. On the 26th the pupil was very dilated,
+and fingers could not be seen at half a foot's distance. Visual field
+very limited, globe hard. A large upper iridectomy was made. After this
+the pupil was contracted, the pains diminished, visual power 10 Jager,
+field seven inches. In the middle of February the hysterical attacks
+recurred with great force; the patient was unconscious half the day; she
+was clear enough in senses when awake, but complained of buzzing in her
+head, as if a cock-chafer were inside it. From this till the middle of
+March, the left eye did not alter, the impairment of vision remained,
+with normal pupil and no pain in the globe, and the iridectomy seemed at
+least to have done good in one direction; but on the 13th of March the
+operated eye was again attacked with pain, visual power fell to No. 17,
+pupil became dilated, and after a few days the swelling, heat, and
+tenderness of the cheek recurred. During the years 1862 and 1863 the
+condition remained pretty much the same; _i. e._, the right eye sound,
+the left painful (in spite of the iridectomy) with dilated pupil,
+concentrically narrowed visual field, visual power fluctuating between
+No. 15 and mere finger-counting without any ophthalmoscopic appearances.
+A number of paracentesis and subcutaneous injections of morphia (which
+last were the more indicated as the supra-orbitalis was tender on
+pressure) always brought relief merely for a few hours. On the 19th of
+April, 1864, vision being complete in right eye, and No. 19 in left,
+Wegner punctured the latter. On the 2d of May the eye read No. 10
+slowly, the pains had gone and not returned, the pupil became smaller.
+On the 31st of March, 1865, the patient was pronounced well; the eye was
+painless, the pupil somewhat larger than the other; the finest type
+could be read when looked at very close.
+
+3. The next group of affections secondary to neuralgia are the paralysis
+of muscles. These are pretty common; I find them in twenty-eight of the
+hundred cases which have been referred to. But of these twenty-eight
+instances of paralytic affections no less than twelve were connected
+with neuralgia of the trigeminus, and in most of these it was one or
+more of the muscles connected with the eye that were affected. Sciatica
+is nearly always attended with much weakening of voluntary power of the
+muscles of the thigh and leg; and in some instances this reaches to
+decided or even complete paralysis. In looking for this phenomenon we
+must be very careful that we do not mistake the mere reluctance to move
+the limb, on account of the painfulness of all movements, for true
+paralytic weakness of nerve and muscle. And it is also necessary to bear
+in mind, in prolonged cases, the probability that much of the weakness
+may have been caused by degeneration of the muscles owing to forced
+inaction. Still, there is a class of secondary paralyses that are in no
+way to be confounded with such effects as these: for instance, it
+occasionally happens, almost in the very first onset of severe sciatic
+pain, that the limb hangs absolutely helpless; and in one such case
+lately, being struck with the completeness of the loss of power, I
+tested the Faradic irritability by directing a sharp current on
+comparatively exposed portions of the painful nerve (_e. g._, in the
+popliteal space, and behind the head of the fibula), and elicited only
+the most feeble contractions, entirely unlike what the same current
+evoked in the opposite limb. I regret that I have as yet found it
+impossible to carry out a regular inquiry as to the sensibility to the
+different currents of motor nerves which are centrally connected with
+neuralgic sensory nerves.
+
+Muscular viscera which are composed of unstriped fibre, like the
+intestines, or of a mixture of striped and unstriped, like the heart,
+are probably very liable to a secondary paralytic influence from certain
+special neuralgię. It is ascertained that the pain of a certain degree
+of severity in the branches of the fifth may absolutely stop the heart's
+action for a moment--an effect which is succeeded, usually, by violent
+and disorderly pulsations. I have myself once known the operation of
+"pivoting" a tooth, which gave frightful pain, cause instantaneous and
+most alarming arrest of the heart's motion, which for a minute or two
+seemed as if it were going to be fatal. But the variety of visceral
+paralysis which is probably far the most frequent is secondary paralysis
+of the bladder, from neuralgia in one or other of the pelvic organs, or
+of the external genitalia; and next to this comes paralytic distension
+of the cęcum, colon, or rectum, secondary to various abdominal and
+pelvic neuralgic affections. In one instance of acute ovarian neuralgia
+that I saw, the paralytic distention of the colon was by far the most
+remarkable circumstance, so enormously was it developed; and for some
+days after the neuralgia had ceased, and when the flatulence had nearly
+disappeared, the intestine remained absolutely torpid.
+
+4. Convulsive actions of muscles, as every one knows, are very common
+complications of neuralgia. In trigeminal neuralgias these may be
+observed (according to the division or divisions of the nerve that are
+affected) in the proper muscles of the eye, or in those supplied by the
+fourth and sixth nerves, or (perhaps only when two or three divisions
+of the fifth are neuralgic at once) by the portio dura. It is curious,
+however, that those formidable spasmodic affections of the face which
+belong to the same order as torticollis and writer's cramp, are not
+frequently, if ever, directly associated with trigeminal neuralgia. The
+only connection between them seems to be that these peculiar spasmodic
+affections are only developed in highly-neurotic families, some of whose
+members are almost sure to be found suffering from some form of regular
+neuralgia. In severe sciatica it has several times happened to me to see
+convulsive action of the flexors, bending the leg spasmodically upon the
+thigh. And in a very large proportion of all neuralgias, wherever
+situated, attentive observation of the patient during the paroxysms will
+detect the existence of local twitching or local spasm of muscles,
+though these may be slight in degree.
+
+Among the convulsive affections must be reckoned convulsive movements
+and tonic spasms of various portions of the alimentary canal. Vomiting
+is a common example of this; in migraine it is the regular and necessary
+climax of attacks which last with severity for a certain time; indeed,
+any severe attack of neuralgia involving the ophthalmic division of the
+fifth may excite vomiting. Convulsive action of the pharyngeal muscles,
+as a complication of pharyngeal or laryngeal neuralgia, occasionally
+occurs to such an extent as to render deglutition difficult or
+impossible for the time. And I have seen what I do not doubt to have
+been a spasmodic condition of the rectum induced by peri-uterine
+neuralgia. The genito-urinary organs are also not unfrequently affected
+spasmodically in consequence of a neuralgic affection either
+peri-uterine or pudendal. I have seen spasmodic stricture of the male
+urethra thus produced, and likewise vaginal spasm.
+
+5. Impairments of sensation, both common and special, are very frequent
+attendants of neuralgia. As regards the special sensations, we may first
+mention that of touch; this is almost constantly impaired, immediately
+before, during, and some little time after a neuralgic paroxysm, in the
+skin supplied by the painful nerves. I was first led to make this
+observation by my own experience; the skin all round the inner angle of
+my right eye is permanently less sensitive to distinctive impressions
+than that of the opposite side, and this impairment is always decidedly
+greater, and spreads over a larger surface, before, during, and for some
+time after, the attacks of pain. More extended observation has convinced
+me that a certain amount of bluntness of distinctive skin-sensation
+accompanies nearly every neuralgia. As regards the sense of taste, I
+have found this decidedly perverted, at the time of an attack, even in
+my own case, although the neuralgia never extends into the third branch
+of the nerve. It is interesting to notice, in connection with this,
+that the epithelium of my tongue has been seen, on one occasion, to be
+exaggerated on the side of the neuralgic affection, showing a
+probability that there is perturbed function, at any rate of certain
+fibres, of the third division. But I have seen much more decided
+alteration, indeed temporary entire abeyance of the power to distinguish
+between the tastes of different substances, with the affected side of
+the tongue, in a case of severe epileptiform tic in which the third
+division was strongly affected with neuralgia; and Notta records a
+similar instance. As regards vision, besides minor perversions and
+disturbances, I have observed more or less complete amaurosis in several
+instances of ophthalmic neuralgia; in one case it was absolute, and
+lasted, with but slight improvement in the intervals between the
+paroxysms, for nearly a month, but disappeared entirely, though somewhat
+gradually, after the final cessation of the neuralgia. As regards
+hearing, I have noticed serious impairment only in five cases, all of
+them of a severe type of trigeminal neuralgia, involving all three
+divisions of the nerve. Smell, I have never observed to be more than
+doubtfully impaired, except in one case (_vide_ Chapter III), where it
+was completely destroyed.
+
+Common sensation was reported by Notta as affected in only three cases
+out of a hundred and twenty-eight; but my own experience has afforded a
+much larger proportion of instances in trigeminal neuralgia. Indeed, in
+all situations neuralgia appears to me to involve this effect, in the
+larger number of instances, in the early stages; later, it is supplanted
+in part by great tenderness on pressure in the well known _points
+douloureux_, and sometimes the tenderness becomes diffused over a
+considerable surface. I agree with Eulenburg in thinking that anęsthesia
+is more frequent in sciatica than in other neuralgias.
+
+6. Secretion is often very notably affected in neuralgia; the phenomena
+are necessarily more easily observed in connection with affections of
+the trigeminal than of other nerves. In the great majority of cases the
+affection is in the direction of increase; at least, the watery elements
+of secretion are often poured out in profusion. Thus, profuse
+lachrymation is exceedingly common in ophthalmic neuralgia; in a large
+number of cases there is also copious thin nasal flux on the affected
+side; sometimes, however, the secretion, though copious, is
+semi-purulent, or bloody. Increased salivation has been noticed, by a
+large number of observers, in neuralgia involving the lower division of
+the fifth. In a smaller number of instances, the secondary effect on
+secretion is precisely opposite; thus both Notta and myself have
+observed complete dryness on the nostril on the affected side in
+ophthalmic neuralgia.
+
+I might expand this chapter on the complications of neuralgia to a very
+much greater length; but, as regards the clinical history of these
+affections, it is perhaps better not to occupy more time and space. It
+will, however, be necessary to return to the consideration of the
+subject in connection with Pathology.
+
+FOOTNOTE:
+
+[15] Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.
+
+
+
+
+CHAPTER III.
+
+PATHOLOGY AND ETIOLOGY OF NEURALGIA.
+
+
+The pathology and the etiology of neuralgia cannot be considered apart;
+they must be discussed together at every step. I do not mean to say that
+neuralgia is singular among diseases in this respect; it seems to me
+merely a case in which the intrinsic defects of the conventional system
+of separating the "causes" of disease from its pathology happen to be
+more glaring and more easily demonstrable than usual.
+
+Neuralgia possesses no "pathology," if by that word we intend to signify
+the knowledge of definite anatomical changes always associated with the
+disease, in a manner that we can exhibit or exactly describe. It also
+possesses no demonstrable causes, if we employ the word "causes" in the
+old metaphysical sense. And yet I am very far from admitting, what seems
+to be so generally taken for granted, that we know less about the seat,
+the nature, and the conditions of neuralgia than of other diseases. On
+the contrary, I believe, with all deference to the supporters of the
+ordinary opinion, that we know more about neuralgia, in all these
+respects, than we do about pneumonia, only our knowledge is not of the
+superficial and obvious kind, but requires the aid of reason and
+reflection to develop and turn it to account. It has long been a matter
+of surprise to me, that even able writers have been content to talk
+about this disease (as, indeed, they have been content to speak of many
+nervous diseases) with an inexplicable looseness of phraseology. They
+speak of its "protean" forms; whereas, in my humble judgment, its forms
+are by no means specially numerous. They insist on the mysterious and
+unintelligible manner of its outbreaks, remissions and departure; but I
+shall try to show that, although, in the investigation of neuralgia, we
+are continually stopped in particular lines of inquiry by what seems to
+be ultimate facts, susceptible of no further immediate solution, the
+channels of information open to us are so unusually numerous as to
+enable us to accumulate a mass of information which, upon further
+reflection, will be found to furnish the materials of a synthesis of the
+disease singularly clear and effective for every practical purpose of
+the physician. In one important particular I especially hope to convince
+the reader that a large proportion of the mystification as to the
+pathology of neuralgia is gratuitous, and the result of great
+carelessness in estimating the comparative value of different facts. I
+hope to show clearly that, as regards both the seat of what must be the
+essential part of the morbid process, and the general nature of the
+process itself, we possess very definite information indeed. I expect,
+in short, to convince most readers that the essential seat of every true
+neuralgia is the posterior root of the spinal nerve in which the pain is
+felt, and that the essential condition of the tissue of that nerve-root
+is atrophy, which is usually non-inflammatory in origin. This doctrine
+seems, at first sight, presumptuous,[16] in the confessed absence or
+extreme scarcity of dissections which even bear at all upon the
+question. But one source of the extraordinary interest which the
+pathology of neuralgia has long possessed for me resides in this very
+fact, that I am convinced we can demonstrate the above apparently
+difficult theorem by means of pathological observations on the living
+subject, taken in conjunction with physiological experiments, and with
+only the aid of a very few isolated facts of positive morbid anatomy. I
+need hardly say that I am none the less anxious for that further
+assurance which we shall one day, perhaps, obtain by means of
+greatly-improved processes for microscopic detection of minute changes
+in nerve-centres; but, looking to the necessary rarity of opportunities
+for post-mortem examinations of the nervous system in any but the most
+advanced stages of neuralgias, it will hardly be disputed that, if I am
+right in my main position, we are singularly fortunate to be so
+unusually independent of the need for this source of information.
+
+1. The first fact which strikes me as of decided importance is the
+position of neuralgia as an hereditary neurosis; and this character of
+the disease is so pregnant with significance, that I shall take some
+considerable pains to put the fact beyond doubt in the reader's mind.
+
+There are two series of facts which support the theory of the
+inheritance of the neuralgic tendency: (_a_) instances in which the
+parent of the sufferer had also been affected with the disease; and
+(_b_) instances in which the family history of the patient being traced
+out more at large it appeared that, among the members of two or more
+generations, while one, two, or more individuals had been actually
+neuralgic, other members had suffered from other serious neuroses (such
+as insanity, epilepsy, paralysis, chorea, and the tendency to
+uncontrollable alcoholic excesses), and, in many instances, that this
+neurotic disposition was complicated with a tendency to phthisis.
+
+(_a_) The question of the direct transmission of neuralgia itself from
+the parent seems the easiest of decision, though even this cannot always
+be satisfactorily cleared up by the hospital patients, among whom one
+collects the largest part of one's clinical materials. However, I have
+been at the pains of investigating a hundred cases of all kinds of
+neuralgia, seen in hospital and private practice, with the following
+results: twenty-four gave distinct evidence that one or other parent had
+suffered from some variety of neuralgia; fifty-eight gave a distinctly
+negative answer; and eighteen would not undertake to give any answer at
+all. Among the twenty-four affirmatives are inserted none in which the
+history of the parent's affection did not clearly specify the liability
+to localized pain, of intermitting type, but recurring always in the
+same situation during the same illness. In three of these twenty-four
+instances, the patient stated that both parents had suffered from such
+attacks, and, in one of these, it appeared that the grandfather had
+likewise suffered.
+
+(_b_) The question of the tendency of a family, during two or more
+generations, to severe neuroses of more or less varying kinds, including
+neuralgia, is difficult to work out perfectly, though in a large number
+of instances we may get enough information to be very useful. I have
+spent much time and trouble in endeavoring to collect such information;
+but there are two main difficulties in connection with all such
+attempts. From hospital patients you frequently can get no reliable
+information whatever respecting any members of the family farther back
+than the immediate parents; and, even respecting uncles and aunts and
+first cousins, it is often impossible to learn any thing. And when you
+get to a higher class of society, especially when you approach the
+highest, although the information may exist, it may be withheld, or you
+may be purposely mystified. One would doubt beforehand, under these
+circumstances of difficulty, whether it would be possible to obtain
+affirmative evidence of the neurotic temperament of the families of
+neuralgic patients in general; but, in truth, the evidence is so
+overwhelming in amount, that more than enough can be obtained for our
+purpose. I shall give, first, the results of one special inquiry which,
+by the kindness of a patient, I have been able to carry out with more
+than usual completeness; it relates to the medical genealogy of a
+sufferer from sciatica; the account is fairly complete for four
+generations. The great-grandfather was a man of splendid physique (an
+only son), who lived very freely, but died an old man. His children were
+three sons, one of whom (though strictly temperate) was a man of
+eccentric and somewhat violent temper, and suffered from a spasmodic
+facial affection. This one, the grandfather of my patient, married a
+lady who died of phthisis, and among the ten children she bore him, two
+sons died of phthisis, two sons became chronically insane, one son died,
+probably of mesenteric tubercular disease (aged fifty-six), two sons are
+still alive at very advanced ages, and have always been perfectly
+healthy and strong; one daughter died in middle age, it is not certain
+from what cause; one daughter lived healthily to the age of eighty, and
+then was attacked by facial erysipelas, followed by violent and
+intractable epileptiform tic, which clung to her for the remaining four
+years of her life; and the remaining daughter, an occasional sufferer
+from migraine, died at the age of sixty-seven, almost accidentally, from
+exhausting summer diarrhoea. The fourth generation, in this branch of
+the family, consisted of thirty-one individuals; of whom seven have died
+of phthisis, or scrofulous disease; one from accidental violence, one
+from rheumatic fever, one from scarlet fever; and among the surviving
+twenty-two one has been insane, but recovered; two are decided
+neuralgics; one is occasionally migraineuse, and once had a smart attack
+of facial erysipelas, corneitis, and iritis, as the climax to a severe
+neuralgic attack; one has been a sufferer from chorea; one has become
+phthisical; one developed strumous disease, but has fairly recovered
+from it. The remaining fifteen enjoy good health, but are distinguished,
+almost without exception, by a markedly neurotic temperament, indicated
+by an anxious tendency of mind, quickness of perception, ęsthetic taste,
+disposition to alternations of impulse and procrastination. Of the young
+fifth generation growing up, there have been twenty-five children, of
+whom only one has died (from fever), the rest are apparently healthy
+(most of them specially so); but, as few have yet reached the age for
+the development either of phthisis or of neurotic diseases, the future
+of this generation can only be guessed at. [It is unnecessary to trace
+the other descendants of the second generation, but I may state that
+their medical history, also, strongly supports the theory of inheritance
+of the neurotic tendency, and of the influence of an imported element of
+phthisis in aggravating the latter.] I suspect that, as regards the
+young children now growing up, everything will depend on the care with
+which they are fed, and the kind of moral influences brought to bear on
+them, two subjects which will be fully dwelt on in the chapter on
+Treatment.
+
+Of less perfect inquiries on the subject of neurotic disposition
+inherited by neuralgic patients, I have made a great number, though I
+regret to say that I have not attempted the task in the whole number of
+those from whom I inquired as to direct inheritance of neuralgia from
+their parents. However, in eighty-three cases this was done with all
+possible care, and any deficiency of completeness in the results is not
+my fault. I shall take first those that were private patients,
+twenty-two in number, respecting whom, I may say, that the evidence is
+of the best, as far as it goes, since I was better able to discriminate
+as to the worth of statements, than in dealing with hospital patients,
+and have rejected every case in which the informant did not seem
+intelligent enough, or otherwise to have the means, to give a thoroughly
+reliable account.
+
+    I. Neuralgia cervico-brachialis; in a lady, aged seventy-one.
+       Mother suffered from epileptiform facial tic; uncle was
+       paralyzed; patient herself eccentric to the verge of insanity.
+
+   II. Bilateral sciatica of great severity; in a gentleman, aged
+       seventy-three. Gout, paralysis, and neuralgia, have been
+       frequent in the family.
+
+  III. Cardiac neuralgia; in a man, aged twenty-four. Father epileptic
+       and a drinker; grandfather died of softening of the brain,
+       aged thirty-eight.
+
+   IV. "Cerebral" neuralgia; in a single lady, aged thirty-eight.
+       Mother has been insane; first cousin epileptic.
+
+    V. Lumbo-abdominal neuralgia; in a gentleman, aged fifty-two.
+       Father a drinker; mother insane; maternal grandfather
+       phthisical.
+
+   VI. Severe neurotic angina pectoris; in a gentleman, aged fifty.
+       Almost every one of the graver neuroses among patient's near
+       relations.
+
+  VII. Migraine and cervico-occipital neuralgia; in a young lady, aged
+       twenty-five. Immediate causes, brain-work, and influence of
+       cold weather. Father and brother both epileptic; father's
+       family much affected with neurotic diseases.
+
+ VIII. Sciatica; highly-nervous temperament. Father died insane from
+       drink; and probably other members of the family also nearly or
+       quite insane.
+
+   IX. Auriculo-temporal neuralgia; in a married lady, aged
+       twenty-eight. Father's family markedly phthisical and neuralgic.
+
+    X. Intercostal neuralgia; in a girl (phthisical), aged twenty-four.
+       Mother and two uncles phthisical; maternal grandfather epileptic
+       and a drinker.
+
+   XI. Facial neuralgia (third branch trigeminal); in a gentleman, aged
+       fifty-four, a great whiskey-drinker. Drinking hereditary for
+       three generations; father died insane; grandfather epileptic;
+       sister phthisical; two brothers very "eccentric."
+
+  XII. Migraine, severe; in a lady, aged thirty-three. Grief was the
+       immediate cause. Mother hemiplegic at forty-second year; first
+       cousin insane; two aunts (maternal) epileptic.
+
+ XIII. Extremely severe sciatica and cervico-brachial neuralgia of the
+       left side, with singular inflammatory consequences; in a lady,
+       aged fifty-two. A family history remarkably free from neurotic
+       diseases and from phthisis. The neuralgia was probably caused
+       partly by excessive ptyalism, partly by over brain-work.
+
+  XIV. Migraine; in a young lady, aged sixteen; very profuse
+       menstruation, which had lasted for two years. Family history
+       very free both from phthisis and neuroses.
+
+   XV. Frontal and nasal neuralgia; in a man. Repeated attacks of
+       localized facial erysipelas; drinking-habits for some years;
+       fatal acute insanity in middle age. Father insane, committed
+       suicide; mother subject of violent epileptiform tic.
+
+  XVI. Angina pectoris (neurotic); spasmodic asthma, twenty years;
+       facial neuralgia and erysipelas; in a gentleman, aged fifty.
+       Family medical history scanty and imperfect; but, as far as it
+       goes, entirely without evidence of either phthisis or neuroses.
+
+ XVII. Neuralgia of testis, immediately caused by local irritation.
+       Father died of phthisis; paternal uncle epileptic and insane.
+
+XVIII. Ovarian neuralgia; in a girl, aged twenty-six, liable to
+       occasional migraine. Mother has suffered sciatica; brother
+       died of phthisis.
+
+  XIX. Gastralgia; in a man, aged twenty-seven; highly intellectual and
+       nervous. Family history very free from neuroses; but some
+       evidence of phthisis, in two previous generations, on mother's
+       side.
+
+   XX. Sciatica; in a lady, aged sixty; second attack. Ancestors, on
+       both sides, for some generations, clever, and in several
+       instances decidedly eccentric, if not insane; much neuralgia
+       in the family.
+
+  XXI. Migraine; in a young lady, aged seventeen; menstrual
+       difficulties. No neurotic nor phthisical family history.
+
+ XXII. Sciatica; in a married lady, aged twenty-seven; first pregnancy;
+       had rheumatic fever and subsequent chorea in childhood. Paternal
+       uncle epileptic; mother had rheumatic fever and cardiac disease;
+       paternal grandfather suffered from sciatica late in life.
+
+No one, I think, can look down the above list and fail to be struck with
+the great preponderance of cases in which the general neurotic
+temperament plainly existed in the patients' families; and let me add
+that, in not a few of these cases, the neuralgia in the individual under
+observation might have been easily set down as dependent merely upon
+peripheral irritation, which, indeed, plainly did act as a concurrent
+cause.
+
+Fortunately, however, I am not dependent upon my own evidence alone, for
+the proofs of the proposition that neuralgia is eminently a development
+of hereditary neuroses. The great French alienists, Morel and Moreau of
+Tours, some years ago laid the foundations of the doctrine of hereditary
+neurosis. They enforced this chiefly with reference to the manner in
+which insanity is transmitted through a chain of variously-neurotic
+members of a family stock; and Moreau laid special stress on the deeply
+interesting connection of the phthisical with the neurotic tendency.
+Since then various observers have insisted on the same thing. Of late,
+Dr. Maudsley has worked out this subject with great ability, in his work
+"On the Physiology and Pathology of Mind," and in his recent "Gulstonian
+Lectures;" and Dr. Blandford dwells on it with emphasis in his
+interesting "Lectures on Insanity." [Dr. Blandford does not, however,
+admit that the phthisical diathesis has any such close and causal
+relation with neuroses as has been imagined by some recent pathologists;
+and, on the other hand, he points out that phthisis in neurotic
+subjects, _e. g._, the insane, must, in a large measure, be considered
+the product of the accidentally unhealthy circumstances in which they
+pass their lives. In the latter opinion I entirely agree.] Indeed, it
+may be taken as a recognized fact, among the more advanced students of
+nervous diseases, that hereditary neurosis is an important antecedent of
+neuralgia, in at least a very large number of instances. I shall
+conclude this part of the argument by stating the general results of my
+inquiries respecting sixty-one hospital patients. Of these cases,
+twenty-two were migraine, or some other affection of the ophthalmic
+division of the fifth nerve; seven were sciatica; two were epileptiform
+facial tic; ten were neuralgias affecting chiefly the second and third
+divisions of the fifth nerve; three were intercostal neuralgias pure;
+one was intercostal neuralgia plus anginoid pain; seven were intercostal
+neuralgias with zoster; three were brachial neuralgias; and five were
+abdominal neuralgias (hepatic, gastric, mesenteric, etc.) Of
+eighty-three hospital and private patients [It must be understood that
+the respective numbers do not indicate with any accuracy the relative
+frequency of the different neuralgias as seen in my practice. (Sciatica,
+_e. g._, was proportionally more frequent.) They represent but a small
+part of the neuralgic patients whom I have seen during fourteen years of
+dispensary, hospital, and private practice, and they were selected for
+inquiry merely because I happened to be able to give the time for the
+necessary questions. Every one who knows out-patient practice will
+understand how seldom this happened.] I obtained evidence of the
+presence, among blood-relations, of the following diseases: Epilepsy,
+fourteen cases (eight were examples of migraine); hemiplegia or
+paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen
+cases; "consumption," eighteen cases; "St. Vitus's dance," four cases.
+I am well aware that these figures must be taken with caution, and that
+considerable doubt must rest on the accuracy of some of these details,
+more especially with regard to "epilepsy," as it was impossible, with
+the greatest care, to be sure that this was not given, by mistake, for
+hysteria in some cases; and the same may apply to the statement that
+relations had suffered from "consumption." The facts are given for what
+they are worth, and with the express reservation that their total
+reliability is far less than that of the accounts obtained respecting
+private patients belonging to the more educated classes. But, in one
+respect, viz., as regards drunken habits, it is possible that a truer
+estimate is gained from the statements of hospital patients than from
+those of private patients, who would usually be more prone to reticence
+on such a topic.
+
+The evidence as to the hereditary character of neuralgia assumes a yet
+higher importance when supplemented by the facts respecting the
+alternations of neuralgia with other neuroses as the same individuals.
+Every practitioner must be aware how frequent is the latter occurrence.
+Nothing is more common, for example, than to see insanity developed as
+the climax of minor nervous troubles, especially of neuralgia. And there
+is one form of neuralgia, the true epileptiform tic, which is intimately
+bound up with a mental condition of the nature of melancholia, and even
+with the markedly suicidal form of the latter affection. I have lately
+had under my care a lady in whom the prodromata of a severe facial
+neuralgia were mental; the disturbance commenced with frightful dreams,
+and there was great mental agitation even before the pain broke out;
+this disturbance of mind, however, continued during the whole period of
+the neuralgia, and was relieved simultaneously with the cessation of the
+attacks of pain. This is contrary to what happens in some cases; thus,
+Dr. Maudsley quotes the case of an able divine who was liable to
+alternations of neuralgia and insanity, the one affection disappearing
+when the other prevailed. Dr. Blandford has met with several instances
+in which neuralgia has been followed by insanity, the pain vanishing
+during the mental disturbance, and reappearing as the latter passed
+away. And he remarks that, in the transition of a neuralgia (to mental
+affection), we may well believe that the neurotic affection is merely
+changed from one centre to another, from the centres of sensation to
+those of mind. He says that the ultimate prognosis of such cases is bad;
+a point to which we shall have to refer again.
+
+The prominent place which quasi-neuralgic pains hold in the earlier
+history of locomotor ataxy is a fact that cannot but engage attention.
+In this volume we have not treated these pains as belonging to the truly
+neuralgic class, for the very practical reason that they are but
+incidents in a most important organic disease, and that in a diagnostic
+and prognostic point of view it is necessary to dwell on their
+connection with that disease. But, in considering the pathological
+relations of neuralgia, it would be improper to omit the consideration
+of the pains of locomotor ataxy, which bear a striking semblance to
+neuralgic pains. The fact that they are an almost if not quite constant
+feature of a disease which is from first to last an atrophic affection
+(mainly of the posterior columns of the cord), in which the posterior
+roots of the nerves are almost always deeply involved, has a bearing on
+our present inquiry too obvious to need further remark.
+
+Equally important to our investigation is the fact that pains, closely
+resembling neuralgia, are not very uncommonly a part of the phenomena of
+commencing, and more frequently of receding, spinal paralysis. I have
+the notes of three cases of partial recovery from paraplegia, in all of
+which the patients remained for years, in one case for nearly twenty
+years (ending with death), the victims to a singularly intractable
+neuralgia of both lower extremities. In the worst of the cases the
+patient was the victim of excessive and continuous labor at literary
+work of a kind which hardly exercised the mental powers, but was
+extremely exhausting to the general power of the nervous system; he
+broke down at about the age of fifty, but dragged on a painful existence
+for the long period above mentioned.
+
+We are also certainly entitled to adduce the example of the so-called
+neuralgic form of chronic alcoholism as an instance of the close
+relationship of neuralgia to other central neuroses. I refer to those
+cases, more common perhaps than is generally admitted, in which pains in
+the extremities, often quite resembling neuralgia in their
+intermittence, are either superadded to or take the place of the
+muscular tremors and general restlessness that are more popularly
+considered as the essential nervous phenomena of chronic alcoholic
+poisoning. That the pains are usually bilateral, and more diffuse in
+their character than those of ordinary neuralgia, is a fact which it is
+not difficult to explain by the _modus operandi_ of the cause; but we
+shall have more to say on the general relations of alcoholic excess to
+neuralgia presently. The pains themselves will be fully described in the
+second part of this book, which treats of the affections that simulate
+neuralgia; here we need only remark that it is not uncommon for them to
+occur interchangeably with true neuralgia in the same person.
+
+The occasional interchangeability of migraine with epilepsy is a
+well-known fact; every practitioner who has seen much of the latter
+disease will have seen some cases in which the patient had been liable,
+at some point of his medical history, to "sick-headaches" of a truly
+neuralgic kind; although it is quite true, as Dr. Reynolds points out,
+that the kind of sensorial disorder specially premonitory of the
+attacks consists rather in indefinable distressing sensations, than in
+actual pain. The genealogical connection between migraine and epilepsy
+is, as I have already stated, apparently very close. Such instances as
+one mentioned by Eulenburg are rightly explained by him; it is the case
+of a girl who suffered at an unusually early age (nine) from migraine;
+her mother had been a migraineuse, and her sister was epileptic; the
+strong neurotic family tendency is believed by Eulenburg to account for
+the appearance of migraine at such a period of life.
+
+This seems the fitting place to introduce some special remarks on
+migraine in its relations to other neuralgias of the head, because
+Eulenburg has mentioned and combated my view, according to which
+migraine is a mere variety of neuralgia of the ophthalmic division of
+the fifth nerve. I call it my view, because, though several other
+authors had previously expressed it, I was first lead to entertain it by
+observations made before I had studied their works, and especially by
+the impressive teaching of my own case, as to which more will be
+presently said. Eulenburg, though he fully allows that migraine is a
+neuralgia, urges a series of objections to the identification of
+migraine with ophthalmic neuralgias; of which objections one, based on
+the doctrine of Du Bois Reymond as to the action of the sympathetic in
+migraine, must be reserved for consideration when we discuss the general
+pathology of the vaso-motor complications of neuralgia. The other
+grounds of distinction that he urges are the following: In the first
+place, he remarks that the site of the pain is by far less distinctly
+referred to definite foci on the outside of the skull than in trigeminal
+neuralgia; the patient's sensations very usually lead him to declare
+that the pain is in the brain itself. Secondly, he says that the points
+douloureux (in Valleix's sense) are almost constantly absent in true
+migraine. Thirdly, he specifies the character of the pain in
+migraine--dull, boring, straining, etc.--as differing from that of
+trigeminal neuralgia, which is ordinarily much more acute and darting.
+Fourthly, he notes the long duration of individual attacks of migraine,
+and the long intervals (very commonly three or four weeks) between them.
+Fifthly, he dwells on the frequent prodromata of migraine referable to
+the organs of sense (flashes before the eyes, noises in the ears), or to
+the stomach (nausea), or more generally to the reflex functions of the
+medulla oblongata (_e. g._, convulsive rigors, excessive yawning, etc.)
+
+Now, I should have nothing to say against the accuracy of this
+description, did it apply merely to the distinctions between
+highly-typical cases of the "sick-headache" of the period of bodily
+development, and highly-typical cases of the ophthalmic neuralgias which
+are commonest in the middle and later periods of life; nor indeed should
+I greatly care if it were finally decided that migraine and clavus
+should be separated from the true trigeminal neuralgię, provided the
+following points were well impressed on the minds of practitioners. In
+the first place, I must insist that in my own experience the great
+majority of undoubtedly neuralgic headaches, which subordinate stomach
+disturbance, are far less sharply separated than the above description
+would allow from the unmistakable trigeminal neuralgias; it is only a
+minority of cases that wear this extreme type, and a far larger number
+shade imperceptibly away toward the type of ophthalmic neuralgia pure
+and simple. And so, again, of the so-called clavus there is every
+variety, from a form bordering closely on the migraine type to another,
+differing in nothing from an unusually severe ocular and frontal
+neuralgia of the fifth, except in the presence of a tremendously painful
+parietal focus. But the fact on which I would most particularly insist
+is one that was first taught me by my personal experience, viz., that
+migraine is, with extraordinary frequency, the primary or youthful type
+of a neuralgia which, in later years, entirely loses the special
+characters of sick-headache, and assumes those of ordinary frontal
+neuralgia, with or without complications. In my own case, the
+"sick-headache" character of the affection was strongly marked during
+the first two or three years, after which time it gradually but steadily
+lost all tendencies to stomach complications, and, what is more, the
+type of the recurrence became entirely changed. Yet it is quite
+impossible to believe that the malady is now a different one, in any
+essential pathological point, from what it was at first; if any disproof
+of this were needed, it might be remarked that the singular series of
+secondary trophic changes which have complicated my case have been
+impartially distributed between the respective periods when the
+affection was frankly migraineuse, when it was mixed, and when it was
+simply ophthalmic neuralgia (as it is at present;) indeed, some of the
+most decided of these trophic complications (orbital periostitis,
+corneal ulceration, fibrous obstruction of the nasal duct) occurred
+within the period in which every attack of pain, unless I succeeded in
+getting to sleep very shortly, ended in violent vomiting. The experience
+thus gained has made me very attentive to the past history of those who,
+in later life, complain of frontal neuralgia without stomach
+complication, and it is surprising to find in how many cases patients,
+who at first declare that they never had neuralgia before, on reflection
+will recall the fact that they were often "bilious" in their youth;
+which "biliousness" turns out to have been regularly preceded by
+one-sided headache, and to have been severe in proportion to the
+severity and duration of that previous headache.
+
+I ask the reader to dwell with fixed attention on this fact of the
+exclusiveness, or almost exclusiveness, with which the neuralgias of
+the anterior part of the head are represented during the period of
+bodily development, and especially in the years just succeeding puberty,
+by migraine or by clavus. When this fact has thoroughly entered the
+mind, we can hardly help joining with it that other and most important
+fact already noticed, of the close connection between the predisposition
+to migraine and the predisposition to epilepsy, and reflecting further
+on the strong tendency which epilepsy likewise shows to infest the
+earlier years of sexual life. In view of these things, it is difficult
+to avoid the inference that both the epileptic and the neuralgic
+affections of this critical period of life are the expression of a
+morbid condition of the medulla oblongata, in which the sensory root of
+the trigeminus has its origin; and further, that this morbid condition
+(tending to explosive and atactic manifestations of nerve-force) must
+have its basis in defective nutrition. For, be it remembered, the epoch
+of sexual development is one in which an enormous addition is being made
+to the expenditure of vital energy; besides the continuous processes of
+the growth of the tissues and organs generally, the sexual apparatus,
+with its nervous supply, is making by its development heavy demands upon
+the nutritive powers of the organism; and, it is scarcely possible but
+that portions of the nervous centres, not directly connected with it,
+should proportionally suffer in their nutrition, probably through
+defective blood-supply. When we add to this the abnormal strain that is
+being put on the brain, in many cases, by a forcing plan of mental
+education, we shall perceive a source not merely of exhaustive
+expenditure of nervous power, but of secondary irritation of centres
+like the medulla oblongata, that are probably already somewhat lowered
+in power of vital resistance, and proportionably irritable. Let us
+suppose, then, that to all these unfavorable conditions there was added
+the circumstance that the structure of the medulla oblongata, or of
+parts of it, was congenitally weak and imperfect; then surely it would
+be scarcely possible for these loci minimę resistentię to escape being
+thrown into that state of weak and disorderly commotion which eminently
+favors pain in the sensory, and convulsion in the motor apparatus.
+
+2. We have so far been mainly considering the relations to the
+production of neuralgia of certain conditions of the central nervous
+system which indisputably are inherent from birth. Let us now pass quite
+to the other extreme, and consider a class of momenta which take a
+decided part in producing many neuralgię, but which are altogether
+accidental and factitious, and cannot be included among the necessary
+hostile conditions of life. To push the contrast to the utmost, let us
+inquire first, what amount of influence in the production of neuralgia
+can be given by such a purely "functional" influence as educational
+misdirection of intellect and emotion?
+
+It is somewhat strange, though every one accepts as a mere truism the
+maxim that sudden emotional shock may produce almost any degree or
+variety of nervous disorder, the slower but far surer influence of
+long-continued mental habit is often practically ignored. It cannot,
+indeed, be left out of sight as a cause of disorders of the mind itself,
+nor are there many who would deny that such diseases as cerebral
+softening are, in a considerable number of cases, the premature ending
+to a life that has been broken down by harassing work and anxiety. But
+what is far less appreciated is the tendency of certain unfortunate
+mental surroundings and modes of mental life to produce a generally
+neurotic condition, which may express itself in a variety of functional
+disorders, among which not the least common is neuralgia.
+
+I may fairly hope to be acquitted of any predisposition to lay
+exaggerated stress on this kind of influence in the production of
+neuralgia, considering all that I have said of the importance of that
+inevitable cause, the neurotic inheritance, and all that I shall have to
+say presently as to the effects of a variety of external influences of a
+totally different kind. But I confess that, with me, the result of close
+attention given to the pathology of neuralgia has been the ever-growing
+conviction that, next to the influence of neurotic inheritance, there is
+no such frequently powerful factor in the construction of the neuralgic
+habit as mental warp of a certain kind, the product of an unwise
+education. This work is not intended as a treatise either on religion or
+psychology, and yet it is impossible for me to avoid some few words that
+may seem to trench on the province of each: for I believe that there are
+certain emotional and spiritual and intellectual grooves into which it
+is only too easy to direct the minds of young children, and which
+conduct them too often to a condition of general nervous weakness, and
+not unfrequently to the special miseries of neuralgia. As regards the
+working of the intellect, it is easier to speak in a free and
+unembarrassed manner than respecting the other matters. There can be no
+doubt that, of intellectual work, that sort which exhausts and harasses
+the nervous system is the forced, the premature, and the unreal kind;
+and this it is which predisposes, among other nervous maladies, to
+neuralgia. It is more difficult to speak the truth about emotional
+influences generally, and especially about those which are concerned
+with the highest spiritual matters; but I should do wrong were I to
+suppress the statement of my convictions on this point. I believe that a
+most unfortunate, a positively poisonous influence upon the nervous
+system, especially in youth, is the direct result of efforts, dictated
+often by the highest motives, to train the emotions and aspirations to a
+high ideal, especially to a high religious ideal. It is not the object
+that is bad, but the machinery by which it is sought to be attained. In
+modern society there are two principal methods which are popularly
+employed for this purpose; I shall describe them, by two epithets which
+are selected with no offensive intention, as the Conventual and the
+Puritan methods of spiritual training. By the former is meant that kind
+of education which deliberately dwarfs the nervous energy, with the hope
+of preserving the mind from the contamination of unbelief and of sinful
+passion. It is a system which is not peculiar to the Roman Church, nor
+even to the Christian religion, and it need the less detain our
+attention, as its effects, so far as they are evil, are mainly seen in
+general nervous and mental enfeeblement, rather than in the outbreak of
+explosive nervous disorders, such as convulsion, insanity, or neuralgia.
+There are doubtless exceptions to the rule; but that is the rule. It is
+far otherwise with the spiritual education which is here called Puritan,
+but which is confined to no party in the Church. This is a system which
+seeks to purify and exalt the mind, not by enforcing obedience to a
+series of spiritual rules for which another mind is responsible, but by
+compelling it to a perpetual introspection directed to the object of
+discovering whether it comes up to a self-erected spiritual standard.
+The reader will understand that I have not the remotest intention to
+depreciate either a true and manly self-restraint in obedience to the
+direction of "pastors and masters," or an honest watchfulness over one's
+own conduct and thoughts. But the lessons which our psychologists are
+rapidly learning, as to the evil effects on the brain of an education
+that promotes self-consciousness, are sorely needed to be applied to the
+pathology of nervous diseases generally, and of neuralgia among the
+rest. Common sense and common humanity, when united with the physician's
+knowledge, cry out against the system under which religious parents and
+teachers subject the feeble and highly mobile nervous systems of the
+young to the tremendous strain of spiritual self-questioning upon the
+most momentous topics. More especially is such a practice to be
+condemned in the case of boys and girls who are passing through the
+terrible ordeal of sexual development--an epoch which, as we have
+already seen, is peculiarly favorable to the formation of the neurotic
+habit, and I must emphatically state my belief that among the
+seriously-minded English middle classes, more especially, whose life is
+necessarily colorless and monotonous, the mischief thus worked is both
+grave and widely spread.
+
+Perhaps the maximum of damage that can be inflicted through the mind
+upon the sensory nervous centres is effected when to the kind of
+self-consciousness that is generated by an excessive spiritual
+introspection there is added the incessant toil of a life spent in
+sedentary brain-work, and checkered with many anxieties, and many griefs
+which strike through the affections. Doubtless, such a combination of
+morbid mental influences is sufficient of itself to generate the
+neuralgic disposition in its severest forms, without any hereditary
+neurotic influence, and without any other peripheral irritations; I have
+more than one such instance in my mind at this moment. But, if they can
+do this, much more can such influences arouse inherent tendencies to
+neuralgia; to persons who are predisposed in this manner they are most
+highly deleterious.
+
+3. We come now to the peripheral influences which in a more obvious
+manner become factors in the production of neuralgia. Of such influences
+there are an immense variety, and the only common quality that can be
+predicated of all is the tendency directly to depress the life of the
+sentient centre upon which their action impinges.
+
+If we search among the external influences which contribute to the
+production of neuralgia for one that is apparently trivial as to the
+amount of material disturbance which it can cause, and yet is very
+frequently effective, we may select the agency of cold. The effect of a
+continuous cold draught of air impinging on the naked skin for some time
+is comparatively frequently seen in the provocation of neuralgic attack:
+we say comparatively, because this influence is more frequently
+effective than blows, wounds, or temporary irritations of any kind,
+applied to the peripheral ends of sensory nerves. But if neuralgia be a
+more frequent consequence of cold than of these other influences, a
+moment's reflection will show that it is by no means an absolutely
+common result. One has only to think of the numerous omnibus-drivers,
+engine-drivers, cab-drivers, etc., etc., who pass their whole working
+lives in presenting the (more or less) naked expanse of their trigeminal
+and their cervico-occipital nerves to every variety of wind, to perceive
+that, were this sort of influence very potent in itself, male neuralgic
+patients should swarm as thick as bees in our hospital and dispensary
+out-patient rooms; which is notoriously quite contrary to the fact. The
+same remarks, in both directions, may be applied to the direct influence
+of atmospheric moisture, either with or without the effect of wind (of
+course I am not speaking of the more recondite effects of damp soil on
+the persons who live about it). [Among the hundred patients who formed
+the basis of the inquiries mentioned in this work, forty-one accused
+external cold of producing the attack, but many of these produced
+insufficient evidence that such was the case.] In short, the direct
+effects of atmospheric cold would seem to be these. Mere lowness of
+temperature goes for something, but not much; [The most marked instance
+of the effect of cold, _per se_, that I have seen, was exhibited by a
+young lady who was under my care during the past severe winter
+(1870-'71). During much of the time she was confined to a
+carefully-warmed apartment, on penalty of a violent paroxysm if she left
+it.] for about as much, perhaps, as it does in the way of aggravating
+all neurotic tendencies. Cold joined with wind is much more powerful.
+And the maximum of ill-effect seems reached by very cold wind mingled
+with sleet or driving rain, which keeps the skin sodden. But the
+conclusion at which I long ago arrived is, that none of these influences
+ever take more than a small (though it is sometimes an important) part
+in the production of neuralgia; and that in the majority of cases there
+is no pretence for supposing that they had the slightest share in its
+causation.
+
+A word or two must be said as to the _modus operandi_ of cold and cold
+wind, as these are the most frequent of external, so-called "exciting"
+causes. The popular use of such phrases as the latter has an
+extraordinary influence in disguising the plain fact, which is, that
+these influences operate wholly in the direction of robbing the nerves
+of force. The continuous abstraction of heat from the surface, which of
+course is materially aided by rapid movement of the air, must
+necessitate a readjustment of the distribution of energy, the only
+result of which must be to drain the sensory nervous centre of its
+reserve of force. But, in fact, there is an experiment, ready performed
+to our hands, which may amply satisfy us as to the kind of influence
+exerted by cold on superficial nerves, viz., the sensations experienced
+in recovering from frost-bite, which has been severe enough to paralyze
+the nerves without causing actual gangrene of the tissues. The passage
+of the nerves back from temporary death to full functional life is
+marked by a half-way stage in which there is agonizing pain.
+
+4. We must next consider the effects of a class of peripheral influences
+which act, where they exist, in a more constant manner than any others;
+viz., those in which the trunk or periphery of a sensory nerve either
+receives a severe injury, or becomes more or less engaged in
+inflammatory processes, or compressed or otherwise damaged by the growth
+of tumors or the spread of destructive ulcerations.
+
+With regard to ordinary nerve-wounds as a cause of neuralgia, we have
+already said (_vide_ Chapter II.) nearly as much as it is necessary to
+say; we need only here point out that, like the influence of cold
+applied to superficial nerves, that of wounds must necessarily be a
+depressing one to the centre with which the wounded nerve is connected,
+and the resulting neuralgia must be regarded as an expression of impeded
+and imperfect nerve-energy, not of heightened nerve-function. The pain
+is set up during the process of nerve-healing; that is to say, at a
+stage intermediate between those of abolished function and completely
+restored function; and there can be little doubt that the obstinacy with
+which it is often protracted is due to the slowness with which a wounded
+nerve recovers its full functional activity; when once the latter is
+completely restored there is an end of neuralgic pain. It is exactly
+analogous to the course of events in recovery from freezing.
+
+There remain for consideration, however, (a) a small class of cases of
+nerve-wounds in which the healing process is not simple; but the lesion
+is followed by the development of a tumor of the kind denominated true
+neuroma. The process consists of hyperplastic changes in the
+nerve-fibres; its commonest examples are seen in the extraordinarily
+painful swellings that occur on the ends of nerves left in stumps after
+amputations; but, in fact, a neuroma of this kind may occur after any
+kind of severe nerve-injury, as, _e. g._, a cut from broken glass, the
+impaction of foreign bodies, etc. The true neuromata are composed mainly
+of nerve-tissue, with a relatively small element of connective tissue:
+the nerve-fibres can be traced directly to the nerve-tumor. Besides the
+traumatic neuromata which form permanent tumors, incapable of being got
+rid of except by actual excision, a minor variety of the same kind of
+change has in several cases been known to take place in consequence of
+an abiding local irritation from the impaction of a foreign body, on the
+removal of which the neuromatoid enlargement completely disappeared. (b)
+There are likewise a certain number of cases in which a tumor is
+developed from the neurilemma, and does not consist of nervous tissue;
+these are distinguished as false neuromata, and may be of various kinds,
+the fibromatous and gliomatous being far the most common, but cysts and
+cystic tumors also sometimes occurring.
+
+The case of the neuromata is well worth reflecting upon, in the course
+of our endeavors to clear up the Pathology and Etiology of Neuralgia. If
+ever we could find a merely peripheral influence which would of itself
+be invariably competent to excite neuralgic pains, it would surely be
+found in neuroma; but the case is not merely not so, it is strikingly
+contrary. Just as wounded and inflamed nerves frequently go through the
+whole processes of disease and recovery without once eliciting a
+neuralgic pang, so is it with neuromata; they are not unfrequently quite
+indolent, and neither excite neuralgia, nor are themselves at all
+particularly tender to the touch. And what is most remarkable is, that,
+as Eulenburg correctly remarks, among the pseudo-neuromata the kind of
+tumor which is most frequently associated with neuralgia is by no means
+the dense fibroma or glioma, which might be expected by its mechanical
+pressure to excite inevitable neuralgic pain, but the far softer and
+more yielding cystic tumors. I do not know how the facts may affect the
+reader, but to me they suggest the strongest possible arguments against
+the belief that peripheral irritation can of itself produce neuralgia
+without the intervention of some centric change. The tendency to such
+change (from inherent constitution) in the sensory root of the nerve
+must surely be the reason why neuroma causes neuralgia in a given number
+of subjects, instead of letting them go scot-free, as it does other
+persons.
+
+The same remarks apply to the result of observations on the effect of
+tumors commencing in tissues altogether unconnected with the nerve, and
+merely coming to involve it, secondarily, in pressure. It has been often
+noted that, among these tumors, fluid-containing cysts and soft
+medullary cancers are far more frequently the cause of decided and
+distressing neuralgia than the denser and less yielding neoplasms. Of
+kinds of tumors that are specially apt to produce severe and even
+intolerable neuralgia by the pressure on nerves, it has been remarked
+that aneurisms are among the worst: here every pulsation often sends a
+dart of agony through the nerve. There is a reason here, however, which
+is often left out of sight; not merely is the perpetually varying
+pressure specially harassing and exhausting to the nerve, but in many of
+these cases there is general arterial degeneration, and the sensory root
+of the nerve is exceedingly likely to be very badly nourished. [This
+result will be more directly brought about when the aneurism happens to
+press on the ganglion of a posterior root.] We pass now to the
+consideration of the influence exerted by other great series of
+peripheral impressions in the production of neuralgia. These impressions
+are connected chiefly with the functions of the digestive and of the
+genito-urinary organs, the functions of the eye, and the nutrition of
+the teeth.
+
+To take the least important of these first, I may surprise some readers
+by the statement, which I nevertheless make with much confidence, that
+irritation of any part of the alimentary canal is, on the whole, a rare
+concurrent cause, even in the production of neuralgia. There are, as has
+been already fully explained, cases of neuralgia seated in these viscera
+themselves (or the plexuses in their immediate neighborhood), although
+their number is immensely smaller than that of the neuralgias of
+superficial nerves. But it is not at all common--it is even exceedingly
+rare--for irritation conveyed from the alimentary canal to take any
+important part in setting up neuralgia of a distant nerve, even when
+that nerve has close connections, through the centres, with those coming
+from the irritated portion of the alimentary canal. Valleix had the
+great merit to perceive this, even in the case of neuralgias of the
+head, where appearances are so likely to lead the observer to a contrary
+opinion. And it is not a little remarkable that this should be the case,
+when we consider the close central connections which the vagus, the
+great sensory nerve of a large portion of the alimentary canal, has with
+the sensory root of the trigeminus. In fact, however, there are certain
+peculiar forms of gastric irritation which do react upon the trigeminus;
+for instance, a lump of unmelted ice, suddenly swallowed, almost
+invariably produces acute pain in the supra-orbital branch of the fifth,
+on one side or the other, and occasionally (as in a case cited by Sir
+Thomas Watson) in other nerves. But that common dyspeptic troubles at
+all frequently or importantly contribute to the production of neuralgia,
+I do not for a moment believe: it needs some very powerful irritation,
+such as that just mentioned, or as impaction of great masses of scybalę
+in the intestines, or severe irritation from worms, to produce such an
+effect.
+
+It is far otherwise with the genito-urinary apparatus; in a large number
+of cases, irritations proceeding from these organs do undoubtedly
+contribute to the production of neuralgia, though by no means in the
+important degree which many authors seem to have assumed. There can be
+no doubt, for example, that the irritation of a calculus, either within
+the kidney itself, in the ureter, or in the bladder, may set up violent
+neuralgia, which for the most part is localized in the branches of the
+lumbo-abdominal nerves. The instance of the eloquent Robert Hall is an
+example of renal calculus acting in this way: he suffered the most
+excruciating agony for years, and was obliged to take enormous
+quantities of opium in order to make life endurable. An instance of
+calculus impacted in the ureter, in a gentleman somewhat past middle
+age, occurred in my own practice; the lumbo-abdominal neuralgia occurred
+in frequent paroxysms of dreadful severity; and another case, already
+referred to was that of a woman, in whom ovarian neuralgia was
+undoubtedly in great part due to the irritation of an impacted calculus
+in the ureter. These cases, however, are very rare in comparison with
+others in which the peripheral source of the neuralgia is either the
+uterus or ovary, or the external genitals. I have no means of
+ascertaining, with anything like accuracy, the frequency with which the
+internal sexual organs are the starting-point of neuralgia, because the
+majority of such cases pass, naturally, to the care of physicians who
+practice chiefly in the diseases of women, and consequently not
+adequately represented either in my hospital or my private practice;
+still, I have seen a good many of these affections, and, though I speak
+with the reserve necessitated by the circumstances just named, I am much
+inclined to believe that even such powerful centripetal influences as
+those of the states of commencing puberty, of pregnancy, of the change
+of life, and uterine diseases generally, are very rarely the cause of
+true unilateral neuralgia, except in subjects with congenital tendencies
+to neuralgia. But in predisposed subjects there can be no doubt that
+these influences assist most powerfully in producing the malady.
+
+Of the power of irritation of the external genitalia to act as a
+so-called "exciting cause" of neuralgia, there is abundant evidence. I
+would especially call attention to the remarkable monograph of M.
+Mauriac, ["_Etude sur les Nevralgies Reflexes symptomatiques de
+l'Orchi-epididymite blenorrhagique_" Par C. Mauriac, Medecin de
+l'Hospital du Midi. Paris, 1870.] on the neuralgias consecutive to
+blenorrhagic orchi-epididymitis, as illustrating this with a force that
+was to me, for one, surprising. I shall, perhaps, have further occasion
+to these researches; here it will be enough to mention that M. Mauriac's
+enormous experience of blenorrhoea and orchitis at the Midi has shown
+that, in an exceedingly large number of cases, certainly not less than
+four per cent., this combination is followed by reflex neuralgias, of
+which a large number are not seated in the genital apparatus, but affect
+the track of some distant sensory nerve, through the intermediation of
+the spinal centres; and that with these reflex pains there is often
+profound general disturbance, including very often an extremely profound
+general anęmia. The most frequent kind of these neuralgias is
+rachialgia, _i. e._, pain in the superficial posterior branches of
+spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and
+crural, visceralgic (abdominal), etc.; and besides all these there are
+numerous instances of neuralgia in the testis. As to the nervous
+"reflection," more hereafter.
+
+It has surprised me, somewhat, that while M. Mauriac has seen so many
+reflex neuralgias set up by orchi-epididymitis, he does not appear to
+have noticed cases of trigeminal neuralgia from this source; because, in
+the very analogous instance of the peripheral irritation produced by
+excessive masturbation, we undoubtedly do frequently get a development
+of the tendency to migraine, and also to other forms of neuralgia of the
+fifth: moreover the effect of such local irritation can be occasionally
+traced with much distinctness in the trigemini, by a tendency to certain
+forms of eye-disease without positive neuralgia. This was remarkably
+exemplified in a case which was under my care some years ago, and in
+which both eyes were greatly damaged by vaso-motor and trophic changes;
+partial insanity also supervened with hallucinations of sight and
+hearing.
+
+We come now to one of the most powerful sources of peripheral irritation
+tending to set up neuralgia; viz., functional abuse of the eye. This is
+one of the very few peripheral influences which occasionally we see
+producing neuralgia unaided by hereditary predisposition, or any other
+observable cause whatever, and in a far larger number producing it with
+the sole aid of more or less defective general nutrition. The latter
+occurrence is well exemplified by a case which Mr. Carter sent me the
+other day, and which also illustrates (second attack) the effect of the
+superaddition of syphilitic taint:
+
+Matilda W----, aged thirty-three, married, and has three very healthy
+children. Comes of a remarkably healthy family, of which she told me the
+entire history for three generations, with unusual intelligence and
+clearness. No neuroses, properly so-called, in any of her relatives
+during all this time. She herself was a very strong and hearty girl
+until the age of seventeen; between this date and her marriage, three
+years later, she was obliged to work tremendously hard at fine sewing,
+by which means she gained a very scanty livelihood. After a
+comparatively short period of this work she began to suffer from typical
+attacks of migraine, very severe, and recurring every three or four
+weeks, but in no particular connection with the menstrual function,
+which was normal. On her marrying and ceasing to do needle-work, the
+migraine entirely disappeared, and she retained perfect health till the
+commencement of 1871. At this time she had suckled a very hearty baby
+for ten months, and was not able to furnish such good living as usual.
+She was attacked early in January, with violent neuralgia affecting all
+three branches of the right fifth, and she the more readily applied for
+advice because she soon found that the neuralgia was becoming
+complicated with dimness of vision in the eye of the affected side, "as
+if she was going to have a cast." Was quite unconscious of ever having
+had syphilis. The medical man encouraged to believe that the whole
+malady was nervous, and would soon disappear under appropriate remedies,
+and gave her quinine, under which treatment she declares that she was
+rapidly improving, both as to pain and vision, but that her resources
+came to an end, and she could no longer pay for the medicine. She then
+neglected herself, and rapidly got worse in all regards, till at last
+she was compelled to apply to the South London Ophthalmic Hospital,
+whence Mr. Carter sent her to me, on the 6th of April. At this time the
+paroxysms were excessively violent and frequent, though brief. On
+examination, tender points were found at the supra-orbital notch, at the
+infra-orbital foramen; in front of the ear; in the temporal region; in
+the parietal region, and the inferior dental region. There was strongly
+marked anęsthesia of the skin of the right half of the face, of the
+gums, and of the side of the tongue. The teeth were absolutely perfect:
+not one spot of caries could be seen. Taste was completely destroyed in
+left half of anterior part of the tongue. Smell was totally lost on both
+sides, and had been so, the woman declared, from a very early period in
+the illness. The right eye showed complete paralysis of the levator
+palpebrę and of the external rectus; nearly complete paralysis of the
+superior and inferior rectus, rather less marked paralysis of the
+internal rectus. Pupil normal, conjunctiva moderately congested,
+lachrymation profuse, photophobia partial. The functions of the retina
+were perfect. Accommodation was affected in the following degree and
+manner. The vision of the affected eye was perfect at long distances,
+very imperfect at short distances. With both eyes open she saw every
+thing double, but could still count all the bricks in a whitewashed wall
+at sixteen feet distant. There was no secondary disturbance of the
+stomach whatever. On the first visit she assuredly had no visible
+signs, in skin or throat, of syphilis; the perfect health of her
+children, and absence of abortions, made syphilis the less probable. But
+on her second visit she complained of sore throat, and a week later a
+palpably specific sore appeared on the soft palate. She declared, with
+apparent sincerity, that it was the first symptom of the kind she had
+ever had. The neuralgia rapidly disappeared under thirty grains of
+iodide of potassium daily. The lesions of taste and smell disappeared
+exactly pari passua with the trigeminal pains. The ocular paralysis
+threaten to be much slower in departing. I think we must believe that
+this woman contracted syphilis after the birth of her last child. It is
+at any rate certain that the migraine of her youth was perfectly
+unconnected with syphilis, being as unlike the pains evoked by the
+latter as it is possible for two kinds of pain to be. In all probability
+she was infected during her last lactation.
+
+Last among the peripheral influences of sufficient importance to be
+specially mentioned as effective factors in the production of neuralgia,
+must be mentioned caries of the teeth, and the comparatively rare
+accident of the mal-position or abnormal growth of a "wisdom-tooth." It
+is an undoubted fact that these things may cause neuralgia even of a
+very serious type, and attended with extensive complications; as in Mr.
+Salter's cases, already mentioned, of reflex cervico-brachial neuralgia
+from carious teeth. Looking to the extreme frequency of caries, however,
+as compared with the rarity of true neuralgia (not mere toothache) as a
+consequence of it, it is impossible not to suppose that the share of the
+carious teeth in the production of such neuralgia must be very small,
+compared with that of other influences.
+
+5. The next influence which we shall mention as undoubtedly very
+effective in assisting the production of neuralgia in certain cases is
+that of anęmia and mal-nutrition generally; but it is not necessary to
+dwell on this at any length. The fact is notorious that severe loss of
+blood is always followed by headache; and if there be the least
+predisposition to neuralgia, this headache will very commonly take the
+form of the severest clavus. And, in like manner, chronic states of
+anęmia and of mal-nutrition undoubtedly aggravate every existing
+neuralgia, and bring out lurking tendencies to the disease. But I do not
+believe that anęmia, or starvation pure and simple, ever generates true
+neuralgia by its sole influence.
+
+6. The question how far, and in what way, the neuralgic tendency is
+helped by certain constitutional diatheses, such as rheumatism and gout,
+and by certain toxęmię, such as malaria, alcoholism, lead-poisoning,
+etc., is a very much more difficult one than might be supposed from the
+off-hand manner in which many writers speak of the "rheumatic," the
+"gouty," or the "alcoholic" forms of "neuralgia." We may, however,
+simplify it a good deal. In the first place, it seems obvious to me that
+the only manner in which alcohol helps the production of true neuralgia
+is by its tendency, after long abuse, to produce degeneration of the
+nervous centres: it will therefore be considered, shortly, under another
+division of the present subject. Lead-poisoning, again, only produces so
+highly special a form of neuralgia (if colic be neuralgia at all) that
+it need not detain us here. The influence of malaria is, for the most
+part, an utter mystery to us, but by so much as we can see it appears
+plain that one of the most important features in the disease is a
+powerful disturbance of the spinal vaso-motor centres. But the most
+interesting consideration that we have to deal with is the question of
+the supposed relations of the rheumatic and the gouty diatheses, and the
+syphilitic dyscrasia, to the neuralgic tendency. On this point I am
+obliged to disagree _in toto_ with the popular view that assigns these
+diatheses among the most frequent predisposing causes of neuralgia.
+
+To take the case of rheumatism first, I am willing to allow that there
+are a number of facts which superficially appear to countenance the idea
+of a close connection of this disease with neuralgia. But of these facts
+a considerable proportion consist only of examples of inflammation of
+the nerve-sheath, with a certain amount of effusion within and around
+it, occurring in persons who have never shown any symptoms which warrant
+the assumption of a general rheumatic diathesis; and these local
+phenomena really differ in nothing from many trophic and vaso-motor
+changes which have been already described as plainly secondary to
+ordinary neuralgia in which there could be no pretence of a rheumatic
+pathology except on the slender foundation of a suspicion that the
+affection was immediately excited by the influence of cold, which is
+really no argument at all. Such patients will be found to have
+exhibited, not special rheumatic, but special neuralgic tendencies in
+their past history. On the other hand, there undoubtedly are a certain
+number of patients who, having previously given signs of a tendency to
+generalized rheumatic inflammation of fibrous membranes, are, on some
+particular occasion, attacked with similar inflammation extending over a
+more or less considerable tract (not a small limited spot) of a nerve
+sheath. But so far from agreeing with those who think that this is a
+frequent case, my experience teaches me that it is quite exceptional;
+nor do I believe that the common opinion could ever have arisen had it
+not been for the rage that exists for connecting every disease with a
+special diathesis which the profession flatters itself that it
+understands. Few persons have taken more pains than myself to ascertain
+the frequency with which neuralgic patients show a history of previous
+rheumatism, whether in the so-called "fibrous," or in the synovial
+form; but it is remarkable how seldom I have found this to be the
+case--a result which surprised me, because it happened that I, a
+neuralgic subject, had suffered in youth from regular acute rheumatism,
+and had fancied that I should discover a close connection between
+rheumatism and neuralgia. Eulenburg states that neuralgia caused by cold
+more frequently attacks the sciatic nerve than any other, and thinks
+that the tendency to sciatica is characteristic of the relations of
+rheumatism to sensory nerves. For my own part, I see no reason to call
+in the rheumatic diathesis as a _deus ex machina_ to explain the
+frequency with which sciatica follows comparatively trifling peripheral
+impressions like that of cold. The true reason I believe to be, that
+what would have been a slight and trivial neuralgia elsewhere, becomes a
+serious affection in the instance of the sciatic nerve, by reason of the
+strong muscular pressure end dragging which are always going on in the
+thigh in locomotion. I shall return to this subject when speaking of
+Treatment.
+
+As regards the relations, of gout to neuralgia, I can hardly express my
+own view better than by quoting the words of Eulenburg:[17] "Much more
+doubtful is the influence of gout, which in rare cases, perhaps,
+produces neuralgia directly, by means of neuritis, or by the deposit of
+tophus-like calcareous concretions in the nerve-trunks. Gout has been
+reckoned as a great influence among the causes of superficial neuralgias
+(sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but
+this influence is more probably only an indirect one, operating through
+circulation changes which are often produced by chronic liver-diseases
+or by diseases of the heart and vessels, (_e. g._ Valvular diseases and
+narrowing of the coronary arteries in angina)." To which I will add this
+argument against any close connection of gout with neuralgia, that it is
+exceedingly seldom that colchicum effects any decided good, a fact which
+is as unlike the relations of colchicum to true gout as any thing could
+be. For, whatever may be thought of the advantages or disadvantages, on
+the whole, of employing colchicum against gout, at least no one with any
+experience will deny that in the immense majority of cases of true gouty
+pain, it gives rapid relief to the acute suffering. I doubt if it
+ever[18] acts in that way in real neuralgia, though I have occasionally
+seen it apparently useful in a more limited way, as will be said
+hereafter.
+
+As regards the relation of the syphilitic dyscrasia to neuralgia, I
+agree in general with Eulenburg. "Syphilis," he says, "may be the direct
+cause of neuralgia, either by the development of specific gummata in
+the nerve-trunks or in the centres, or by arousing chronic irritative
+processes in the nerve sheaths, the membranes of the brain and spinal
+cord, or, especially, in the bones and periosteum (syphilitic osteitis
+and periostitis)." The case of periostitis, however, is a doubtful one:
+it may be questioned whether this affection (which will be among the
+diseases discussed in Part II. of this work) ever give rise to true
+neuralgia. Persons who are, by inheritance, highly predisposed to
+neuralgia, may from the mere general lowering of their health produced
+by constitutional syphilis, become truly neuralgic simultaneously with,
+or subsequently to, the appearance of painful nodes on their bones. And
+as regards the whole relations of syphilis to neuralgia, I must, from my
+experience, conclude that the former is, after all, but rarely concerned
+in the production of the latter. Syphilis has a strong specialty for
+producing limited motor paralyses, but a much weaker one for producing
+limited affections of the sensory system.
+
+7. We now come to the discussion of a group of momenta whose influence
+in the production of neuralgia is at once very powerful, and of the
+highest significance as regards the general pathology of the disease.
+These are the degenerative changes of the arterial and capillary systems
+which are a part of the normal phenomena of old age, but may occur at
+earlier periods of life, in consequence either of certain constitutional
+diseases, especially gout, or of special toxic influences on nutrition,
+of which persistent alcoholic excess is very far the most important.
+
+The reader does not need to be told the familiar story of the
+degenerative changes in the vessels which, commencing usually some time
+during the fifth decenniad, by degrees convert the elastic arterial
+coats, and the almost membranous walls of the capillaries, into more or
+less rigid tubes; nor does he need to be informed that the tendency of
+these changes, as they operate in the great motor and intellectual
+centres, is notoriously to produce innutrition of the tissues that
+depend for their blood supply on the affected vessels, whence cerebral
+softening so commonly results. That analogous changes take place in the
+vessels supplying the spinal centres is certain; but it is a remarkable
+fact that these do not very commonly produce motor paralysis. What they
+do produce is rather a slow enfeeblement both of (spinal) sensation and
+motion, but where the process of decay has been prematurely forced, or
+the inheritance of neurotic weakness is very marked, the process of
+sensorial decay (the decline, that is, of true sensorial function) is
+apt to be mingled with pain. That this pain should be localized, often
+in a single nerve, is no more surprising than the fact that the
+degenerative process itself should vary so greatly in the degree of its
+development at one point from that which it shows at others. I have
+already insisted (_vide_ Chapter I.) on the marked correspondence
+between the period of life in which degenerative changes commence and
+progress (the last third, roughly speaking, of a fairly long life), and
+that in which the most severe, intractable, and progressively increasing
+neuralgias are developed. I must here notice a singular statement of
+Eulenburg's, that neuralgia never attacks people who are over seventy.
+That statement shows that persons of a greater age than seventy are rare
+in this world, and that no such patient happened to come under
+Eulenburg's notice; for I have (by mere chance, doubtless) seen several
+instances of first attacks occurring after seventy; and almost the worst
+case of epileptiform tic I ever saw began when the patient was eighty;
+she was a member of a highly neurotic family whose medical genealogy is
+given at a previous page. In general terms, it may be said that every
+additional year of life after fifty increases the probability that a
+neuralgia, should such arise, will be severe and rebellious to
+treatment; and in the very aged the cure of such affections is probably
+impossible.
+
+8. This seems the proper place to introduce such facts as have been
+observed, and they are very few, that directly illustrate the material
+changes occurring in neuralgia.
+
+Very much the most important of these facts is the history of a
+remarkable case recorded by Romberg. ["Diseases of Nervous System," Syd.
+Soc. Trans., vol. i.] The patient, a man sixty-five years old at the
+time of his death, had suffered for several years from the most violent
+and intractable epileptiform trigeminal neuralgia, complicated with
+interesting trophic changes of the tissues. Post-mortem examination
+showed that the pressure of an internal carotid aneurism had almost
+destroyed the Gasserian ganglion of the painful nerve, that the trunk
+and posterior root of the nerve were in a state of advanced atrophic
+softening, and the atrophic process had extended in less degree to the
+nerve of the opposite side. Now, the value of this case is by no means
+restricted to the fact that it records the existence of a particular
+anatomical change in one example of neuralgia. Its most striking
+teaching is the fact that the acutest agonies of neuralgia can be felt
+in a nerve, the central end of which is reduced to such a pitch of
+degeneration that conduction between centre and periphery must very
+shortly have entirely ceased had the patient lived. And hardly less
+important is its illustration of the fact that permanent injury to the
+ganglion of the posterior root of a spinal nerve impairs the vitality of
+the posterior root itself--a fact which has been independently made out
+by the physiological researches of Bernard and of Augustus Waller.
+
+On the other hand, if we examine the tolerably numerous histories of
+cases in which the painful nerves have been examined at the apparent
+site of pain, we discover nothing to lead us to connect neuralgia
+definitely with any one sort of change. Assuredly, for example, local
+neuritis is by no means universally, it is probably even not commonly,
+present in the early stages of neuralgia; it has also been repeatedly
+detected in nerves that had been wholly free from neuralgia; and, on the
+other hand, it has been entirely absent in nerves that have been the
+seat of the severest pains. Moreover, many facts which have been put
+down without reflection, as showing a local peripheral cause for
+neuralgia, are at least open to another and, as I believe, truer
+explanation; as (_e. g._) in the following remarks of Eulenburg on
+mechanical irritations of nerves as causes of neuralgia: "Diseases of
+bones are extraordinarily frequently the cause of neuralgias in
+consequence of compression or secondary disease, which affects the
+branches of nerves passing through canals, foramina, fissures, or over
+processes of bone. The appearances which the opportunities of resections
+of the trigeminus for facial neuralgia have permitted to be discovered,
+have given us valuable information in that direction. Flattening and
+atrophy of nerves from periostitis, or from concentric hypertrophy in
+narrowed bony canals, have frequently been discovered. The neurilemma at
+the narrowed parts was often seen reddened, ecchymosed, infiltrated with
+serum, or surrounded with fibrous exudation; occasionally inflammation
+had been followed by partial thickening of the neurilemma (fibrous
+knots) and turbidity (Trubungen) of the nervous cord at the
+corresponding spot. Similar appearances have been noted in other
+neuralgias (neuralgia-brachialis, sciatica)." For my own part, I believe
+that the above description represents the facts from an erroneous point
+of view. True neuralgia, if by that we understand a pain of intermittent
+character limited to one or more nerves, is in my experience an
+extremely uncommon result of periosteal disease, or of inflammation of
+the linings of bony canals; but in a great number of instances such
+diseases appear to be set up as the secondary consequence of the
+neuralgic process (whatever the essential nature of that may be) going
+on in sensory nerves which supply the parts when these inflammations
+appear. And it must be remembered that the specimens obtained by
+resection of nerves are comparatively few in number, and are taken
+universally from old-standing and desperate cases of disease; in short,
+from cases which are just in those advanced stages of neuralgia in
+which, as has already been amply shown, these secondary inflammations
+are almost always present. On the other hand, I have myself had one
+opportunity of examining the local condition of an intercostal nerve,
+which during life, and quite up to death, had been the site of the most
+pronounced neuralgia, which, however, had only existed for a few days.
+The patient, a young man, aged twenty-seven, was probably insane, and
+had attempted suicide. Not a trace of inflammation, either in the nerve
+itself or in any of the tissues to which it was distributed, could be
+detected. (This was a case in which I greatly regretted the
+impossibility of getting a family history that was at all reliable.) The
+spinal cord, unfortunately, could not be examined. And I strongly
+believe, from the marked absence of tenderness on pressure which is
+almost universally observed in ordinary cases of neuralgia at an early
+stage, that primary inflammation of neurilemma, periostem, etc., as a
+cause of neuralgia, is altogether exceptional; so much so, that we are
+entitled to believe it can never be more than a concurrent, and then not
+the most important, cause.
+
+It is necessary here to inquire, more particularly than we have yet
+done, into the nature of the "painful points" first signalized by
+Valleix as a distinctive symptom of neuralgia. Very great differences of
+opinion have prevailed among subsequent writers, both as to the
+frequency and the significance of these points. It may be said, however,
+to be now quite settled that the presence of definite points, painful on
+pressure, and also corresponding to the foci of severest spontaneous
+pain, is far from universal in neuralgia. Upon this point there is
+probably no reason to doubt the correctness of Eulenburg's observations
+made in the surgical clinic of Greifswald and the polyclinic of the
+University of Berlin; he says that he discovered the existence of tender
+points in "Valleix's sense," in rather more than half the cases of
+superficial neuralgia, but in the rest he could not by any means
+discover them. In many other cases, however, he found more indefinite
+points of tenderness, not accurately corresponding to nerve-branches,
+but affecting individual portions of skin, bone, or joints; the relation
+of these to the neuralgic symptoms was difficult of explanation.
+Eulenburg lays down the principle that "hyperęsthesia" may depend on
+three sorts of causes--(1) On local disease of the peripheral ends of
+nerves; (2) on alterations of the psychical centres; and (3) on morbidly
+exaggerated conduction in the nerve-trunks themselves; and it is to this
+third source that he attributes many of the phenomena of the neuralgic
+painful points, and especially their multiplicity, in many cases. The
+_locus in quo_ of the mischief which sets up this exaggerated conduction
+of sensory impression is, upon this theory, between the psychical centre
+and the main point of branching of the nerves; hence a large number of
+peripheral nerve-termini might be practically sensitive to touch,
+because the mischief, though localized in a comparatively small spot,
+might easily affect many bundles of fibres, which diverge widely from
+each other in their course. It will be seen presently with what limits
+and for what reasons we believe this to be a true theory. But to return
+to the question of painful points in Valleix's sense, we must state one
+or two facts which seem certain from our own experience, but have not
+been adequately recognized, we believe, by others. The first is, that
+localized tender spots, accurate pressure on which will set up or
+aggravate the neuralgic pain, are not early phenomena, save in
+neuralgias of exceptional severity of onset; but that a certain
+persistence and severity of neuralgia are always followed by the
+formation of one or more true points douloureux. The second fact relates
+to the clinical history of migraine. Roughly speaking, it is true, as
+Eulenburg states, that, in pure migraine, painful points in Valleix's
+sense are not to be found; in place of them we observe, after the
+paroxysms have passed away, a more generalized soreness of considerable
+tracts of the scalp, forehead, etc., or diffuse tenderness of the
+eyeball. But I must here again refer to the fact, first observed in my
+own case, and afterward verified in many others, that migraine may be
+only the youthful prelude to a regular trigeminal neuralgia attended
+with the formation of characteristic localized painful points at a later
+period. And the third fact that must be specially mentioned is that the
+true Valleix's point, when it has become established for some time, is
+not a mere spot of sensitive nerve, but is the scene of trophic changes,
+involving hyperęmia and thickening of parts surrounding the nerve. To
+give one example, it is quite a frequent thing to find a patch of tender
+and sensibly thickened periosteum of irregular shape, but equal
+sometimes to a square inch in size, over the frontal bone at and
+immediately above the inner end of the eyebrow, in cases where
+supra-orbital neuralgia has recurred frequently during some years,
+although no such thing was present when the neuralgia first commenced.
+In my own case, the bone has become sensibly thickened at that point.
+
+The general result of such post-mortem and clinical information as can
+be had seems clearly to be that positive anatomical changes, either of
+nerve-terminals or superficial nerve-branches, are but casual and
+infrequent factors in the first production of neuralgia, and, in
+particular, it would seem that inflammation of a nerve itself by no
+means necessarily produces neuralgic pain, but (far more commonly)
+simple paralgesia or anęsthesia of the parts external (peripheral) to
+the lesion. The one marked exception to this general proposition is to
+be found in the case of the severe and peculiar injuries inflicted on
+the trunks of nerves by gunshot-wounds which, as we have seen (from the
+American experiences), can produce some of the most dreadful forms of
+neuralgia. But the nature of the injury here inflicted is, it must be
+remembered, quite different from any thing which either disease or
+accident in civil life would produce, save in the most exceptional
+instances. For the chief material element in the production of the
+neuralgias of ordinary life we are really driven, by exclusion, to the
+condition of the posterior roots of special nerves, in some cases,
+perhaps, to the (spinal) ganglia on which the nutrition of these roots
+probably is considerably dependent.
+
+With the field thus narrowed for us, it is surely legitimate, in the
+necessary scarcity of anatomical records referring directly to the state
+of the nerve-roots in ordinary neuralgia, to place great weight on the
+facts of a disease like locomotor ataxy, in which the main anatomical
+change is a progressive atrophy of the posterior columns which usually
+falls with peculiar severity on the posterior nerve-roots, or on the
+parts of the gray matter immediately adjoining these, and in which
+neuralgia may be said, for practical purposes, to be a constant and most
+characteristic phenomenon. If any one desires to see how strikingly the
+connection of the neuralgic phenomena with the anatomical-change comes
+out, I recommend him to study Dr. Lockhart Clarke's papers on locomotor
+ataxy (_vide_ "St. George's Hospital Reports, i." 1866; _Lancet_, June,
+10 1865; "Med.-Chir. Soc. Transactions," 1869), or the excellently
+reported case by Nothnagel (_Berlin Klin. Wochensch._, 1865). It is
+really not too much to say that the only important difference between
+the clinical aspect of the pains of locomotor ataxy and those of
+ordinary neuralgia is simply such as depends on the fact that the
+anatomical change in the former case is bilateral, and usually affects
+the roots of several, sometimes of a great many pairs of nerves. I
+infer, from a conversation with Dr. Clarke, that he fully recognizes the
+force of the analogy, and the great strength of the presumption which it
+sets up in favor of an atrophic change of the posterior roots in
+neuralgia.
+
+It may, of course, be urged, against the view that neuralgia depends on
+any change analogous to those which occur in ataxy, that quantities of
+cases of the former recover speedily, and must be supposed to be either
+independent of material change altogether or, at any rate, to have
+involved only very trivial anatomical changes, not formidable diseases,
+like atrophy of nerve-centres. I find it impossible to admit that this
+argument has the slightest force. Are we to suppose that the posterior
+nerve-roots alone, of all tissues and organs of the body, are incapable
+of minute and partial changes in the direction of molecular death which
+may be perfectly recovered from in weeks, months, or even days? I, for
+one, cannot doubt, that such changes are of frequent occurrence, in all
+parts of the central nervous system, when I can consider the absolute
+dependence of these portions of the organism upon a perfect
+blood-supply, and the immense number of possible causes of temporary
+interference with that source of nutrition. And I can see no probable
+difference, except in degree and persistence between the effects on
+sensation which would be produced by such a change of the posterior
+roots as this, and that which would result from the more serious and
+fatally continuous change which is involved in locomotor ataxy.
+
+9. We come now to a most important but most complex and difficult
+portion of the argument respecting the _locus in quo_ of the essential
+pathological process (if such there be) in neuralgia; viz., as to the
+paths and the character of the so-called "reflex" influences which
+intervene in the causation, both of neuralgia itself, and also of the
+numerous complications with which we have seen that neuralgia is liable
+to be attended. The clinical facts which confront us here, and demand
+explanation, are the following: (1) Irritation so called, of sensory
+fibres may apparently evoke pains attributed to the site of the
+irritation, or to the parts on the peripheral side which are supplied by
+the same sensory nerves. (2) Peripheral irritation of a particular
+sensory nerve may evoke neuralgic pains in nerves connected with that
+irritated only through the spinal centre. (3) Neuralgia in a sensory
+nerve may (and almost always does, to some extent) produce secondary
+vaso-motor paralyses: these paralyses may affect fibres which run in the
+same branch of the nerve as that which is painful, or fibres that run in
+another branch of the same nerve, or fibres that run with another
+sensory nerve, or the ganglionic chain of the sympathetic itself. (4) In
+like secondary manner, neuralgia may produce vaso-motor spasms in any of
+the directions just specified; this is usually a short-lived phenomenon,
+giving place quickly to paralysis; but Du Bois Reymond's often-quoted
+analysis[19] of his own sufferings from migraine seems to show that
+spasm-producing irritation of the trunk of the sympathetic may last
+during some hours. (5) Neuralgia in a sensory nerve may increase, alter,
+or (more rarely) suspend the secretions of glands supplied by fibres
+bound up either in the same branch, or in another branch of the same
+nerve, or in a different nerve with which it is connected only through
+the centre or (possibly) only through a plexus. (6) Neuralgia in a
+sensory nerve can produce paralysis of muscles supplied by motor fibres
+bound up with the painful branch, or with another branch of the same
+nerve, or in muscles supplied by a totally distinct nerve connected only
+through the centre. (7) It may produce convulsion and spasms of muscles,
+in all the above directions; this usually alternates with great
+weakness, or actual paralysis of the same muscles. (8) It may produce
+partial or complete loss of common or special sensation in nerve-fibres
+that run either with the same branch, or with another branch of the same
+nerve. (9) It may produce trophic changes, either in the direction of
+simple atrophy or of subacute inflammation with proliferation of
+lowly-vitalized tissue (_e. g._, connective) in the parts with which are
+supplied with sensation by the painful branches or by other branches of
+the same nerve.
+
+It is necessary to go over again the proof of these facts; they are
+given pretty copiously in the chapter on Complications; and could have
+been made much more numerous. But the point to which I desire to compel
+the reader's attention is the impossibility as it seems of me, of
+accounting for the variety and complexity of these phenomena, except by
+the supposition that there is in every case of neuralgia a central
+change, which is the one most important factor in the producing both of
+the pain and of the secondary phenomena. For the result of my experience
+is that neuralgia, unless very slight and brief, is never unattended by
+these complications and in the great majority of cases involves several
+different secondary alterations of function which must (so to speak)
+radiate from the central end of the sensory nerve, and from no other
+place whatever. And it must be remembered that the most elaborate
+"_symptome-complexe_" is found equally in cases where no suggestion of
+any peripheral origin of the pain can be made, and in cases where, at
+first sight, one might fancy there was a very obvious peripheral cause
+for pain. I am quite willing to admit, with Eulenburg and others, that
+the evidence, powerful and varied though it be of the relations of
+neuralgia to hereditary neuroses, to alcoholic and senile degeneration,
+etc., only raises a strong probability that some part of the central
+nervous system is the _locus in quo_ of the essential morbid processes
+in the majority of neuralgias. But the case stands far otherwise now
+that we are able to show, not merely that the majority of neuralgic
+patients suffer from such influences as those above mentioned, but that
+every variety of neuralgia is liable to be complicated with secondary
+affections of the most divergent nerves, the only common meeting-place
+of which is in the spinal centre of the painful nerve; and when we find
+moreover, that many of these secondary affections can equally be
+produced by undoubted atrophic changes (as in ataxy of those same
+posterior roots).
+
+At this point we must introduce a remark relative to the true nature of
+so-called "reflex" effects. The word is constantly used, and is also
+much abused, as Eulenburg remarks. We all understand, of course, what is
+intended by the commonest use of the word: the case of sneezing produced
+by the irritation of snuff applied to the peripheral branches of the
+fifth nerve in the nose is a stock example. But another application of
+the phrase, of much more questionable propriety, is that where it is
+employed to designate functional nervous actions, which merely arise
+simultaneously with or subsequently to sensory phenomena as to which
+there is no proof whatever that they were produced by peripheral
+irritation. This particular inaccuracy of customary speech has probably
+contributed largely to the inveteracy with which writers on nervous
+disease have insisted on assuming a peripheral origin in every case for
+neuralgia itself. In the case of sciatica, for example, complicated,
+secondarily, with paralysis of the flexors of the limb, it seemed easy
+and scientific to speak both of the neuralgia and the paralysis as
+"reflex" effects of a local peripheral mischief--gouty, rheumatic, or
+the like; and it appears to have been perfectly forgotten by many that
+the whole phenomena might be explained by an original morbid action in
+the sensory root of the nerve, extending subsequently to the motor root,
+without any intervention of peripheral irritation whatever, or under the
+influence only of the ordinary peripheral impressions, which, in health,
+evoke no painful nor paralytic symptoms. It is by this kind of extension
+of a central morbific process, leading to radiation of the perturbing
+influence centrifugally along divers nervous paths, that I believe we
+must explain the facts observed in complicated cases.
+
+Take, for example, the following case, which, in its history of
+twenty-three years, presents a fair example of a type of trigeminal
+neuralgia which I believe to be the rule rather than the exception,
+though the trophic changes were somewhat unusually varied and
+interesting. The following would be the pathological order of events,
+according to the radiation theory: First or true migrainous stage;
+failure of nutrition of a portion of the sensory root of the right fifth
+nerve within medulla oblongata, lesser degree of the same condition in
+the adjoining and closely-connected vagus root (hence supra-orbital
+pain, local anęsthesia and vomiting); extension of the morbid process to
+the motor root (hence vaso-motor paralysis and secretory and trophic
+changes in the cornea, superciliary periosteum, etc). Second period:
+recovery, to a large extent, of the nutrition of the posterior root of
+the trigeminus, complete recovery of the root of the vagus (hence
+alteration of the type of recurrence of the pains, which now occur at
+increasingly long intervals, and needed special provocation, _e. g._,
+excessive fatigue, to bring them on; hence, also, disappearance of the
+stomach symptoms); continuance of the affection of the motor portion of
+the nerve (hence, continuance of the tendency to trophic, secretory, and
+vaso-motor changes); development of the true points douloureux during
+and after the paroxysms, instead of the diffused tenderness following
+the old attacks of migraine. Third stage: neuralgic attacks become rare
+and comparatively unimportant; tendency to trophic changes greatly
+lessened; local anęsthesia persists. Presumption, that the nutrition of
+the nerve-centre has nearly recovered itself, but that that centre is
+still the _locus minimę resistentię_ of the central nervous system,
+liable to suffer from any cause of general nervous depression.
+
+Now, in interpreting the above phenomena, as I do, upon the theory of
+one essentially uniform nutritive change affecting the fifth nerve
+within the medulla oblongata, I shall be met with the following
+objections: First, there is the common and superficial difficulty that
+pain and paralysis of sensation must be opposite states, and that it is
+impossible to refer them both to one and the same pathological process.
+I have already in many places given instances how constantly pain and
+sensory paralysis interchange in a manner which is totally
+incomprehensible except upon the supposition that their physiological
+basis is essentially the same; but the most satisfactory evidence,
+perhaps, that could possibly be produced on this point is to be found in
+the perusal of a group of cases observed by Hippel,[20] and entitled by
+him "Anęsthesia of the Trigeminus," the loss of sensation being the most
+remarkable feature. The cases are so deeply interesting that I would
+gladly transfer them bodily to these pages, but must abstain from want
+of space. Suffice it to say here, that, in the first place, the
+anęsthesia was accompanied, in every one of these cases, by a most
+distinct and typical neuralgia; and, secondly, that trophic changes
+occurred which most interestingly (though not with absolute
+completeness) reproduced the phenomena observed after complete section
+of the trigeminus at the Gasserian ganglion.
+
+The second objection sure to be raised to the theory of a simple
+spreading of a nutritive central change, as the cause of all the
+phenomena in such a case as the above, is this: It will be asked how the
+process extended itself to the motor root, which, in the case of the
+fifth nerve, is removed by a somewhat formidable anatomical distance
+from the sensory root. I am, of course, well aware of the latter fact,
+and it is an additional reason for selecting neuralgia of the fifth, as
+an extra difficult test of the value of my theory. A few words must be
+premised, reminding the reader of the physiological anatomy of the
+nerve.
+
+The trigeminus is in all its characters a spinal nerve; but it has
+sundry peculiarities both of structure and of connections with other
+nerves. Its posterior or sensory root is enormous, and, as Schroder van
+der Kolk showed, takes a direction from behind downward and forward,
+which is intended to facilitate its numerous and important connections
+with the nuclei of other nerves: of these the most notable are its
+connections with the vagus, facial, glosso-pharyngeal, and hypo-glossal
+nuclei. The motor root, much smaller than the sensory, was shown by
+Lockhart Clarke to be traceable as low as the inferior border of the
+olivary body, as a column of cells which occupies a situation
+corresponding to that of the anterior course of the spinal gray matter.
+
+As this column passes onward in the medulla oblongata, on a level with
+the glosso-pharyngeal nerve, it forms a group of cells of large size.
+Besides numerous other connections which it forms, Clarke describes the
+motor root as sending processes forward, like tapering brushes or tails
+of fibres, in connection with more scattered cells lying in their
+course, which may be frequently seen to communicate with the transverse
+bundles which traverse the "gray tubercle" and the sensory roots of the
+fifth contained therein. In this way the sensory root, though seemingly
+much separated from, is really in very direct connection with, the motor
+root.
+
+Now, proofs, which must be considered almost positive, have recently
+been adduced to show that the nerve-fibres concerned in those peculiar
+alterations in the tissues supplied by the ophthalmic division of the
+fifth, which occur in section of the trigeminus, come entirely from the
+motor root of the fifth, and form a very small band in the inner or
+medial margin of the ophthalmic trunk. The observation of Meissner[21]
+goes to show that it is possible (by good luck) to divide the trunk in
+such a partial manner as to cut only the inner fibres, and thereby
+produce the trophic eye-changes without any anęsthesia, or only the
+sensory fibres, and thereby induce anęsthesia without any trophic
+changes; and it must be owned that this really affords the only
+reasonable explanation of the discrepancy between the experimental
+results obtained by Magendie and Bernard; and also the facts of such
+cases as those related by Mr. Hutchinson,[22] who in two instances found
+that a completely anęsthetic eye recovered perfectly well from the wound
+made in a surgical operation. The nature of the nervous influence
+(whether ordinary vaso-motor only, or a special trophic function) has
+been greatly disputed. Dr. Wegner,[23] from observing the remarkable
+group of glaucomatous cases under Horner (of which one has been
+related), made experiments, from which he concluded that the
+augmentation of intra-ocular pressure in glaucoma was a phenomenon
+dependent upon the sympathetic, which was irritated by reflection from
+the trigeminus. But the researches of Hippel and Grunhagen, especially
+their latest,[24] give a different explanation, excluding the
+sympathetic; they found that irritation of the medulla oblongata, in the
+neighborhood of the trigeminus root, produced a lasting and very
+pronounced augmentation of intra-ocular blood-pressure, an effect which,
+they remark, could not depend on irritation of the vaso-motor centre,
+since that must produce contraction of the vessels and lowering of the
+blood-pressure. They conclude that "the trigeminus contains specific
+fibres which possess the property of actively dilating the blood-vessels
+of the eye;" and in reference to the secretion of the fluid humors of
+the eye, they conclude also that "the trigeminus also plays the part of
+an (active) nerve of secretion."
+
+Of these conflicting opinions I can have no difficulty in at any rate
+rejecting that of Wegner; for the clinical phenomena of the
+complications attending trigeminal neuralgia, such as they are described
+in my last chapter (and could have been described at much greater
+length), seem to me utterly to exclude vaso-motor spasm except as a
+temporary phenomenon at the commencement of the attacks of acute pain.
+Vaso-motor palsy undoubtedly is very often present, in fact every attack
+of neuralgia of a certain severity is thus complicated; and there is no
+reason to doubt that this paralysis could be caused by lesions within
+the medulla. Are we, then, to admit functions of active dilatation of
+vessels, and active impulse to secretion in certain fibres of the fifth?
+It is necessary at any rate to clear the ground in one respect: it must
+not be supposed that I for a moment entertain the idea that there can be
+direct active dilatation, _i. e._, that there can be any system of
+muscular fibres (and nerve-fibres stimulating them) whose office is to
+open the calibre of the vessels; the idea is wildly improbable--in fact
+almost inconceivable by any one who reflects on the necessary
+machinery--and there is not a single observed anatomical fact to give it
+support. If, then, I speak of the possibility of "active" dilatation, it
+must be understood that I refer to a theory of "inhibition," which
+supposes certain fibres to be gifted with the power of paralyzing or
+inhibiting the vaso-motor nerves. It is my duty to speak with all
+reasonable reserve on that most difficult _quęstio vexata_, the
+existence of special inhibiting systems of nerves, and the extent to
+which a double series of opposed nervous actions is generalized in the
+body; but it is impossible to avoid the subject altogether, and I offer
+the following remarks, with deference, to our professional
+physiologists. The strongest instances of the apparent inhibiting action
+are probably afforded by the _nervi erigentes_, as shown by Loven, the
+cardiac depressor, by Ludwig and Cyon, and the splanchnics (upon the
+intestine), by Pfluger. But there is not a single one of these examples
+that has not been challenged by experimenters of repute. Thus the theory
+of the distinctive restraint-action of the splanchnics upon the
+intestine, and of the vagus upon the heart, has been especially
+controverted by Piotrowski, who, indeed, rejects the whole theory of
+special inhibitory nerves.[25] And, from another point of view, Mr.
+Lister long ago attacked the views of Pfluger, maintaining that it was
+possible to produce exactly opposite effects through the medium of the
+very same nerves, according as the experimental irritation applied to
+them was weak or strong. To Dr. Handfield Jones[26] this seems a still
+unanswerable objection to the inhibitory theory. And in the remarkably
+able and judicial summary of the "Physiology and Pathology of the
+Sympathetic or Ganglionic System,"[27] by Dr. Robert T. Edes, a less
+decided but still tolerably strong acquiescence is given to Mr. Lister's
+criticisms of this theory. Personally, I must express very strongly the
+distrust (which is probably felt by many others) of doctrines which
+assert an exact opposition between the functions of any two nerves, on
+the basis of an observation that the same apparent effects may be
+produced by section of the one and galvanization of the other; both
+processes seem far too pathological, and too remote from the conditions
+of ordinary vitality, to admit of any such absolute deductions from
+their results.
+
+In the present state of our information I am inclined to explain all the
+congestive complications of trigeminal neuralgia on the basis of
+vaso-motor paralysis. And I further believe that the cause of that
+paralysis is a direct extension of the original morbid process from the
+sensory root to the motor, affecting the origin of fibres in the latter,
+which are destined to govern the calibre as ocular and facial vessels.
+These fibres I suppose it is that Meissner succeeded in dividing when he
+partially cut the trigeminus, and got nutritive and vascular changes
+without anęsthesia.
+
+There must be more than this, however, to account for the whole of the
+trophic phenomena; for there is a great body of evidence to show that
+mere vaso-motor paralysis does not produce any phenomena of such an
+actively morbid kind as those we are endeavoring to explain. The
+phenomena on the side of secretion might indeed be possibly explained by
+vaso-motor paralysis. [It must be remembered that I am speaking of such
+augmented secretion as is seen in neuralgia. I agree with Prof.
+Rutherford (Lectures on Experimental Physiology, Lancet, April 29, 1871)
+that it is difficult thus to explain the effects of galvanization of the
+chorda tympani on the submaxillary gland.] Consisting as they do (a), in
+the great majority of cases, of a mere outpour of what seems little more
+than the aqueous part of the secretion, and (b) in a few cases of
+arrested secretion, a phenomenon otherwise by no means unfamiliar as the
+result of sudden, passive engorgement of glands. But the mere cessation
+of vaso-motion will not account for such facts as the rapid and
+simultaneous development of erysipelatous inflammation, of corneal
+clouding and ulceration, of iritis and glaucoma, of nutrition-changes in
+hair and mucous membrane. I must, for the present, be content to believe
+it probable that there is a special set of efferent fibres in the
+trigeminus, emanating from the motor-root, whose office it is in some
+unknown way to preside over the equilibrium of molecular forces in the
+tissues to which the nerve is distributed; trophic nerves, in fact,
+though not active dilators of blood-vessels.
+
+It seems to me that, without enlarging further on this almost endless
+topic, I should be justified in assuming that I had shown the very high
+probability that the common starting-point both of the neuralgia and of
+its vaso-motor secretory, and trophic complications, was in the sensory
+root of the trigeminus. But the argument is greatly strengthened when we
+consider the fact that loss of peripheral common, and also tactile
+sensation, to a greater or less degree, is constantly observed to occur
+simultaneously with the pain and with the other complications. When we
+observe a patient suffering from racking supra-orbital and ocular
+neuralgia, and discover that at the very same period the skin round the
+eye is markedly insensitive to impressions, except in the _points
+douloureux_, what can we rationally suppose, except that both pain and
+insensibility are the result of one and the same influence, which
+radiates from the sensory centre?
+
+Nor are we likely to reach a different conclusion, if we test the matter
+by the consideration of a rarer, but still sufficiently common kind of
+case, such as I have described in Chapter I., in which a very strong
+peripheral influence (traumatic) produces neuralgia, accompanied by
+vaso-motor and secretory phenomena, and by anęsthesia, but not in the
+district of the painful nerve, but in the territory of a quite different
+nerve. How can we doubt, in the case, _e. g._, of a trigeminal neuralgia
+thus complicated, the exciting cause of which was a wound of the ulnar
+nerve, that the morbid influence, traveling inward from the lesion,
+would have passed without any special consequences (as happens in
+thousands of such nerve-wounds), had it not, in its passage along the
+medulla, encountered a _locus minoris resistentię_ in the roots of the
+trigeminus? It seems impossible to account for the phenomena on any
+other theory. [Eulenburg says, in reference to my reported cases of the
+kind: "_Solche Falle begunstigen in hohem Grade die Annahme
+pradisponirender Momente, die in der ursprunglich schwacheren
+Organisation einzelner Abschnitte des centralen Nerven-apparates
+beruhen._" _Op. cit._, p. 56.]
+
+It is necessary, in the next place, to consider a very important
+question, how far irritation can pass over from one nerve to another,
+without reflection through a spinal centre, solely in virtue of a
+connection through the medium of a nervous plexus. The case which
+apparently presents such phenomena in the most unmistakable way is that
+of _angina pectoris_.
+
+The site to which the essential heart-pain is referred in this disease
+is probably the cardiac, or this and the aortic plexus; in a
+comparatively small number of cases the pain does not extend farther.
+But much more frequently it spreads in various directions, and we have
+to account for its presence (_a_) in intercostal nerves, (_b_) cervical
+nerves, (_c_) nerves springing from the brachial plexus.
+
+Before we inquire into the mechanism by which this extension of the pain
+takes place, we ought in strictness to ask ourselves whether the
+essential heart-pain is felt only in the spinal sensory branches, or
+whether the sympathetic fibres are themselves capable of feeling pain.
+The latter supposition, notwithstanding all that has been argued in its
+favor from the supposed analogies of the pain of colic, gall-stone,
+etc., seems to me very doubtful. It would appear more probable that both
+the latter pains, and also those of angina, are really connected with
+branches either of the vagus or of other spinal nerves. And there is no
+need to invoke the sympathetic as a sensory nerve, to account either for
+the essential heart-pain of angina, or for its extension into arm,
+chest-wall, and neck. For the plexus cardiacus receives spinal branches,
+both from the vagus and also (through the medium of the sympathetic
+ganglia of the neck) from the whole length of the cervical and the
+uppermost part of the dorsal cord-centres. And, in this way, it would
+seem quite possible intelligibly to account for the pain radiating into
+intercostal, cervical, and brachial nerves, merely by extension of a
+morbid process essentially seated in the cord. Usually, however, one
+sees it explained not in this way, but by the inter-communications that
+exist outside the spine, between the branches from the cervical ganglia
+and the lower cervical and upper dorsal nerves; and the pain in the arm
+is especially explained by the connection (outside the spinal canal) of
+the inferior cervical ganglion, on the one hand with the lower cervical
+nerves, which go to the brachial plexus, and, on the other hand, with
+the heart itself. There remains to be explained, however, the singular
+tendency of the arm-pain to be one-sided (this happens in at least four
+cases out of five); and this explanation seems to me insuperably
+difficult, on the theory that the transference of morbid action to the
+brachial nerves takes place through external anastomoses. It appears
+greatly more probable that angina is essentially a mainly unilateral
+morbid condition of the lower cervical and upper dorsal portion of the
+cord; liable of course to be seriously aggravated by such peripheral
+sources of irritation as would be furnished by diseases of the heart,
+and especially by diseases of the coronary arteries; the latter
+affection probably involving constant mechanical irritation of the
+cardiac and the aortic plexuses. It is noteworthy that the arm-pain is
+sometimes (I do not know how often) accompanied by vaso-motor paralysis
+in the limb; this phenomenon could also certainly be more easily
+accounted for on the supposition of radiation from a spinal vaso-motor
+centre (to which the morbid process had extended from a posterior
+nerve-root) than on that of communication between painful sensory nerves
+and vaso-motor nerves; through either of the plexuses independently of
+the spinal centres.
+
+In truth, I suspect that, whatever part the plexuses, with their
+reenforcing ganglionic cells, may play during physiological life, they
+are not often the channels of mutual pathological reaction of one kind
+of nerve with another. It would be possible to argue this even more
+strongly in the case of trigeminal neuralgias; but I must not
+unnecessarily expand this already too lengthy discussion.
+
+From the varied considerations which have now been adduced, the reader,
+unless I altogether miscalculate the value of the facts, will probably
+have arrived at the following conclusions: (1) That the assumption of a
+positive material centric change as the essential morbid event in
+neuralgia is almost forced upon us; (2) that, whereas the morbid
+process, if centric, is _a priori_ infinitely more likely to be seated
+in the posterior root of the painful nerve, or the gray matter
+immediately connected with it, than anywhere else; so, again, the
+assumption of this locality will explain, as no other theory could
+explain, the singular variety of complications (all of them nearly
+always unilateral, and on the same side as the pain) which are apt to
+group themselves around a neuralgia; and some of which are very seldom
+absent in neuralgia of any considerable severity. To this we may
+certainly add that it is extremely probable that the vast majority of
+neuralgic patients inherit the tendency to this localized centric
+change; in support of this we may finally mention two considerations
+derived from the sex and the ages most favorable to neuralgia. Eulenburg
+saw a hundred and six cases of neuralgia of all kinds, of which
+seventy-six were in women and only thirty in men; my own experience is
+very similar; namely, sixty-eight women and thirty-two men out of a
+hundred hospital and private patients. The strong connection between the
+hysteric and the neuralgic temperament in women, and the great
+preponderance of women among neuralgics, strengthen in no small degree
+the probability of inherent tendencies to unstable equilibrium as a very
+common predisposing factor in neuralgia. And, on the subject of age, I
+need only recall what I have said so strongly about the coincidence of
+neuralgia with particular epochs in life, as affording evidence of the
+most powerful kind that neuralgics are, save in exceptional instances,
+persons with congenitally weak spots in the nervous centres, which break
+down into degeneration, temporary or permanent, under the strains
+imposed by one or other of the physiological crises of the organism, or
+the special physical or psychical circumstances which surround the
+patient's life.
+
+Having thus decidedly expressed my belief in the essential material
+participation of the nerve-centre in neuralgia, it remains for me to
+discuss two points: first, as to the character of the material change in
+the nerve-root, and next, as to the extent to which mere peripheral
+influence, without special inherited tendencies, may suffice to set this
+process going.
+
+The morbid change in the nerve-centre is probably, in the vast majority
+of cases, an interstitial atrophy, tending either to recovery, or to the
+gradual establishment of gray degeneration, or yellow atrophy, of
+considerable portions of the whole of the posterior root, and the
+commencement of the sensory trunk as far as the ganglion.
+
+It is probable, however, that in a certain number of cases, the atrophic
+stage may be preceded by a process of genuine inflammation, and that
+this inflammation is centripetally produced in consequence of
+inflammations of peripheral portions of the nerve. The considerations
+which make this probable are chiefly derived from the analysis of cases
+in which a more or less chronic, but severe, visceral disorder has been
+followed by so-called reflex paralysis, but in which neuralgic
+phenomena, have been conspicuous. In reference to this subject I
+recommend to the reader's attention the very interesting paper on
+"Reflex Paralyses" by Prof. Leyden, of Konigsberg.[28] He is immediately
+commenting upon a case in which dysenteric affection of the bowel were
+followed by the symptoms of myelitis, attended with febrile
+exacerbations, and also with severe pains in the region of the sacrum,
+in the course of the dorsal intercostal nerves of the right side, and in
+the knees, and semi-paralytic weakness of the lower extremities, and
+with pains between the shoulder-blades and the left arm. Leyden
+discusses the doctrine of reflex paralyses in general, starting from
+the cases of urinary paraplegia brought forward by Stanley, in 1835, and
+tracing the growth of opinion through the phases represented by Graves,
+Henoch, and Romberg, by Valentine and Hasse, then by Pfuger, and other
+professors of the inhibitory doctrine; by Brown-Sequard (in his
+well-known, and now very generally discredited, theory of spasm of the
+vessels in the nervous centres), by Jaccoud in the "Erschopfung"
+(exhaustion) theory, down to the more careful and reliable researches of
+Levisson on the temporary reflected paralyses induced by experimental
+squeezing of the kidney or uterus of animals; and then gives the history
+of the more recent doctrine of a positive material change in the cord
+centripetally introduced. Gull[29] (1856) may be said to have
+inaugurated the new doctrine of a morbid process transmitted along the
+pelvic nerves to the cord, and causing material changes there.
+Remak,[30] on the other hand, suggested a material change operating in
+the opposite direction; _a neuritis descendens_, starting in the very
+nerves (within the pelvis) which showed the paralysis in the
+extremities. The symptoms are supposed by him to be distinctive,
+inasmuch as there is both violent pain in the nerves of the soles of the
+feet, and also tenderness of the same. On the other hand, Remak said
+that myelitis, with neuritis, might be the origin of paraplegia and
+simultaneous palsy of bladder and rectum. The theory of neuritis
+descendens was supported by Kussmaul,[31] in the record of a case where
+disease of the bladder was complicated with pelvic inflammation,
+atheromatous degeneration of the arteries, and consequent fatty
+degeneration of the sciatic nerves, causing direct paraplegia. We return
+to the centripetal theory of urinary paralysis with Leyden's own cases,
+published in 1865; of three patients with urinary paraplegia, two died,
+and the existence of a secondary (centripetal) myelitis seems to have
+been established, and by all analogy it must have existed in the third
+case, which recovered. The only puzzle and doubt that ensued was caused
+by the fact that there was an absence of neuritis in the different
+nerves themselves; though it seemed plain that the starting point of the
+myelitis was at the entrance of these nerves into the cord. This mystery
+seemed to be cleared up by the important experiments of Tiesler, ("Ueber
+Neuritis" Konigsberg, 1860) a pupil of Leyden's. This observer excited
+local traumatic inflammation in the sciatic nerve of rabbits and dogs;
+the rabbit became paraplegic and died three days afterward. At the site
+of the artificial irritation there was a localized formation of pus, and
+there was a second similar formation within the vertebral canal at the
+point where the posterior roots of the sciatic enter the cord; but
+there was no neuritis of the intervening portion of the nerve.
+
+Upon this and similar evidence is based the modern doctrine of a
+neuritis migrans, with centripetal tendencies, upon which it is supposed
+that a very large proportion, at least, of the urinary, dysenteric, and
+uterine paraplegias, miscalled "reflex," depend; and it is clear that
+the application of the word "reflex" in such a case is a grave abuse,
+tending to produce such confusion of thought and error in practice. In
+relation to the subject of our own inquiry--neuralgia--it is obviously
+of the highest consequence to investigate the question whether
+peripheral irritations, analogous to those which produce urinary
+paraplegia, are at all frequently the cause of the changes in the
+posterior roots which produce true neuralgia; for of course an
+inflammation may be the beginning of an atrophy which may presently
+exhibit no distinction whatever from one of which the origin was
+altogether non-inflammatory. I think that there is strong reason for
+thinking that this is not at all frequently the case. In the first
+place, all the evidence that exists respecting these centripetal
+inflammations of the cord is opposed to the idea that, save in the
+rarest instances, the inflammatory process limits itself to one small
+segment of the cord. Secondly, the description of the pains that have
+usually accompanied such inflammations of the cord is considerably
+different from the strictly localized, frankly intermittent character of
+a true neuralgia; in fact, all we know of the history of myelitis
+(except when complicated with a large amount of meningitis) forbids us
+to suppose that severe pain would be an immediate symptom. But, thirdly,
+a far more important objection to the theory of an origin in localized
+centripetal myelitis, the result of a neuritis migrans, is the rarity of
+motor paralysis as an early symptom, instead of which we ought to find a
+very distinct history of decided paralysis (much more decided than those
+secondary paralyses which actually do occur in some neuralgias) of the
+muscles supplied by the anterior roots of the painful nerve, in every
+case in which such a peripheral origin could be assumed. Again, the
+totally feverless commencement of neuralgias, a character which is
+maintained throughout the progress of the milder cases, is entirely
+opposed to the idea of a direct connection between myelitis and
+neuralgia. The superficial appearance of pyrexia is sometimes given by a
+local vaso-motor paralysis, which makes the neuralgic part, after a long
+bout of pain, hot and red; but of general pyrexia there is nothing.
+
+Taking every thing into consideration, one is inclined to say that there
+is a probability that in a very limited number of cases peripheral
+irritation does cause actual limited myelitis, which escapes recognition
+at the time, but which issues in an atrophy, the subjective expression
+of which is actual neuralgic pain. We may well ask ourselves, also,
+whether there is not some likelihood that a peripheral irritation, which
+stops short of producing an actual neuritis migrans capable of
+centripetally exciting a myelitis, may not, by a lower degree of
+centripetal irritation, give a bias toward certain forms of
+non-inflammatory atrophy in cells of posterior nerve-roots which are
+congenitally of weak organization. I am inclined to believe strongly
+that this does occur. For example, I should explain thus the majority of
+the peripheral cases of ciliary neuralgia, migraine, etc., that we meet
+with in poor young needle-women, especially the hypermetropic, who, at
+an age when they can ill afford the strain, work so constantly and
+strenuously at an occupation which fearfully taxes the eye.
+
+I would also go farther, and express the opinion that peripheral
+influences of an extremely powerful and continuous kind, where they
+occur with one of those critical periods of life at which the central
+nervous system is relatively weak and unstable, can occasionally set
+going a non-inflammatory centric atrophy which may localize itself in
+those nerves upon whose centres the morbific peripheral influence is
+perpetually pouring in. Even such influences as the psychical and
+emotional, be it remembered, must be considered peripheral--that is,
+they are external to the seat and centre of the neuralgia. And there are
+probably few practitioners of large experience who have not seen a
+patient or two in whom the concurrence of some unfortunate psychical
+with some other noxious peripheral influence, the whole taking place at
+some critical period of life (especially in the years between puberty
+and marriage), seems to have totally deranged the general balance of
+nervous forces, and induced morbid susceptibilities and morbid
+tendencies to some particular neurosis. It is a comparatively frequent
+thing, for example, to see an unsocial solitary life (leading to the
+habit of masturbation), joined with the bad influence of an unhealthy
+ambition, prompting to premature and false work in literature and art.
+The bad peripheral influence of constant fatigue of the eyes in study
+may so completely modify a young man's constitution as to make a wreck
+of him in a very few years, changing him from the state of habitual and
+conscious health to that of chronic neurosis of one sort or another.
+And, though it is doubtless on persons with congenital tendencies to
+nervous diseases that such a combination of bad influences produces its
+most serious effects, yet there unquestionably are a few persons in whom
+they appear to entirely generate the neurotic constitution. I have
+already touched upon the part that misdirected psychical influences,
+especially religious and other forms of emotional excitement, may play
+in this unfortunate perversion of the natural and healthy nervous
+functions, more especially in youth; and need only add, here, that
+perhaps the most fatal combination of all the bad influences is the
+melancholy union of highly-strained religious sentiment with peripheral
+sexual irritation, which is, unfortunately, a too common phenomenon
+under certain systems of education. The most frequent neurotic
+consequences of the class of influences which have now been referred to
+are probably neuralgia--in the form either of migraine, of nervous
+angina, or of sciatica--or else asthma.
+
+But, if the combination of several such centripetal influences may
+generate the neurosis unaided, even a single one of them operating
+powerfully for a long period may produce most serious consequences in
+those who are hereditarily predisposed. The influence of prolonged
+fatigue of the eyesight, independently of any special intellectual or
+emotional strain, was strongly illustrated in my own case about three
+years ago. I was then engaged upon a piece of scientific writing which
+demanded no great intellectual effort, but was being done against time,
+and by working, night after night, many hours by gas-light. My neuralgic
+(trigeminal) attacks came on with great severity, accompanied by
+vertiginous sensations of so alarming a kind as to make me fear the
+invasion of some serious brain-mischief. I broke off all work, and went
+to the sea-side, but was greatly disappointed to find, for the first few
+days, that the symptoms were not in the least mitigated. The mystery was
+soon explained. The weather had been such as to confine me a good deal
+to the house, and, thinking it would do no harm, I amused myself with
+reading newspapers and novels. At last I suspected that the use of my
+eyes in reading was altogether mischievous; I desisted from reading any
+thing, and in forty-eight hours every symptom had vanished.
+
+Among peripheral influences of a more mechanical kind there is one cause
+of neuralgia, the force of which has been variously estimated, but which
+some authors rate as very important, viz.: the influence of the
+pressure, and especially of the varying pressure, of blood-vessels, or
+other hollow viscera, upon the trunks of the nerves. We must set aside
+one such action which is undoubtedly very powerful, as essentially
+differing from the others; I mean the pressure of dilated blood-vessels,
+especially aneurisms, when this happens to be exerted upon the ganglion
+of the sensory trunk. Here there can be no doubt of the mischief; for
+the pressure, if at all severe, gradually destroys the life of the
+ganglion, upon which, as was proved by Waller, the nutrition of the
+posterior nerve-root hangs with very intimate dependence, and the
+pulsations of the vessel seem greatly to aggravate both the irritation
+and the centripetal tendency to atrophy. In short, it is plain that such
+lesion of a ganglion may be the whole and sufficient cause of a
+neuralgia of the most desperate and incurable kind. It is another matter
+when we are asked to believe that the mere varying pressure of
+intestines, in different states of fullness, or plexuses of pelvic veins
+liable to temporary congestions, can so affect the sciatic nerves as to
+set up neuralgia. Considering the extreme frequency of cases in which
+such momenta must be partially coming into operation, especially in
+women--a frequency altogether out of proportion to that of sciatica--I
+cannot admit the probability that this influence is more than an
+occasional and very secondary factor, and that only in cases where the
+disposition to neuralgia is uncommonly strong.
+
+A sufficiently complete explanation of my theory as to the pathology and
+etiology of neuralgia has now been given, although the subject might be
+elaborated at far greater length; and I hope it will be apparent to the
+reader that the view now advocated is at once important, and also
+vouched for by strong evidence. I claim for it that the whole argument
+shall be taken together, for it is a case of cumulative proof; every
+link must be weighed and tested, before the remarkable strength of the
+chain can be felt. And it may fairly be said that, if the proof of a
+definite kind of material change in a definite organ, as the essential
+factor in neuralgia, has been established upon reasonable grounds, an
+important step has been taken toward removing a serious opprobrium and
+difficulty in practical medicine. Although the true neuralgias are not
+among the most frequent of human diseases, they form a class of enormous
+practical importance, for they are sufficiently common to be sure to
+occur in considerable numbers in the practice of every medical man, and,
+both from the suffering which they inflict, and the rebelliousness which
+they often show to treatment, they are among the gravest sources of
+anxiety which the practitioner is likely to encounter. There are
+probably few disorders which so often occasion mortification and loss of
+professional credit to the physician. The helplessness which men, who do
+not enjoy special opportunities of seeing those diseases with frequency,
+so often show in dealing with them, is largely caused by the extreme
+timidity and vagueness with which the standard treatises on medicine
+deal with the question of their pathology; and a very unfair advantage
+has thus been given to the specialists, who, by the mere force of
+opportunity, and continual blind "pegging away" in an entirely empiric
+manner, have acquired a certain rude skill in the treatment of these
+maladies which enables them to outshine practitioners who often have far
+more in them of the veritable _homme instruit_ as regards general
+scientific education and habits of mind. It will be evident, as a mere
+abstract proposition, that the enunciation of a reasonable pathology of
+the disease, and the sweeping away of a mass of unmeaning phrases about
+"mysterious functional affections" and the like, must be a distinct gain
+to practitioners of plain common-sense and good general knowledge, to
+whom neuralgia is merely one of a vast number of different diseases
+among which their attention and study are divided. And I hope that, in
+the further remarks on Diagnosis, Prognosis, and Treatment, yet to be
+made, the value of clear pathological ideas of disease will be brought
+more practically and clearly into view. [The reader will find, at the
+end of Part I. of this volume, a note which contains a brief discussion
+on the "Erschopfung" theory of Jaccoud, and the doctrines of Dr.
+Handfield Jones respecting inhibition, with which I thought it best not
+to encumber the text of the present chapter.]
+
+FOOTNOTES:
+
+[16] Eulenburg, to whose excellent work ("Lehrbuch der functionellen
+Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to
+refer, has partly misunderstood the drift and scope of my argument, a
+misfortune which I owe to the impossibility of giving, in the "System of
+Medicine," more than the briefest and most superficial sketch, both of
+my ideas and of the facts on which they rest.
+
+[17] _Op. cit._, p. 60.
+
+[18] This opinion is somewhat stronger than that expressed in my article
+in the "System of Medicine." I can only say it is the result of much
+increased experience.
+
+[19] _Journal de la Physiologie, v._
+
+[20] "Ernährungsstörungen der Augen bei Anęsthesie des Trigeminus."
+Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f.
+Ophthalm. Band. xiii.
+
+[21] Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from
+independent sources, of the truth of Meissner's views. His own
+observation only proved half the case; but he quotes an observation of
+Buttman's in which the exact converse of his own experience happened,
+the external fibres being affected without the inner band, and
+anęsthesia without trophic changes being the result. Moreover, Schiff
+(Gaz. hebdom., 1867) obtained experimental results (in operating on cats
+and rabbits) which coincide with Meissner's.
+
+[22] London Hospital Reports, vol. iii., p. 305.
+
+[23] Wegner, loc. cit.
+
+[24] Archiv f. Ophthalm., xv., 1.
+
+[25] "Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware
+whether Piotrowski has at all altered his opinions since the
+(subsequent) observations of Ludwig and Cyon upon the "depressor" nerve.
+
+[26] "Functional Nervous Disorders." Churchill, 2d edit., 1870.
+
+[27] "Prize Essay of the New York Academy of Medicine." New York: Wood &
+Co., 1869.
+
+[28] Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex
+Lahmungen," von E. Leyden. Leipzig, 1870.
+
+[29] "Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.
+
+[30] Wurzburg. Med. Zeitsch., iv., 56-64.
+
+[31] Med. Cent. Ztg. 21, 1860.
+
+
+
+
+CHAPTER IV.
+
+DIAGNOSIS AND PROGNOSIS OF NEURALGIA.
+
+
+_Diagnosis._--This subject is much simplified and shortened, in regard
+to our present purpose, by the plan of the present work, which, by
+separately describing (in Part II.) the other disorders which resemble
+neuralgia, and are liable to be confounded with it, avoids the necessity
+for stating here the negative diagnosis of neuralgia itself. We are only
+concerned here to give a clear picture of the positive signs which it is
+necessary to verify before we can suppose disease to be neuralgia. The
+special modes of searching for these are interesting, and in some
+respects peculiar;
+
+(1) The first and most essential characteristic of a true neuralgia is,
+that the pain is invariably either frankly intermittent, or at least
+fluctuates greatly in severity, without any sufficient and recognizable
+cause for these changes.
+
+(2) The severity of the pain is altogether out of proportion to the
+general constitutional disturbance.
+
+(3) True neuralgic pain is limited with more or less distinctness to a
+branch or branches of particular nerves; in the immense majority of
+cases it is unilateral, but when bilateral it is nearly always
+symmetrical as to the main nerve affected, though a larger number of
+peripheral branches may be more painful on one side than on the other.
+
+(4) The pains are invariably aggravated by fatigue or other depressing
+physical or psychical agencies.
+
+The above are characteristics which every genuine neuralgia possesses,
+even in its earliest stages; if they be not present, we must at once
+refer the diagnosis to one or other of the affections described in Part
+II. of this work.
+
+Supposing the above symptoms to be present, we expect to find--
+
+(5) In by far the largest number of instances that the patient has
+either previously been neuralgic, or liable to other neuroses, or that
+he comes of a family in which the neurotic disposition is well marked.
+Failing this, we are strongly to doubt the neuralgic character of the
+malady, unless we detect that there has been--
+
+(6) A poisoning of the blood by malaria (but this very rarely causes
+neuralgia, save in the congenitally predisposed); or--
+
+(7) A powerfully operating or very long-continued peripheral irritation
+centripetally directed upon the sensory nucleus of the painful nerve;
+which irritation may be (_a_) "functional," as where the eye has been
+persistently and severely over-strained and trigeminal pain results, or
+a sudden severe shock has been received; or, (_b_) coarsely material, as
+where inflammation, ulceration, etc., of surrounding tissues involve the
+periphery of the painful nerves in a perpetually morbid action, or
+chronic but profoundly depressing psychical influences; or--
+
+(8) A constitutional syphilis. In this case there will either be marked
+syphilitic local affection of the trunk of a nerve, or if, as is more
+common, the syphilitic change is in the nerve-centre, there will most
+likely be other syphilitic centric mischiefs, leading to scattered motor
+or vaso-motor paralyses, characteristic modifications of special
+sense-functions, etc.
+
+If the neuralgia be of some standing and a certain degree of severity,
+there will inevitably be found--
+
+(9) Some of the fixed tender points of Valleix, in such situations as
+have been described in Chapter I.; and--
+
+(10) Secondary affections (_a_) of secreting glands, or (_b_) vaso-motor
+nerves; or (_c_) of nutrition of tissues; or secondary localized
+paralyses of muscles, or localized anęsthesia of a somewhat decided
+though not complete kind, as described in Chapter II.; any one or any
+number of these various complications may be present.
+
+I must insist that the above picture includes only the essentials for a
+diagnosis of neuralgia; if the painful affection will not answer to the
+conditions therein included, we have no right to call it a neuralgia--it
+belongs, for every practical purpose, to some other category of disease.
+Let me add one more essential characteristic, which is, that the pain
+begins and assumes its characteristic type before any other of the
+phenomena appear, with the single and partial exception of anęsthesia.
+
+There are some special modes of diagnosis of the varieties of
+neuralgia, developed of late years, that require notice here; they are
+chiefly the result of the researches of Moriz Benedikt.
+
+As regards the quality of the pain, Benedikt says that the curve of
+intensity has an intimate relation to the _locus in quo_ of the
+neuralgia (_i. e._, whether in the periphery, trunk, or roots). An
+inflammatory irritation set up at the periphery of a nerve (by a
+joint-inflammation, for instance) produces a continuous pain; the same
+kind of irritation, attacking a nerve-trunk (_e. g._, in the bony
+canals), produces a paroxysmal pain; an inflammation spreading from the
+vertebrę to the nerve-roots or the cord-centres produces momentary
+lancinating pains. The latter characteristic he supposes to be
+especially characteristic of the centrally-produced neuralgias; and I
+may observe, as so far confirmatory of this idea, that this is
+especially the character of the pains in locomotor ataxy. There are
+sundry special cases to be considered, however: thus, Benedikt himself
+remarks that the pain set up by the pressure of a pulsating aneurism is,
+from the nature of things, lancinating from moment to moment.
+Eulenburg,[32] moreover, says that Benedikt's tests of the locality of
+the primary mischief only hold good under the following circumstances:
+(1) When the irritability and the exhaustibility of the nerves are in a
+normal condition during the neuralgia; (2) when the irritation that
+calls forth the paroxysm is either identical with the original cause of
+the disease, or at least operates upon the same spot. The two
+conditions, however, do not concur. The irritability and exhaustibility
+may be sometimes excessive in neuralgias, sometimes normal, and perhaps,
+in certain cases, beneath the normal standard; by which means the form
+of the curve of intensity must be considerably modified. Moreover, the
+irritation that provokes an attack may from the periphery attack the
+primary seat of the disease, even when this is central, on account (says
+Eulenburg) of exaggerated conductivity of the nerves (his second
+cause[33] of "hyperęsthesia"), as is, in fact, very frequently the case.
+He also thinks the distinction between paroxysmal and lancinating pains
+too indefinite to serve as a sufficiently reliable basis of diagnosis,
+especially considering the endless _nuances_ of the form which the pain
+is apt to take. I agree with Eulenburg upon this point; and am
+convinced, from my own observations, that such a distinction as that
+between lancinating and paroxysmal pains is illusory, [I have taken some
+pains to investigate the character of the pains, not only in neuralgia,
+but in locomotor ataxy. It is true that the lancinating character
+predominates, on the whole, in the latter disease; but there are great
+differences in different individuals, and even in the same patient at
+various times, which plainly depend on subjective influences. Compare
+for instance, Dr. Headlam Greenhow's report on an ataxic patient, with a
+report on the same man by Dr. Buzzard and myself. ("Trans. Clin. Soc.,"
+vol. i., 1868, pp. 152-162.)] the two kinds being frequently found
+alternate in the same case. The only useful distinction, in my opinion,
+is Benedikt's first one: he is probably right in saying that, where such
+an affection as an inflamed joint forms the source of peripheral
+irritation that immediately provokes a neuralgia, the pain is apt to be
+unusually continuous.
+
+The extent to which the pain of neuralgia spreads into different termini
+of the same nerve has been made the basis of distinctions as to the seat
+of the original mischief. For example, it has been said that pain in the
+mental branch of the third division of the trigeminus, which does not
+invade the auriculo-temporal branch, can hardly depend on an irritation
+operating on the trunk of the inferior dental; it must be distinctly
+peripheral, or else it must act upon limited portions of the central
+origin of the fifth nerve. But the fact seems rather to be that, whether
+the neuralgia was excited by lesions at the periphery, in the
+nerve-trunk, or in the centre, it is equally possible that either a
+small or a large part of the peripheral expanse of the nerve may become
+the seat of the pain: this almost necessarily follows from the entire
+independence of individual fibres in nerves.
+
+As regards the evidence afforded by the motor, vaso-motor, and trophic
+complications, there is this very positive diagnostic value in
+them--that they enable us to say, with greater assurance than we could
+otherwise do, that the disease is a real neuralgia. But, the only
+evidence that they afford as to the situation of the mischief is, that
+they uniformly point to the central end of a particular nerve; and
+accordingly I have already shown, in the chapter on Pathology, that the
+attentive study of these very complications furnishes us with some of
+the most powerful arguments upon which rests my theory that in neuralgia
+there is always centric mischief. What share in the production of the
+malady, in any given case, has been taken by the centric disease, and
+what if any by a peripheral irritation, the existence of these
+complications in no way helps us to determine; far less does it enable
+us to localize a peripheral lesion which may have acted as a concomitant
+cause; on the contrary, I believe that there is no more fertile source
+of erroneous judgment on this very point, than some of these
+complications, especially the vaso-motor and trophic. I suspect that it
+has happened, in hundreds of instances, that a localized congestion or
+inflammation, which is a mere secondary phenomenon, produced in the
+centrifugal manner already so fully explained, has been taken for the
+veritable _fons et origo_ of the malady: hence the neuralgia has been
+confidently reckoned as one peripherally produced, and, what is even
+worse, the whole energy of treatment has been directed to a mere
+outlying symptom, under the idea that the primary source of mischief was
+being attacked.
+
+The application of electricity as a test of the nature of a neuralgia
+has been employed by Benedikt,[34] who lays down certain laws as the
+result of his researches. He says that (_a_) in idiopathic peripheral
+neuralgias the nerves are not sensitive to the current; (_b_) in
+neuralgias dependent on neuritis or hyperęmia of the nerve-sheath there
+is general electric tenderness of the nerve; (_c_) in cases where the
+pain has been set up by morbid processes in tissues surrounding the
+nerve, there is electric tenderness only at the site of these changes. I
+may, in general terms, express concurrence in these statements; but I
+must add that, as diagnostic rules they apply only to the early stages
+of neuralgia; for the occurrence of secondary complications may and does
+altogether change the condition of electric sensitiveness. It need
+hardly be said that the above remarks on diagnosis apply for the most
+part only to the superficial neuralgias, which, however, include an
+immense majority of the cases of neuralgias. The diagnosis of visceral
+neuralgias is, it need hardly be said, in most cases, a far more
+difficult and complicated matter. In these diseases we have often little
+more to guide us, in the actual symptoms, than (_a_) the intermittence
+of the pain, and (_b_) the absence of commensurate constitutional
+disturbance, especially the complete freedom from sense of illness in
+the intervals between the pains. We shall be obliged to rely greatly on
+such historical facts as the presence or absence of neurotic tendencies
+in the patient and his family; the possibility of his having been
+exposed to blood-poisoning (_e. g._, from malaria or chronic alcoholic
+excess, or extreme over-smoking); the circumstance that he has been
+habitually overworked, or greatly exposed to agitating psychical
+influences; perhaps that he has been subject to a combination of several
+of these morbific momenta. To say truth, the diagnosis of visceral
+neuralgias must, at the best of times, be a difficult and anxious
+matter, and we can hardly ever thoroughly satisfy ourselves until we
+have procured some decided results from treatment; fortunately, however,
+it happens tolerably often that we can do this, and sometimes in a very
+striking way.
+
+_Prognosis._--The prognosis of neuralgia varies exceedingly, according
+to the form and situation of the disease, and many other considerations.
+There are, of course, in the first place, certain neuralgias in which
+the prospect is perfectly hopeless as to cure; such are the cases in
+which the nerve is involved in a continuously growing tumor (especially
+within a rigid cavity, like the skull), or a slow but persistent
+ulcerative process.
+
+Supposing, however, that the case is none of these, the very first
+prognostic consideration is that of age.
+
+Of the neuralgias of youth, the majority either disappear altogether
+after a first attack, or recur a certain number of times during some
+years, the neuralgic tendency either disappearing or becoming greatly
+mitigated when the process of bodily consolidation is over. In another
+group the neuralgic tendency is never lost, but the form of the attacks
+changes, and there is far less spontaneity in the manner of their
+production. It is exceedingly common to see delicate boys and girls
+between puberty and the age of eighteen or twenty, attacked with typical
+migraine, which recurs regularly every three or four weeks for perhaps
+two or three years, then ceases to occur at regular periods, then loses
+the tendency to stomach complication; and, by the age of twenty-five or
+somewhat later, has left, as its only relic, a tendency to attacks of
+ophthalmic neuralgia, which come on when the patient is excessively
+fatigued, or encounters the close air of a theatre, or undergoes an
+unusual strain of mental excitement or anxiety, etc.; but which never
+come on without some such special provocation. So, again, there is a
+variety of sciatica which belongs mainly to the period between puberty
+and the twenty-fifth to thirtieth year, and which seems really to
+belong, pathologically, to the age of unsettled and irregular sexual
+function, the tendency to it usually disappearing after the patient has
+settled down happily in married life. Ovarian and mammary neuralgia have
+very commonly a similar history.
+
+On the other extreme we find the neuralgias of the period of bodily
+decay: these are of very bad prognosis. A neuralgia which first develops
+itself after the arteries and capillaries have begun to change decidedly
+in the direction of atheroma is extremely likely, even if apparently
+cured for a time, to recur again and again, with ever-increasing
+severity, and to haunt the patient for the remainder of his days. It
+therefore becomes exceedingly important, in a prognostic point of view,
+to assure ourselves as soon as possible whether this arterial
+degeneration has decidedly commenced; and for this purpose I am in the
+habit of insisting to pupils on the great importance of sphygmographic
+examination for all neuralgic patients who have passed the middle age.
+Where we get the evidence which is furnished by the formation of a
+distinctly square-headed radial pulse-curve, even though there be no
+palpable cord-like rigidity of superficial arteries, we are bound to be
+exceedingly cautious of giving a favorable prognosis.
+
+In women the period of involution of the sexual apparatus forms a crisis
+which, in regard to neuralgias, is of great prognostic importance. On
+the one hand, if the general vital status be good, and the arterial
+system fairly unimpaired, we may look to the completion of the process
+of involution as a probable time of deliverance from neuralgic troubles
+that have hitherto beset a woman; we know that she will probably suffer
+a temporary aggravation of her pains, but we hope to see her lose them
+altogether. On the other hand, if it should happen that she enters on
+the period of sexual involution with her general nutrition considerably
+impaired and her arterial system decidedly invaded by atheroma, it is
+only too likely that neuralgias recurring now, or attacking her for the
+first time, will assume the worst and least manageable type.
+
+Of almost or quite equal importance with the question of the
+physiological age of the patient is that of his personal and family
+history with regard to the tendency to neuralgia and to other severe
+neuroses. Upon this subject I have dwelt so very fully in other parts of
+this work, that it is merely necessary here to repeat, that the balance
+of chances is most heavily swayed to the bad side by all evidence
+tending to prove congenital neurotic tendencies in the patient and vice
+versa.
+
+Of prognostic hints that are to be gathered from our knowledge of the
+immediate causes of the attack, there are none so valuable as those
+which we gather from the detection of a malarial or a syphilitic factor
+in the production of the malady. In the former case, we hope to cure the
+patient either with quinine or arsenic, with almost magical certainty
+and rapidity; in the latter, we expect an almost equally brilliant
+result from iodide of potassium.
+
+The particular nerve in which the neuralgia is seated does not so
+decidedly influence the prognosis, according to my experience, as is
+stated by some authors; nevertheless, there are differences of this
+kind. For instance, sciatica, though by no means so frequently a mild
+and trifling complaint as Eulenburg would make it to be, is certainly,
+on the whole, more curable than the trigeminal neuralgias taken as a
+group. I, however, cannot share Eulenburg's opinion as to the rarity of
+a central cause for sciatica, nor his consequent explanation of its more
+frequent curability; the latter I explain by the fact that it is
+possible far more completely to remove the concomitant causes in
+sciatica than in trigeminal neuralgia. By simply keeping a sciatic
+patient in the prone posture, shielded from cold and from pressure on
+the nerve, we have it in our power to remove nearly all peripheral
+sources of irritation; but in trigeminal neuralgia there are many
+influences, particularly psychical ones, which cannot be shut out, and
+which will continue to act with disastrous effect in many cases. With
+all this, however, we see a sufficiently large number of incurable
+sciaticas, on the one hand, and of severe trigeminal neuralgia cured on
+the other. It is only the genuine epileptiform tic, occurring in
+subjects whose arterial system is an advanced stage of degeneration,
+that stands out clearly and unmistakably pre-eminent among neuralgias
+for rebelliousness to treatment of every kind.
+
+FOOTNOTES:
+
+[32] _Op. cit._, pp. 65, 66.
+
+[33] Idem, p. 8.
+
+[34] "Elektrotherapie." Wien, 1868.
+
+
+
+
+CHAPTER V.
+
+TREATMENT OF NEURALGIA.
+
+
+I now approach what is really the most difficult portion of my task;
+for, although it would be easy enough to write copiously on the
+treatment of neuralgia, it is extremely difficult to keep a just medium
+between the opposite extremes of undue meagreness and of useless
+profusion of detail in the handling of this subject. There are also
+difficulties connected with the present uncertain and transitional state
+of opinion, even among high authorities, as to the value of particular
+remedies, and even of large groups of remedial agents, altogether there
+has been more hesitation in my mind as to this part of the present work
+than about any other, and the present chapter has been rewritten more
+than once. I mention this only to account for what there may very likely
+be found in it--an imperfect literary style such as too commonly marks
+work which has been repeatedly patched and corrected. At the same time,
+it should be said that my hesitation does not apply to the main
+principles of treatment which will be recommended below; it proceeds
+rather from the fear of seeming to ignore from carelessness modes of
+treatment which are still much used, but which I have really rejected,
+because, after full trial, they appeared to me valueless. Space is,
+after all, limited, and a complete account of all the remedies for
+neuralgia in vogue, in English and Continental clinics, would of itself
+fill a large volume.
+
+The treatment of neuralgia may be divided into four branches: (1)
+Constitutional remedies; (2) narcotic-stimulant remedies; (3) local
+applications; (4) prophylaxis.
+
+1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_)
+anti-toxic, and (_c_) medicinal tonic.
+
+(_a_) The importance of a greatly-improved diet for neuralgic patients
+is a matter which is more fully appreciated by the English school of
+medicine than by either the French or the German; it has, for instance,
+very much surprised me to notice the almost entire silence of Eulenburg
+on this topic. For my part, the opinions expressed three years ago[35]
+on this matter have only been modified in the direction of increasing
+certainty; I have learned by further experience that the principle is
+even more extensively applicable than I had supposed.
+
+That neuralgic patients require and are greatly benefited by a nutrition
+considerably richer than that which is needed by healthy persons, is a
+fact which corresponds with what may be observed respecting the chronic
+neuroses in general; and it gives me much satisfaction to point out this
+position of neuralgia as belonging to this large class of disorders, not
+merely by its pathological affinities, but by its nutritive demands. In
+a very excellent and suggestive paper by Dr. Blandford[36] it is stated,
+as the result of a large experience in mental and other nervous
+disorders, that the greater number of chronic insane and hypochondriacal
+cases, as well as neuralgic patients, are remarkably benefited by what
+might seem at first sight almost a dangerously copious diet.
+Occasionally it happens that the patients discover this by the teaching
+of their own sensations, and the apparent excesses in eating which some
+epileptic and hypochondriacal persons habitually commit are looked on by
+many practitioners as the mere indications of a morbid _bulimia_ which
+represents no real want, but only the craving of a perverted sensation
+which ought to be interfered with and allayed rather than encouraged. It
+is now many years since I began to doubt the justice of this opinion;
+the particular instance which called my attention to it being that of
+epilepsy, of which disease I saw a considerable number of cases, within
+a short period of time, that were distinguished by the presence of
+enormous appetite for food; and I finally came to the conclusion that,
+so far from this symptom being of evil augury, and likely to lead to
+mischief, it is, with certain limitations, a most fortunate occurrence.
+It is hardly necessary to say that over-eating, such as produces
+dyspepsia and distention of a torpid intestine with masses of fęces, may
+distinctly aggravate the convulsive tendency; but the truth is that,
+with a little careful direction and management of the unusual appetite,
+these bulimic patients can in most cases be allowed to satisfy their
+desires without harm of this kind following; a larger portion of food
+really gets applied to the nutritive needs of the body, and the nervous
+system unmistakably benefits thereby, the tendency to atactic disorder
+being visibly held in check.
+
+That which I have thus observed in the case of epilepsy, and which Dr.
+Blandford more particularly affirms concerning chronic mental diseases
+and the large number of neuroses that hover on the verge of insanity,
+has been most distinctly verified in my experience of the treatment of
+neuralgia. It is, unfortunately, by no means a frequent occurrence that
+the sufferer from this malady is inclined to eat largely, but the few
+patients of this type that I have seen were, in my judgment, distinctly
+the better for it. Far more common in neuralgia is a disposition of the
+patient to care little for food, to become nice and dainty, and in
+particular to develop an aversion--partly sensational and partly the
+result of morbid fear about indigestion--for special articles of diet.
+Dr. Radcliffe pointed out the special tendency of neuralgics to neglect
+all kinds of fat; partly from dislike, and partly because they believe
+it makes them "bilious;" and I have had many occasions to observe the
+correctness of this observation. In fact, by the time patients have
+become sufficiently ill with neuralgia to apply to a consulting
+physician, they have already, in the great majority of cases, got to
+reject all fatty foods, and have cut down their total nutriment to a
+very sufficient standard. Young ladies suffering from migraine are
+especially apt to mismanage themselves, to a lamentable extent, in this
+direction: this is natural enough, because the stomach disorder seems to
+them the origin of the pain, instead of being, as it is, a mere
+secondary consequence of the neurosis. But it is not only the sufferers
+from sick-headache in whom we find this tendency to insufficient eating,
+especially of fat; not to mention that all severe pain usually tends to
+disorder appetite and make it fastidious, there is nearly always some
+wiseacre of a friend at hand, ready to suggest that neuralgia is
+something very like gout, that gout is always aggravated by good living,
+and, _ergo_, that the patient should be "extremely cautious as to diet;"
+the end of which is that the poor wretch becomes a half-starved
+valetudinarian, but, so far from his pain getting better, it steadily
+becomes worse. I cannot too strongly express the benefits that I have
+seen accrue, in the most various kinds of neuralgic cases, from
+persistent efforts to remedy this state of things, and to convert the
+patient from a valetudinarian to a hearty eater; and I wish particularly
+to say that this success has always been most marked when I have from
+the first insisted on fat forming a considerable element of the food.
+Cod-liver oil is the form in which I much prefer to give it, if this be
+possible; there can be no mistake about the relatively greater power of
+this than of any other fatty matter, I believe simply from its great
+assimilability. But the very cases in which we most urgently desire to
+give fat are often those in which the patient's fantastic stomach openly
+revolts at the idea of the oil; we must then try other fats; and we
+should go on trying one thing after another--butter, plain cream,
+Devonshire cream, even olive or cocoanut oil (though these are the
+poorest things of the sort we can use)--till we get the patient well
+into the way of taking a considerable, if possible a decidedly large,
+daily allowance of fat, without provoking dyspepsia. It is surprising
+what can be done in this way by perseverance and tact, and it is no less
+striking to observe the good effects of the treatment. Nothing is more
+singular than to see a girl, who was a peevish, fanciful, and really
+very suffering migraineuse, brought to a state in which she will eat
+spoonful after spoonful of Devonshire cream, and at the same time lose
+her headaches, lose her sickness, and develop the appetite of a
+day-laborer; and, though such very marked instances as this are
+uncommon, they do sometimes occur, and a minor but still important
+degree of improvement is very frequent.
+
+As for the _modus operandi_ of the fatty food, there is no certainty.
+Dr. Radcliffe believe it acts as a direct nutrient of the nervous
+centres; and I also cannot help feeling that there is some evidence in
+favor of this idea. But, whether this be so or not, there is another
+kind of action of fat that is more simple and obvious; namely, it seems
+to be certain that the enrichment of the diet by fat greatly assists the
+assimilation of food in general, and thus the patient's nutrition is
+altogether improved.
+
+It is not merely, however, by increasing any one element of food that we
+should seek to enrich the diet of neuralgics, but rather by such a
+steady and persistent effort as Dr. Blandford describes, to increase the
+total quantity of nutriment to perhaps as much as one-third more than
+the patient would probably have taken in health. To those who from
+prejudice are incredulous of the propriety of this method, I would say,
+"Try it, and I venture to say your incredulity will disappear." More
+especially I would urge the great importance of this system in modifying
+the nervous status of very young, and also of aged, sufferers from
+neuralgia; it is the indispensable basis of a sound treatment for such
+patients.
+
+This seems the proper place for such remarks as must be made upon the
+function of alcohol in neuralgia; for, though this agent is a true
+narcotic when given in large doses, it is not under that aspect that I
+can recommend its use in neuralgia at all. I have written so much on
+this subject lately, that I shall here content myself with an emphatic
+repetition of my protest against the use of alcoholic liquors as direct
+remedies for pain. They ought only to be given, in neuralgia, in such
+moderate doses, with the meals, as may assist primary digestion without
+inducing any torpor, or flushing of the face, or artificial
+exhilaration. I cannot too expressly reprobate the practice of
+encouraging neuralgics, especially women, to relieve pain and depression
+by the direct agency of wine or spirit; it is a system fraught with
+dangers of the gravest kind.
+
+(_b_) The anti-toxic remedies include agents addressed to the
+modification of a special condition of the blood and tissues induced by
+the presence of morbid poisons, of which syphilis, malaria, and (more
+doubtfully) gout and rheumatism, are the representative examples.
+
+Of syphilitic neuralgia the treatment may be summed up in a few words:
+Give iodide of potassium in doses rapidly increased up to a daily
+quantum of twenty to thirty grains. If this fails, give one-twelfth of a
+grain of bichloride of mercury thrice daily.
+
+Of malarial neuralgia I can only speak from such a limited experience
+that I am by no means in a position to give an exhaustive account of the
+treatment. Quinine is, of course, the remedy that should first be tried;
+and, as the paroxysms are usually regular in their recurrence, I prefer
+to give the drug after the plan which is, I think, incontestably the
+best in ordinary ague--_i. e._, to administer one large dose (five to
+twenty grains) about an hour before the time when the attack is
+expected. With a few exceptions the malady, unless it had taken very
+deep root before we were consulted, will yield to a few doses given in
+this way; after the morbid sequence has been thus interrupted, it will
+be proper to continue the action of quinine in smaller and more frequent
+doses, given for three or four weeks continuously. For the comparatively
+rare cases in which quinine fails, the prolonged use of arsenic
+(Fowler's solution, five to eight minims three times a day), especially
+with the simultaneous employment of cod-liver oil, is to be recommended.
+
+The part which gout may play in inducing neuralgia is, as I have already
+said, a far more doubtful question than the popular medical traditions
+assume it to be; and treatment directed to gout as a cause is an
+extremely uncertain affair. The direct relief of neuralgic pain by the
+administration of colchicum, for example, is, in my experience, a very
+rare occurrence, even where the gouty diathesis is unmistakably present;
+and, on the other hand, the depressed vitality which gouty neuralgics
+usually show in a marked degree, renders it very doubtful whether the
+relief of the pain may not be too dearly purchased at the cost of the
+general lowering effects of colchicum. It is probable that neuralgia
+occurring in gouty subjects is more safely, and equally effectually,
+treated upon general principles. At the same time it may be admitted
+that, in the subordinate function of an adjuvant to the aperients which
+it is sometimes advisable to give, small doses of the acetic extract of
+colchicum seem to possess some value.
+
+The question of treatment addressed to a supposed rheumatic element in
+neuralgia will, of course, be differently judged according to the
+respective ideas of various practitioners as to the pathological
+affinities of the two diseases; and the reader already knows that I
+believe these affinities to be different in kind from what is generally
+believed. The utmost that I should concede is, that in a certain very
+limited number of cases the peripheral factor in neuralgia is an
+inflammation of the nerve-sheath, or surrounding tissues, which forms
+part of a chain of phenomena of local fibrous inflammations in different
+parts of the body. Iodide of potassium, in five or ten grain doses
+three times a day, is the proper treatment for such cases. I have never
+found alkalies do any direct good to the pain.
+
+(_c_) The medicinal tonic variety of constitutional treatment is more
+especially represented by the use of iron and arsenic in cases where
+poverty of the blood seems to exist in a marked degree, and by the
+administration of certain tonics--quinine, phosphorus, strychnia, and
+zinc--which are supposed to exert a specially restorative influence upon
+the nervous tissues.
+
+The use of quinine as an anti-malarial agent has been already referred
+to; its employment in non-malarial cases is of much more restricted
+scope and benefit. Experience has taught me to agree in general with the
+opinion of Valleix, that it is a very unreliable agent; the one marked
+exception to this being the case of ophthalmic neuralgias. What the
+reason may be I cannot in the least say, but it is a fact that quinine
+does benefit these neuralgias, in cases where there is no room for
+suspicion of malaria, with a frequency which is very much greater than
+in the treatment of the painful affections of any other nerve in the
+body. The quantity given should be about two grains three times a day.
+
+The preparations of phosphorus which I have employed in the treatment of
+neuralgia are the phosphuretted oil, the hypophosphite of soda (five to
+ten grains three times a day), and pills of phosphorus (according to Dr.
+Radcliffe's recommendation) containing one-thirtieth of a grain, given
+twice or thrice daily. Either of the two last will do all that
+phosphorus can do, but its utility is not very extensive or reliable. I
+have found it to do most good in cases where there was a high degree of
+anęsthetic complication.
+
+Preparations of zinc have, in my hands, done no particular good,
+although I have tried them in all manner of doses.
+
+Strychnia, on the other hand, is a remedy which I have learned to prize
+much more highly during the last few years than previously. Its most
+decided efficacy has been shown in some of the visceralgię, especially
+gastralgia, and (to a less extent) angina pectoris. Its internal use for
+these complaints is best effected by giving doses of five to ten minims
+of tincture of nux-vomica three times a day; but a method which I have
+several times employed with good effect is the subcutaneous injection of
+very small doses of strychnia (one-eightieth to one-fiftieth of a grain)
+twice daily. For the superficial neuralgias, on the other hand, I
+generally administer one-fortieth of a grain, with ten or fifteen minims
+of tincture of sesquichloride of iron, by the stomach, three times a
+day; this is a very powerful prophylactic remedy to prevent the
+recurrence of the attacks when once the sequence of them has been broken
+through by other means.
+
+Of iron generally, as a remedy in anęmic cases, I have only to remark
+that, in order to get its full benefits, it is necessary to use large
+doses. I give the saccharated carbonate in twenty-grain doses twice or
+three times a day.
+
+But of the sesquichloride of iron I am inclined to say something more;
+it has seemed to me that, besides its effects on the blood, it has a
+marked and direct influence upon the nervous centres, which is different
+from anything which one observes in the action of other preparations of
+iron. It is certain that the action of sesquichloride of iron, in those
+cases of chlorosis which are distinguished by profound nervous
+depression, is something quite peculiar; and the effect which it
+produces in the anęmic neuralgias, more especially of young women, is
+equally remarkable. I cannot help alluding here to the striking effects
+which large doses of the tincture, as recommended by Dr. Reynolds,
+produce in acute rheumatism; the severest pain is often checked within
+twenty-four hours after the commencement of this treatment. Both in this
+disease and in neuralgia, I employ the old-fashioned tincture: if given
+alone it should be used in large doses (thirty or forty minims three
+times a day); but an excellent combination is that, already mentioned,
+of ten-minim doses of this tincture with one-fortieth of a grain of
+strychnia. There is something in the revivifying effects of this mixture
+that is quite peculiar. I have very lately employed it in the case of a
+gentleman, aged thirty-five, who was the subject of frontal neuralgia
+complicated with paralysis of the internal rectus, and who was decidedly
+anęmic, and greatly depressed and worried in mind by the consciousness
+of his inability to overtake professional work which had accumulated
+upon him. This patient improved with great rapidity, and in the course
+of three weeks lost, not merely his neuralgia, but also his strabismus,
+almost entirely; but he then got into a condition which, though not of
+permanent importance, was sufficiently undesirable to make me mention it
+here, especially as I have seen the same thing in more than one patient
+besides him. It is a peculiar state of restlessness during the day and
+sleeplessness at night, without any positive exaltation of reflex
+excitability such as one used to see from strychnia in the days when
+mischievously large doses of that drug were very commonly given, and
+patients used to complain of decided twitchings and startings of the
+limbs. It is clearly not a strychnia effect pure and simple, nor an iron
+effect only; it is a _tertium quid_ compounded of the actions of both
+drugs.
+
+The direct effects of arsenic in the improvement of the quality of the
+blood seem to me incontestable; and its use for this purpose in anęmic
+neuralgias is certainly something over and above its special neurotic
+action. No one, who has employed it much in the cases of anęmic children
+suffering from chorea after rheumatism, can have failed to observe its
+frequently striking influence upon blood-formation even long before the
+nervous ataxia is materially reduced. The misfortune is, however, that
+we possess no indications by which to judge beforehand whether we may
+reckon on its most favorable action in any given (non-malarious) case,
+with certain special exceptions. In angina pectoris it has a most direct
+effect, which is rarely altogether missed, and is sometimes surprising:
+the cases in which it succeeds best are those distinguished by anęmia,
+but we may well suppose, from its remarkable action upon other neuroses
+of the vagus, that it is something more than an action on the
+blood-making process which produces such powerful effects in allaying
+the tendency to recurrence of the paroxysms. My attention was called to
+its action in this disease chiefly by the remarkable case published by
+Philipp;[37] this was a purely neurotic angina, but one of the severest
+type, and the influence of arsenic was very striking. Since that time I
+have employed it in several cases, and, after trying various forms of
+administration, I conclude that nothing is better than Fowler's
+solution, in doses of three minims (gradually increased, if the remedy
+be well tolerated, up to eight or ten) three times a day. Unfortunately,
+there are some neurotic patients who cannot bear arsenic, the
+irritability of their alimentary canal is such that the drug always
+provokes vomiting, or diarrhoea, or both; this was the case with one
+of my patients, in whose case I had allowed myself to hope for the very
+best results from arsenical treatment. But where the patient tolerates
+it--and usually he tolerates it extremely well--the prolonged use of
+arsenic seems really to root out the anginoid tendency, or at least to
+confine it to the more trivial and manageable manifestations. I believe
+that in at least three patients, I have so completely broken down a
+succession of cardiac neuralgic attacks as to substitute for them a mere
+remnant of a tendency to "tightness at the chest" after any severe
+bodily exertion or mental emotion. It might be a question, in cases
+where the stomach does not tolerate the ordinary administration of the
+agent, whether it would not be worth while to try the effect of
+subcutaneous injection (two to four minims of Fowler), or inhalation of
+the smoke of arsenical cigarettes. But, in truth, it is not certain that
+even in this case we escape the characteristic effects of the drug upon
+those persons who are abnormally sensitive to it.
+
+A remarkable instance of the beneficial influence of arsenic occurred in
+the case of a woman, aged forty-six, the solitary example of severe
+angina in a female that I have ever seen. [It is by no means uncommon,
+however, to see the milder forms of cardiac neuralgia in women; the
+remarkable statistics of Forbes, quoted in Chapter I., must certainly
+have been taken exclusively from cases of the severest type of the
+disease.] This was a hospital patient, who had always suffered much
+from hysteria, and from childhood had been liable to hemicranic
+headache; she had entered on the period of "change" at the time the
+attacks began, but menstruation, though irregular, still continued, and,
+in fact, did not cease till four years later, long after the anginal
+attacks had been subdued. The patient had been attacked for the first
+time at the end of a heavy day's washing; she dropped on the ground with
+the sudden agony and faintness, and thought she should "never come to
+life again." The paroxysms returned five times within the next month,
+though not always so severely as on the first occasion; but the poor
+woman lived in a constant state of terror. On the occasion of her second
+visit to me, she had a most severe attack in the waiting-room at the
+hospital: being called to her I found her very nearly pulseless,
+gasping, and with the kind of complexion which is so suggestive of
+approaching death. She was recovered by a large dose of ether. It was a
+rather uncommon feature in this case that the pain was only at and
+around the lower end of the sternum, except that occasionally it shot
+along the sixth intercostal space. The employment of Fowler's solution
+(in doses gradually mounting to twenty-one minims daily) for six months
+completely eradicated the anginal tendency; the proof that it was a real
+therapeutic effect was given by the result of an attempt to leave the
+medicine off at the end of eight weeks' treatment; the patient
+immediately began to suffer again. When she really left off, at the end
+of six months' treatment, she had had no tendency to heart-pang for more
+than a month, and, besides this, looked quite another creature in her
+improved vitality and vigor. Yet the menstrual troubles went on, and the
+function was not finally suppressed for a long time afterward.
+
+I suspect, however, that the most frequent successes with arsenic will,
+after all, be made in the cases of more or less anęmic male patients who
+are attacked with the neurotic form of angina in the midst of a career
+(as is especially the case with some professional careers) that implies
+not merely incessant labor, but great anxiety of mind. The drug does
+little good, however, if not positive harm, in that form of angina
+pectoris minor which is not the result purely of these causes, but of
+these, or some of these, plus the morbid action of the alcoholic excess,
+to which the patient has fled in order to relieve mental harassment and
+the fatigue that comes from overwork, especially overwork at tasks that
+are not congenial to his natural disposition; there is usually in such
+cases a heightened irritability of the alimentary canal, which is almost
+sure to cause arsenic to disagree: the really useful treatment is
+quinine for the first few days, and then, when the stomach will bear it,
+cod-liver oil in increasing doses, up to a large daily amount given for
+a long time together.
+
+On the whole, arsenic, from its singularly happy combination of powers
+as a blood-tonic, a special stimulant of the nervous system, and withal
+as a special opposer of the periodic tendency, must be regarded as one
+of the most powerful weapons in the physician's hands, and (although it
+seems to act best in the neuralgias of the vagus and of the fifth) there
+is a possibility of its proving the most effective remedy in almost any
+given case which may come before us.
+
+2. The narcotic-stimulant treatment for neuralgia includes some of the
+most powerful remedies for the disease which we possess. These remedies
+have very different properties, but they all agree in this, that in
+small doses they appear restorative of nerve-function--in large doses
+depressors of the same.
+
+Four very different types, at least, of narcotic-stimulant drugs are
+useful in neuralgia: (_a_) There is the opium type, by which pain is
+very directly antagonized, and, besides this, sleep is also directly
+favored. (_b_) There is the belladonna type, by which pain is also much
+relieved, though with far greater certainty in some regions than in
+others (_e. g._, much the most powerful effect is seen in cases of pelvic
+visceralgia), but sleep is by no means so certainly or directly produced
+as by opium. (_c_) There is the chloral type, which is almost purely
+hypnotic; it is represented almost solely by chloral itself, which is
+resembled by scarcely any other drug. (_d_) There is bromide of
+potassium, which stands alone for its powerful action on the cerebral
+vaso-motor nerves, and which is useful in neuralgia simply by its power
+to check psychical excitement directly (through the circulation) and
+indirectly (through the production of sleep).
+
+(_a_) Opium and the remedies that resemble it are, for the treatment of
+neuralgia, fully represented by the hypodermic use of morphia, which is
+the only kind of opiate treatment that ought ever to be employed, save
+in very exceptional instances. The great reasons for the preference of
+the subcutaneous administration over the gastric are, the economy of the
+drug which it affects and the much smaller degree of disturbance of
+digestion which it causes. The hypodermic injection of morphia, if
+conducted on correct principles, enables us, when necessary, to repeat
+the dose a great number of times with but little loss of the effect, and
+consequently with a much smaller rate of progressive increase of the
+quantity required; and the absence of depressive action on digestion
+enables us to carry out simultaneously that plan of generous nutrition
+which has already been shown to be so important a part of treatment.
+Indeed, the case is hardly expressed with sufficient strength, when we
+say that hypodermic morphia is usually harmless to the digestive
+functions; for in a great number of instances it will be found actually
+to give an important stimulus both to appetite and digestion; and the
+patient, who without its aid could hardly be persuaded to take food at
+all, will not unfrequently eat a hearty meal within half an hour after
+the injection.
+
+The remarkable effects of hypodermic morphia have, however, caused it to
+be rashly and indiscriminately used, and so much harm has been done in
+this way that it is necessary to be exceedingly careful in the rules
+which we lay down for its employment. Upon these grounds I must hope to
+be excused if, in order to render this work complete, I repeat a good
+deal of what I have already said in other places. In the first place, I
+shall speak of the mode of administration, and then of the dose.
+
+As regards the mode of administration, I prefer the use of a solution of
+five grains of acetate of morphia to the drachm of distilled water; if
+the acetate be a good specimen, this will dissolve easily (and keep some
+time without precipitation) without the use of any other solvent. With a
+solution of this strength we require nothing elaborate in the form of
+the syringe; a simple piston arrangement does well; only it is advisable
+that the tube shall have a solid steel triangular point, and a lateral
+opening. As regards the place of injection, I must repeat the
+opinion[38] which I have already published, that Mr. Hunter's plan of
+injection at an indifferent spot is, in the great majority of instances,
+fully as effective as the local injection would be; nevertheless, there
+is one consideration which in some cases may properly induce us to adopt
+the latter plan. Very nervous and fanciful patients will sometimes be
+much more readily brought to allow the operation when it seems to go
+directly to the affected spot, when they would be sufficiently
+incredulous of the benefits of an injection performed at a distance to
+indulge their dislike of incurring pain by refusing to submit to it. And
+there is one class of cases in which it is likely that there are real
+physical advantages in the local injection; in instances of old-standing
+neuralgia with development of excessively tender "points," which are
+also the foci of the severest pain, it will sometimes be advisable to
+inject into the subcutaneous tissue at these points. There is undeniable
+reason for thinking that the sub-inflammatory thickening of tissues
+around a certain point of nerve delays the transit of the morphia into
+the general circulation, and enables it to act more directly and
+powerfully on the nerve, which it thus renders insensitive to external
+impressions; an important respite is thus gained, during which the
+nerve-centre has time to recover itself somewhat. At the same time it
+must be remarked that this immediate injection of a tender point is apt
+to be exceedingly painful, and it may be absolutely necessary to apply
+ether-spray before using the syringe. In early stages of neuralgia,
+before the formation of distinct tender points, there is no advantage
+whatever (except the indirect one above mentioned) in the local
+injection. And, on the other hand, it is often of great consequence not
+to run the chance of disfiguring such a part as the face, the neck,
+etc., when the injection can easily be done over the deltoid, or in the
+leg, or in some other part which even in women is habitually covered by
+the dress.
+
+The dose to be employed is an exceedingly important matter, and one as
+to which practitioners are still very often injudicious. We ought never
+to commence with a larger dose than one-sixth of a grain; but very often
+as little as one-twelfth of a grain will give effective relief, and in
+not very severe cases it is well worth while to try this smaller
+quantity. When no larger quantity than one-sixth of a grain is employed
+we commonly observe no narcotic effects, _i. e._, there is no
+contraction of pupil, no heavy stupor, and, although the patient very
+often falls asleep, on waking he does not experience headache, nor is
+his tongue foul. I cannot too strongly express the opinion that it is
+advisable by all means to content ourselves with this degree of the
+action of hypodermic morphia, unless it fails to produce a decided
+impression on the pain. But in very severe cases our small doses will
+fail; and then, rather than allow the patient to continue having severe
+paroxysms unchecked, we must frankly admit the necessity of using a
+narcotic dose from one-quarter to one-half of a grain, according to
+circumstances. Whatever actual dose be employed, it is important not to
+repeat it with unnecessary frequency; once a day in the milder, and
+twice a day in the more severe cases, will be all that is advisable,
+save in very exceptional cases: the point being to administer it as
+quickly as possible after the commencement of an exacerbation. If by
+these means we can prevent the patient having any severe pains during a
+period of several days, we often give time to the affected nerve to
+recover itself so completely, especially with the aid of other measures
+to be presently mentioned, that the tendency to neuralgia is completely
+broken through, and we can drop the injections, either at once or by
+rapid diminution of the dose, and thereafter treat the case merely with
+tonics, and with the precautionary measures to be dwelt upon under the
+heading of Prophylaxis. But, if we have been driven to the use of
+distinctly narcotic doses, and these do not very speedily break the
+chain of neuralgic recurrence, it will not do to continue to rely upon
+hypodermic morphia; it will be best to try some of the local remedies
+(blistering, galvanism) with it. If this combination fails, we should
+then try the effect of atropine, the sulphate of which, hypodermically
+injected, fully represents for all useful purposes the mydriatic class
+of narcotics.
+
+(_b_) The commencing hypodermic dose of atropine should be one-one
+hundred and twentieth grain; it is not often that so small a quantity
+will do any good, but it is necessary to use this agent with great
+precaution, as we occasionally meet with subjects in whom extremely
+small doses provoke most uncomfortable symptoms of atropism, as dry
+throat, dilated pupil, delirium, and scarlet rash. Commonly we shall
+find ourselves obliged to increase the dose to one-sixtieth,
+one-fiftieth, or one-thirtieth of a grain; and in a very few cases it
+may be necessary to go even as high as the one-sixteenth or one-twelfth.
+In my experience such instances are excessively uncommon; and I cannot
+but suppose that the practitioners who use the high doses frequently
+must inject in such a manner as to fail to get the whole dose taken up.
+[Absolutely inexplicable to me is the statement of the illustrious
+Trousseau--that hypodermic remedies are "less active" (!) than gastric
+remedies--except on his hypothesis.]
+
+The most remarkable effects that I have seen from hypodermic atropia
+were obtained in cases of peri-uterine neuralgia, especially
+dysmenorrhoeal neuralgia. Speaking generally of atropine, it must
+undoubtedly be counted far inferior to morphia as a speedy and reliable
+reliever of neuralgic pain, but for all pelvic neuralgias it appears to
+me on the whole to surpass morphia. And besides this, in other
+neuralgias, where opiates altogether disagree (as with some subjects
+they do), it is not uncommon to find that atropia acts with
+exceptionally good effect. And to some extent I am inclined to confirm
+Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does
+so more permanently than morphia.
+
+There is another special use of hypodermic atropine which I have not
+seen mentioned by any one but myself, but which is probably very
+important, namely, in ophthalmic neuralgia where acute iritis, or
+especially glaucoma, seems coming on. I may be mistaken, but I believe
+that in three cases I have succeeded, by prompt injection of sulphate of
+atropine (one-sixtieth to one-fortieth of a grain), in saving a
+neuralgic eye from damage, and possibly from destruction, from impending
+glaucoma.
+
+(_c_) The class of cases for which merely hypnotic remedies are of much
+value is limited; nevertheless, in the milder kinds of migraine and
+clavus, especially when they have been brought on or are kept up by
+mental worry or hysterical excitement, these remedies will sometimes
+prove very useful. In former days, before we knew chloral, I used to
+employ camphor for this purpose; three or four grains being administered
+every two hours: and in hysterical hemicrania of a not very severe type
+this not unfrequently produced a short sleep, from which the patient
+awoke free from the pain. But chloral infinitely transcends in value any
+agent of this kind that was known before. Perfectly valueless for the
+really severe neuralgias, it is of the greatest possible use as a
+palliative in migraine and clavus, where the great object, for the
+moment, is to get the patient to sleep. A single dose of twenty to
+thirty grains will often effect our object: it may be repeated in two
+hours if sleep has not been induced; it should be given as soon as the
+pain has at all decidedly commenced.
+
+And here I wish to make some special remarks on the subject of
+"palliation," and the relation it bears to "cure." Nothing is more
+common than to read serious admonitions, in medical works, about the
+folly of trusting to remedies which only palliate for the moment but
+leave the root of evil untouched; and, of course, there is a certain
+respectable modicum of the fire of truth behind all this orthodox smoke.
+In the case of neuralgia, however, it is most important to understand
+that mere palliation, that is, stopping of the pain for the moment, may
+be either most useful or highly injurious, according to the way in which
+it is done. The unnecessary induction of narcosis for such a purpose,
+doubtless, is most reprehensible; but if it were possible simply to
+produce sleep from which the patient should awake refreshed, without any
+narcotic effects, then, certainly, that sort of palliation must be good.
+That is precisely what the judicious use of chloral does; and I may
+mention, as resembling though not equalling it, the action of Indian
+hemp, which has been particularly recommended by Dr. Reynolds. From
+one-fourth to one-half of a grain of good extract of cannabis, repeated
+in two hours if it has not produced sleep, is an excellent remedy in
+migraine of the young. It is very important, in this disease, that the
+habit of long neuralgic paroxysms should not be set up; and if the first
+two or three attacks are promptly stopped, by the induction of sound,
+non-narcotic sleep, we may get time so to modify the constitution, by
+tonics and general regimen and diet, as to eradicate the neuralgic
+disposition, or at least reduce it to a minimum. But I would decidedly
+express the opinion that such remedies as either opium or belladonna are
+mostly unsuited to this purpose. If the migraine of young persons does
+not yield to chloral, to cannabis, or to muriate of ammonia (in twenty
+or thirty grain doses), it will not be advisable to ply the patient with
+any remedies of the narcotic-stimulant class, but to trust to tonic
+regimen and the use of galvanism.
+
+The mention of muriate of ammonia, which, for migraine and clavus and
+the milder forms of sciatica, not unfrequently proves useful in stopping
+the violence of a paroxysm and enabling the patient to get some
+refreshing sleep, leads me to notice that not only may a variety of the
+milder narcotic-stimulants be employed in this way, but the external
+stimulus of heat to the extremities (very hot pediluvia) greatly
+assists the action of any such remedies; especially if mustard-flour be
+added, so that a mild vapor of mustard rises with the steam and is
+inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is
+to give twenty grains of chloral, and make the patient plunge his feet
+in very hot mustard-and-water and breathe the steam. He can hardly fail
+to fall asleep for a longer or shorter time, and awake free from pain.
+
+(_d_) The use of bromide of potassium in neuralgia is a subject of great
+importance, and which requires much attention and discrimination. In
+common with, I dare say, many others, I made extensive trial of this
+agent when it first began to be much talked of, but was so much
+disappointed with its effects in neuralgias, that at one time I quite
+discarded it in the treatment of those affections. Renewed experience
+has taught me however, that, though its use is restricted, it is
+extremely effective if given in appropriate cases and in the right
+manner. For the great majority of neuralgias it is quite useless, and,
+what is more, proves often so depressing as indirectly to aggravate the
+susceptibility of the nervous system to pain. The conditions, _sine quis
+non_, of its effective employment seem to be the following: The general
+nervous power, as shown by activity of intelligence, and capacity of
+muscular exertion and the effective performance of co-ordinated
+movements, must be fairly good, find the circulation must be of at least
+average vigor; the patient must not have entered on the period of
+tissue-degeneration. Among neuralgics who answer to this description,
+those who will benefit by the bromide are chiefly subjects--especially
+women--in whom a certain restless hyperactivity of mind and perhaps of
+body also, seems to be the expression of Nature's unconscious resentment
+of the neglect of sexual functions. That unhappy class, the young men
+and young women of high principle and high mental culture to whom
+marriage is denied by Fate till long after the natural period for it,
+are especial sufferers in this way and for them the bromide appears to
+me a remedy of almost unique power. But I wish it to be clearly
+understood that it is not to the sufferers from the effects of
+masturbation that I think the remedy specially applicable: on the
+contrary, it is rather to those who have kept themselves free from this
+vice, at the expense of a perpetual and almost fierce activity of mind
+and muscle. The effects of solitary vice are a trite and vulgar story;
+there is something far more difficult to understand and at the same time
+far more worth understanding in the unconscious struggles of the
+organism of a pure minded person with the tyranny of a powerful and
+unsatisfied sexual system. It is in such cases, which it heeds all the
+physician's tact to appreciate, that it is sometimes possible to do
+striking service with bromide of potassium; but it will be necessary to
+accompany the treatment with strict orders as to generous diet, and,
+very likely, with the administration of cod-liver oil.
+
+Having decided that bromide of potassium is the proper remedy, we must
+use it in sufficient doses. Not even epilepsy itself requires more
+decidedly that bromide, to be useful, shall be given in large doses. It
+is right to commence with moderate ones (ten to fifteen grains), because
+we can never tell, beforehand, that our patient is not one of those
+peculiar subjects in whom that very disagreeable phenomenon--bromic
+acne--will follow the use of large doses. But we must not expect good
+results till we reach something like ninety grains daily. Let me add
+that it is not so far as I know, by reducing any "hyperęsthesia" of the
+external genitals, of which the patient is aware, that the remedy acts;
+I have not seen such a nexus of disease and remedy in these cases.
+
+3. Local Measures.--The external remedies which may be applied for the
+treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_)
+paralyzers of peripheral sensory nerves; (_c_) remedies adapted to
+diminish local congestion; (_d_) remedies adapted to diminish arterial
+pulsation; (_e_) electricity; (_f_) mechanical means of protection.
+
+(_a_) Among the skin-stimulants blisters hold the highest place as a
+remedy for neuralgia; indeed the assertion of Valleix, that they are the
+best of all remedies, is still not very wide of the truth. They are by
+no means universally applicable, and the degree to which their action
+should be carried varies materially in different forms of the disease,
+but they are of the greatest possible service in a large number of
+instances.
+
+It is possible to view the action of blisters in neuralgia in more than
+one way. When applied in such a manner as to vesicate decidedly, and
+especially if kept open and suppurating for some time, they cause
+considerable pain of a different kind from that of neuralgia itself and
+the mental effect of this, operating as a diversion of the patient's
+thoughts from his original trouble, may be thought to assist in breaking
+the chain of nervous actions by which he is made to feel neuralgic pain.
+There may be something in this, but I confess that I do not believe this
+kind of effect goes for much in genuine neuralgia. It is rather in the
+pain of hypochondriasis, and the so-called spinal irritation (to be
+described in the second part of this work), that such an action of
+blisters proves useful.
+
+Another action of blisters, which some authors hold to be perhaps the
+most effective portions of their agency, is that which is produced by
+the drain of fluid, specially when they are kept open, by which means a
+kind of depletion is set up, and the morbid irritation that causes the
+nerve pain removed. I cannot at all assent to this view. In the first
+place, I believe that any one who has large experience of blistering in
+neuralgia will ultimately come, as Valleix did, to believe that
+prolonged drain from a blister is rarely or never useful, and that a far
+better plan is that of so-called flying blisters, renewed at intervals
+if necessary. The most genuine successes that I have procured from
+blistering have certainly been got in this way. But I should go further,
+and say that the prolonged drain and the peculiar kind of chronic
+irritation produced by a suppurating blistered surface can very
+decidedly aggravate a neuralgia; this is more especially the case when
+the blister is applied immediately over the focus pain.
+
+The view which I am strongly convinced alone explains the beneficial
+action of blisters is that which supposes them to act as true stimulants
+of nerve-function. In order that this effect shall be produced, it will
+be necessary that the skin-irritation be either produced at some
+distance from the seat of the greatest pain, or that, if applied in that
+spot, it shall be comparatively mild in degree. And accordingly, I have
+been led, in my observations to apply the blister at some distance from
+the focus of pain. An indifferent point, however, will not do--there
+must be an intelligible channel of nervous communication between the
+irritated portion of skin and the painful nerve. This object is
+accomplished by placing the blister as close as may be to the
+intervertebral foramen from which the painful nerve issues; the effect
+of this is probably a stimulation of the superficial posterior branches,
+which is carried inward to the central nucleus of the nerve. I must say
+that the results which I have derived from this plan of treatment have
+been far more satisfactory than those which I used to obtain when I
+habitually applied the vesication as near as might be to the focus of
+peripheral pain; and I think that this result tallies well with the idea
+that the essential mischief in neuralgia consists in an enfeebled
+vitality of the central end of the posterior root. An exceedingly
+interesting confirmation of this idea as to its _modus operandi_ has
+been afforded me by the fact that not merely neuralgic pain, but also
+trophic and inflammatory complications attending it, have been sensibly
+relieved, in several cases that I have seen, by this mode of reflex
+stimulation. This has been particularly the case in herpes zoster, where
+the process of inflammation and vesiculation has been very promptly
+checked by the application of a tolerably powerful blister by the side
+of the spine at the proper level; and I am gratified to mention that Dr.
+J. K. Spender, of Bath, pointed out this fact[39] at a time when he had
+only seen my statement that the pain could be relieved in this way. In
+the case of the trigeminus, the same kind of reflex stimulation is most
+effectively obtained by applying the blister over the branches of the
+cervico-occipital, at the nape of the neck; and it is remarkable what
+powerful effects are sometimes thus produced, even in cases that wear
+the most unpromising aspect. For example, in the desperate epileptiform
+tic of old age, I have more than once seen a complete cessation of
+suffering, which lasted for a very long time--so long, in fact, as to
+make me hope against hope that it might never return. I do not now
+entertain any such expectations from this remedy; still, its value is
+very great.
+
+There are curious differences between the effects of blistering in
+trigeminal or intercostal neuralgia and in sciatica. On the whole, it
+would appear that blistering in the neighborhood of the spine is less
+frequently effective in the latter, and we sometimes, after failing with
+this method, obtain immediate success by two or three repetitions of the
+flying blister, somewhere over the trunk of the nerve, especially just
+outside the sciatic notch. I have one lady patient in whom this series
+of phenomena has several times been observed; and I have seen it occur
+in a particular attack, in other patients, in whom, nevertheless, on
+another occasion the spinal blistering has been promptly effective.
+
+I consider blistering of the posterior branches to be an important, and
+usually an essential, element in the treatment of all cases of sciatica
+in the middle period of life which have reached some severity and lasted
+long enough to become complicated with decided secondary affections.
+
+In all cases where blistering is employed it is advisable to adopt the
+simultaneous use of hypodermic morphia or atropine; this combination of
+remedies is exceedingly powerful.
+
+Lastly, it must be said of blistering, that, on the whole, it is a
+remedy not well fitted to be applied to aged subjects; and in its
+severer forms it should never be applied to patients who are greatly
+prostrated in strength. For it must be borne in mind that the remedy may
+miss its aim of relieving the neuralgia, in which case it is necessary
+to remember, more accurately than many practitioners appear to do, what
+a very serious element of misery and prostration will be introduced into
+the case by the vesication itself.
+
+I am not convinced that any of the other forms of severe skin-irritation
+(_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to
+such a degree as to produce not the anęsthetic but the irritant effects)
+are of any particular value; if blistering failed, I should not expect
+to see them succeed.
+
+A milder degree of skin-stimulation is represented by rubefacient
+liniments of various kinds, which may be briskly rubbed into the skin
+along the track of the painful nerve, without any danger of producing
+vesication. Among this class I continue to prefer chloroform diluted,
+with six or seven parts of chloroform, to any other; in the milder forms
+of neuralgia, especially in young persons and first attacks, it is
+surprising how frequently the paroxysm may be greatly relieved, if not
+arrested. Still, this can only be regarded as the merest palliative; and
+in severer cases such applications are useless. Occasionally, when
+chloroform-liniment has failed, a mustard plaster will do good.
+
+The mildest degree of skin-stimulation is represented by the continuous
+application of moist warmth, which is best effected by the simple
+application of moistened spongio-piline; so far as I have observed,
+however, it is rather in cases of myalgia than in true neuralgia that
+this does good; in the latter it is probably little more than a mere
+protector against cold.
+
+(_b_) A variety of agents can be employed with the object of temporarily
+interrupting the conductivity of the painful nerve; by this means a
+period of rest is obtained during which the centres--sensory and
+psychical--have time to regain a juster equilibrium, and the habit of
+pain is, _pro tanto_, broken through.
+
+There is one agent of this class which for general purposes I do not
+think is worth retaining on our list of sensory paralyses--namely, cold.
+Cold, to be of any value, ought to be of the degree which is represented
+by ice allowed to melt slowly in contact with the skin; and for the
+majority of neuralgias this is decidedly inferior to other remedies that
+can be applied by painting or inunction. The one case in which ice is
+supremely useful is in neuralgia of the testis; here I make no doubt
+that it is almost, if not quite, the most useful remedy we can employ,
+although of course other means must be taken to modify the neuralgic
+temperament. It should be applied the moment an attack comes on.
+
+Far more useful, in neuralgias generally, is the external application of
+aconite or of veratrine. Aconite may be employed in the milder or the
+stronger form; in the former case, we simply paint the ordinary tincture
+on the skin over the painful nerves (avoiding any cracks or sores); in
+the latter, we rub in an ointment containing one grain of the best
+hydrate of aconitine to the drachm of lard, about twice a day, and to
+such an extent as to maintain complete numbness of the parts
+continuously, for two, three, or four days. I do not believe that this
+will ever, by itself, cure a true neuralgia of any considerable
+severity; but I have more than once known its intervention, at a crisis
+in treatment when it seemed that other remedies might fail, produce a
+striking change in the progress even of a very bad case.
+
+A milder, but still very useful form of the same kind of action, is
+produced by veratrine-ointment. I would recommend, however, as a rule,
+that it be employed, at any rate at first, of weaker strength than that
+recommended in the Pharmacopoeia, for with some persons it is easy to
+pass the anęsthetic, and to enter on the irritant, action of veratrine
+upon the skin. This leads me to give a caution that should properly
+have come earlier, when I was speaking of skin-stimulants. In aged
+subjects, especially, we rather frequently meet, in neuralgia, with a
+specially irritable state of the skin, even although there may be at the
+same time some loss of common and tactile sensation; and the
+practitioner must be warned against the danger of producing an amount of
+skin-irritation which will fearfully annoy his patient. I speak
+feelingly, having by such an indiscretion lost the richest patient who
+ever favored my consulting-room with his presence!
+
+The inunction of mild veratrine-ointment is extremely useful, as an
+adjunct to other treatment, in migraine and supra-orbital neuralgias of
+suckling women, and of chlorotic girls. I have also seen it do much good
+in mammary neuralgia.
+
+The last division of the subject of paralyzing agents in the treatment
+of neuralgia includes the surgical operations for division or resection
+of a painful nerve. Upon this question there is much difficulty in
+speaking decidedly. I admit at once, of course, that surgical
+interference is evidently indicated when, along with decided and
+intractable neuralgic pain, there is plain evidence either of the
+existence of a neuromatous tumor, or the presence of a foreign body
+impacted, or a tight cicatrix pressing upon a nerve. I admit, also,
+though with much greater qualifications, that carious teeth may need to
+be extracted before we can cure a neuralgia; but even here I should put
+in the decided caveat that we must consider whether the system is in a
+state to bear the shock, and that in any case we probably ought to
+mitigate the effects of the operation by performing it under chloroform.
+And I need hardly tell any one, who is familiar, either practically or
+from reading, with the subject, that thousands of carious teeth have
+been extracted from the mouths of neuralgic patients, not only without
+benefit, but with the effect of distinctly aggravating the disease. And
+I am yet more doubtful as to the advisability of such surgical
+procedures as the division or the resection of a piece of the painful
+nerve. Theoretically, as the reader will understand from the strong
+opinion I have given as to the mainly central origin of neuralgias, I
+never could anticipate that such a procedure would be more than
+temporarily successful; on the contrary, the mischief in the central end
+of the nerve remaining, I should suppose that the trying process of the
+reunion of the nerve (which always takes place) would be almost
+certainly attended with a revival of the neuralgia, too probably in an
+aggravated form. The only two cases of excision of a piece of the nerve,
+that I have ever seen, completely answered to this anticipation. In
+common fairness, however, I must admit that there is a large amount of
+evidence on the other side. Neuralgias of the trigeminus are pretty
+nearly the only cases in which the proposal of neurotomy or neurectomy
+ought to be entertained; in mixed nerves the inconvenience of the
+muscular paralyses that would follow would be usually too serious to
+allow of our incurring them. But resection of painful branches of the
+trigeminus has been performed in a great number of instances, more
+especially by German surgeons, with results that merit our attention;
+the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be
+especially referred to. On the other hand, with the exception of simple
+division of the nerve, which can be subcutaneously performed, and is a
+trivial proceeding (but has very short-lived effects), these operations
+are by no means without danger, especially when they are pushed to such
+a length as the opening of bony canals, and the resection of
+considerable portions of bone in order to get sufficiently far toward
+the centre, and fatal results have in more than one case followed. Above
+all, we can never too seriously reflect on the most interesting case of
+Niemeyer's reported by Wiesner,[40] in which the most formidable
+operations of this kind have been performed, in an apparently desperate
+case of epileptiform facial tic, and in which, after all, the
+application of the constant current painlessly effected an infinitely
+greater amount of good than had been done by all those severe and
+painful surgical manipulations. I think it is impossible, after this,
+not to conclude that neurectomy ought never to be even thought of except
+as a last resort, in cases of extreme severity, after other measures had
+been patiently tried and had decisively failed.
+
+(_c_) Of remedies that are intended to relieve local congestion, I must
+speak with very doubtful approbation. Leeches or scarifications are, I
+think, very seldom of value. The only remedy that has sometimes seemed
+to do good is local compression, and, after all, it is quite as likely
+that this acts by anęsthetizing the nerve as by reducing congestion.
+
+(_d_) Remedies that interfere mechanically with arterial pulsation are
+of considerable value where they can be effectively applied. I have
+already pointed out the specially aggravating effect of the
+momentarily-repeated shocks of arterial pulsation upon neuralgic pain.
+Where, then, it is possible, effectively to control an artery pretty
+near to the point where it divides into the branches that lie close to
+the painful part of the nerve, it is always worth while to try the
+experiment. But such a measure as the compression of the carotid in
+trigeminal neuralgia is of very doubtful propriety; I suspect the
+consequent anęmiation of the brain more than does away with any benefit
+that might be mechanically produced. And any attempt to interfere with
+the general arterial circulation by cardiac depressants is not to be
+permitted for an instant.
+
+(_e_) We enter now upon a most important subject, the treatment of
+neuralgia by electricity. It is necessary to exercise much caution in
+speaking upon this topic, and, as I shall have to express somewhat
+decided opinions, I may be excused for referring to the circumstances
+under which I have arrived at my present stand-point upon this question.
+I can hardly be accused of having, with any very rash haste, espoused the
+cause of medical electricity in the therapeutics of pain, as any one will
+see who cares to turn to my article on Neuralgia[41] written only three
+years ago. At that time I had already been studying the subject for a
+considerable period, but was so convinced of the multitude of
+opportunities for fallacy that beset the student of electro-therapeutics,
+that I was unwilling to state more than the minimum of what I hoped and
+believed might be affected by this mode of treatment. Since that time I
+have become more fully acquainted with the researches of foreign
+observers, and, with the help of their indications, have been able to
+apply myself more fruitfully to my personal inquiries into the matter.
+The result is, that I am now able to speak with far greater assurance of
+the positive value of electricity as a remedy for neuralgic pain. I shall
+make bold to say that nothing but the general ignorance of the facts can
+account for the extraordinary supineness of the mass of English
+practitioners with regard to this question.
+
+In the first place, I have arrived at a decided conviction that Faradic
+electricity is of little or no value in true neuralgias, and that the
+cases which are apparently much benefited by it will invariably be
+found, on more careful investigation, to belong to some other category.
+
+On the effect of frictional electricity I have had such very small
+experience that I cannot venture to speak with any confidence, and the
+accounts that I have heard from others whose experience is much larger
+have not led me to attribute much importance to this agent. If I am to
+judge at all, I should say it merely acts as a skin-stimulant, and is,
+in that capacity, inferior to many other simpler and more facile
+applications.
+
+Very different is the verdict of experience as regards the effects of
+the constant current; here the results which I have obtained have been
+so remarkable that even now I should distrust their accuracy, were it
+not that they are in accord with the general result which (among minor
+discrepancies) may be gathered, we may fairly say, from all the more
+important researches that have lately been carried out in Germany. The
+constant current, as I now estimate it, is a remedy for neuralgia
+unapproached in power by any other, save only blistering and hypodermic
+morphia, and even the latter is often surpassed by it in permanence of
+affect; while it is also applicable in not a few cases where blistering
+would be useless or worse.
+
+The English medical profession has not as yet adequately appreciated the
+necessity for great care in the choice of apparatus and the mode of
+application of electricity. It is all-important, however, and especially
+in the case of applying galvanism for the relief of pain. The first
+quality that must be absolutely required in a battery, that is to be
+used for this purpose, is that it shall deliver its current with as
+little as possible variation of tension, in fact that it shall be
+constant, and not merely continuous; a vast majority of all the various
+galvanic apparatus that have been used have been merely the latter, and
+have consequently been almost valueless for the relief of pain. Such are
+Pulvermacher's chains, the voltaic piles made with elements of metallic
+gauze, Cruickshank's battery, and many others that have been used. A
+sufficiently constant current may be obtained from either of the
+following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's.
+For hospital use, the Daniell battery (in Muirhead's modification, or
+with the form of cells introduced by Siemens-Halske) is perhaps the most
+desirable; but for private practice it is worth while to sacrifice
+something of the superior constancy which we gain in the Daniell battery
+for the sake of comparative portability. All purposes which we aim at in
+the electric treatment of neuralgia may be sufficiently obtained by the
+use either of the Bunsen battery (zinc-carbon, excited by dilute
+sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc
+and platinized silver, excited by dilute sulphuric acid), as in the
+highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It
+must be remarked that, for the purpose of treating neuralgia, we shall
+never need to employ more than fifteen, or at the utmost twenty, cells
+of either of these batteries. Both the Stohrer's Bunsen and the modified
+Smee of Weiss are made so that the elements are not immersed in the
+exciting fluid until the moment when the battery is going to be used; a
+simple mechanism at once throws the battery into or out of gear. In this
+way, destruction of the elements is minimized; and either of these two
+batteries may be used for from three to six months without any renewal,
+supposing the average work done to be one or two daily seances. If the
+battery is worked harder, it will require more frequent revivification.
+I strongly recommend London practitioners to deliver themselves from all
+care and trouble about the repair of their batteries, by making an
+agreement with the manufacturers to inspect and set them in order at
+stated intervals. The country practitioner, on the other hand, will do
+well to familiarize himself with the process of renewing the acid, of
+cleaning the plates, of amalgamating the zinc, etc.; in fact, to make
+himself independent of the manufacturer in every thing short of an
+actual renewal of the elements, when that becomes necessary. For all
+further details respecting the above-named, and other batteries, I must
+refer the reader to systematic works on medical electricity.[42] I must
+now pass on to the various modes of application, and the cautions to be
+observed.
+
+It is, in the first place, necessary to say, that all the best observers
+coincide in the statement that the use of a current intense enough to
+produce actual pain or severe discomfort is never to be thought of in
+the treatment of true neuralgias; such practice will infallibly do harm.
+Only such a current is to be employed as produces merely a slight
+tingling, and (on prolonged application) a slight burning sensation,
+with a little reddening of the skin at the negative electrode. This
+being the case, it is perhaps not unnatural for those who have not had
+practical experience, to suspect that an application which causes so
+little palpable perturbation is devoid of any positive influence at all.
+Such skepticism will certainly not survive any tolerably lengthened
+observation of the actual facts; but, as some persons may be deterred by
+this _prima-facie_ view of the case from making any fair trial of the
+current, it may be worth while, here, to allude to the unmistakable
+physical effects which similarly painless constant currents are
+repeatedly observed to produce in cases of motor-paralysis attended with
+a wasted condition of muscles. Those who have had experience of the
+treatment of such cases know that it is a by no means infrequent thing
+to see both muscles and nerves aroused from a state of complete
+torpidity, and brought into a condition in which the Faradic current,
+quite powerless before, is again able to excite powerful contractions,
+while, at the same time, the bulk of the muscles has increased most
+sensibly. These, surely, are sufficient indications of a positive action
+of the painless constant current; and such facts have now been recorded,
+in multitudes, by most competent observers.
+
+The next maxim of first-rate importance is that the applications of the
+current should be made at regular intervals, and at least once daily; in
+most instances, this is enough, but occasionally it will be found useful
+to operate twice in the day. The matter of regularity is, I find, of
+great consequence, and it will not do to intermit the galvanism
+immediately on the occurrence of a break in the neuralgic attacks: it
+should be continued for some days longer.
+
+The length of sittings is a point as to which there is considerable
+difference of opinion between various authorities; but my own
+experience coincides with that of Eulenburg, that from five to ten, or,
+at the utmost, fifteen minutes, is almost the range of time.
+
+Closely connected with the question of the length of sittings, is that
+of the continuity with which the current is to be applied. I have seen
+the best results, on the whole, from passing a weak current, without any
+breaks, for about five minutes. But, where there are several foci of
+intense pain, it will often be advisable to apply the current to each of
+these, successively, for three or four minutes.
+
+The places to which the electrodes should be applied vary much according
+to the nature of the case.
+
+Benedikt's rule, that the application of electricity, to be useful, must
+be made to the seat of the disease, is undoubtedly true; but it is
+capable of being applied in a somewhat different manner from that which
+he recommends in particular cases, the difference being due to the view
+of the pathology of neuralgia which is taken in this work. That view is,
+that the essential _locus morbi_ is always in the posterior nerve-root
+(and usually in that portion of the root which is within the substance
+of the cord), and that the peripheral source of irritation, if any, is
+only of secondary--though sometimes of considerable--importance. Hence
+the main object, in electrization, would seem to be to direct the
+influence of the current upon the posterior nerve-root. This may,
+however, be done in different ways, according to the situations in which
+we place the electrodes, and the direction in which we send the current.
+
+There are, as yet, very considerable differences of opinion among
+electro-therapeutists as to the principles which should govern us, both
+in the localization of the effect and the direction of the current.
+Benedikt, for example, recommends that the current should be directed
+toward the supposed seat of the mischief. Thus, if we suppose a
+neuralgia to depend on morbid action within the spinal cord, then we may
+galvanize the spine, taking care to make the current come out through
+any vertebra over which we detect tenderness. If we suppose the seat of
+the disease to be in the nerve-root in the mere ordinary sense of the
+word, then we apply the positive pole to the vertebra opposite the
+highest nerve-origin that can be concerned, and we stroke the negative
+pole down by the side of the spinous processes, some forty times in
+succession. The proportion of cases of idiopathic neuralgia in which
+this treatment succeeds is, according to Benedikt, very large. In other
+cases, he sends the current from the cord to the apparent seat of pain.
+
+On the other hand, Althaus[43] tells us that, whether the application
+be central or peripheral, it is the positive pole, alone, which should
+be applied to the part which we intend to affect: and that the
+application of the negative pole in this situation is rather likely to
+do harm than good, as proving too exciting. Eulenburg, also, says that
+in general the positive pole should be applied to the seat of the
+disease, the negative on an indifferent spot, or on the peripheral
+distribution of the nerve.
+
+It is, however, very doubtful to me whether, in the majority of cases,
+the direction of the current makes any considerable difference in its
+effects, provided only that the stream is fairly directed so as to
+include the _locus morbi_ in the circuit, and care is taken to apply it
+with sufficient persistence and with not too great intensity. Upon this
+point I am glad to be able to cite the authority of Dr. Reynolds, whose
+experience is very large. This author, while admitting that in theory
+the "direct" and the "inverse" currents would seem likely to have
+different effects, declares that in practice this does not prove to be
+the case, either in the instance of pain of nerve or of spasm of muscle.
+Dr. Buzzard, also, in relating a very striking case (which I had the
+advantage of personally observing) before the Clinical Society,
+particularly mentioned that the direct and the inverse currents had a
+precisely similar effect in relieving the pain. The patient suffered
+from severe and probably incurable cervico-brachial neuralgia; the poles
+were placed, respectively, on the nape of the neck and in the hand of
+the affected limb, and whether the positive was on the nape and the
+negative in the hand, or _vice versa_, the effect was the same. Very
+striking remission of the pain was always produced, and the immunity
+from suffering sometimes lasted for a considerable time, while no other
+plan of treatment seemed to have more than the most momentary effect.
+
+My own experience tells the same story very decidedly, for I have on
+very many occasions obtained great benefit, both by the direct and by
+the inverse currents, in the same patient. I shall here relate a few
+instances:
+
+CASE I.--A married woman, aged forty-eight, whose menstrual periods had
+ceased quietly some six years previously. She was, on the whole, a
+healthy person, but had suffered from migraine in her youth, and came of
+a neurotic family. She was attacked with severe cervico-brachial
+neuralgia, which resisted all treatment for nearly three months, and, on
+her then trying a month's change of air and absence from medication,
+became worse than ever. The constant current was applied, from ten (and
+afterwards fifteen) cells of Weiss's battery, daily for twenty-four
+days, the pain vanished finally at the end of thirteen days, and the
+accompanying anęsthesia and partial paralysis disappeared before the
+treatment was concluded. In this case the negative pole was applied by
+the side of the three lower cervical vertebrę, and the positive was
+applied, successively, to three or four different parts of the most
+intense peripheral pain.
+
+CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the
+leg. Galvanization (twenty cells Daniell), from the anterior tibial
+region to the spine was found invariably to cut short the pain. I now
+reversed the current; the effect was the same. After ten sittings I
+suspended the treatment, as there had been no attack for three days; but
+a week later the neuralgia returned in full fury. I resumed
+galvanization from periphery to spine; after twelve more sittings the
+attacks had become rare and slight. I continued treatment for eight days
+longer, during the whole of which time there was no pain. It had not
+recurred when I saw her fifteen months afterward.
+
+CASE III.--H. G., a footman, aged twenty-three, applied to me at
+Westminster Hospital, with neuralgia of the first and second divisions
+of the right trigeminus, of six weeks' standing. The right eye was
+bloodshot and streaming with tears, the skin of the right side of the
+nose and right cheek was anęsthetic, the right levator palpebrę was
+partially paralyzed. Hypodermic injections of morphia proved only very
+temporarily beneficial. After a fortnight's treatment with this and with
+flying blisters to the nape of the neck and the mastoid process, I
+commenced the use of the constant current daily (ten cells, Weiss). The
+first application (positive on nape, negative on infra-orbital foramen)
+stopped the pain, and procured fourteen hours' immunity. On the next day
+I reversed the current; the pain stopped after three minutes'
+galvanization; it did not recur for four days, during which time,
+however, I continued the daily use of the direct current. On the sixth
+day of treatment the patient came to me with a somewhat severe paroxysm,
+almost limited to the ophthalmic division; it was accompanied by
+spasmodic twitchings of the eyelid, and copious effusion of altered
+Meibomian secretion, looking like pus. Galvanization from supra-orbital
+foramen to nape stopped the pain in five minutes. The next day the
+patient presented himself, quite free from pain, which had not returned;
+the conjunctiva was clear, and there was no visible Meibomian secretion.
+Inverse galvanization was continued for ten days; but no recurrence of
+the pain took place. The cure was permanent three months later.
+
+On the contrary, we sometimes see complete failure of the current to
+affect any good whatever; and in these cases the reversal of the current
+has not, so far, appeared to me to make any particular change in the
+result. Such was the case with a patient whose history I detailed (along
+with that of Case I.) to the Clinical Society. She was an ill-fed and
+overworked unmarried needle woman, aged thirty; the neuralgia was a most
+violent double occipital pain, with foci, on each side, where the great
+occipital nerves become superficial. The current was passed daily, for
+some days, from one focus to another (necessarily passing through the
+nerve-roots and the spinal cord), and the positions of the conductors
+were occasionally reversed; this not succeeding, the current was applied
+altogether to the spine, the negative pole being placed on the highest
+cervical vertebrę, but no good effect was produced after a treatment,
+altogether, of sixteen days.
+
+Notwithstanding these, and a good many similar facts that could be
+adduced, I should hesitate to go so far as to say that there is never
+any importance in the direction of the current. In old-standing cases,
+where there are well-marked _points douloureux_ that are exceedingly
+sensitive, I have found that the application of the positive pole,
+successively, on the most tender points, the negative being placed on
+the spine opposite the point of origin of the nerve, has had a more
+beneficial effect than any other mode of application.
+
+There are very considerable differences, both as to the best manner of
+galvanization, and also as to the chances of doing good with it, in the
+case of neuralgias of different nerves; and, on the whole, I find
+Eulenburg's conclusions on this matter very just. He indicates sciatica
+as the affection which is by far the most curable by the constant
+current; he says that many cases are cured in from three to five
+sittings, while others require as many weeks, or even months of
+treatment; and that a total absence of benefit is only seen in rare
+cases dependent on central causes, or on diseases which are irremovable
+(like malignant pelvic tumors). On the other hand, he reports that
+intercostal neuralgia has never been materially benefited by
+galvanization in his hands. With regard to ordinary trigeminal
+neuralgias, he speaks strongly of the current as a palliative, but very
+doubtfully of its power to cure, in genuine and severe cases. In
+cervico-brachial neuralgia he speaks of it as dividing with hypodermic
+morphia the whole field of useful treatment, in the majority of cases.
+In cervico-occipital neuralgia he says it rarely does much good. I shall
+return to Eulenburg's estimate of its utility in migraine, presently.
+Let me here say that I am inclined to indorse everything in the
+above-detailed statements, excepting that I should place a considerably
+higher estimate on the curative powers of the current in ordinary
+trigeminal neuralgias. The remedy, like every other, will doubtless fail
+in a considerable number of those very bad cases which occur in the
+degenerative period of life; but if anyone desires to see the proof of
+the power it sometimes exerts, even in extreme cases, he should study
+the two most remarkable cases treated by Prof. Niemeyer, of Tubingen,
+and reported by Dr. Wiesner.[44] The patients were respectively aged
+sixty-four and seventy-four, and the duration of the neuralgia had been
+respectively five and twenty-nine years; in both the pain was of the
+severest type, and in both the success was most striking. In one of them
+every possible variety of medication, and several distinct surgical
+operations for excision of portions of the affected nerve, had been
+quite vainly tried. The cases are altogether among the most interesting
+facts in therapeutics that have ever been recorded. Dr. Russell Reynolds
+has also told me of a case under his own care, in which a lady, who had
+been the victim, for twenty years, of an extremely severe neuralgia of
+the ophthalmic division of the fifth, which attacked her daily, and had
+caused great injury to her general health and nutrition, was not merely
+benefited, but the affection absolutely removed, at any rate for a long
+period, by a single application of the current. I have personally seen
+no such remarkable cases as these but I have had some extremely severe
+cases under my care in which the effect of the current was to arrest the
+pain in a few applications, and procure a remission for several days, or
+even weeks. And I have had several slighter cases which were as much
+cured, to all appearance, as any disease can be, by any remedy.
+
+As a general rule, neuralgia of the limbs requires to be treated with a
+more powerful current than neuralgia of the face (twenty cells instead
+of ten). In the latter case, indeed, it is necessary to be exceedingly
+cautious (commencing with five cells), since a current of high power has
+been known to produce most serious effects upon the deeper-seated
+organs; the retina has been permanently paralyzed, by too strong a
+current applied on the face, and still graver dangers attend the
+incautious use of galvanization of the brain or of the sympathetic, of
+which we have now to speak.
+
+Galvanization of the brain is a remedy chiefly employed in true
+migraine, and is certainly very effective in that disease. I have not
+found it useful to apply the current in the long axis of the cranium,
+but transmitted from one mastoid process to the other it has proved most
+useful; and I am glad to find that my experience on this point coincides
+with that of Eulenburg. But the use of this remedy is highly perilous in
+careless hands. In working with either Daniell's or Weiss's battery, it
+is necessary to use at first only three or four cells, and to increase
+the number only with the greatest caution. The sittings should never
+last more than half a minute; but the slightest giddiness should make us
+stop even sooner. On the other hand, the applications ought to be made
+daily, and usually twice a day. Ten cells (Daniell or Weiss) is the
+utmost that will ever be required, few patients will bear so much; and,
+apart from the possibility of more serious mischief, there is nothing
+which annoys and frightens patients more seriously than the sudden and
+intense vertigo which over-galvanization of the brain may induce.
+
+Even more ticklish than the galvanization of the cerebral mass is
+galvanization of the sympathetic. I am not going to raise here the vexed
+question in physiological electricity as to the possibility of a
+galvanization the effects of which shall be accurately limited to the
+sympathetic. The fact is unquestionable, that very powerful and peculiar
+effects, utterly unprocurable in any other way, can be produced by
+placing one pole on the superior cervical ganglion (just behind and
+below the angle of the jaw) and the other on the manubrium sterni. This
+is a mode of galvanization which has been highly praised, more
+especially by Remak, and after him by Benedikt, but it has yielded
+rather disappointing results in neuralgia in my hands. Either I have not
+observed any distinct effect at all, or, if a current even a very little
+too strong were applied, I have repeatedly seen most uncomfortable, and
+sometimes very alarming, symptoms. I shall not easily forget a patient
+who applied at the Westminster Hospital, suffering from a severe form of
+facial neuralgia, and who was persuaded to come to my house and have his
+sympathetic galvanized. I used only twenty cells of Daniell, but the
+current had not been applied more than a few seconds when the patient
+fell on the floor, and remained in a state of half swoon for a
+considerable time. I allude to this and other less dangerous accidents
+that I have seen follow galvanization of the sympathetic, not with the
+view to prove that the method is useless in trigeminal neuralgia--I
+should certainly hesitate to say that, considering the large amount of
+respectable evidence in its favor--but I think that it is a procedure
+requiring the utmost caution, and meantime I have not personally found
+it nearly so useful as the methods already described.
+
+There are sundry special applications of galvanism to particular forms
+of neuralgia which require a few words of notice. Of electrical
+treatment in regular angina pectoris I have had no experience; and in
+the one case of intercostal neuralgia, complicated with quasi-anginal
+attacks, in which I applied the constant current to the spine and the
+cardiac region, in the direction of the affected intercostal nerve, no
+effect was produced. I shall, however, mention the experience of
+Eulenburg, as he is a sober and dispassionate writer on the effects of
+electric treatment in general. He says he believes that in the proper
+use of the constant current we shall discover the chief, possibly the
+only direct, remedy for angina; and he describes the apparently
+favorable results he has already obtained in three or four cases. The
+current was from thirty cells; the positive pole was placed on the
+sternum (broad electrode), the negative on the lower cervical vertebrę.
+The alternative method which Eulenburg suggests, but has not, so far,
+put in practice, is direct galvanization of the sympathetic and vagus
+in the neck.
+
+The application of the constant current in neuralgic affections of the
+larynx and pharynx is of most indisputable service; the experience of
+Tobold[45] upon this point is fully borne out by my own, as far as it
+goes. In many cases it will be sufficient to place the positive pole
+(from fifteen cells Weiss) on the pomum Adami, and the negative on the
+nape of the neck, and to keep up a continuous current for five or ten
+minutes daily; but in some cases the direct application of the current
+to the pharynx or larynx may be required; in such, a modification of Dr.
+Morell Kackenzie's laryngeal conductor will be found useful. [I shall
+have occasion, in Part II., to notice the superior action of
+Faradization in mere hysteric throat-pain, as distinguished from true
+neuralgia.]
+
+Neuralgia of the testicle can be best treated, if galvanism be thought
+necessary, by immersing the whole scrotum in a basin of salt and water,
+in which the positive pole is placed: the negative pole is to be placed
+on the upper lumbar vertebrę; the current should be from fifteen cells
+Weiss, and the application should last continuously for ten minutes. In
+neuralgia of the urethra, I should be inclined to adopt a plan,
+mentioned to me by Dr. Buzzard, of attaching one conductor to an
+ordinary silver catheter introduced into the urethra, and placing the
+other pole upon the perinęum.
+
+Neuralgia of the neck of the bladder I have found to be materially
+relieved by the constant current from twenty cells passed through from
+pubis to perinęum; the sittings being rather long. I have also, on one
+occasion, tried the introduction of a proper _porte-electricite_,
+insulated, except at the tip; but the result was not superior to that
+obtained in the other way.
+
+As a general rule, it may be said that electricity, like other local
+measures which tend to concentrate the patient's attention on the parts,
+is only to be applied to the genital organs as a last resort. This is,
+of course, especially true in the neuralgias of these organs in women.
+
+In concluding what will doubtless seem to some English readers an
+over-long and over-favorable estimate of the employment of galvanism in
+neuralgias, I must carefully guard myself against the supposition that I
+consider it a remedy to be applied in all cases, or likely to meet with
+uniform success, even in the forms of the disease to which it is most
+appropriate. It is a weapon which I seldom employ in the first instance,
+for many reasons; the principal of which is the costliness of the
+proceeding to the patient. Either the physician must personally
+administer the remedy, daily, often for a considerable period, or he
+must make the patient provide himself with an expensive battery; and in
+the latter case there is, after all, the unsatisfactory consideration
+that the application (even after the most careful directions have been
+given) will perhaps be unskilfully and inefficiently made. On the other
+hand, it is not desirable to delay the employment of galvanism too long,
+if other remedies have been fairly tried; and the practitioner will do
+well to remember the distinctions above laid down as to the varieties of
+neuralgia in which it is specially likely to prove decidedly and quickly
+beneficial. More especially in sciatica it would really, with our
+present knowledge, be a decided neglect of duty were we to allow the
+disease to run any considerable length without giving the constant
+current a thorough trial. [I can only briefly refer, here, to the novel
+mode of galvanization introduced by Dr. Radcliffe, and based upon his
+ingenious theory, according to which the true effects of the voltaic
+current upon nerve are the result of the charge of free electricity
+which it sets up, and not of the current directly. The reader will find
+the whole argument elaborately worked out in Dr. Radcliffe's recent work
+on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be
+enough to say, here, that the object to be attained, according to this
+view, is to replace the neuralgic nerve in its healthy physiological
+state, by charging it with free positive electricity. The manner in
+which this is done is as follows: In a case, _e. g._, of
+cervico-brachial neuralgia, we place the positive pole as near as may be
+to the central origin of the affected nerve; the negative pole is held
+in the hand of the same side, which is immersed in a basin of warm salt
+and water. In this same basin is another electrode, the wire from which
+is put in communication with the earth--most conveniently by putting it
+in contact with a gas-pipe. The patient, and the battery, ought properly
+to be insulated. The result of this arrangement is, that the free
+negative electricity is carried off by the earth-wire, and the limb
+remains charged with free positive electricity. I have had no sufficient
+experience of this method to give any opinion of its merits, but the
+inventor thinks it decidedly superior to the ordinary modes of applying
+the constant current.]
+
+(_f_) The last kind of local remedies for neuralgia of which we have to
+speak are those by which we seek to mitigate the paroxysm by thoroughly
+excluding the air from the site of apparent pain. These are chiefly of
+value in those cases where a distinct inflammation (herpetic or
+erysipelatoid), or an unusual degree of sensitiveness on pressure, etc.,
+has become developed around the superficial branches of the neuralgic
+nerve. Very much the best agent of this kind with which I am acquainted
+is the flexible collodion; in neuralgic herpes and erysipelas the effect
+of this application, conjoined with the hypodermic injection of morphia
+(preferably in the immediate neighborhood), is of the greatest possible
+service in mitigating the pain. In herpes it has this further special
+advantage, that it prevents the occurrence of sores after the vesicles
+fall, an accident which otherwise will sometimes happen, and which very
+much increases the severity and intractability of the consecutive
+neuralgic pain.
+
+4. Lastly, we have to speak of prophylactic measures, which really ought
+never to be thought of as a separate matter, but always as an essential
+and most important part of the treatment of neuralgia. The prophylaxis
+of neuralgia is divisible into (_a_) measures for preventing the
+development of the neuralgic habit in those who may be supposed to have
+a predisposition to it; (_b_) measures between the paroxysms; (_c_)
+measures to be adopted after the attacks have ceased.
+
+(_a_) The measures that should be taken to avert neuralgia, in those who
+may be reasonably assumed to be predisposed to it, have scarcely
+received any consideration at the hands of systematic writers; yet this
+is a most important subject. The persons in question are children who
+belong to families known to be infected with tendencies to neurotic
+diseases, or persons whose daily occupations submit them to peculiarly
+strong predisposing influences of an external kind. The hostile
+influences that should be avoided, or at any rate compensated, are of
+several kinds: (1) Psychical; (2) defects of nutrition; (3)
+mismanagement of the muscular system; (4) sexual irregularities; (5)
+over-fatigue of the special senses, and insufficiency of sleep,
+especially the latter; (6) unhealthy atmosphere and climate.
+
+(1) The psychical influences which must be especially avoided, if we
+would avert the formation of the neuralgic habit, form a large and
+somewhat indefinite group, which it is doubtless difficult to deal with
+satisfactorily. The matter is, however, highly important, and the
+attempt must be made. And there are, at any rate, some leading
+principles that I feel justified in laying down with confidence.
+
+We shall best commence the inquiry by directing our attention once more
+to the fact, so often insisted upon in this work, that the large
+majority of neuralgic patients carry in them the seeds of their malady
+from their birth. It has been amply proved that every child born of a
+family that has shown strong tendencies to insanity, epilepsy,
+paralysis, etc., etc., ought to be looked on as a neurotic subject, and
+as a potential sufferer from neuralgia. It has been shown that such
+children will be exposed, even under favoring external circumstances, to
+the danger of neuralgia at certain important stages of their
+physiological history. The earliest of these critical periods is marked
+by the occurrence of puberty; and it is not till this time that
+psychical influences, as such, come to have any serious bearing on the
+formation of the neuralgic habit. Mischief may, indeed, be done to the
+brain and the general nervous system, by injudicious mental training, at
+a far earlier period; but this mischief, serious or even fatal as it may
+be, usually takes some other form than that of neuralgia. It will be
+necessary, here, to reflect a little upon certain features of the
+childish mind, in order that we may rightly estimate the kind of
+influence which puberty exerts upon it.
+
+A very young child is selfish, in the purely animal sense; it is
+greedily acquisitive, and its selfishness is unchecked by any sense of
+shame. With later childhood there comes a sense of right and wrong, and
+a sensitiveness to shame, which check this tendency; still it is the
+exception rather than the rule to find any great capacity of
+self-abnegation in young school-boys. But a moderately healthy-minded
+child, up to the age of puberty, is only acquisitively selfish; he is
+not self-centered in the sense of dwelling upon his own mental state,
+and reflecting upon the nature of his motives and feelings. It is with
+the age of puberty that self-consciousness begins to be a feature in the
+mind of the young, and its appearance marks the entrance of a dangerous
+element into the character. It is an inevitable stage in mental growth,
+and, if wisely dealt with, is ultimately productive, not of evil, but of
+good; but it is more perilous to some children than to others, and it is
+especially fraught with danger to those whose nervous centres are, by
+inheritance, weak and unstable in whole or in parts. The mental antidote
+to its possible evil effects is to be found in a vigorous (but not
+excessive) training of the mind in studies which shall be as far as
+possible external, and the discouragement of all tendencies to
+introspection. I would venture to express the decided opinion that the
+common idea, that close study injures the young, is only true in a
+modified sense. It is, however, unquestionably the fact, that hasty and
+imperfect cram-work does very seriously impair the stability of the
+brain and the nervous system in young people; there is a spurious
+excitement about this kind of learning (especially when it is mainly
+competitive, and directed to the gaining of prizes and medals) which
+must be injurious. But I think it is quite ridiculous to suppose that,
+in this country, the actual amount of intellectual labor undergone by
+boys and girls at school is sufficient to do harm, were it only regular
+and systematic, and carried out in a conscientious manner; on the
+contrary, though I think that the total daily period occupied in study
+ought not to exceed some six or seven hours, I believe that the
+insisting on strenuous diligence during school hours, and the
+maintenance of a high standard as to the quality of the work exacted, is
+all on the side of nervous health. But, an even more serious and
+difficult matter than the regulation of the amount of intellectual work
+to be done is, the question how we are to deal with the unfolding
+emotional instincts of the boy or girl who has reached the age of
+puberty. It is useless to ignore this side of the mental life; it will
+assert itself either for good or for evil. At the risk of seeming to
+meddle with matters that belong to the school-master rather than to the
+physician, I would urge very strongly that a portion of the training be
+deliberately directed to a serious study of one or other of the fine
+arts--to that one, whether poetry, painting, sculpture, or music, to
+which the boy or the girl instinctively leans. I am aware that there is
+a prejudice among parents that the study of the fine arts renders young
+people idle and indifferent to other branches of education and other
+duties of life. I believe that this only applies to the miserably
+inefficient way of teaching these subjects which prevails at present in
+all but a few English schools; and that, in truth, a thorough knowledge
+of the principles of either music or painting, and a real study of the
+best masters, would be sure to prevent the development of that lazy,
+conceited manner, and that neglect of other duties, which no doubt
+unfavorably distinguish a good many of the young ladies and gentlemen
+who dabble a little in music, or painting, or versification. We want the
+German rather than the English type of training, we want the acquirement
+of sound knowledge of the principles of music (at any rate) to be made
+so common that the accidental possession of two pennyworth of
+superficial accomplishment in that line shall not enable young ladies
+and gentlemen to give themselves airs in society. The truth is, that the
+young people who make music or painting an excuse for idleness
+respecting other matters are invariably imposters even in that which is
+their own supposed _forte_. On the other hand, the serious study of art,
+a certain definite portion of time being set apart for it, and
+thoroughness being insisted upon, is, I believe, an admirable vent for
+the emotional effervescence of commencing sexual life; and I no less
+firmly believe that the things that are usually substituted for it are
+intensely pernicious. I have already, in the chapter on Pathology,
+remarked on the mischief which is often done by the anxiety of religious
+parents to make their children (usually somewhere about this perilous
+time of puberty) experience the emotional struggle which is believed to
+end in a change of heart and principles. I need, therefore, only now
+repeat the expression of my intense conviction that the results of this
+process, as seen by the physician to occur within that mental region
+where the emotions and the organic nervous system come into closest
+relations, are simply disastrous. It is not my business to suggest the
+proper alternative to a mode of spiritual training which I think
+deleterious; I can only intimate, in the most general way, my belief
+that a calm and systematic training in the simplest principles of duty
+and religion is greatly more suitable to the immature mind and brain of
+youth than any strong emotional excitement on such topics. But if
+ill-regulated spiritual emotion of a religious kind be a dangerous thing
+for young persons in the most serious crisis of bodily development, far
+more decidedly pernicious is the spurious excitement of feeling which is
+directed to lower and often most unworthy objects. The increasing
+precocity of boys and girls, in their familiarity with the most
+objectionable aspects of passion and intrigue, is steadily fed, in the
+present day, by a system that allows them, too often, unlimited access
+to light literature which (as is strikingly the case with many novels of
+our day) is at once devoid of true literary and artistic merit and at
+the same time replete with sensational incident of a vulgarly exciting
+kind. The same degrading tendency is very distinctly to be noted in the
+character of the dramatic and other public exhibitions which are most
+popular at the present day; the main characteristics being, bad art, and
+thinly-veiled sensuality, all the more pernicious for being veiled at
+all. It would be a hundred times better that a boy, or even a girl,
+should study the frank and outspoken descriptions to be found in
+Shakespeare or Fielding, with all their occasional coarseness, than that
+they should enervate their minds with the sickly trash that is most
+current and most popular at the present day, in theatre and circulating
+library.
+
+(2) The defects of nutrition that assist the development of the
+neuralgic tendency are often the consequence of a system which, it is to
+be hoped, is to a large extent becoming effete, but which, nevertheless,
+survives in sufficient vigor and extent to demand express reprobation.
+It was till lately the general, and it is still a too common practice,
+to keep children and young persons on a very insufficient allowance of
+the most important elements of food; the state of things in this
+respect, both in public and private schools, in the first half of the
+present century, is a lasting reproach to the medical practitioners of
+those days, who scarcely lifted a finger to amend it, even when they did
+not expressly approve it, under the influence of absurd theories about
+the dangers of excessive "grossness of blood." It is indeed amazing
+that, with the palpable fact staring them in the face, of the rapid and
+incessant additions to tissues which are being made by children and
+young people, medical men should have failed to perceive the necessity
+for supplies of food practically unlimited except by the capacity of
+digestion. Yet this seems hardly ever to have been thought of, and the
+unfortunate results seem scarcely to have been noticed, except when they
+led to emaciation or consumptive disease. But the effects were perhaps
+even more disastrous where, with a maintenance of a fair amount of
+muscular nutrition, there was only a little dyspepsia, and perhaps some
+slight tendency to nervousness, to show that anything was wrong. The
+children who were born of strong and healthy parents, may have suffered
+comparatively little from this regimen as regards their nervous system,
+but those who were born of neurotic ancestors undoubtedly suffered
+extensively. The crisis of puberty was, in such ill-nourished children,
+too frequently the signal for an explosion of epilepsy, chorea, or
+neuralgia; and too often the mischief was yet further increased by a
+most injudicious medical treatment, including a deterioration rather
+than an improvement in the already insufficient dietary system. At the
+present day, however, we may fairly hope that common sense is
+prevailing, so as to put an end to this mischief as regards the children
+of the upper and middle classes. Unfortunately, with the poor a similar
+ill-nourishment of the young is too often inevitable, and the
+consequences are constantly to be traced in enfeeblement of the nervous
+system, of which neuralgia is a pretty common result.
+
+It cannot be too frequently repeated that for those children, more
+especially those who come of nervous families, any considerable error in
+this direction has a fatal tendency to awaken the disposition to nervous
+disease. At every step of the infancy, childhood, and youth of such
+persons, the most generous allowance of the more nutritive elements of
+food is of the first importance. At the same time I am entirely opposed
+to the practice of giving stimulants to any considerable extent, or
+indeed to any extent, save in exceptional instances. Good meat, bread,
+milk, butter, fruit, and vegetables, are really the efficacious means of
+fortifying the nervous system against the impending dangers. With
+hospital out-patients, for whom we cannot command such diet, our best
+course, whenever they show signs of deficient nutrition, will be the
+steady administration of cod-liver oil for a long period.
+
+(3) The true and proper training of the muscular system is among the
+most important means of antagonizing the tendency to the development of
+the neuralgic habit. It is a great mistake to suppose that over-training
+in athletics of any kind is of use; but the systematic employment of
+means which tend to make the muscular system hardy and efficient is of
+very great benefit. The parents of children who may be supposed by
+inheritance to possess a tendency to neuralgia would do well to study
+such a methodical series of directions as those which are given by Mr.
+Maclaren, in his excellent work on physical training. I suspect that the
+benefit of judicious gymnastics is wrought in two ways: first, by its
+improving circulation and general nutrition, including the nutrition of
+the nervous centres; and, secondly, that it gives the nervous centres an
+education, so to speak, by the variety of difficult co-ordinative
+movements over which it trains those centres to preside. But
+unquestionably the matter is a science, not a mere rude art, and
+requires to be studied as such.
+
+(4) Of unspeakable importance to the object of averting the formation
+of the neuralgic habit is the prevention of sexual irregularities in the
+young. Under this heading is included a large and various group of
+influences; of these the first that requires notice is the prevention of
+precocious sexual stimulation, whether by talk or by acts, which may
+precipitate the occurrence of puberty at an unnaturally early age. I
+know very well how difficult it is to devise any scheme which really
+would effectively control and antagonize the worst mischief of schools;
+but it is at least a duty to say here, that no experienced physician can
+doubt that such a scheme must be found, if we are ever to hope for a
+healthier race of children and of young men and women, and if we are to
+break down one of the most potent of the influences that go to the
+production and maintenance of the neurotic disposition. I would be
+clearly understood not to suppose for a moment, either that this sort of
+cause is usually at work in the production of neuralgia in the young, or
+that of itself it is sufficient to produce the disease; but I would say,
+for certain, that on children of nervous families such influences act
+with disastrous energy; and, moreover, that where we see signs, in a
+neuralgic young person, of that general form of bad health which is
+connected with precocious puberty, we may be nearly certain that such
+influences have actually been at work. At all cost, and by all
+conceivable means, all children, but most especially the delicate and
+nervous ones, ought to be shielded from the risk of this occurring.
+
+Another form of sexual irregularity which can be counted as a
+contributor to the formation of the neuralgic habit is menstrual
+irregularity, especially at the commencement of sexual life. By far the
+most mischievous in this way is menorrhagia of the young. I have seen
+exceedingly severe and intractable neuralgia set up by it. As regards
+the influence of simple amenorrhoea, I am by no means clear: it seems
+pretty nearly as likely that the deficient excretion (when not dependent
+on mechanical cause) is a mere sign of the general weakness which also
+predisposes to the neuralgia, as that the neuralgia is in any way the
+direct consequence of the amenorrhoea.
+
+Leucorrhoea, especially when profuse and long-continued, is a much
+more indisputable factor in many neuralgias. It is a point of real
+importance to put an end promptly to such a discharge, if it exists, and
+the usual remedies--cold bathing, mild astringent injections,
+etc.--should be at once prescribed.
+
+Dysmenorrhoea, a painful menstruation, when not dependent on a purely
+mechanical cause, affords a strong example of neuralgia connected with
+sexual difficulty; but there is every reason to think that the neuralgia
+is the primary and not the secondary affection. The only effective
+prophylaxis, therefore, is the adoption of such general measures as will
+raise the whole tone of nervous health. It often happens that marriage
+completely cures the tendency to these attacks.
+
+(5) Insufficiency and irregularity as to the allowance of sleep are
+potent influences in developing neuralgia in those who are hereditarily
+predisposed. It is needless to say a single word to prove the imperative
+need of the young for periodical and prolonged repose from the conscious
+actions of the nervous system. Full ten hours of sleep in the
+twenty-four, for boys and girls who are at or near the period of
+puberty, is an absolute necessity if we would prevent any existing
+irritability of the nervous system from developing into the fully-formed
+neurotic temperament. Indeed, I believe that, for all young people (but
+especially girls) up to the age of twenty-five, this allowance is not
+the least beyond what is necessary: only the need is most pressing at,
+and just before, the development of the sexual organs. Of course a much
+larger allowance of sleep is necessary in actual infancy: from seven to
+twelve we may be content if we get nine hours clear sleep; but during
+the two or three years preceding puberty we should insist upon ten
+hours, at any rate for children who possess the nervous temperament.
+
+(6) Impurity of the atmosphere in which they habitually or daily reside
+must be carefully shunned for young children, especially for the
+nervous. The kind of dull and diffused headache which children often
+complain of, after study for some time in a close, ill-ventilated
+school-room, is very likely (if the bad influence be continued for a
+number of years) to develop itself, at puberty, into a regular migraine.
+Purity of air in the school-room must therefore be scrupulously provided
+for; and the same thing must be attended to as regards the sleeping
+rooms.
+
+Of the climatic influences we may speak in a few words. Besides the
+avoidance of distinctly malarial districts, and also of places where,
+although there is no distinct ague, there is a prevalence of neuralgic
+or even of so-called "rheumatic" complaints, it is necessary very
+carefully to shun damp soils, and places where there is a great deal of
+harsh and cold wind. Mere lowness of average temperature is not in
+itself a strong predisposer to neuralgia, at any rate if guarded against
+by abundant food and the use of such clothes as will prevent children
+from ever feeling chilly and depressed. But damp and harsh winds are
+actively bad; and when joined to habitual or frequent lowness of
+temperature, they constitute very unfavorable surroundings for the
+nervous systems of delicate children.
+
+(_b_) We come now to the prophylaxis which is to be adopted in the
+intervals of the paroxysms when neuralgia has been actually set up. This
+consists essentially in three things: (1) Physiological rest, as perfect
+as possible, of the affected parts; (2) protection from cold; (3)
+protection from sunlight; (4) avoidance of injurious mental emotions.
+
+(1) The maintenance of physiological rest, to the greatest extent that
+is possible, is an absolute necessity, if we would shield a nerve, which
+has lately been attacked with neuralgia, from fresh paroxysms. The most
+evident illustrations of this fact are afforded by those neuralgic
+affections in which it is most difficult to adopt this precaution. Thus
+the greatest embarrassment from this cause is met with in the case of
+sciatica; a mild case is often converted into one of great severity and
+intractability because the patient, in the early stages, either cannot
+or will not maintain the recumbent posture. So, too, though in less
+marked degree, the cure of cervico-brachial neuralgia is often greatly
+impeded by the difficulty of maintaining complete rest of the limb.
+Again, in neuralgia affecting the third division of the fifth, the
+movements of mastication and of speech are a terrible hinderance to the
+progress of recovery; and it often becomes necessary, in severe cases,
+to prescribe absolute silence, and even to feed the patient exclusively
+with such liquid or semi-liquid food as shall require no efforts of
+chewing.
+
+(2) Preservation from external cold is highly important. When a nerve of
+the arm, or leg, or trunk, is affected, warm flannel under-clothing
+ought immediately to be adopted. The patient who has been suffering from
+cervico-occipital neuralgia should for some time, in anything but quite
+summer weather, never go out without wearing a warm comforter round the
+neck. The sufferer from facial neuralgia should for some time after the
+cessation of actual attacks never face wind without wearing a thick
+veil.
+
+(3) Exposure to bright light must be scrupulously avoided by sufferers
+from ophthalmic neuralgia. The affection known as "snow-blindness" is
+really a neuralgia, with vaso-motor complications, produced by the glare
+of light reflected from snow; and one of the severest attacks of
+neuralgia which I personally ever experienced was provoked in this way.
+Even the comparatively slighter, but for an Englishman unusual, glare of
+sunlight which one meets with during the first days of a Continental
+holiday, in wandering about towns made up of clean white stone or
+whitewashed houses, is enough to provoke an attack, unless the eyes are
+carefully guarded with colored glasses.
+
+(4) It is scarcely necessary, after what has been already said, to
+insist upon the absolute necessity of mental quietude, as far as this
+can be obtained. This precaution is more or less important in all
+neuralgic affections; but in migraine and in other trigeminal neuralgias
+it is almost of more consequence than any other prophylactic measure;
+and in angina pectoris it is so essential that adoption or neglect of it
+may easily turn the scale between life and death. All forms of abdominal
+visceral neuralgia, also, are greatly affected by emotion, and passion
+or strong excitement of any kind must be scrupulously shunned if the
+neuralgic habit is to be broken through. Unfortunately, it too often
+happens that the mental surroundings of the patient cannot be so changed
+as to enable us to carry out this kind of prophylaxis effectually; and
+neuralgic cases of this class are among the severest trials of the
+physician's tact and skill, and too frequently defy his efforts.
+
+(_c_) The precautionary measures which are to be adopted, after the
+neuralgic habit has apparently been fairly broken through, in order to
+prevent the patient from sliding again into the old vicious groove, can
+hardly be defined with exactness though their general character will be
+readily gathered from the picture of the clinical history and pathology
+of the disease which has been exhibited at large in this work. They
+mainly consist in the avoidance of severe, and especially of unequal,
+strains upon bodily or mental powers; and in redoubled carefulness in
+these respects at those natural crises in the life of the organism which
+have been shown to exercise so important an influence upon the neuralgic
+tendency. To a certain extent, also, but with much precaution, we may
+attempt to modify the peripheral sensibility by what is commonly called
+a hardening regimen. Thus, with great care, and proceeding in a very
+gradual manner, we may by degrees accustom the patient to a larger
+amount of exposure to free air, and even at last to rough weather, so
+that in the end he may become less sensitive to some of the commonest
+immediately exciting causes of neuralgia. If one were to construct an
+advancing scale of such measures, one might arrange them something like
+this: First, in-door gymnastics, and gentle horse-exercise for out-door
+work, in fine weather only; then horse-exercise alternated with
+pedestrianism, sea-bathing in warm weather; and, finally, we should try
+to reach a stage at which the patient can well endure a ten or fifteen
+miles' walk or ride every day, and be comparatively careless about the
+weather. In reaching this latter stage I have seen some patients helped,
+in an extraordinary degree, by the frequent use of the Turkish bath,
+followed by douche. Upon this latter subject I beg to offer some
+remarks, which are the result of pretty careful and extensive study of
+the effects of the Turkish bath in a variety of chronic nervous
+diseases. I believe it to be a very great mistake to suppose that,
+either in rheumatism or in true neuralgia, the process of the bath
+should be prolonged to such an extent as is commonly done. Instead of
+the usual slow heating process, gradually carried to a point at which
+excessive sweating occurs, I believe that the really scientific is the
+following: The patient should as quickly as possible get into the
+hottest atmosphere he intends to expose himself to, which should never
+be more than about 170° Fahr. He should stay in this place just long
+enough to get thoroughly hot, and, with the assistance of a glass or so
+of water drunk, throw himself into a free but gentle perspiration. He
+should then be rapidly shampooed, exposed to the spinal douche for two
+or three minutes, and then pass to the cooling-room. Let him beware of
+too long dawdling in the latter place, and let him avoid smoking there.
+It is a positively dangerous thing to cool one's self quite down to the
+normal heat, still more so to induce the slightest chilliness; the body
+should be still in a universal glow when one issues into the street.
+Over and over again I have proved upon myself that it is the beneficial
+method, whereas the prolonged use of the bath, the production of very
+copious sweating, and above all a lengthened cooling process, most
+seriously exhaust the nervous energy.
+
+There are certain special considerations as to the habits of life that
+require a word or two. I need say nothing more to enforce the views
+already put forward as to the necessity of copious supplies of food. I
+need only refer to what I have already said about the decidedly
+mischievous tendency of anything like habitual excess in the use of
+alcohol, merely adding a special caution against such indulgence during,
+and particularly toward, the end of the period of sexual activity. There
+is one more topic upon which something must be said, namely, the extent
+to which sexual intercourse should be allowed. Speaking of neuralgia
+generally (excluding neuralgic affections of the sexual organs
+themselves), it may decidedly be said that the regular and moderate
+exercise of the function, during the natural period of sexual life, is
+beneficial; but that excess is always dangerous, and that the
+continuance of sexual intercourse, after the powers naturally begin to
+wane, is extremely pernicious in its tendency to revive latent
+tendencies to neuralgia. As regards neuralgias of the sexual organs, it
+is very difficult to speak positively; and yet I believe that (once the
+neuralgic habit broken through by other means) it is very desirable that
+the patient should live according to the laws of normal physiological
+life.
+
+
+NOTE I.
+
+ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE.
+
+The following cases must be now added to those recorded in my list of
+private patients whose family history has been ascertained with reliable
+accuracy.
+
+CASE I. is that of a gentleman, aged forty-seven, the subject of
+lumbo-abdominal neuralgia: no history of nervous disease in the family;
+his mother, however, was of a "nervous" temperament.
+
+CASE II.--A gentleman, aged sixty-four, suffering from angina. His
+family nervous history is fearful. On the father's side it is not
+possible to get a clear account. But on the maternal side there has been
+a strong tendency to insanity and suicide; and in the patient's own
+generation one brother committed suicide from insanity, and one sister
+is still alive, insane. An interesting fact is, that the mother's family
+have shown an extraordinary proclivity to erysipelas.
+
+CASE III.--The young gentleman, whose single but extremely severe attack
+of angina is previously described, comes of a family in whom the
+tendency to neuralgia is undoubtedly very strongly inherited. His father
+is frequently and very severely _migraineux_, and in early life suffered
+cardiac symptoms not unlike his son's. A brother was also liable to
+attacks of true migraine between puberty and the age of twenty-one.
+
+CASE IV.--On the other hand, a case of angina which I saw in the
+country, last year, occurred in a gentleman, aged fifty, whose family
+presented no traceable neurotic history. But the damage inflicted upon
+his nervous system by various external influences was quite
+extraordinary. In some way or other he got some attacks of migraine at
+the age of fifteen or sixteen; for these he was treated with bleeding,
+and with a most savage antiphlogisticism generally. From that time he
+never got free of the neuralgic tendency. He used to have not only
+facial, but intercostal neuralgia; for this last he was repeatedly bled,
+under the idea that it was pleurisy. Added to all this he habitually did
+an immense deal of brain-work in his study, and for years had performed
+clerical duties of the most exacting and exhausting character. It is not
+much wonder that these combined circumstances had sufficed to generate
+the neurotic temperament.
+
+
+NOTE II.
+
+THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD.
+
+In the present transitional state of opinion concerning the mode in
+which the phenomena are produced that are popularly known under the name
+of "reflex paralysis," I cannot pass without notice the doctrines of
+these two observers. The reader will have perceived that, as regards the
+secondary paralytic symptoms observed in neuralgias, I explain the
+phenomena mainly on the theory of a process which is central, and not
+peripheral, in origin. And, even where, as in some few instances, it
+seems possible that the starting-point was an organic affection of some
+viscus, we must always consider the possibility that the link between
+this and the neuralgia and paralyses was a neuritis migrans travelling
+inward to the sensory centre, and from that passing over to motor
+centres and thus producing paralysis; or that, without the intervention
+of any truly inflammatory process, the continual impressions streaming
+in upon the cord from the original seat of organic disease may damage
+the nutrition of the sensory nerve-root, producing a partial atrophy,
+and that this process may extend to the motor root.
+
+It remains, however, to inquire whether the influence of powerful
+peripheral agencies may not, in a purely "functional" manner, disable
+the nerve-centres for a time, causing paralysis with or without
+neuralgia. The main supporters of such a doctrine are Dr. Handfield
+Jones[46] and M. Jaccoud.[47]
+
+Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to
+spasm of the vessels in the nerve-centres, and we need not repeat his
+arguments on that head, because it seems to be generally felt that the
+vascular spasm theory will not account for the facts. Jones believes
+that the state produced in the nerve-centre by the peripheral influence
+is one of paresis from shock-depression, and that from the sensory
+centre this state can communicate itself to motor and vaso-motor
+centres, though commissural fibres. He does not believe in the existence
+of a special inhibitory portion of the nervous system: he believes that
+an impression may prove stimulating when it is mild, or paralyzing when
+it is strong; and that any afferent nerve may convey either the one
+influence or the other to the centres and thus produce secondary
+stimulus or secondary paralyses in various efferent nerves. Jones has
+the distinguished merit of being one of the first authors distinctly to
+perceive that pain must rank on the same level with paralysis: hence he
+sees nothing unintelligible in the communication of paralysis to a motor
+centre from a sensory centre that was in the state which the mind
+interprets as pain.
+
+The _theorie d'epuisement_ of Jaccoud (Erschopfungs-theoric) also denies
+the possibility of Brown-Sequard's idea of prolonged spasm of the
+vessels of the centres. It imagines that powerful peripheral excitements
+exhaust the irritability of the nerve, and through that of the centres,
+and induce a state of unimpressibility--analogous to that which exists
+in a nerve or nerve-centre, which is included in the circuit of a
+constant current. The nervous force is wasted, and, until an opportunity
+of repose is afforded to the centre, the faculty of impressibility
+cannot again revive.
+
+I must say that of these two theories I decidedly incline to that of
+Handfield Jones (though I imagine that in reality the cases are
+extremely rare, if there be any, in which the change in the centres is
+really only functional and non-organic), I prefer the idea of
+paralyzing shock to that of exhaustion from over-excitement, from a
+consideration of the nature of that form of peripheral influence which
+has been specially mentioned by authors as competent to produce this
+sort of "reflex" affections, namely, intense and persistent cold. It
+seems to me a mere abuse of words to speak of this as an agent that
+could exhaust the nerve by over-stimulation; it must surely exhaust it
+in a much more direct manner than this, namely by the direct physical
+agency of withdrawing heat from the nerve, and spoiling its physical
+texture, _pro tanto_. If such an effect as that which must thus be
+produced on the nerve, and through it on the centre, is to be looked on
+as a case of over-stimulated function, then, it seems to me, there is no
+meaning in language, and no possibility of attaining to clear ideas on
+the subject of nervous influence.
+
+
+NOTE III.
+
+ARSENICAL TREATMENT OF VISCERALGIĘ.
+
+Since writing the above chapter on the Treatment of Neuralgia, I have
+had two fresh and very striking examples, in private practice, of the
+power of arsenic to break the morbid chain of nervous actions in angina
+pectoris.
+
+The first example was that of a medical man, aged seventy-five, in whom
+a neuralgia, originally malarial in origin, and of some years' duration,
+had fixed itself for some time in the fifth and sixth left intercostal
+spaces, and of late had become complicated with anginoid attacks of an
+unmistakable character, though not of the highest degree of severity.
+The case certainly seemed very unpromising, looking at the patient's age
+and the consequent high probability that there was much arterial
+degeneration. However, the use of Fowler's solution (five minims three
+times a day) was commenced and steadily pushed. The anginoid attacks
+rapidly diminished in frequency and at the end of ten days' time were
+entirely gone, and after one month of treatment he still had no return
+of them, although they had previously been of daily occurrence. It is a
+curious fact, whether a mere coincidence or not I cannot say, that, some
+few days after the anginoid attacks ceased, he began to experience
+somewhat severe pains, rheumatic in feeling, but unattended with heat or
+swelling, in the elbows, wrists, and fingers, symmetrically. This has
+nearly disappeared, but he is still free from angina. There is no
+discoverable heart-lesion in this patient.
+
+The other case was that of a fine old man of sixty-four, who, but for
+some few slight attacks of gout, a few small calculi, and a troublesome
+prostatic affection, had always enjoyed remarkably good health, until
+about five months ago, when he began to notice tightness across the
+chest, etc., when he walked uphill. About a fortnight before he came to
+me, he was seized with very violent and alarming paroxysms of pain
+across the chest and running down both arms, extreme intermittence
+of pulse, and a sense of impending dissolution. The attack had recurred
+daily, at the same hour (6 P. M.), ever since; besides which there was
+an abiding sense of uneasiness in the cardiac region, and a
+consciousness that the least excitement or exertion would bring on the
+paroxysm. I put the patient on five minims of Fowler, three times a day,
+with directions to take ether when the paroxysms came. At the end of the
+first week there was already much improvement, the paroxysms having been
+both less frequent and less severe. At the end of a fortnight's
+treatment he reported that there had been nothing like a paroxysm for
+the last eight days, although there was still a good deal of uneasiness
+from time to time. The hour at which the attack was expected passed by
+absolutely without a trace of angina. It remains to be seen how long
+this improvement will last, but the altered state of things, and
+particularly the suddenness of the change, cannot be overlooked, and has
+very much struck the patient himself. It is now six weeks since he had
+any paroxysm.
+
+It becomes more and more apparent that arsenic is generally applicable
+to neuroses of the vagus. In asthma, I have long held it to be the most
+powerful prophylactic tonic that we possess. It is also an excellent
+remedy in gastralgia; although I have rather dwelt (in the text of this
+work) on the action of strychnia in this disease, I would not omit my
+testimony to arsenic. Dr. Leared has related some exceedingly
+interesting cases bearing on this point. (See _British Medical Journal_,
+November 23 and 30, 1867.)
+
+
+NOTE IV.
+
+INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT.
+
+Dr. Reynolds pointed out to me the exceedingly curious fact, which I have
+several times verified, that the constant current, in relieving facial
+neuralgia, not unfrequently disperses, almost instantaneously, the brown
+skin-pigment that has collected in the painful region; _e. g._, near the
+orbit.
+
+
+NOTE V.
+
+THE ACTUAL CAUTERY.
+
+A remedy for inveterate neuralgia which of late years I had almost
+discarded--the actual cautery--has quite recently yielded me very good
+palliative results in two cases. Its omission from the text of the
+chapter on Treatment was an accident due to the effect of habit in
+making one, half unconsciously, reckon this remedy as a
+"counter-irritant." The longer I practise, however, the more decidedly I
+am convinced that the actual cautery, if properly applied, does not act
+as an irritant at all; and this fact was sufficiently in my mind, when
+writing of irritant remedies, to make me omit the cautery from that
+section. I should have inserted it under the heading of remedies that
+interrupt the conductivity of nerves, and thus give the centres
+temporary rest. The only useful way to apply it is, to make an iron
+white hot, and very lightly brush the skin over so as to make an eschar
+not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is
+the best for the purpose, but I have made the flat-iron cautery serve
+very well.
+
+FOOTNOTES:
+
+[35] Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)
+
+[36] Practitioner, vol. iv., 1870.
+
+[37] Berlin. klin. Wochensch., 1865.
+
+[38] In a paper on the "Hypodermic Use of Remedies," in the
+_Practitioner_ of July, 1868, I gave the reasons for this opinion in
+full; and I see no reason to alter any thing I then said.
+
+[39] Practitioner, vol. iv.
+
+[40] Berlin. klin. Wochensch., 17, 1868.
+
+[41] "System of Medicine," vol. ii.
+
+[42] The English reader may consult Althaus ("A Treatise on Medical
+Electricity," second edition, Longmans), or Meyer ("Medical
+Electricity," translated by Hammond: Trubner & Co.)
+
+[43] "A Treatise on Medical Electricity," second edition, Longmans.
+
+[44] _Op. cit._
+
+[45] Berlin. klin. Wochensch., 22, 1865.
+
+[46] _Op. cit._
+
+[47] "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris,
+1864.
+
+
+
+
+PART II.
+
+DISEASES THAT RESEMBLE NEURALGIA.
+
+
+
+
+CHAPTER I.
+
+MYALGIA.
+
+
+Of all the diseases which superficially resemble neuralgia, none are so
+likely to be confounded with it, on a cursory glance, as myalgia. More
+careful inquiry, however, furnishes, in nearly all cases, ample means
+for distinguishing between the two affections.
+
+Myalgia is an exceedingly painful affection, and it is also much more
+common than was formerly supposed. It is to Dr. Inman that we
+undoubtedly owe the demonstration of the frequent occurrence of this
+malady, and the facility with which it may be mistaken for other, and
+sometimes much more serious, diseases, with very disastrous results. At
+the same time, I must express the opinion that this ingenious author has
+decidedly exaggerated the importance of this local disease at the
+expense of an unjust depreciation of the frequency and significance of
+other painful disorders which have their origin within the nervous
+system.
+
+Myalgia proper includes all those affections which are severally known
+as "muscular rheumatism" (for the muscles generally), and "lumbago,"
+"pleurodynia," etc. (according to locality). It is essentially pain
+produced in a muscle obliged to work when its structure is imperfectly
+nourished or impaired by disease.
+
+The clinical history of the different varieties of myalgia absolutely
+requires this key for its interpretation; otherwise, the appearance of
+the sufferers from different kinds of myalgia is so widely dissimilar
+that we should be exceedingly likely to miss the important features of
+treatment, which must be applied to them all in common. Nothing, for
+instance, can be more strikingly unlike than the appearance of the
+pallid, stunted, under-nourishment cobbler who complains of epigastric
+myalgia, and that of the ruddy and muscular navvy who suffers from acute
+lumbago, or the similarly plethoric-looking country commercial
+traveller, who has been driving in his gig against wind and rain, and
+complains of violent aching pains in one or both shoulders; yet one and
+all of these individuals are suffering from precisely the same cause of
+pain, viz., a temporarily crippled muscle or set of muscles which has
+been compelled to work against the grain. Why this state of things
+should invariably be interpreted as sensation in the form of acute pain
+never absent, but severely aggravated by every movement of the affected
+part, is a matter beyond our powers of explanation, we must accept it as
+an ultimate fact for the present.
+
+There is scarcely any need to describe the pain of myalgia, since almost
+every one has suffered either from lumbago, or from a stiff neck
+produced by cold. The pain is essentially the same in all cases; it is
+an aching actually felt either in or toward the tendinous insertions of
+the affected muscles, and sharply renewed by every attempted contraction
+of those muscles. The variations in the character and severity of the
+pains are really entirely due to the greater or the less opportunity for
+physiological rest which the muscle can obtain. Thus the most obstinate
+and the most severe, kind of myalgic pain is undoubtedly that of
+pleurodynia--pain in the intercostal muscles and their fibrous
+aponeuroses--a fact which depends on the incessant movements which these
+muscles are compelled to perform in the act of respiration. And next to
+this in severity and obstinacy are myalgias of the great muscles which
+are incessantly engaged in maintaining, by their accurately opposed
+contraction, the erect position of the spinal column and of the head.
+This rate of proportional frequency and severity, however, must be taken
+as strictly relative; _i. e._, it is correct upon the supposition that
+the different sets of muscles were equally worked and that the state of
+nutrition was equal in the different parents. It is otherwise when the
+conditions are reversed. Thus, the unfortunate cobbler or tailor, who
+sits for long hours in one cramped and bent posture, is continuously
+exerting his recti abdominales (probably suffering from an
+under-nutrition common to all his tissues) to a degree perfectly
+abnormal, and out of all proportion to the functional work he is getting
+out of any other part of his muscular system. The consequence is, that
+he comes to us complaining of acute epigastric, and sometimes pubic,
+pain, rising to agony when he assumes his ordinary sitting posture, and
+only reduced to any thing moderate by the most complete extension of the
+whole trunk in the supine posture.
+
+There is no need to dilate at greater length upon the varieties in the
+symptoms of myalgia, according as it affects one or another part of the
+body. We must consider, briefly the different kinds of cause that
+produce it. The immediate source of the pain being, as we have seen, the
+sense of embarrassment in a muscle obliged to contract when unfit for
+the work, we have to ask what are the remoter causes that can produce
+this special unfitness for the work of contraction. They are three:
+(_a_) Overlabor pure and simple (_i. e._, in proportion to the existing
+bulk and quality of the muscle); (_b_) cold, and especially damp cold,
+producing a semi-paralyzing effect on the vaso-motor nerves, and causing
+congestion and sometimes a little effusion among the fibres or within
+the sheath of the muscle; (_c_) fatty degeneration of muscle which is
+exposed to inevitable and incessant work. Either of these conditions may
+so disable the muscle that its unavoidable contractions will set up the
+myalgic state.
+
+Undoubtedly however there is something further, in the shape of a
+natural predisposition not yet understood, which makes some patients so
+much more liable to suffer myalgic pain as a consequence of this sort of
+influences than other persons are. I am in no condition to decide what
+the nature of this predisposition is; I feel sure it is heightened by an
+inherited or acquired gouty taint, but I have seen it in people whom
+there is no reason to suspect of gouty tendencies. It appears to have no
+connection with true rheumatism.
+
+Still after all that can be said, myalgia remains a disease chiefly of
+local origin, and depending for nine-tenths of its causation upon a
+derangement between the balance of work and nutrition in the muscle.
+
+As regards the diagnosis of myalgia from neuralgia, which is a very
+important matter, the following are the main points that we should
+recollect:
+
+          _Neuralgia._                        _Myalgia._
+
+  Follows the distribution of a      Attacks a limited patch or
+    recognizable nerve or nerves.      patches that can be identified
+                                       with the tendon or aponeurosis
+                                       of a muscle which, on inquiry,
+                                       will be found to have been hardly
+                                       worked.
+
+  Goes along with an inherited or    As often as not occurs in persons
+    acquired nervous temperament,      with no special neurotic
+    which is obvious.                  tendency.
+
+  Is much less aggravated,           Is inevitably, and very severely,
+    usually, by movement than          aggravated by every movement of
+    myalgia is.                        the part.
+
+  Is at first accompanied by no      Distinguished from the first, by
+    local tenderness.                  localized tenderness on pressure
+                                       as well as on movement.
+
+  Points douloureux, when            Tender points correspond to
+    established at a later stage,      tendinous origins and insertions
+    correspond to the emergence of     of muscles.
+    nerves.
+
+  Pain not materially relieved by    Pain usually completely and always
+    any change of posture.             considerably relieved by full
+                                       extension of the painful muscle
+                                       or muscles.
+
+The treatment of myalgia is not only satisfactory in itself, but often
+affords, in its results, a very desirable confirmation of diagnosis.
+
+For a very large number of cases, all that is required is (_a_) to put
+and keep the affected muscle in a position of full extension, which is
+only to be changed at somewhat rare intervals; (_b_) to cover the skin
+all over and round it with spongio-piline, so as to maintain a perpetual
+vapor-bath; (_c_) on the subsidence of the acutest pain and tenderness,
+to complete the treatment by one or two Turkish baths, to be taken in
+the manner that I have recommended by speaking of the prophylaxis of
+neuralgia.
+
+When treatment such as this cures a pain which was greatly aggravated by
+muscular movement, we may be sure that pain was myalgic and not
+neuralgic.
+
+The pain, however, is not unfrequently rebellious to such simple
+remedies as these, more especially when (as in pleurodynia) we are not
+able to enforce complete physiological rest of the part. When this is
+the case, we shall find the internal use of twenty and thirty grain
+doses of muriate of ammonia by far the most effective remedy. In the
+first very acute stage of a severe case it may be advisable to inject
+morphia hypodermically; but this is seldom necessary. The
+muriate-of-ammonia treatment may be usefully accompanied by prolonged
+gentle frictions, three or four times a day, with a weak chloroform
+liniment.
+
+When there is visibly a very great deficiency in the general nutrition,
+we shall often fail to obtain a cure until we have remedied this defect;
+and accordingly, in the majority of cases of half-starved and overworked
+needle-women, cobblers, tailors, and the like, who present themselves in
+the out-patient room, I accompany the above-named treatment with the
+steady administration of cod-liver oil for three or four weeks or more.
+
+There is one remedy for this pain which I have myself seen used in only
+a few cases, but which I believe promises exceedingly well for the
+treatment of obstinate myalgia; viz., acupuncture. I have not even
+mentioned it as a remedy for neuralgia, for I believe it to be totally
+useless in true cases of that disease, whether applied in the simple
+form or in that of galvano-puncture. I think very differently of its use
+in myalgia; and I venture to believe that it is entirely to cases of
+this disease that the exceedingly interesting observations of Mr. T. P.
+Teale, in a recent number of the _Lancet_, apply. Where (after the usual
+remedies for myalgia have been applied) we are unable to get rid of a
+deep-seated and fixed muscular pain, I believe it to be excellent
+practice to plunge two or three long needles deeply into the muscle near
+its tendinous attachment.
+
+
+
+
+CHAPTER II.
+
+SPINAL IRRITATION.
+
+
+I retain this phrase, not because it is an absolutely good one, but
+because it has become so familiar that it is difficult to dispense with
+it. We have taken a useful step, however, in separating the true
+neuralgias from the somewhat indefinite group of diseases to which this
+title has been given. I think the reader who has carefully studied Part
+I. of this work will not deny that the latter disorders present a very
+clear and definite common outline which distinguishes them essentially
+from the vaguer affections to be described under the present heading.
+
+Spinal irritation, in my sense, includes all those conditions in which,
+without any special mental affection, and without any single nerve being
+definitely affected, there are sensations varying between mere cutaneous
+tenderness, often of a large and irregular surface, and acute pain
+approaching neuralgia in character, together with fixed tenderness of
+certain vertebrę on deep pressure. A very large majority of the
+phenomena are such as would be popularly included (now that they are
+known not to be of an inflammatory character) under the term
+"hysterical." That unhappy word crosses our path at every turn in a most
+embarrassing manner, and yet it can hardly at present be said that we
+could afford to do without it.
+
+The more typical cases of so-called "hysterical hyperęsthesia" present
+the following phenomena: Along with the general symptoms of the
+hysterical temperament (tendency to causeless depression, variable
+spirits, sensation of globus, semi-convulsive attacks terminated by the
+discharge of a great quantity of pale, limpid urine) there is commonly a
+marked superficial tenderness of the surface everywhere, and an
+exaggeration of reflex irritability. The general tenderness is so far
+merely cutaneous that deep pressure is ordinarily borne better than the
+lightest finger-touch. But besides this there are usually one or several
+spots in which the tenderness is more profound and genuine. There is
+almost sure to be some point in the spinal column where firm pressure
+not merely evokes a complaint of pain, but also induces secondary
+objective phenomena connected with distant organs, such as nausea and
+vomiting when the cervical vertebrę are tender, severe gastric pain when
+the dorsal vertebrę are tender, etc. In such cases there is not only
+spinal tenderness, but very usually also a well-marked tenderness in the
+epigastrium and the left hypochondrium, the _trepied hysterique_ of
+Briquet. The reader must, however, be warned that the whole of these
+three tender points may be merely myalgic, and it is necessary very
+carefully to observe whether local movements do or do not seriously
+aggravate the pain in them. And, on the other hand, the spinal tender
+point may be merely the "point apophysaire" of a true neuralgia which
+exhibits no other symptoms of the so-called hysteric constitution.
+
+The kind of hysteria that is joined with the existence of fixed tender
+spots in definite points of the vertebral column is not commonly
+distinguished by the occurrence of cutaneous anęsthesia; but those
+writers are certainly wrong in saying that such a combination never
+takes place. I have seen examples of the most marked union of the two
+classes of symptoms in the same person.
+
+These cases of so-called spinal irritation with general hysteric
+manifestations are very commonly attended with paroxysmal pains that
+approach true neuralgia in character. Nor is it to be denied that we
+sometimes meet with the combination of general hysteria, spinal
+tenderness in definite points (with secondary spasmodic or paralytic
+phenomena always following pressure exerted on the latter), and true
+neuralgia limited to one nerve. But the more typical spinal irritation
+cases are merely complicated with a tendency to vague pains which are
+shifting both in character and position, not with definite unilateral
+neuralgia always haunting the same nerve and exhibiting more or less of
+the same type. In fact, as far as one can judge in the absence of any
+precise information as to the condition of the nervous centres in such
+cases, it would seem likely that the ordinary cases of spinal irritation
+differ from the true neuralgias chiefly in this--that the injury, or
+inherited weakness of organization, or both, which is at the root of the
+malady, is at once slighter in degree, and spread over a larger tract of
+the nervous centres, than that which produces a true neuralgia. I
+believe that Dr. Radcliffe is right in supposing it to be probable that
+a blow or other injury to the back producing general spinal shock, is
+the original but unsuspected cause of a large proportion of these cases.
+One of the most perfect examples of spinal irritation that I have ever
+seen (and which also contrasts keenly with the commoner hysteric
+affections on the one hand, and the true neuralgię on the other) was
+that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds,
+and Dr. Bridge. This young lady was a most intelligent person, and not
+in the slightest degree inclined to the apathy and idleness so often
+seen in hysterical people. She had received what was thought at the time
+to be a very slight contusion in a railway collision, in which, however,
+her sister, who was in the same carriage, had been severely injured. She
+nursed this sister assiduously, and it was not till three or four months
+later that her own health began to fail seriously; but she then became
+anęmic and extremely depressed. About six months after the accident it
+was quite casually discovered that there was a spot over the lowest
+cervical vertebra, pressure on which gave her exquisite pain and a
+sensation of extreme nausea; and the very curious observation was made
+that such pressure instantaneously produced extinction of the right
+pulse, the left pulse remaining unaltered. In this case it cannot be
+doubted that a serious shock had been communicated to a lateral segment
+of the cord involving chiefly the vaso-motor nerve fibres, in which
+probably some decided material lesion had been gradually set up; and
+besides this there was probably slighter damage to the spinal cord
+generally, as there was great general feebleness of movement, though no
+actual paralysis of the limbs.
+
+Along with the phenomena of fixed spinal tenderness, without distinct
+neuralgia of any particular nerve, we not unfrequently observe the
+development of more or less decided tenderness of some of the internal
+surfaces of the body. I have recently had under my care a young woman in
+whom a very tender point was developed over the second cervical
+vertebra, and who suffered from such persistent tenderness of the whole
+posterior part of the pharynx, that I was for some time seriously
+apprehensive of the existence of spinal caries and post-pharyngeal
+abscess. The general character of her symptoms, however, induced me to
+hope that the case was one of spinal irritation merely, and the event
+proved that this was the case, for under the use of iron and small doses
+of strychnia she recovered completely in about three weeks. In another
+patient who came under my care about twelve months ago, there was
+extraordinary sensitiveness of the gastric mucous membrane, causing
+exquisite pain after she had eaten almost any thing: there was only
+occasional vomiting, however, and there had never been any hęmorrhage,
+so that the evidence for gastric ulcer, which I otherwise inclined to
+think existed, was insufficient. I discovered that pressure on the third
+or the fourth dorsal vertebra gave great pain, and produced a strong
+inclination to vomit; this made it probable that the affection was
+spinal, and accordingly all treatment addressed to the stomach was
+abandoned. Flying blisters to the neighborhood of the painful spinal
+points quickly relieved all the symptoms.
+
+Another distressing class of symptoms, which is very commonly observed
+in connection with these cases of spinal irritation, is that of abnormal
+arterial pulsations: I am not sure whether even severe neuralgia
+produces more distress than does this pulsation. I have repeatedly seen
+abnormal pulsation of the carotids in connection with fixed
+tender-points over the cervical or the upper dorsal vertebrę; and still
+more commonly pulsation of the abdominal aorta in connection with
+tenderness over one or two of the upper dorsal vertebrę. Spasmodic cough
+and spasmodic dyspnoea frequently accompany tenderness of points in
+the upper half of the spinal column; and in one instance I have seen
+pressure on the lowest cervical vertebrę produce a paroxysm which looked
+alarmingly like angina pectoris. A case of singularly prolonged and
+obstinate spasmodic hiccough which came under my notice was
+distinguished by the presence of a fixed tender spot over the third
+dorsal vertebra.
+
+Prolonged spastic contraction of voluntary muscles, going on, sometimes
+for weeks, and even months, is a phenomenon that has often been
+observed; it may attack the arm only, or may affect all the limbs, and
+the muscles of the trunk and of the neck: it is for the most part
+symmetrical, but is occasionally unilateral. It begins in the
+extremities, and is very commonly limited to them; it is much more
+gentle than tetanic spasm, and is also painless, or nearly so; but the
+contraction is often strong enough to resist very vigorous efforts at
+artificial extension.
+
+Paralyses, both of bowel and bladder, have been recorded among the
+occasional phenomena of spinal irritation with fixed tender points; but
+I cannot say that I have ever seen such an occurrence. On the whole, I
+must say that by far the most frequent phenomena of spinal irritation
+that I have seen have been somewhat diffuse cutaneous or mucous
+tenderness and irritability (without acute pain) and the presence of
+tormenting arterial throbbings; also a marked tendency to aggravation of
+some symptoms, especially the gastric, when firm pressure is made upon
+the tender spinal points. For a further and fuller account of the
+phenomena of spinal irritation I may refer the reader to the able
+article of Dr. Radcliffe,[48] and the work of the brothers Griffin,
+already quoted; adding the suggestion, however, that both these
+authorities, and especially the Griffins, appear to me not to draw a
+sufficiently clear distinction between the class of cases that I have
+been attempting to describe and the true neuralgias.
+
+After what has been said, there is no need to draw out a formal list of
+the points of diagnosis between spinal irritation and neuralgia. It must
+be admitted, moreover, that the two forms of diseases have a strong
+connection in the fact that they are each of them most frequently
+developed in the descendants of neurotic families. It is by the more
+generalized character of the symptoms, and the absence of the tendency
+to perpetual recurrence of paroxysmal pain in one definite nerve, that
+spinal irritation is mainly distinguishable from true neuralgia. I may
+add that there is a marked distinction, also, in the results of
+treatment.
+
+The treatment of spinal irritation is, it must be confessed still in an
+unsatisfactory position; and I believe that a good deal of unnecessary
+discouragement has been occasioned to physicians by their failures to
+cure supposed neuralgias which really belonged to the spinal irritation
+class. I would assuredly by no means assert that genuine neuralgia is
+not frequently intractable, or even incurable; but it is certainly much
+more curable than spinal irritation; and for this reason, mainly as I
+believe--that there is much more possibility of aiming our remedies at
+the actual seat of the disease. On the other hand, in spinal irritation
+we are confused and distracted with a variety of phenomena for which
+even the most subtle analysis will frequently fail to trace a common
+origin. It is true that the existence of definite tender spots in the
+spine apparently suggests a strictly local application of remedies; and
+it true also that medication based upon this fact is sometimes very
+effective; but this is, in my experience, only an occasional result, and
+the practitioner who trusts to local measures will frequently be
+disappointed. And, on the other hand, the general tonic treatment, and
+the use of special medicines, like quinine and arsenic, or the
+hypodermic injection of morphia oratropia, have nothing like the
+extensive utility in the treatment of spinal irritation that they
+possess in that of true neuralgia. Of internal remedies, by far the most
+useful in my hands have been sesquichloride of iron with small doses of
+strychnia, and the milder vegetable bitters, especially calumba.
+
+There is one special phase, however, of spinal irritation which is very
+amenable to the direct, treatment, viz., cutaneous and mucous
+tenderness. Whatever the "hyperęsthetic" part is within reach, so that
+we can apply Faradization, we can almost certainly eradicate the morbid
+sensibility very quickly. The secondary current of an electro-magnetic
+or volta-electric induction apparatus is to be employed; the conductors
+should be of dry metal and the negative one, which is to be applied to
+the painful surface, should be in the form of the wire brush. The
+positive pole is to be placed on some indifferent spot, and the negative
+is to be stroked briskly backward and forward over the sensitive skin, a
+pretty strong current being employed. The process is painful so much so
+that it will often be advisable, with delicate patients, either to
+administer chloroform or to inject morphia subcutaneously before the
+Faradization. A very few daily sittings of four or five minutes length
+will generally remove the morbid tenderness completely. Where the tender
+part is within one of the cavities, at the rectum, bladder, vagina, or
+pharynx, we must of course use a solid negative conductor of appropriate
+form, and must content ourselves with applying it steadily to one point
+after another of the sensitive surface.
+
+The fact that Faradization proves so remarkably useful, in these cases
+of spinal irritation with diffuse cutaneous or mucous tenderness, is in
+itself a strong diagnostic between this sort of affection and the true
+neuralgię, which, as I have stated are seldom benefited, and are often
+made worse, by the interrupted current, though the constant current
+frequently mitigates or cures them.
+
+Sometimes where it is not possible to apply the remedy directly to the
+sensitive surface, we may nevertheless do great good by sending the
+interrupted current through it. Thus, in gastric sensitiveness connected
+with spinal tenderness in the upper dorsal region, I have seen very
+great relief afforded by sending a current from the positive pole,
+placed on the tender vertebrę, to a broad, negative conductor placed on
+the epigastrium. And similarly, I have seen an acutely sensitive
+condition of the neck of the bladder greatly soothed by the passage of a
+current from a painful lumbar vertebra to the perinęum immediately
+behind the scrotum.
+
+Undoubtedly, however, the more serious cases of spinal irritation will
+yield only (if they yield at all) to a prolonged treatment in which very
+skilful use is made of general hygienic measures, and especially of
+morbal influences. As the brothers Griffin long ago pointed out,
+although rest is useful in the early stages of this malady, if the
+disease does not quickly yield to this and to appropriate tonic
+medication, and perhaps local applications to the spine, it will not do
+to keep the patient recumbent and confined to the house; on the contrary
+at whatever cost of immediate discomfort, he (or she for these patients
+are by far the most frequently females) must be roused up, and persuaded
+or compelled to take out-door exercise, and if possible to travel, and
+divert the mind by complete change of scene. When such expensive
+remedies are out of the question, it seems better that patients, even
+seemingly very feeble, should take to their ordinary avocations in life
+again, and fight down the tendency to invalidism. But of course, the
+decision on such a point must rest with the tact and judgment of the
+practitioner in each individual case, for there are, doubtless,
+instances in which the attempt to carry out such a plan, even
+moderately, would break down the remaining strength, and make matters
+worse than they were before.
+
+In the worse case of spinal irritation that I ever saw, that of a young
+lady, aged twenty-eight, there were pronounced anęmia and general
+feebleness, the true hysteric _trepied_ of tender points, painful
+irritability of the stomach, which baffled all medical advisers and
+resisted almost every possible form of tonic and nervine medicines,
+counter-irritation to the spine, and, in fact every thing that one dared
+attempt with so feeble-looking a patient, but at once cleared up and was
+quite cured after marriage. And there can be no question that a very
+large proportion of these cases in single women (who form by far the
+greater number of subjects of spinal irritation) are due to this
+conscious or unconscious irritation kept up by an unsatisfied sexual
+want. In some patients there cannot be a doubt that this condition of
+things is indefinitely aggravated by the practice of self abuse; but it
+would be most unjust to think that this is a necessary element in the
+causation; on the contrary, it is certain that very many young persons
+(women more especially) are tormented by the irritability of the sexual
+organs without having the least consciousness of sensual desire, and
+present the sad spectacle of a _vie manquee_ without ever knowing the
+true source of the misery which incapacitates them for all the active
+duties of life. It is a singular fact, that in occasional instances one
+may even see two sisters inheriting the same kind of nervous
+organization, both tormented with the symptoms of spinal irritation, and
+both probably suffering from repressed sexual function, but of whom one
+shall be pure-minded and entirely unconscious of the real source of her
+troubles, while the other is a victim to conscious and fruitless sexual
+irritation.
+
+I have already causally alluded to the danger of mistaking mere myalgia
+for spinal irritation and must again enforce this consideration upon the
+reader. Myalgic tender points in the region of the spine are common
+enough; and it would be easy without careful attention, to mistake them
+for the deeper-seated vertebral tenderness which is truly characteristic
+of spinal irritation. Hence the utmost care must be taken to ascertain
+the true history of the commencement of the disorder whether it
+succeeded to great and long continued fatigue of particular sets of
+muscles, and whether it is specially aggravated by contractions of those
+muscles, and relieved by their full extension. The differences of
+treatment which depend on the diagnosis are too obvious to need dwelling
+upon.
+
+The question of administering remedies with the direct intention of
+procuring sleep, for patients suffering from spinal irritation, often
+becomes an important and a very difficult one. It is, for the most part,
+highly objectionable to commence the use of such remedies; and yet
+sleeplessness is a very distressing symptom with many patients, and is,
+of course in itself exhausting and deleterious. For as long as we
+possibly can, we should content ourselves with efforts to produce sleep
+by the timely administration of nourishment. The same general rule of a
+very generous (though not very stimulating) diet to be enforced as
+carefully as in the case of sufferers from neuralgia. But it is
+especially advisable in spinal irritation; that the patient should take
+some food shortly before bedtime; and it is well, also to place food
+within reach at the bedside, so that if he wakes up he may take some.
+If, however, we are absolutely driven to employ hypnotics, we must
+commence with the very mildest. The popular remedy of a pillow stuffed
+with hops will sometimes suffice; and a better way of administering the
+volatile principle of hops is to scatter a few hops on hot water in an
+inhaler, and let the patient breathe the steam. Hot foot-baths, with
+mustard, are also very useful. If these fail, chloral, in moderate doses
+is probably the best and safest remedy, and, with care not to give too
+much, we may go on using the same dose without increase for a good many
+times.
+
+FOOTNOTE:
+
+[48] Reynolds's "System of Medicine," vol. ii., Art. "Spinal
+Irritation."
+
+
+
+
+CHAPTER III.
+
+THE PAINS OF HYPOCHONDRIASIS.
+
+
+There is perhaps nothing, in the whole range of practical medicine, more
+difficult to seize with clear comprehension, and picture to the mind
+with accuracy, than the group of pseudo-neuralgię which belong to the
+domain of hypochondriasis. They are among the most indefinable, and at
+the same time the most intractable, of nervous affections.
+
+To understand what hypochondriac pains are, we must first be familiar
+with the general character of the hypochondriacal temperament, for the
+pains are only a subordinate and ever-varying phenomena of the general
+disease.
+
+Hypochondriasis is not insanity, if by insanity we mean intellectual
+perversion dependent mainly or entirely on the state of the higher
+nervous centres. But it is closely allied to insanity in its phenomena,
+only that these are, as it were, manifested in a scattered form,
+unequally distributed over the whole central nervous system, and
+especially affecting the spinal sensory centres. And its radical
+relationship to true insanity is strongly indicated by the fact that the
+sufferers from hypochondriasis are nearly, if not quite, always members
+of families in which distinct insanity has shown itself; indeed, more
+often than not, of families which have been strongly tainted in this
+way. In the majority of instances there are psychical peculiarities of a
+marked kind which accompany or precede the development of the abnormal
+sensations which form the especial torment of hypochondriacs. Without
+apparent cause, they begin to evince a heightened self-feeling and an
+anxious concentration of their thoughts upon the state of one or more of
+their bodily organs. Or it may be that, before any such definite bias is
+given to their thoughts, they simply become less sociable and more
+self-centred, and are subject to fits of indefinite and inexplicable
+depression, or at least to great variability of spirits. But before long
+they begin to experience definite morbid sensations, most commonly
+connected with the digestive organs, and very often accompanied by
+positive derangement of digestion of an objective character; such as
+flatulence, sour eructation, spasmodic stomach-pain, etc. Along with
+these phenomena, or soon afterward (and not unfrequently before the
+patient has acquired that intensity of morbid conviction of his having
+some special disease which is afterward so marked a peculiarity of his
+mental state), he very often becomes the subject of the kind of pains
+which it is the special purpose of this chapter to describe.
+
+The pains of hypochondriasis, when they assume any more definite form
+than that of mere dyspeptic uneasiness, present many analogies with
+neuralgia. They are not, usually, periodic in any regular manner, but
+they have the same tendency to complete intermission, and they
+frequently haunt some one or more definite nerves for a considerable
+period of time. Of all nerves that are liable to this kind of affections
+the vagus is undoubtedly the most susceptible; hypochondriac patients
+very frequently complain of pseudo-anginoid and pseudo-gastralgic pains;
+next in frequency are nervous pain in the region of the liver, or in the
+rectum or bladder. The main distinctions by which they are separable
+from true neuralgia are two: in the first place, the character of the
+pain nearly always is more of the boring or burning kind than of the
+acutely darting sort which is most usual in true neuralgia; and,
+secondly, the influence of mental attention in aggravating the pain is
+far more pronounced than in the latter malady; indeed, it is often
+possible, by merely engaging the patient in conversation on other
+topics, to cause the pain to disappear altogether for the time. But in
+hypochondriasis it is not often that we are left, for any long time, to
+these means of diagnosis only; the special character of the disease is
+that the morbid sensations shift from one place to another, in a manner
+that is quite unlike that of the true neuralgias. The patient who to-day
+complains of the most severe gastralgia, or liver-pain, will to-morrow
+place all his sufferings in the cardiac region, or in the rectum, or
+will complain of a deep fixed pain within his head; and these changes
+are often most rapid and frequent. Frequently there are also peculiar
+skin sensations, which usually approach formication in type, and these,
+like the pains, are apt to shift with rapidity from one part of the body
+to another. Later on in the disease, especially in those worst cases
+which approach most closely to the type of true insanity, there are
+often hallucinations of a peculiar and characteristic nature, such as
+the conviction of the patient that he has some animal inside him gnawing
+his vitals, that he is made of glass and in constant danger of being
+broken, and a variety of similar absurdities. In short, it is not the
+fully-developed cases of hypochondriasis that need puzzle us, these are
+usually distinct enough; but the earlier and less characteristic stages
+in which pain may be nearly the only symptom that is particularly
+prominent.
+
+In hypochondriasis, as in hysteria, there is often great sensitiveness
+of the surface; and, as in hysteria, this sensitiveness is found to be
+very superficial, so that a light touch often hurts more than firm, deep
+pressure. As in hysteria, too, the tenderness is a phenomenon so greatly
+affected by the mind, that, if we can divert the patient's attention for
+a moment, he will let us touch him anywhere, without noticing it at all.
+
+It is a marked peculiarity of hypochondriasis that it is far more common
+in men than in women; a relation which is precisely the opposite to that
+which rules in neuralgia. Hypochondriasis is also pre-eminently a
+disease of adult middle life; it is scarcely ever seen in youth, except
+as the result of excessive masturbation acting on a temperament
+hereditarily predisposed to insanity.
+
+The results of treatment frequently assist our diagnosis in difficult
+cases. Almost any medicine will relieve the pains of the hypochondriac
+for a time, and it is generally far easier to do him good, temporarily,
+than it is to relieve a neuralgic patient; but, _en revanche_, every
+remedy is apt to lose its affect after a little while. The only chance
+of producing permanent benefit in hypochondriasis is by the judicious
+combination of remedies that remove symptoms (especially dyspepsia,
+flatulence, etc.), which mischievously engage the patient's mind, with
+general tonics, and, above all, which such alterations in the patient's
+habits of daily life as take him out of himself and compel him to
+interest himself in the affairs of the world around him. And, after all,
+our best efforts will frequently lead to nothing but disappointment.
+
+It is notoriously the fact that hypochondriasis especially affects the
+rich and idle classes; but it would be a great mistake to suppose that
+it never attacks the poor or the hard-worked: only, in the latter
+instances, it apparently needs, for it development, the existence of
+strong family tendencies to neurotic disease, and especially to
+insanity. Among the numerous debilitated persons who attend the
+out-patient rooms of our hospitals we every now and then encounter as
+typical a case of hypochondriasis as could be found even among the rich
+and gloomy old bachelors who haunt some of our London clubs. I have one
+such patient under my care now, who has been a repeated visitor at the
+Westminster Hospital during many years: he has had pseudo-neuralgic
+pains nearly everywhere at different times; but his most complaint has
+been of pain in the groin and scrotum of the right side. The existence
+of what seemed, at first, like the tender points of lumbo-abdominal
+neuralgia, at one time led me to believe it was a case of that
+affection; but I was soon undeceived by finding that the tenderness did
+not remain constant to the same points, but shifted about. This man has
+professed, by turns, to derive benefit from nearly all the drugs in the
+Pharmacopoeia; but the only remedies that have done him good, for
+more than a day or two at a time, have been valerian and assafoetida,
+with the prolonged use of cod-liver oil. He will never be really cured;
+and I suspect that the secret of his maladies is an inveterate habit of
+masturbation acting on a nervous system hereditarily predisposed to
+hypochondriasis.
+
+Sometimes it happens that the starting-point of hypochondriac pains,
+simulating neuralgia, is a blow, or other bodily injury acting on a
+predisposed nervous system. Another of my patients at the Westminster
+Hospital was a policeman, who had received a severe kick in the groin;
+he suffered pains which at first seemed to wear all the characters of
+true neuralgia in the pudic nerve, but afterward shifted to other places
+and exhibited all the intractability of hypochondriasis; the patient
+also developed the regular appearance and the characteristic
+hallucinations of the latter disease. On the last occasion when I saw
+him, he struck me as likely to become really insane, in the melancholic
+form; and the probability is that the casualty which he suffered was
+only accidentally the starting-point of a malady which was inherent in
+him since birth, and would have been developed, in any case, at some
+period of his life.
+
+
+
+
+CHAPTER IV.
+
+THE PAINS OF LOCOMOTOR ATAXY.
+
+
+Considering the vast amount that has been written about this disease
+during the last few years, it might be thought superfluous for me to
+give any description of its general features. But it unfortunately
+happens that there is still great divergence of opinion among
+authorities as to the true limitation of the group of cases that can
+properly be ranked under this title, and, indeed, as to the propriety of
+employing the title at all. The phrase ataxie locomotrice progressive,
+as every one knows, was applied by Duchenne de Boulogne to a class of
+cases which really only form a subdivision of the group known under the
+older title of _tabes dorsalis_ and the most advanced German
+pathologists maintain that the old word was better, and that Duchenne
+was altogether wrong in making the one symptom, ataxy of locomotion, the
+bases of a new phraseology;[49] more especially as his theory as to the
+seat of the morbid changes was undoubtedly erroneous.
+
+In this country, however, there is as yet no disposition to give up the
+phrase locomotor ataxy, and it only remains to define with sufficient
+care the class of cases to which the word is here meant to apply. The
+disease is understood to depend upon a degeneration of the spinal cord,
+of which the following description is given by Lockhart Clarke:[50] "In
+true locomotor ataxy, the spinal cord is invariably altered in
+structure. Its membranes, however, are sometimes apparently unaffected,
+or affected only in a slight degree; but generally they are much
+congested, and I have seen them thickened posteriorly by exudations, and
+adherent, not only to each other, but to the posterior surface of the
+cord. The posterior columns, including the posterior nerve-roots, are
+the parts of the cord which are chiefly altered in structure. This
+alteration is peculiar, and consists of atrophy and degeneration of the
+nerve fibres to a greater or less extent, with hypertrophy of the
+connective tissue, which give to the columns a grayish and more
+transparent aspect; in this tissue are embedded a multitude of corpora
+amylacea. Many of the blood vessels that travel the columns are loaded
+or surrounded to a variable depth by oil-globules of various sizes. For
+the production of ataxy, it seems to be necessary that the changes
+extend along a certain length, from one to two inches of the cord. The
+posterior nerve-roots, both within and without the cord, are frequently
+affected by the same kind of degeneration, which sometimes extends to
+the surface even of the lateral columns, and occasionally along the
+edges of the anterior. Not unfrequently the extremity of the posterior
+cornua, and even deeper parts of the gray substance, are more or less
+damaged by areas of disintegration. The morbid process appears to travel
+from centre to periphery, that is, from the spinal cord to the posterior
+roots. In the cerebral nerves, on the contrary, the morbid change seems
+to travel in the opposite direction, that is, from the periphery toward
+the centres. From the optic nerves it has been found to extend as far as
+the corpora geniculata, but seldom as far as the corpora quadrigemina.
+With the exception of the fifth, seventh, and eighth pair, all the
+cerebral nerves have occasionally been found more or less altered in
+structure."
+
+The symptoms which occur in cases in which the above are the morbid
+appearances found after death are (roughly speaking) as follows:[51] "A
+peculiar gait, arising from want of co-ordinating power in the lower
+extremities, a gait precipitate and staggering, the legs starting hither
+and thither in a very disorderly manner, and the heels coming down with
+a stamp at each step."
+
+No true paralysis in the lower extremities or elsewhere. Characteristic
+neuralgic pains, erratic paroxysmal in the feet and legs chiefly--pains
+of a boring, throbbing, shooting character, like those caused by a sharp
+electric shock.
+
+More or less numbness, in the feet and legs chiefly, in all forms of
+sensibility, excepting that by which differences of temperature are
+recognized.
+
+Frequent impairment of sight or hearing, one or both.
+
+Frequent transitory or permanent strabismus or ptosis, one or both.
+
+No very obvious paralysis of the bladder or lower bowel.
+
+No necessary impairment of sexual power.
+
+No tingling or kindred phenomenon.
+
+No marked tremulous, convulsive, or spasmodic phenomena.
+
+No marked impairment of muscular nutrition and irritability.
+
+No impairment of the mental faculties.
+
+Occasional injection of the conjunctivę, with contraction of the pupils.
+
+The probable limitation of the distinctive phenomenon of locomotor ataxy
+(the want of co-ordinating motor power) to the lower extremities.
+
+The above description includes all the necessary facts for the
+recognition of the disease, except one, namely, that the use of the
+eyesight is always needed in order to prevent the patient from falling
+during progression; and is usually necessary even to enable him to stand
+upright without falling.
+
+The pains of locomotor ataxy are early phenomena in most cases, and they
+are usually present, more or less, throughout the course of the disease.
+
+They are often preceded by strabismus, with or without ptosis; the
+strabismus, is usually accompanied by amblyopia. It may happen, however,
+that neuralgic pains are, for a considerable time, the only noticeable
+phenomena; or they may be attended with a certain amount of anęsthesia.
+
+The most frequent type of the pains is lancinating or stabbing; they are
+like violent neuralgias occurring successively in various nerves;
+shifting about from one to another. Sometimes it will happen that the
+pain remains fixed to one particular nerve for hours together; but it
+never continues long without showing the characteristic tendency to move
+about. Most commonly our diagnosis is soon assisted by the occurrence of
+a greater or less degree of ataxy. But, even before the setting in of
+definite atactic symptoms, the shifting character of the pains, and the
+development of a very noticeable amount of anęsthesia, together with the
+absence of anything like positive motor paralysis, will have given us
+the necessary clew.
+
+The effect of treatment, or rather its want of effect, usually affords
+powerful assistance in distinguishing the pains of locomotor ataxy from
+those of true neuralgia. Even where the pain has been fixed for some
+hours in a single nerve, and has been stopped by some powerful remedy
+(such as hypodermic morphia), it will be apt speedily to recur, and
+frequently in some quite distant nerve.
+
+Locomotor ataxy is a disease affecting chiefly the male sex, and
+occurring in the immense majority of cases between the thirty-fifth and
+the fiftieth year.
+
+Not merely is it strictly limited to individuals who belong to families
+with neurotic tendencies, but it is itself frequently seen to occur in
+several members of the same family, and sometimes of the same
+generation. When, therefore, we meet with neuralgic pains of the
+shifting type above described, it is very important at once to make
+careful inquiries whether any members of the family have suffered from
+symptoms of ataxy going on to a fatal result. Otherwise, we might be the
+more readily deceived into the idea that the pains were merely
+neuralgic, because the symptoms of the disease are not unfrequently
+provoked by such causes as fatigue and exposure to cold or wet, which
+are also very ordinary exciting causes of true neuralgia.
+
+FOOTNOTES:
+
+[49] The most complete and careful work of the German school, on this
+subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin,
+1867.)
+
+[50] _Lancet_, June 10, 1865. (Comment on a case of Dr. J. Hughlings
+Jackson's.)
+
+[51] Radcliffe, in "Reynolds's System of Medicine," vol. ii.
+
+
+
+
+CHAPTER V.
+
+THE PAINS OF CEREBRAL ABSCESS.
+
+
+Cerebral abscesses is, fortunately, a rare disease; but the very fact of
+its rarity makes the resemblance of the pain it causes to that of
+neuralgia the more likely to lead us into serious errors. We are apt to
+forget the possibility of suppuration of the brain on account of its
+infrequence.
+
+Pain in the head is present as an early symptom of abscess in the brain
+in a large proportion of cases in which there is pain at all. [Of
+seventy-five cases of cerebral abscess analyzed by Gull and Sutton
+(Reynolds's "System of Medicine," vol. ii.), pain was a symptom in
+thirty-nine, and most frequently an early symptom.] Many cases are
+recorded in which it preceded every other morbid sign by a considerable
+period. It is usually more or less paroxysmal, often strikingly so; in
+the latter case, it bears a great similarity to neuralgia. On the other
+hand, it sometimes takes the shape of a fixed burning sensation, much
+less resembling neuralgia. The situation of the pain by no means always,
+nor even usually, corresponds to the situation of the cerebral abscess;
+on the contrary, abscess in the cerebellum has often caused pain
+referred to the anterior part of the head, and so on. So long as the
+disease remains characterized only by pain, more or less, of a
+paroxysmal character, the diagnosis must be very uncertain; but in the
+great majority of cases certain more distinctive symptoms soon become
+superadded; either convulsions (sometimes hemiplegic), vertigo, coma,
+paralysis, vomiting, or a combination of some of these.
+
+In the stage in which there is as yet no conspicuous symptom but severe
+pain, the diagnosis of cerebral abscess from neuralgia must rest on the
+following points of contrast:
+
+       _Cerebral Abscess._                   _Neuralgia of Head._
+
+  Often occurs secondarily to caries    Rarely appears before puberty.
+    of internal ear, and purulent
+    discharge the result of scarlet
+    fever, measles, etc., in
+    childhood.
+
+  Frequently follows a blow or          Comparatively seldom caused by
+    injury.                               blow, or other external
+                                          injury or caries of bone.
+
+  No true "points douloureux."          If severe, soon presents, in most
+                                          cases, the "points douloureux."
+
+  Usually the pain does not             Intermissions of pain complete,
+    completely intermit.                  and of considerable length.
+
+  Pain often excruciating from a        Pain usually not very violent at
+    very early period.                    first.
+
+  Pain often limited in situation,      Pain superficial; follows
+    seems deep-seated, though, as         distribution of recognizable
+    often as not, it has no relation      nerve-branches belonging to
+    to the site of the abscess.           the trigeminus or the great
+                                          occipital.
+
+  No well localized vaso-motor or       Usually there are lachrymation,
+    secretory complications.              congestion of conjunctiva, or
+                                          other vaso-motor and secretory
+                                          complications, such as are
+                                          described in Chapter III.
+
+  Very rare in old age; then            Severe and intractable neuralgia
+  usually traumatic.                      is commonest in the
+                                          degenerative period of life.
+
+  Relief from stimulant narcotics       Relief from opium, etc., is much
+    very transitory.                      more considerable and
+                                          permanent.
+
+The only case of cerebral abscess that I have personally seen, in which
+the above points of distinction would have been insufficient, was that
+of a boy of sixteen, in whom the only discoverable symptom, for nearly
+three months, was pain, very strongly resembling ordinary migraine,
+recurring not oftener than once in ten days or a fortnight, lasting for
+some hours at a time, and nearly always ending in vomiting, and
+disappearing after sleep. At the end of the three months, acute pain in
+the left ear set in, and this was followed, soon, by right hemiplegia,
+coma, and death. It was then discovered, although it had formerly been
+denied, that the boy had suffered from discharge from the left ear,
+following a febrile attack which had been marked by sore-throat, and
+followed by desquamation of the cuticle--evidently scarlet fever. In all
+cases of severe pain in the head, it is a golden rule to inquire most
+carefully as to the possible existence, present or past, of discharge
+from the ear, or other signs of caries of the temporal bone; and, even
+if no positive history of this kind be given, we should still regard
+with great suspicion any case in which there has been scarlet fever
+followed by deafness.
+
+
+
+
+CHAPTER VI.
+
+PAINS OF ALCOHOLISM.
+
+
+A very important class of pains, which are occasionally confounded with
+true neuralgias, are those which occur in certain forms of chronic
+alcoholism. The diagnosis of their true nature is a matter of the utmost
+consequence, and the failure to recognize them for what they are may
+have very disastrous results. It is a curious fact that this consequence
+of chronic alcoholic poisoning has been entirely overlooked by some of
+the best known writers on that affection; it has, however, been
+described by Mr. John Higginbottom, and also by M. Leudet.
+
+It must be clearly understood that the pains of which we are now to
+speak are not among the common consequences of chronic excess in drink.
+The affections of sensation which most usually occur in alcoholism take
+the shape either of anęsthesia, or of this combined with anomalous
+feelings partaking more or less of the character of formication. Chronic
+drinking has also a tendency, in its later stages, when the nutrition of
+the nervous centres has been considerably impaired by the habit, to set
+up true neuralgia, of a formidable type, in subjects who are
+hereditarily predisposed to neuroses. But the affection of which I now
+speak may occur at any stage except the very earliest, and, though often
+severely painful, is essentially different both in its seat and in its
+general characters, from neuralgia proper.
+
+The earliest symptoms from which the patient usually suffers in these
+cases are insomnia, and intense depression of spirits, which, however,
+is not incompatible, indeed is frequently combined, with a morbid
+activity and restlessness of thought. There is generally marked loss of
+appetite, but often there is none of the morning nausea so
+characteristic of the common forms of alcoholism. Nor is there,
+ordinarily, any special unsteadiness of the muscular system. The pains
+are usually first felt in the shoulder and down the spine; but as the
+case progresses they especially attack the wrist and ankles; and it is
+in these latter situations that I have found them to be most decidedly
+complained of. Their similarity to neuralgia consists (_a_) in their
+somewhat paroxysmal character; (_b_) in their frequently recurring at
+about the same hour of the day, most commonly toward night; and (_c_) in
+their special aggravation by bodily and mental fatigue.
+
+Their differences from neuralgia are--(_a_) that they never follow the
+course of a recognizable single nerve; (_b_) that they are nearly always
+present in more than one limb, and usually in both halves of the body,
+at the same time; and (_c_) especially, that they are far less promptly
+and effectually relieved by hypodermic morphia than are the true
+neuralgias; indeed, opiates very frequently only slightly alleviate the
+pain, while they excite and agitate the patient and render sleep
+impossible. On the contrary, a large dose of wine or brandy will never
+fail to procure temporary comfort and induce sleep, at least until the
+patient reaches an advanced stage of the disorder, and is, in fact, on
+the verge of delirium tremens.
+
+I am not quite sure that I am right in believing that there is a special
+physiognomy for this form of chronic alcoholism, and yet I am much
+inclined to believe that there is. All the patients whom I have seen
+suffering with it have presented a peculiar brown sallowness of face,
+and a general harsh dryness of the skin, which has usually lost its
+natural clearness, not only in the face, but even more remarkably in the
+hands, which are so dark-colored as to appear as if they were dirty.
+There is usually considerable leanness of the limbs, and, though the
+abdomen may be somewhat prominent, this does not seem to depend much on
+the presence of fat, but rather on relaxation of the abdominal muscles,
+and sometimes flatulent distention of the stomach and intestines. The
+hands are usually hot, sometimes quite startlingly so.
+
+Some of the patients suffer, besides the pains in the limbs (which they
+often describe as resembling the feeling of a tight band pressing
+severely around the ankles or wrists), from frequent or occasional
+attacks of genuine hemicrania; such a combination is to me always a
+suspicious sign, and induces me immediately to direct my attention to
+the possibility of chronic alcoholic poisoning. Otherwise, the
+limb-pains are often spoken of as resembling rheumatism, but there is no
+swelling of joints, and usually no decided tenderness of the painful
+parts. The patient has usually a particular worn and haggard appearance,
+complains of intense fatigue after the most moderate muscular exertion,
+and is usually utterly indisposed to physical exercise even though the
+mind, as already said, may display a feverish activity.
+
+So far as I have seen, the subjects of this affection are by far the
+most frequently women; and I am inclined to attribute this
+predisposition of the sex not to inherent peculiarities of female
+organization, but to the fact that a much larger proportion of
+intemperate women than of intemperate men indulge in secret excess. They
+never get drunk, probably, but they fly to the relief of alcohol upon
+every trivial occasion of bodily or mental distress; and this habit may
+have been going on for years before it comes to be suspected by their
+friends or their medical attendant. Meantime, they have been more or
+less looked upon, and have looked upon themselves as, "debilitated" and
+"neuralgic" subjects, and have come, either with or without mistaken
+medical advice, to consider free stimulation as the proper treatment for
+the very ailments which have been produced by their own unfortunate
+habits. I cannot avoid the expression of the misgiving, that imperfect
+diagnosis, and consequent erroneous prescription, have done great harm
+in many such cases. It has happened to me no less than three times
+within the last six months to be called to lady patients, all suffering
+from alcoholism induced by a habit of taking stimulants for the relief
+of so-called neuralgic pain; and in the most distressing of these the
+mischief had been greatly aggravated by a prescription of brandy, based
+on the erroneous idea that the pains were truly neuralgic. I have
+already protested against this kind of medication, even in cases that
+are truly neuralgic in character; but it is doubly mischievous where
+given for a state of things which actually depends on alcoholic excess.
+
+It is undoubtedly very difficult, sometimes, to elicit the truth, even
+in cases where we may entertain considerable suspicion that alcoholic
+excesses are the real cause of the pains which the patient calls
+neuralgic; more especially where the patient is aware that he or she is
+taking an amount of alcohol which is seriously damaging to health. And
+it is therefore necessary to look out for every possible additional help
+to our diagnosis. Besides the cardinal features of the disease--the
+insomnia, loss of appetite, foul breath, haggard countenance, and pains
+encircling the limbs near the joints rather than running longitudinally
+down the extremities there are certain moral characteristics of the
+patient that often tells a significant tale. The drinker, especially if
+a woman, is shifty, voluble, and full of plausible theories to account
+for this and the other phenomenon. It will be well to try the effects of
+a somewhat sudden though not uncourteous remark, to the effect that the
+diet should be strictly unstimulating. If this be introduced with some
+abruptness, in the course of a conversation not apparently leading to
+it, the patient's manner will not unfrequently betray the truth; while,
+if our suspicions are groundless, we shall also probably perceive that,
+in the unconscious, or frankly surprised, expression of the countenance.
+We may sometimes derive crowning proof of the existence of alcoholic
+excess by cautious questions which at least reveal the fact that the
+patient suffers from spectral hallucinations; this is a far commoner
+occurrence in chronic alcoholism than is generally supposed; it needs to
+be inquired for with great tact, but, when established beyond doubt, and
+joined to insomnia and the peculiar foul breath, is of itself sufficient
+to establish a positive diagnosis of alcoholic poisoning.
+
+The results of treatment, in true neuralgia and in alcoholic pains,
+respectively, establish an important difference between these
+affections. In the former malady, for instance, the hypodermic injection
+of morphia always produces striking palliative, and very often curative
+effects. In alcoholic pains this remedy either affords only trifling
+relief, or more commonly aggravates the malady by increasing the general
+nervous excitement; and the only true treatment is at once to suspend
+all use of stimulants, to administer quinine, and to insist upon a
+copious nutrition. If any hypnotic must be employed, let it be chloral,
+or bromide of potassium with cannabis Indica. It will be well also to
+put the patient upon a somewhat lengthened course of cod-liver oil.
+There is one special symptom from which the chronic alcoholist often
+suffers acutely, namely a hypersensitiveness to cold; for this I found
+the use of Turkish bath two or three times a week, for three or four
+weeks, very useful in one case that was under my care. It will be
+important to insist that the patient shall take the bath only after that
+shorter method which I have described in speaking of the prophylaxis of
+true neuralgia.
+
+
+
+
+CHAPTER VII.
+
+THE PAINS OF SYPHILIS.
+
+
+Syphilis, as has already been shown in Part I. of this work, may excite
+true neuralgia in subjects already predisposed to the latter. The case
+of Matilda W., previously given, is an example. The pains, however,
+which are now to be described, are those which occur in the ordinary
+course of a constitutional syphilitic infection, and have nothing to do
+with neuralgia proper, from which they should be carefully
+distinguished.
+
+There are two varieties of syphilitic pains proper, which are quite
+distinct. The first kind is represented by the so-called _dolores
+osteocopi_, which occur in the early stages of the constitutional
+affection, coincidently with, or just before, the secondary
+skin-eruptions. The second kind are those which occur in the tertiary
+stage, and are the immediate precursors of the formation of periosteal
+nodes.
+
+It is the first of these varieties of syphilitic pains which is least
+commonly confounded with neuralgia. The pain is referred to the
+superficial bones, of which those most frequently attacked are the
+forehead, sternum, clavicle, ulna, and tibia, pretty much those selected
+for the growth of nodes at a later stage of the disease. Besides the
+bones, the shoulders, elbows, and nape of the neck are attacked
+sometimes simultaneously, sometimes successively. The pains are readily
+controlled by proper treatment; if untreated, their course is very
+uncertain. When they manifest themselves at the outset of the disease,
+they usually cease when the cutaneous eruption is fairly out. Commonly,
+there is no swelling or heat at the painful places; but, when the pains
+are very severe, nodes now and then form at this early period.[52]
+
+These early syphilitic pains, in their violent aching character, and
+their intermittence, occasionally resemble true neuralgia very closely;
+but they are usually distinguished from it by their symmetrical
+disposition and by their attacking several bones at once. Moreover, they
+nearly always show the peculiarity of being distinctly aggravated by the
+warmth and repose of bed even if they be not altogether absent (as is
+not unfrequently the case) when the patient is up and moving about. A
+typical case of this kind is not so likely to be confounded with
+neuralgia as with rheumatism; but we occasionally meet with cases in
+which the pains are localized in a manner much more resembling the
+former. Thus I have met with several instances in which a patient,
+entirely unconscious (or professing to be unconscious) of having been
+syphilized, complained of violent pain in one tibia, recurring every
+night at a certain hour, and at first undistinguishable from that
+variety of sciatica in which the pain is principally felt in this
+situation, especially as it was relieved by firm pressure, just as
+neuralgia is in the early stages. And in one remarkable case, which came
+under my care at Westminster Hospital, the resemblance to clavus was
+most misleading:
+
+H. A., aged nineteen, worker in a laundry, presented herself on account
+of a violent pain in the right parietal region, recurring three times
+daily with great regularity. The first two attacks occurred in the
+day-time, the third, which was always the severest, woke her out of
+sleep about midnight; the pain of this last was so agonizing that on
+more than one occasion she had become delirious. The girl (whose
+respectable appearance was against the notion of syphilis) was very
+anęmic; not, however, with the tint either of anęmic from hęmorrhage, or
+with that of chlorosis, exactly. It was rather a dirty sallowness of
+skin; but the gums and the conjunctivę were exceedingly bloodless, and
+she complained of almost constant noises in the head. Menses scanty but
+regular. There was a soft anęmic bruit with the first sound at the base
+of the heart. Having failed to make any impression on the pains with
+iron and with muriate of ammonia in large doses, I was led to observe
+the fact that there was no diffuse soreness of the scalp, such as very
+commonly occurs in clavus, in the intervals of the pains, and the mere
+fact that there was this unusual circumstance in the case led me to
+reconsider the diagnosis thoroughly. In order to be sure of not omitting
+a point, I inquired, though without any expectation of an affirmative
+answer, as to the possibility of syphilitic disease; the girl at once
+confessed to having had sores, and examination detected a papular rash
+about the shoulders and back and on both thighs. Small doses of mercury
+greatly relieved the pain within a week, and cured it in less than three
+weeks; and it was very remarkable that the anęmia, which had obstinately
+refused to yield to iron, improved at once as the mercury began to
+relieve the pains. The eruption disappeared simultaneously.
+
+It is the later pains of syphilis, however, that are most frequently
+confounded with neuralgia, and occasionally with very disastrous
+results. These pains, which are the precursors of the formation of true
+nodes, frequent the same localities as those affected by the earlier
+pains; they may exist in considerable severity for days, or even for
+many weeks, before any node-formation can be detected. The situation in
+which, of all others, they are likely to be mistaken for neuralgia is
+the scalp or face, especially when a single spot is affected on one
+side, and in the situation of one of the usual foci of trigeminal or
+occipital neuralgia. I have personally known the mistake to be made with
+syphilitic affections causing pain, respectively, in the superciliary
+region, in the malar bone, the jaw near the mental foramen, and the
+parietal eminence.
+
+The possibility of mistaking tertiary syphilitic pain for neuralgia is
+fraught with such grave dangers, that we ought to be constantly and most
+vigilantly on the watch against it. But most especially is this the case
+when the pain is situated in some part of the cranium, as the parietal
+or temporal eminences, the mastoid process, or the prominences of the
+occipital bone. For it must be remembered that the same process, which
+forms syphilitic nodes upon the external surface of bones, or within
+bony canals, can produce them on the lining membrane of the skull, with
+most serious consequences, should the symptoms be neglected or
+misunderstood.
+
+The pains produced by nodes upon the internal surface of the cranium are
+usually of a very intense character, and are mostly continuous, though
+aggravated from time to time, especially at night. Where syphilitic
+inflammation is diffused over a considerable portion of the meninges, it
+is certain very quickly to produce symptoms which can hardly fail to
+apprise us of the gravity of the affection; there will be decided and
+rapidly increasing impairment of memory, and general cloudiness of
+intellect, tending toward complete imbecility, the special senses will
+be greatly interfered with or lost, and muscular paralysis will be
+developed. But in the case of a more limited syphilitic affection of the
+dura mater, pain, of the kind already described, may be for some days
+the only very noticeable symptom. The following is an instance:
+
+J. E., aged forty-seven, a street and tavern singer, applied to me
+(November 14, 1861), on account of severe pain in the right temporal
+region, which had on the whole the character of neuralgia, though rather
+more continuous than such pain usually is. He said that it commenced on
+the 10th, without any particular provocation that he knew of, and that
+it had hardly left him at all from that moment. It kept him awake at
+night, and that circumstance seemed to account sufficiently for a very
+worn and depressed look which he presented; he was otherwise a
+robust-looking man, and at first denied having suffered from any
+previous illness. The pain always came to a climax about one o'clock, A.
+M., waking him out of his first sleep in agony, and allowing him little
+rest for the remainder of the night; toward morning he would drop to
+sleep for an hour or so. There was no particular tender point,
+corresponding to any recognized neuralgic focus, yet the pain was
+limited most strictly to a spot that might be covered with two
+finger-points. There was no lachrymation nor conjunctival congestion,
+and nothing to remark in any way about either eye. The patient was
+ordered quinine in large doses, in the belief that the pain was
+neuralgic. On the following day he reported himself a trifle better,
+though still suffering greatly; and on the afternoon of that day there
+was an almost complete intermission of the pain for several hours; but
+it returned severely at the usual nocturnal period. On the 16th, at 10
+A. M., he came to my house looking exceedingly ill, but the only
+additional symptom that I could detect was a small droop of the right
+eyelid. He was subcutaneously injected with one-fourth of a grain of
+morphia and sent home, where he immediately fell into a heavy sleep that
+lasted till bedtime. He awoke, undressed himself without feeling much
+pain, and got to bed; after an hour or so of dozing he was awakened by
+the pain, which was exceedingly severe. On the 17th he called on me in
+the morning, and I at once perceived that the ptosis of the right eyelid
+was much greater, and the right pupil was much dilated and insensitive,
+and the external rectus was paralyzed; the man also wore a look of
+stupidity, and answered questions with an apparent mental effort. I now
+cross-questioned him more closely; and also explored the tibię and other
+superficial bones: on the sternum a distinct though not very advanced
+node was found. Upon this he was induced to confess that he had suffered
+from chancre three years and a half previously, and subsequently had
+"blotches" on the skin, which had quickly disappeared under treatment,
+of which all that could be learned was, that it was fluid medicine and
+did not make his mouth sore. He was immediately ordered to take two
+grains of calomel in pill, with a little opium, every four hours. He had
+only taken one dose when I was sent for to him, and found him in an
+epileptiform convulsion, in which the left side of the body was almost
+exclusively affected; the convulsions recurred several times during the
+next twenty-four hours, and in the intervals he remained almost
+completely unconscious. The mercurial treatment was pushed, in the form
+of calomel-powders placed on the tongue. On the evening of the 18th he
+began to recover consciousness, and then had a little natural sleep; the
+next morning, at 10 A. M., he was found to be fully conscious, had had
+no return of convulsions, but the left arm and leg, especially the
+latter, were almost entirely powerless; the parietal headache had
+vanished; the gums were slightly tender; the third and sixth nerves of
+right side were completely paralyzed. Mercurial treatment was very
+gently continued, so as to keep the patient on the borders of ptyalism
+for the next three or four days; and he was then put on full doses of
+iodide of potassium. The pain never recurred; the left extremities
+recovered power rapidly; but it was six weeks before the ocular
+paralyses were completely well.
+
+Late in the autumn of 1865 I was sent for hastily one evening to see
+this same man, and found him totally unconscious and apparently again
+hemiplegic, but now on the right side. He was miserably wasted, and
+covered with a rupious eruption; I was informed that he had been leading
+a most debauched and drunken life for some time past, and that, after
+looking extremely ill, and apparently half imbecile for a week or two
+past, he had suddenly fallen down unconscious in the street a few hours
+before I saw him. He remained deeply comatose, and died the next
+morning; no _post mortem_ could be obtained.
+
+The true neuralgias in which syphilis only plays the part of secondary
+factor, and which have been referred to in Part I. of this work, may
+depend for their exciting cause on local syphilitic processes, affecting
+either the peripheral distribution, the main trunk or the central origin
+of a sensory nerve; but I have pointed out the fact that, whatever the
+reason may be, syphilis does but rarely attack the central portions of
+individual sensory nerves, in comparison, with the frequency with which
+it attacks individual motor (cranial) nerves. But without any neuralgic
+predisposition at all, and without any limitation of the syphilitic
+process to a particular sensory nerve, the latter may become neuralgic
+in consequence of being involved in extensive intracranial or
+intra-spinal syphilitic mischief. The trigeminus is liable to suffer in
+this way from spreading syphilitic processes about the base of the
+brain; and my own impression is, that the cause of the neuralgic pain in
+some such cases is the extension of the mischief to the vertebral artery
+of the affected side, leading to interfering with the nutrition of the
+trigeminal nucleus in the medulla. A very interesting case is reported
+by Dr. Hughlings Jackson (who has done so much to acquaint us with
+syphilitic affections of cerebral arteries) in vol. iv. of the "London
+Hospital Reports," pp. 318-321. The patient was a woman, aged
+twenty-seven, and the initial symptoms of the malady which destroyed her
+life were violent trigeminal neuralgic pains on the right side:
+subsequently she had complete paralysis of the fifth, and of the sixth,
+seventh, and eighth nerves of the right side. After death the right
+vertebral artery was found engaged in the mass of syphilitic deposit; it
+must be added, however, that the (superficial) origin of the fifth nerve
+was itself softened, opposite the pons. Another mode in which syphilitic
+disease very probably causes neuralgia of the fifth, in a certain number
+of cases, is by injuring the Gasserian ganglion, upon the integrity of
+which (according to Waller's general law concerning the ganglia of
+posterior nerve-roots) the nutrition of the sensory root of the
+trigeminus materially depends. I have seen an example (as I cannot but
+suppose) of this sequence of morbid events; the evidence appears
+sufficiently complete, although I was unable to obtain a _post mortem_
+examination:
+
+W. M., a house painter, of extremely dissipated habits, but who had
+never suffered either from distinct symptoms of alcoholism, nor from any
+affection traceable to lead-poisoning. In March, 1867, he applied to me
+on account of neuralgic pain, affecting chiefly the right eyeball, but
+also darting along the course of the frontal nerve of that side; after a
+short time it extended also into the infra-orbital nerves. He bore
+several scars of tertiary ulcers about the nose and forehead, and made
+no secret of having suffered from chancre six or seven years before, and
+from subsequent secondary and tertiary symptoms. I was consequently not
+at all surprised at his developing severe iritis (right) after he had
+been a fortnight under my care, although I had from the first given
+large doses of iodide of potassium; but I was not prepared for the
+extensive processes of destruction which followed, notwithstanding that
+I immediately commenced mercurial treatment, and applied atropine. I
+remarked that while the inflammation of the iris proceeded with great
+violence, the cornea was also much more severely affected than is
+usually the case in syphilitic iritis; in fact, the changes closely
+resembled those which have been noted after section of the fifth at the
+Gasserian ganglion, and at the date of the patient's death (seventeen
+days from the commencement of the iritis) a corneal ulcer was on the
+point of perforating. For the first three or four days after the iritis
+set in, the neuralgic pains went on augmenting in intensity, and
+extended into all three divisions of the fifth; there was a copious
+discharge from the right nostril. Almost suddenly, on the fourth day,
+the pains abated and then ceased, and it was now evident that the whole
+surface of the right half of the face was completely anęsthetic. Two
+days later a dark-red patch appeared on the cheek, and in the course of
+the next two days this ulcerated, the ulcer presenting a somewhat livid
+appearance, and exuding a sanious discharge; at the same time,
+superficial ulcers appeared on the right side of the tongue, and
+coalesced to form one large sore. The sores both on cheek and tongue
+assumed more and more a gangrenous appearance, and on the sixteenth day
+from the commencement of iritis there was considerable loss of substance
+in both these situations. On the evening of this day (the patient having
+become extremely depressed and much emaciated) general epileptiform
+convulsions set in, and followed each other rapidly; in a few hours coma
+supervened, and the patient sank the next day. No _post mortem_ could be
+obtained; but it seems extremely probable, from the above history, that
+the Gasserian ganglion was early involved in the syphilitic
+inflammation, and that the neuralgia and subsequent anęsthesia, the
+iritis, and the other trophic lesions, were due to the injury inflicted
+upon it.
+
+The treatment of syphilitic pains will, in doubtful cases, often give us
+valuable assurance of the correctness of our diagnosis. Where the
+disease is extensively diffused, we may fail to do any good; but, in
+cases where the syphilitic mischief is limited to a small portion of the
+meninges, we may often arrest it. In all merely suspicious cases, where
+the pain is thus limited, it will be well to use iodide of potassium
+tentatively--forty to sixty grains daily. But, where the pains are very
+severe and continuous, and there is danger to the integrity of the eye,
+or threatenings of a paralytic attack are observed, it is better not to
+trust to anything short of mercury, used in such a manner as just to
+stop short of absolute ptyalism. In very bad cases, like the last one
+narrated, we may fail to produce any good effect, but, where the
+specific treatment is commenced in good time, we may not unfrequently
+succeed in arresting the symptoms with a rapidity that assures us of the
+correctness of the diagnosis of syphilis.
+
+FOOTNOTE:
+
+[52] Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.
+
+
+
+
+CHAPTER VIII.
+
+PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.
+
+
+So firmly is the idea of an essential connection between rheumatism and
+neuralgia implanted in the popular mind, and, indeed, in the minds of a
+certain portion of the medical profession, that the two complaints are
+continually confounded. In the great majority of instances, the mistake
+made is that of calling neuralgia a "rheumatism." But the opposite error
+occasionally occurs, and a patient is styled "neuralgic" who is really
+suffering from chronic rheumatism.
+
+As true neuralgia is an essentially localized disease, there can be no
+excuse for mistaking for it the more typical cases of chronic
+rheumatism, in which a number of different joints, muscles, or tendons,
+are affected, more especially in the advanced stages, when the
+characteristic fixed contractions of the limbs and extremities have
+occurred. But there are a few cases in which, either with or without a
+previous history of acute rheumatism, one, or perhaps two, joints begin
+to suffer vague pains, which after a little time begin to shoot down the
+course of the limb, and are aggravated from time to time in a manner
+which superficially much resembles neuralgia; and when the malady has
+reached a certain intensity the pains may be so much more severely felt
+in the longitudinal axis of the limb than in the immediate neighborhood
+of a joint, that the patient forgets that in reality they commenced
+either within a joint (as the elbow or hip), or in the fibrous
+structures immediately outside it. Certain localities are much more
+frequently the seat of this kind of affection than other parts of the
+body; thus it occurs, perhaps in nine-tenths of the cases, in the
+neighborhood either of the shoulder (especially involving the insertions
+of the deltoid and triceps muscles), of the elbow (particularly
+affecting the tendinous insertions of the muscles on the internal aspect
+of the forearm), or the hip (extending to the aponeuroses on the outer
+and back part of the thigh): in all these cases there is a considerable
+superficial resemblance to true neuralgic pains. Nevertheless, the
+diagnosis need not present any serious difficulties after the earliest
+stages; for there soon arises a very diffuse and acute tenderness of the
+parts, and usually an amount of generalized swelling, which, though it
+may not be readily detectable by the eye, is sensible enough to the
+touch. Movement of the parts is also very painful; but usually not with
+the acute and agonizing pain which occurs in myalgia.
+
+It is, however, upon signs which are of a more general character that we
+ought chiefly to rely for diagnosis. The fact that the patient has
+previously experienced a genuine attack of acute rheumatism, though of
+some value, is by no means to be taken as a conclusive argument that the
+present attack is of a rheumatic nature. The really important matter is,
+that whether the patient has or has not suffered acute rheumatism before
+the occurrence of the subacute or chronic form, the latter will always
+be attended by more or less of the specific constitutional disturbance
+of rheumatism. I would carefully abstain from the assumption that
+rheumatism is originally dependent on a blood-poisoning, a theory which
+I believe to be most doubtful and very probably false; but there is,
+nevertheless, a truly specific character about the general phenomena in
+acute rheumatism, and I maintain that similar though less-marked
+phenomena are always to be seen even in the mildest and least acute
+forms of rheumatism. Thus there will be, invariably, more or less of the
+peculiar sallow anęmia, together with red flushing of the cheeks when
+the pain is at the worst; and there will be a certain amount of the oily
+perspiration which makes the faces of rheumatic patients look shiny and
+greasy. No doubt these characteristics will sometimes be very slightly
+developed, but I believe that attentive observation will always discover
+them in any case which is genuinely rheumatic. One case, in particular,
+which has been under my care, very strongly impresses me with the value
+of these diagnostic signs, where otherwise the symptoms are obscure:
+
+L. P., aged thirty-one, single, a printer by trade, applied to me,
+January, 1863, suffering from what I at first decidedly thought was
+cervico-brachial neuralgia, the pain having followed exposure to cold
+and wet, situated in the lower part of the neck, the shoulder, elbow and
+inner side of the right arm, and existing nowhere else. The character of
+the pain was described as at least remittent, if not distinctly
+intermittent. The pulse was not more than 78; the tongue was thickly
+coated with white fur, but the man did not complain of thirst, and there
+were no evident signs of fever. As the pains had only existed for about
+a fortnight, it appeared an excellent case for cure by the hypodermic
+injection of morphia; and, accordingly this was used in quarter-grain
+doses twice a day. After about ten days an attempt was made to do
+without the morphia, but the pains returned, worse than before, and
+meantime the tongue had remained uniformly coated, and was now very
+yellow; the appetite was bad, and there was some increase in frequency
+of pulse. It now struck me, for the first time, that the man presented,
+in a slight degree, the sallow and red tint and oily features of a
+rheumatic patient; it was now found that sweat and urine were distinctly
+acid. Acting on this idea, I administered five grains of iodide of
+potassium, and thirty grains of bicarbonate of potassium, four times
+every twenty-four hours, after giving a moderate saline aperient. The
+result was manifest improvement within twenty-four hours, and almost
+complete relief of the pain within three or four days (the urine never
+becoming distinctly alkaline, however.) As the attack subsided, the oily
+appearance of the skin disappeared, and the rheumatic tint was replaced
+by mere ordinary pallor, which the patient lost after taking a short
+course of steel.
+
+At the time this case occurred to me, I was not aware of the importance,
+in doubtful instances, of looking to the temperature; but subsequent
+experience has convinced me that in every truly rheumatic case, however
+limited in extent, there is a real, though it may be a small, rise of
+temperature. The thermometer will be found to mark from 99-1/4° to 100°
+Fahr., and this, joined with the appearances above mentioned, and a
+strong acidity of urine, will be sufficient to distinguish the complaint
+as rheumatic; and the striking effect of such remedies as iodide with
+bicarbonate of potash, followed up with sesquichloride of iron, in full
+doses, helps still further to distinguish the cases from true
+neuralgias. Since the introduction of the full doses of the
+iron-tincture in the treatment of acute rheumatism, I have had the
+opportunity of treating two of these cases of subacute rheumatism in the
+same manner, viz., with the iron from the first, and the results have
+been most satisfactory in every way. These cases were independent of a
+much larger number, treated in the same way, in which the symptoms of
+rheumatism were more generalized and more severe.
+
+
+
+
+CHAPTER IX.
+
+PAINS OF LATENT GOUT.
+
+
+Pains which are connected with a chronic and more or less latent form of
+gout not unfrequently receive the designation "neuralgic," and are
+treated upon that erroneous theory of their pathology. I have already
+endeavored to show that there is by no means that intimate causal
+relation between gout and neuralgia which is very commonly assumed to
+exist: true neuralgia is, I believe, only caused in an indirect and
+secondary manner by the gouty condition setting up changes of the
+blood-vessels, which precipitate the occurrence of the neuralgic malady,
+to which the patient was otherwise predisposed from birth. But the
+common idea, both without and within the profession, seems to be that
+neuralgia is only one expression, and that a quite common one, of the
+gouty habit. Nevertheless, with strange inconsistence, the kind of truly
+gouty pains of which I am now speaking are constantly treated upon a
+special plan, upon the supposition that they are neuralgic.
+
+There are six situations in which gouty pains are apt to be developed in
+a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2)
+more indefinitely within the cranium; (3) in the stomach, simulating
+gastralgia; (4) in the chest, simulating angina pectoris; (5) in the
+dorsum of the foot, simulating neuralgia of the anterior tibial nerve;
+(6) in a somewhat diffuse manner about the hip and back of thigh,
+simulating sciatica.
+
+It is not really a common thing to find such cases very difficult of
+diagnosis, provided that the possibility of their occurrence has been
+carefully noted; for the gouty habit has a number of slight
+manifestations which are usually enough to discover it even when its
+more decided symptoms are entirely wanting.
+
+Thus, in the first place, it will be almost invariably found, on
+inquiry, that the patient has always been intolerant of beer and of
+sweet wines. Also, he has been liable (either after a single large
+excess in eating or a prolonged course of a diet too highly animalized
+in proportion to the amount of exercise taken) to attacks of general
+malaise, with or without uneasiness, just short of decided pain, about
+the metacarpo-phalangeal joint of the great-toe, and ending after a few
+hours or days with a free discharge of uric acid. Less frequently, but
+still very often, it will be found that he has some deposit of lithate
+of soda (chalk-stone) in some situation where its presence does not
+necessarily arrest attention; Dr. Garrod has shown how often these
+little tophi are found in the cartilage of the ear. Careful examination
+will sometimes detect their presence in the sclerotic of the eye. But in
+doubtful cases it would be always well to make a cautious trial of
+colchicum, which, if the case be gouty, will nearly always produce an
+amount of relief sufficient to confirm the diagnosis of gout. At least,
+this rule holds goods for the external forms; but in the case of the
+supposed gouty pseudo-angina it is far best to trust to opium, as
+colchicum may prove too depressing to a heart which may quite possibly
+be already the subject of organic disease. My own impression is, that it
+was these cases of gouty heart-pain, which are not true angina at all,
+that procured for opium its high reputation for relieving the latter
+disease, a reputation which is by no means confirmed by my own
+experience, since I have found that drug enormously inferior to
+stimulants like ether in its power to relieve genuine angina.
+
+Lastly, if there be no other possibility of making ourselves certain
+whether there is or is not a gouty taint at the bottom of the
+quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the
+serum of the blood to a search for uric acid (thread-test).
+
+
+
+
+CHAPTER X.
+
+COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.
+
+
+Colic, or painful half spasm, half paralysis of the large intestines, is
+the best example of a kind of spasmodic pains to which some authors
+accord the name of neuralgia, as it seems to me without good reason.
+They appear to be quite independent of the operation of the neurotic
+temperament, and to be caused entirely by the operation of some local
+irritant, or narcotic irritant, upon the muscular fibres of the viscus.
+In the case of colic this influence is most frequently and most
+powerfully exerted by lead, which undoubtedly becomes locally deposited
+in chronic poisoning with that metal; at other times it is produced by
+the irritation of indigestible food passing along the alimentary canal.
+
+That there may be such a thing as enteralgia, of really neuralgic
+character, I do not deny; on the contrary, so far as regards the rectum,
+I have myself seen such a case. But true neuralgia of the large bowel is
+exceedingly uncommon; what goes by the name is usually either colic from
+local irritation of the viscus; or a mere hysterical hyperęsthesia of
+the lining membrane, which is one of the occasional phenomena of spinal
+irritation; or else it is a case of neuralgia of the abdominal wall,
+such as is included in the description of "lumbo-abdominal neuralgia,"
+in Part I. of this work.
+
+There is no occasion to describe minutely the symptoms of so familiar a
+disease as lead-colic, or as colic from irritation by indigestible food,
+when they occur in their typical forms. In the former case the marked
+constipation which ushers in the attack of pain, and the peculiar
+greenish-yellow sallowness nearly always seen in the countenance, ought
+to be sufficient to direct examination to the gums (for the blue line)
+and inquiry as to any possible impregnation of the system with lead,
+owing either to the nature of the patient's occupation, or to some
+accidental entry of the poison into the drinking-water, or its
+inhalation from the walls of newly-painted rooms, etc. In the latter
+case, the fact that the attack of colic was shortly preceded by a meal,
+either of obviously indigestible food, or too copious in quantity and
+heterogeneous in kind, or too hastily eaten without sufficient
+mastication, supplies a clew.
+
+But there are a few cases representing minor degrees of either of these
+kinds of colic, that are much less easy to diagnose distinctly.
+
+Lead-poison sometimes enters the system continuously, for a long period,
+but in proportions too minute to produce the effects which we identify
+as an attack of lead-colic. I believe that for the production of the
+latter complaint it is necessary that the poisoning shall be
+sufficiently intense completely to paralyze a considerable piece of
+bowel, thus altogether hindering peristalsis, or, rather, making the
+peristaltic acts of the non-paralyzed portions above worse than
+fruitless. But there is a minor degree in which it may happen that the
+local affection (owing, I believe, to a less extensive deposit of lead
+in the bowel) does not reach the decidedly paralytic stage; the state
+then is one of irregular and painful spasm of individual fibres (quite
+possibly intermingled with paralysis of a few others), and the practical
+result is irregularity of evacuation--now diarrhoea, and again
+constipation--and the frequent recurrence of twinges of pain that are
+easily mistaken for abdominal neuralgia. Such symptoms as these are
+nearly always found to have occurred, if proper inquiry be made, in
+those examples of chronic lead-poisoning in which the toxic process goes
+on to the development of epilepsy, or marked symmetrical paralysis of
+the wrist-extensors, without the patient having ever suffered an attack
+of ordinary colic. In these slow and insidious cases the constitutional
+affection may not have reached the height at which the complexion and
+general aspect of the patient suggests metallic poisoning: and the case
+may present very neuralgia-like features. The absence of the _points
+douloureux_ is not, as we have seen, conclusive against neuralgia in its
+early stages. It is therefore an excellent rule, in all cases of chronic
+recurrent spasmodic pain in the abdomen, especially in men, to
+investigate the possibilities of lead-poisoning; and, if the slightest
+suspicious appearance of the gums be found, this track of inquiry must
+be followed up exhaustively before we abandon the idea. The absence of
+all special neurotic history in a patient's family should increase our
+suspicions respecting pains of this character that continue with an
+obstinacy which makes it unlikely they are due to improper food.
+
+Pains of abdominal irritation are, however, without doubt produced in
+some cases by unsuspected faults of diet, and may even recur in such a
+quasi-periodic manner as to strongly suggest the idea of neuralgia in
+the lumbo-abdominal nerve. One special variety of this happens, I
+believe, much more often than is thought. A patient will habitually take
+considerable quantities of some article of food which he does not
+readily digest, but which is not at all acutely irritant: under these
+circumstances a simple accumulation is apt to take place in the colon,
+especially at the top of the ascending colon, the top of the descending
+colon, or just above the sigmoid flexure, or else in the cęcum. The
+result of accumulation in the last of these places is not unfrequently
+typhlitis and perityphlitis, this part of the bowel having (for some
+reason) a special tendency to inflammation. Deposits in the other
+localities named are rarely the cause of inflammation, but they very
+frequently give rise to violent pain, which is exceedingly apt to be
+taken for the pain either of gall-stone, of renal calculus, or else of
+some abdominal neuralgia. In cases, therefore, where there is any
+possibility that accumulation is the cause of pain, it is highly
+desirable to commence with a dose of castor-oil and laudanum, followed
+up, if needful, by the administration of a large warm-water enema, given
+through an O'Beirne's tube. The most violent and recurrent attacks of
+pain in the renal region, the flank, the abdomen, or the groin, will
+sometimes be instantly cured by such means, sufficiently proving the
+non-neuralgic character of the complaint.
+
+I have elsewhere explained that the impaction of a renal or an hepatic
+calculus, in the ureter or the ductus choledochus, may set up a true
+neuralgia in persons with the requisite congenital predisposition. The
+passage of renal or hepatic calculi may give rise to symptoms falsely
+suggesting neuralgia, which require just to be mentioned here. But there
+is no need to dwell much upon the diagnosis, for the passage of renal or
+hepatic calculi has always attendant symptoms and features of
+constitutional history, which ought to preserve the physician from
+mistake. The sensation of constriction, of nausea and vomiting, the
+faintness approaching to collapse, the persistent and constantly
+increasing severity of the pain up to the moment at which mechanical
+relief occurs, to say nothing of other phenomena, are distinctive to the
+skilled observer, and, when taken in conjunction with the history of
+past attacks, if any, will always prevent mistakes. In the few cases
+which might still be doubtful it will be well to try the effect of a
+relaxing dose of chloroform, which, in the case of calculus, will often
+put an end to the paroxysm at once and finally.
+
+
+
+
+CHAPTER XI.
+
+DYSPEPTIC HEADACHE.
+
+
+A final word or two must be given to the distinction between neuralgia
+of the head and an affection so utterly different that it is surprising
+that they should be so frequently confounded. One constantly hears
+medical men speak of "sick headache" (migraine) as if it were the same
+thing as headache from indigestion; and, unfortunately, they often treat
+migraine upon this confused and erroneous notion, doing no little
+mischief thereby.
+
+But, although migraine, already amply described, is entirely independent
+of the state of digestion, and its stomach-phenomena are purely
+secondary to the affection of the fifth nerve, there is a kind of
+headache really dependent on imperfect digestion. The sufferers from
+these headaches are dyspeptics whose stomach troubles are the result of
+chronic gastric catarrhal inflammation. (In the acute form of gastric
+catarrh there are even more severe headaches; but the general symptoms
+of the disorder are too marked to allow us to mistake the case for
+neuralgia complicated with secondary stomach disturbance.) The patients
+in question have frequently passed so gradually into the dyspeptic
+condition as to have become accustomed to it, and inclined to forget
+that the stomach was the organ which first gave them annoyance. The
+headaches, which occur from time to time, are either frontal or (more
+frequently) occipital in position, and they are usually quite evenly
+bilateral; still, there is not enough uniformity of difference between
+them and true migraine, in this respect, to enable us to establish a
+decided diagnosis upon it. This much may be said, however: that the pain
+is rarely or never seated in one parietal region, as is frequently the
+case with migraine and with clavus. The patient suffers very strikingly,
+in almost every case, from languor and a feeling of inability to exert
+himself; and has also much aching pain in the limbs, and usually a pain
+(sometimes very severe) in the scapular region. The tongue may vary a
+good deal in appearance, especially as regards the degree of general
+redness; but it always has enlarged papillę, most prominent toward the
+tip, and more or less thick furring at the back, and reaching forward,
+in some cases, nearly to the tip, to which the "strawberry" aspect is
+then confined. The headache is frequently joined with nausea, but never
+with absolute vomiting, unless the stomach has been provoked with a meal
+that gives it more trouble than usual. The desponding frame of mind
+which this kind of dyspeptics always exhibit distinguishes them, in most
+cases, quite sufficiently (together with the unwholesome complexion, the
+appearance of the tongue, and the great complaints of general malaise
+and aching and feebleness of the limbs) from the victims of migraine,
+who are often persons of bright spirits and lively intelligence in the
+intervals of their attacks; but, above all, there is nothing of the
+regular and characteristic sequence of events which distinguishes the
+attacks of migraine. The attacks are not periodic, but nearly always
+depend on some chance dietary indiscretion, or other imprudence, which
+has visibly aggravated the stomach irritation. And, when the pain does
+come on, it has no uniform tendency to go on intensifying for some hours
+and culminate in vomiting, followed by sleep, after which the patient is
+free. On the contrary, the digestive disturbance is the provocation, and
+the pain itself is of a heavy character, with a sense of tension or
+fulness, and it does not go on intensifying in a regular manner, up to a
+climax, but hangs about in a dull, tormenting way, and frequently is
+just as bad after sleep as it was before. The diagnosis of these
+headaches from neuralgic headache is not really difficult; it only
+requires the use of a fair amount of caution in observation. It would,
+however, be exceedingly advantageous that the word "sick-headache"
+should be dropped altogether, and that migraine should always be called
+by that name (or "megrim," if you will), and that headaches really
+proceeding from chronic catarrhal disease of the stomach should be
+called "dyspeptic" headaches. The present state of nomenclature does
+much to perpetuate a confusion of ideas which ought not to exist any
+longer, and which leads to much practical mischief.
+
+       *       *       *       *       *
+
+Transcriber's Notes:
+
+Punctuation and spelling errors fixed. Variant spellings and
+hyphenations changed when there is a clear majority. Other unusual
+spellings retained.
+
+Discrepancies in headings and outline labels repaired. In some cases,
+this required adding headings implied but not present in the original,
+to agree with headings that were present.
+
+Table of Contents, Part 1, Chapter IV: original reads "DIAGNOSIS AND
+PROGRESS OF NEURALGIA." "PROGRESS" has been corrected to "PROGNOSIS" as
+shown in the Chapter heading.
+
+P. 51, "but her mensural troubles" changed to "but her menstrual
+troubles".
+
+P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat."
+"Chim." is typo for "Chir." as in footnote just above.
+
+P. 96, "investigation of neralgi" changed to "investigation of
+neuralgia".
+
+P. 105, "genealogical connection between migraine and epilepsy": in all
+reviewed copies of this 1882 edition, original shows "aological" with 4
+or 5 spaces in front of it, an apparent printer error. However, in the
+1872 edition, the entire sentence reads as presented here.
+
+P. 206, "I have already causually" changed to "I have already causally".
+
+
+
+
+
+End of the Project Gutenberg EBook of Neuralgia and the Diseases that
+Resemble it, by Francis E. Anstie
+
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+      The Project Gutenberg eBook of Neuralgia and the Diseases That Resemble It, by Francis E. Anstie, M.D.
+    </title>
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+<pre>
+
+The Project Gutenberg EBook of Neuralgia and the Diseases that Resemble it, by 
+Francis E. Anstie
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Neuralgia and the Diseases that Resemble it
+
+Author: Francis E. Anstie
+
+Release Date: October 1, 2011 [EBook #37592]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT ***
+
+
+
+
+Produced by Bryan Ness, JoAnn Greenwood and the Online
+Distributed Proofreading Team at https://www.pgdp.net (This
+file was produced from images generously made available
+by The Internet Archive/Canadian Libraries)
+
+
+
+
+
+
+</pre>
+
+<p><span class="pagenum"><a name="Page_1" id="Page_1">[1]</a></span></p>
+
+
+
+<h1>
+NEURALGIA</h1>
+<div class="bigskip"></div>
+<h3>AND</h3>
+<div class="bigskip"></div>
+<h1>THE DISEASES THAT RESEMBLE IT.</h1>
+<div class="hugeskip"></div>
+<h3>BY</h3>
+
+<h2>FRANCIS E. ANSTIE, M.D., <span class="smcap">London</span>,</h2>
+<div class="center"><p>FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S
+COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER
+HOSPITAL; LECTURER ON MEDICINE IN WESTMINSTER
+HOSPITAL SCHOOL; PHYSICIAN TO THE BELGRAVE
+HOSPITAL FOR CHILDREN.</p></div>
+
+<div class="medskip"></div>
+
+<div class="figcenter" style="width: 150px;">
+<img src="images/shield-logo.png" width="150" height="200" alt="shield logo" title="" />
+</div>
+
+<h4>NEW YORK:<br />
+BERMINGHAM &amp; CO., UNION SQUARE.<br />
+1882.</h4>
+<div class="bigskip"></div>
+<hr style="width: 85%;" />
+<p><span class="pagenum"><a name="Page_2" id="Page_2">[2]</a></span></p>
+
+<h5><span class="smcap">W. L. Mershon &amp; Co.</span>,<br />
+<i>Printers, Electrotypers and Binders</i>,<br />
+<span class="smcap">Rahway, N. J.</span></h5>
+
+
+
+<hr style="width: 85%;" />
+<p><span class="pagenum"><a name="Page_3" id="Page_3">[3]</a></span></p>
+
+<h2>PREFACE.</h2>
+
+
+<p><span class="smcap">I believe</span> it will not be disputed that there was considerable
+need for an English treatise dealing rather fully with the subject
+of Neuralgia, and therefore I hope that the profession will
+be willing to give me a hearing. The present work, moreover,
+does not profess to be a mere compilation of standard authorities
+corrected down to the present time, but puts forward a substantially
+new view of the subject&mdash;at least, a view that has
+been only briefly sketched by me in an article that appeared,
+three years ago, in Reynolds's "System of Medicine." My
+principal object, in writing this volume, was to vindicate for
+Neuralgia that distinct and independent position which I have
+long been convinced it really holds, and to prove that it is not
+a mere offshoot of the Gouty or Rheumatic diatheses, still less
+a mere chance symptom of a score of different and incongruous
+diseases. In order to set the diagnosis of true Neuralgia from
+its counterfeits in the clearest light, it seemed advisable to draw
+separate pictures of each of the latter (at least of as many as
+are of real importance) and present them separately, as a kind
+of gallery of spurious neuralgias, and this I have done in the
+second part of the volume. No one who had not tried to do it
+would imagine how difficult this latter kind of work is. It was
+necessary for the sketches to be very brief (unless my book was
+to become unmanageably large), and yet to be as truthfully
+characteristic as possible; and it was necessary also that only
+those diseases which so much resemble Neuralgia as practically
+to lead medical men astray in diagnosis, should be dealt with.
+The selection of the subjects, and the execution of this part,
+took a long time, though it only covers about fifty pages. Then,
+as regards Neuralgia itself, it became necessary to completely
+recast the chapters on "Pathology" and on "Complications,"
+on account of some of the polite criticisms which Dr. Eulenburg
+directed (in his recent "Lehrbuch der Nervenkrankheiten")<span class="pagenum"><a name="Page_4" id="Page_4">[4]</a></span>
+to my argument in the article above referred to, since
+it was obvious that a too brief statement of my views had
+caused them to be partially misunderstood by the German physician.
+These chapters (Part I., Chapters II. and III.) are
+certainly the most important portion of my book, and I would
+particularly direct attention to them, in order that their contents
+may be affirmed or corrected: the reader will at any time
+find that they contain a kind of investigation never before systematically
+carried out with regard to Neuralgia. The causes
+above mentioned, together with others over which I had no
+control, have kept back the appearance of this work so long
+beyond the date for which it was originally announced, that I
+feel I ought to apologize for an amount of delay that would
+seem hardly justified by the moderate size of the volume.</p>
+
+<p><span class="smcap">16 Wimpole Street, London</span>, <i>October</i> 1, 1871.</p>
+
+
+
+<hr style="width: 85%;" />
+<p><span class="pagenum"><a name="Page_5" id="Page_5">[5]</a></span></p>
+<h2>CONTENTS.</h2>
+
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="right"></td><td align="left"><br /><a href="#intr">INTRODUCTION&mdash;ON PAIN IN GENERAL</a></td><td align="right"><br />7</td></tr>
+<tr><td align="right"></td><td align="center"><br /><br />PART I.</td></tr>
+<tr><td align="right"></td><td align="center"><i>ON NEURALGIA.</i></td></tr>
+<tr><td align="right"><span class="smcap">Chap.</span></td><td align="left"></td><td align="right"><span class="smcap">page</span></td></tr>
+<tr><td align="right">I.</td><td align="left"><a href="#clin"><span class="smcap">Clinical History</span></a></td><td align="right">12</td></tr>
+<tr><td align="right">II.</td><td align="left"><a href="#comp"><span class="smcap">Complications of Neuralgia</span></a></td><td align="right">79</td></tr>
+<tr><td align="right">III.</td><td align="left"><a href="#path"><span class="smcap">Pathology and Etiology of Neuralgia</span></a></td><td align="right">96</td></tr>
+<tr><td align="right">IV.</td><td align="left"><a href="#diag"><span class="smcap">Diagnosis and <ins title="Transcriber's Note: Original reads 'Progress'">Prognosis</ins> of Neuralgia</span></a></td><td align="right">142</td></tr>
+<tr><td align="right">V.</td><td align="left"><a href="#trea"><span class="smcap">Treatment of Neuralgia</span></a></td><td align="right">149</td></tr>
+<tr><td align="right"></td><td align="center"><br /><br />PART II.</td></tr>
+<tr><td align="right"></td><td align="center"><i>DISEASES THAT RESEMBLE NEURALGIA.</i></td></tr>
+<tr><td align="right"><span class="smcap">Chap.</span></td><td align="left"></td></tr>
+<tr><td align="right">I.</td><td align="left"><a href="#myal"><span class="smcap">Myalgia</span></a></td><td align="right">196</td></tr>
+<tr><td align="right">II.</td><td align="left"><a href="#spin"><span class="smcap">Spinal Irritation</span></a></td><td align="right">200</td></tr>
+<tr><td align="right">III.</td><td align="left"><a href="#hypo"><span class="smcap">The Pains of Hypochondriasis</span></a></td><td align="right">207</td></tr>
+<tr><td align="right">IV.</td><td align="left"><a href="#loco"><span class="smcap">The Pains of Locomotor Ataxy</span></a></td><td align="right">210</td></tr>
+<tr><td align="right">V.</td><td align="left"><a href="#cere"><span class="smcap">The Pains of Cerebral Abscess</span></a></td><td align="right">213</td></tr>
+<tr><td align="right">VI.</td><td align="left"><a href="#alco"><span class="smcap">The Pains of Alcoholism</span></a></td><td align="right">215</td></tr>
+<tr><td align="right">VII.</td><td align="left"><a href="#syph"><span class="smcap">The Pains of Syphilis</span></a></td><td align="right">218</td></tr>
+<tr><td align="right">VIII.</td><td align="left"><a href="#suba"><span class="smcap">The Pains of Subacute and Chronic Rheumatism</span></a></td><td align="right">225</td></tr>
+<tr><td align="right">IX.</td><td align="left"><a href="#late"><span class="smcap">The Pains of Latent Gout</span></a></td><td align="right">227</td></tr>
+<tr><td align="right">X.</td><td align="left"><a href="#coli"><span class="smcap">Colic, and other Pains of Peripheral Irritation</span></a></td><td align="right">229</td></tr>
+<tr><td align="right">XI.</td><td align="left"><a href="#dysp"><span class="smcap">Dyspeptic Headache</span></a></td><td align="right">231</td></tr>
+</table></div>
+<p><span class="pagenum"><a name="Page_6" id="Page_6">[6]</a></span></p>
+
+
+
+
+
+<hr style="width: 65%;" />
+<p><span class="pagenum"><a name="Page_7" id="Page_7">[7]</a></span></p>
+<h2><a name="intr" id="intr"></a>INTRODUCTION.</h2>
+
+<h3>ON PAIN IN GENERAL.</h3>
+
+
+<p>Although it is, in a general way, unadvisable to introduce
+abstract discussions into a treatise which should be strictly
+practical, it is almost impossible to avoid some few general
+reflections on the physiological import of Pain, as a preliminary
+to the discussion of the maladies which form the subject
+of this volume. This whole group of disorders is linked together
+by the fact that pain is their most prominent feature;
+and, with regard to most of them, the relief of the pain is the
+one thing required of the physician. It seems, therefore, very
+important that we should ascertain, at least approximately, in
+what the immediate state consists, which consciousness interprets
+as pain. It is not necessary to enter at this stage into
+any inquiry as to the pathological causes of the phenomenon;
+what we know of these, and it is unfortunately too little, will
+be discussed in detail under the headings of the several affections
+which I shall have to describe.</p>
+
+<p>The question before us now is this: What is that functional
+state of the nerves which consciousness interprets as pain? Is
+it, or is it not, an exaltation of the ordinary function of sensation?</p>
+
+<p>The latter question is generally answered affirmatively,
+without much thought, by those to whom it casually occurs;
+but indeed there is plenty of prescriptive authority for so dealing
+with it. Pain has been described by some of the most distinguished
+writers on nervous diseases as a hyperęsthesia.
+Yet there is really little difficulty in convincing ourselves, if
+we institute a thorough inquiry into the matter, that pain is
+certainly not a hyperęsthesia, or excess of ordinary sensory
+function, but something which, if not the exact opposite of
+this, is very nearly so.</p>
+
+<p>The leading fallacy in the common view is the confusion
+which is perpetually being made between function and action.
+Now, the function of individual nerves is very nearly a constant
+quantity, at least, it varies only within narrow limits;
+while the action of the same nerves may be almost any thing.
+The function of the nerve is that kind of work for which it is
+fit when its molecular structure is healthy; it is the series of<span class="pagenum"><a name="Page_8" id="Page_8">[8]</a></span>
+dynamic reactions which are necessarily produced in nerve-tissue
+by the external influences which surround and impinge
+upon it in the conditions of ordinary existence. The action of
+nerves, under the pressure of extraordinary influences, may
+include all manner of vagaries which really have nothing in
+common with the effects of ordinary functional stimulation;
+which are, in fact, nothing but perturbation. No one can
+suppose, for instance, that the explosive disturbances of nerve-force
+which give rise to the convulsions of tetanus are any
+mere exaggerated degree of the orderly and symmetrical action
+by which the healthy nerve responds to the stimulus of volition
+ordering a given set of muscles to contract; they are something
+quite different in kind. And so it is with the sensory
+nerves. The functions of these conductors, in health, is to
+convey to the perceptive centres the sensations, varying only
+within a most limited range, which correspond to a state of
+well-being of the organs, and which excite only those reflex
+actions that are necessary to life. Thus the large surface of
+sensitive nerve terminals which is represented by the collective
+peripheral branches of the fifth cranial conveys to the medulla
+oblongata an impression, derived from the temperature and
+movement of the surrounding air, when the latter is neither
+too hot nor too cold, which imparts to the brain a perception
+of comfortable sensations, and excites in return the reflex
+action of breathing, which is necessary to life. But the impression
+produced on this same peripheral expanse of nerve-branches
+by prolonged exposure to cold wind may, and often
+does, convey to the centres sensations which are quite different
+and provokes reflex movements which are altogether abnormal.
+Pain is the product in one direction; sneezing, perhaps, in the
+other. It seems absurd to say that sneezing is any part of the
+function of those motor nerves whose action regulates the performance
+of expiration. And it appears to me not less absurd
+to say that pain is the function of the sensitive fibres of the
+trigeminus. But the best way, perhaps, to illustrate the looseness
+and incorrectness of applying the term "hyperęsthesia"
+(implying exalted function) to the state of sensitive nerves
+when suffering pain, is to examine the condition of distinctive
+perception in the very same parts to which the painful nerves
+are distributed. It will invariably be found, as we shall have
+occasion to see more fully proved hereafter, that, in parts
+which are acutely painful, a marked bluntness of the tactile
+perceptions can be detected. The tactile perceptions are, no
+doubt, conveyed by an independent set of fibres from those
+which convey the sense of pain.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> Yet it is surely impossible
+to believe the effect of the same influence, in functional power
+can be different&mdash;much more than it can be exactly opposite&mdash;in
+the two cases.</p>
+<p><span class="pagenum"><a name="Page_9" id="Page_9">[9]</a></span></p>
+<p>If pain be not a heightening of ordinary sensation, then we
+seem to be shut up to the idea that it is a perversion owing to
+a molecular change of some part of the machinery of sensation
+which frustrates function. For it is to be observed that, while
+the sensations conveyed by the healthy nerve are correct in
+the indications which they afford to the percipient brain, the
+indications given by pain are vague and untrustworthy, and
+often seriously misleading. Not to speak of the nerves of special
+sense, or of the fibres which convey the sensations of muscular
+movement, even the nerves of common sensation do carry
+to the internal perception, in health, a distinct impression of
+the well-being of the organs to which they are distributed. Mr.
+Bain<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> has well pointed out the positive character of this feeling,
+which is so often incorrectly referred to as if it were a
+mere negation of feeling. It is a sensation of equable and diffused
+comfort, if I may be allowed to use the expression, which
+streams in from all parts of the organism; and there is no
+possibility of comparing it, in any scale of less or more, with
+the sensation of pain; for the latter commonly conveys no
+correct information as to the organ from which it proceeds, or
+appears to proceed. Especially is this the case in the neuralgias,
+for more commonly than not the apparent seat of the pain
+is widely removed from the actual seat of the mischief which
+causes it.</p>
+
+<p>If we inquire a little further into the circumstances under
+which various kinds of pain occur, we gain some fresh suggestions.
+Among the neuralgias, those are the most acutely
+agonizing which occur under circumstances of impaired nutrition
+incident to the period of bodily decay, and strong reasons
+will be hereafter adduced for the belief that there is especial
+impairment of the nutrition of the central end of the painful
+nerves. To find a parallel to the severity of this kind of pains
+we must turn to the case of organic tumors, which, from their
+position, structure, and mode of growth, necessarily exercise
+continuous and severe pressure on the branches or the trunk
+of a nerve; or to the class of pains which attend severe cramp,
+or tonic contraction of muscles. Now, it can scarcely be
+doubted that in the latter instance there is an abnormally rapid
+and violent destruction of tissue going on; at the very least
+there is an extraordinarily violent and irregular manifestation
+of motor force. In any case the patent fact here is dynamic
+<span class="pagenum"><a name="Page_10" id="Page_10">[10]</a></span>
+perturbation of a severe kind; and, in the instance of organic
+tumors exercising steady and continuously increasing pressure
+on nerves, one can scarcely doubt that a similar perturbation,
+less intense but more enduring, is necessarily set up. That
+which can be done in the way of producing severe pain by
+these severe affections of the peripheral portions of nerves, or
+of tissues lying outside them, we might <i>a priori</i> expect would
+be effected by slighter but continuous changes in the nutrition
+of the more important portion of the nerve itself&mdash;its central
+gray nucleus. One would say that a pathological process
+which continuously and progressively lowered the standard
+of nutrition here must interfere from hour to hour, certainly
+from day to day, with that regular and equable distribution of
+force which is the essence of unimpeded function.</p>
+
+<p>Take, again, the case of the very severe pain which frequently
+attends inflammation of the pleura and of the peritoneum.
+Whatever theory of the causation of these pains we
+may adopt, it is certain that one most important element in
+their production and maintenance is the continual movement
+and friction of the affected parts. But there is little doubt that
+the moving muscles are involved in the inflammatory process,
+as Dr. Inman has correctly observed. It would seem plain that
+under these circumstances&mdash;an inflamed muscular structure
+forced to perform its ordinary contractions as well as it can&mdash;there
+must be powerful dynamic perturbation going on.</p>
+
+<p>If perturbation of nerve-function&mdash;a disturbance quite different
+from mere exaltation of the normal development of nerve-force&mdash;be
+the essence of pain, how comes it that pains of the
+severest type may be produced by changes in structures which
+are usually described, for practical purposes, as lying outside
+the nervous system? We must, in the first place, remark that
+the externality of any bodily tissue to the nervous system is
+more apparent than real. Microscopic researches are constantly
+revealing nerve-fibres, in ever-increasing profusion, which penetrate
+to parts seemingly the least vitalized in the organism.
+But, in any case, the nerves are certainly the ultimate channel
+of communication between the suffering part and the sentient
+centre. It seems, therefore, the inevitable conclusion that a
+dynamic perturbation going on in the non-nervous tissue is
+continued along the nerves themselves: and that the severity
+of the pain perceived by the conscious centres is proportionate
+to the tumultuousness, the want of coordination, and the waste
+with which force is being evolved in the cramped muscle, or
+whatever structure it may be, in which the pain takes its source.</p>
+
+<p>Not to pursue these topics further, we may sum up the considerations
+which have now been adduced, in the following
+general propositions, which will tend to simplify the examination
+of the various painful disorders which we are about to
+discuss:<span class="pagenum"><a name="Page_11" id="Page_11">[11]</a></span></p>
+
+<p>1. Pain is not a true hyperęsthesia; on the contrary, it involves
+a lowering of true function.</p>
+
+<p>2. Pain is due to a perturbation of nerve-force, originating
+in dynamic disturbance either within or without the nervous
+system.</p>
+
+<p>3. The susceptibility to this perturbation is great in proportion
+to the physical imperfection of the nervous tissue, until
+this imperfection reaches to the extent of cutting off nervous
+communications (paralysis).</p>
+
+
+
+<hr style="width: 85%;" />
+<p><span class="pagenum"><a name="Page_12" id="Page_12">[12]</a></span></p>
+<h2><a name="clin" id="clin"></a>PART I.</h2>
+
+<h2>ON NEURALGIA.</h2>
+<p><br /></p>
+<h2>CHAPTER I.</h2>
+
+<h3>CLINICAL HISTORY.</h3>
+
+
+<p>Neuralgia may be defined as a disease of the nervous system,
+manifesting itself by pains which, in the great majority
+of cases, are unilateral, and which appear to follow accurately
+the course of particular nerves, and ramify, sometimes into a
+few, sometimes into all, the terminal branches of those nerves.
+These pains are usually sudden in their onset, and of a darting,
+stabbing, boring, or burning character; they are at first unattended
+with any local change, or any general febrile excitement.
+They are always markedly intermittent, at any rate at
+first; the intermissions are sometimes regular, and sometimes
+irregular; the attacks commonly go on increasing in severity
+on each successive occasion. The intermissions are distinguished
+by complete, or almost complete, freedom from suffering,
+and in recent cases the patient appears to be quite well at
+these times; except that, for some short time after the
+attack, the parts through which the painful nerves ramify remain
+sore, and tender to the touch. In old-standing cases,
+however, persistent tenderness, and other signs of local mischief,
+are apt to be developed in the tissues around the peripheral
+twigs. Severe neuralgias are usually complicated with
+secondary affections of other nerves which are intimately
+connected with those that are the original seat of pain; and
+in this way congestions of blood vessels, hypersecretion or
+arrested secretion from glands, inflammation and ulceration of
+tissues, etc., are sometimes brought about.</p>
+
+<p>The above is a general description of neuralgia which will
+identify the disease sufficiently for the purpose of introducing
+it the attention of the reader. We must now proceed to give
+a more accurate account of its</p>
+
+<p><i>Clinical History and Symptoms.</i>&mdash;These vary so greatly in
+different kinds of neuralgia that it will be necessary to discuss
+the greater part of this subject under the headings of the special
+varieties of the disease. There are certain common features,
+however, in all true neuralgias.<span class="pagenum"><a name="Page_13" id="Page_13">[13]</a></span></p>
+
+<p>I. In the first place, it is universally the case that the condition
+of the patient, at the time of the first attack, is one of
+debility, either general or special. I make this assertion with
+confidence, notwithstanding that Valleix, and some other very
+able observers, have made a contrary statement. In the first
+place, it is certainly the case that the larger half of the total
+number of cases of neuralgia which come under my care are
+either decidedly anęmic, or else have recently undergone some
+exhausting illness or fatigue; and if other writers have failed
+to see so many neuralgic patients in whom these conditions
+were present, it must certainly be because they have limited
+the application of the term "neuralgia" within bounds which
+are too narrow to be justified by any logical argument; as
+will, indeed, be shown at a later stage. On the other hand,
+although a considerable number of neuralgic patients have an
+externally healthy appearance, as indicated by a ruddy complexion
+and a fair amount of muscular development, it cannot
+be admitted that these appearances exclude the possibility of
+debility, either structional or functional, of the nervous system.
+The commonest experience might teach us that, so far from the
+nervous system being invariably developed with a corresponding
+completeness and maintained with a corresponding vigor to
+those which distinguish the muscular system and the organs
+of vegetative life, there is often a very striking contrast between
+these in the same individual. What physician is there
+who has not seen epileptic patients, in whom mental habitude,
+a low cranial development, imperfect cutaneous sensibility,
+and other obvious marks of deficient innervation, were marked
+and striking features at, or even before, the first occurrence of
+convulsive symptoms, while the body was robust, the face well
+colored, and the muscular power up to or beyond the average?
+Now, it will invariably be found, on carefully sifting the history
+of apparently robust neuralgic patients, that they, too,
+have given previous indications of weakness of the nervous
+system: thus, women, who, after a severe confinement attended
+with great loss of blood, are attached with <i>clavus hystericus</i>
+or with <i>migraine</i>; will inform us that whenever, in
+earlier life, they suffered from headache, the pain was on the
+same side as that now affected, and chiefly or altogether confined
+to the site of the present neuralgia. In a considerable
+number of cases, also, in which I have been able to observe
+accurately the events which preceded an attack of neuralgia, it
+has been found that the skin supplied by the nerves about to become
+painful was anęsthesic to a remarkable degree; and it is
+very often the case that a more moderate amount of blunted sensation
+was perceptible in these parts during the intervals between
+attacks of pain. A somewhat delusive appearance of general
+nervous vigor is often conveyed to the observer of neuralgic
+patients, by reason of the intellectual and emotional characteristics<span class="pagenum"><a name="Page_14" id="Page_14">[14]</a></span>
+of the latter. Both ideation and emotion are, indeed,
+very often quick and active in the victims of neuralgia, who
+in this respect differ strikingly from the majority of epileptics.
+But this mobility of the higher centres of the nervous system
+is itself no sign of general nervous strength; which last can
+never be possessed except by those in whom a certain balance
+of the various nervous functions is maintained. Much more
+will be said on this topic when we come to discuss the etiology
+of neuralgia. Meantime I may content myself with repeating
+the fact which is indubitably taught by careful observation&mdash;that
+neuralgics are invariably marked by some original weakness
+of the nervous system; though in some cases this defect
+is confined strictly to that part of the sensory system which
+ultimately becomes the seat of neuralgic pain.</p>
+
+<p>Another circumstance is common to all neuralgias of superficial
+nerves; and, as a large majority of all neuralgias are
+superficial in situation, this is, for practical purposes, a general
+characteristic of the disease. I refer to the gradual formation
+of tender spots at various points where the affected
+nerves pass from a deeper to a more superficial level, and particularly
+where they emerge from bony canals, or pierce fibrous
+fascię. So general is this characteristic of inveterate
+neuralgias, that Valleix founded his diagnosis of the genuine
+neuralgias on the presence of these painful points. Herein he
+appears to me to be decidedly in error. I have watched a great
+many cases (of all sorts of varieties as to the situation of the
+pain), and I have uniformly observed that in the early stages
+firm pressure may be made on the painful nerve without any
+aggravation of the pain; indeed, very often with the effect of
+assuaging it. The formation of tender spots is a subsequent
+affair: they develop in those situations which have been the
+foci, or severest points, of the neuralgic pain. There is however,
+a point which, though not always, nor often, the seat of
+spontaneous pain, is nevertheless very generally tender.
+Trousseau, who criticises unfavorably the statement of Valleix
+as to the situation of the points douloureux, insists that this
+tender spot, which is over the spinous processes of the vertebrę
+corresponding to the origin of the painful nerve, and which he
+calls the points apophysaire, is more universally present than
+any of those pointed out by Valleix. I shall hereafter endeavor
+to show that these spinal points are by no means characteristic
+of neuralgia; they are present in a variety of affections which
+were ably described, under the heading of "Spinal Irritation,"
+many years ago, by the brothers Griffin. ["Observations on
+the Functional Affections of the Spinal Cord," by William
+and Daniel Griffin. London, 1834] and they are also present
+with misleading frequency in cases of mere myalgia, such as
+I shall have to describe at a later stage.</p>
+
+<p>Another characteristic of neuralgic patients in general is, I<span class="pagenum"><a name="Page_15" id="Page_15">[15]</a></span>
+believe, a certain mobility of the vaso-motor nervous system
+and of the cardiac motor nerves; but I insist less on this than
+on the above-named features, because a more extended experience
+is necessary to establish the fact with certainty. Within
+my own experience it has always seemed to be the case that
+persons who are liable to neuralgia are specially prone to sudden
+changes of vascular tension, under emotional and other
+influences which operate strongly on the nervous system.
+The observation of this fact has been made accidentally, without
+any previous bias on my part, in the course of a large
+number of experiments made upon individuals free from manifest
+disease at the time, with Marey's sphygmograph.</p>
+
+<p>Neuralgic attacks are always intermittent, or at the least
+remittent, in every stage of the disease.</p>
+
+<p>The manner in which neuralgic pain commences is characteristic
+and important. There is always a degree of suddenness
+in its outset. When produced by a violent shock, it may,
+and often does, spring into full development and severity at
+once, of which, perhaps, the most striking example is the sudden
+and violent neuralgic pain of the eyebrow which some persons
+experience from swallowing a lump of undissolved ice.
+Usually, however, the first warning is a sudden, not very
+severe, and altogether transient dart of pain. The patient has
+probably been suffering from some degree of general fatigue
+and malaise, and the skin of the affected part has been somewhat
+numb, when a sudden slight stitch of pain darts into the
+nerve at some point which corresponds to one of the foci hereafter
+to be particularized. It ceases immediately, but in a few
+seconds or minutes returns; and these darts of pain recur more
+and more frequently, till at last they blend themselves together
+in such a manner that the patient suffers continuous and violent
+pain for a minute or so, then experiences a short intermission,
+and then the pain returns again, and so on. These intermittent
+spasms of pain go on recurring for one or several
+hours; then the intermissions become longer, the pain slighter,
+and at last the attack wears itself out. Such is generally the
+history of first attacks, especially in subjects who are not past
+the middle age, nor particularly debilitated from any special
+cause.</p>
+
+<p>A point of interest in connection with the natural history of
+the neuralgic access is the condition of the circulation. The
+commencement of pain is generally preceded by paleness of
+skin and sensations of chilliness. At the commencement of
+the painful paroxysm, sphygmographic observation shows
+that the arterial tension is much increased, owing, in all probability,
+to spasm of the small vessels. This condition is gradually
+replaced by an opposite state, the pulse becoming large,
+soft, and bounding, though very unresisting, and giving a
+sphygmographic trace which exhibits marked dicrotism. Simultaneously<span class="pagenum"><a name="Page_16" id="Page_16">[16]</a></span>
+with this the skin becomes warmer, sometimes
+even uncomfortably warm, and there is frequently considerable
+flushing of the face.</p>
+
+<p>The final characteristic common to all neuralgias is that fatigue,
+and every other depressing influence, directly predispose
+to an attack, and aggravate it when already existing.</p>
+
+<p><i>Varieties.</i>&mdash;It is possible to classify neuralgias upon either of
+two systems: first (<i>a</i>), according to the constitutional state of
+the patient; and, secondly (<i>b</i>), according to the situation of the
+affected nerves. It will be necessary to follow both these lines
+of classification, avoiding all needless repetition.</p>
+
+<p>(<i>a</i>) In considering the influence of constitutional states upon
+the typical development of neuralgia, it will be convenient to
+commence with the group of cases in which the general condition
+of the organism produces the least effect. This is the case
+when the pain is the result of direct injury to a nerve-trunk,
+whether by external violence, by the mechanical pressure of a
+tumor, or by the involvement of a nerve in inflammatory or
+ulcerative processes originating in a neighboring part. As regards
+the development of symptoms, the important matters are,
+that the pain in these cases commences comparatively gradually,
+that the intermissions are usually more or less complete, and
+that the pain is far less amenable to relief from remedies, than
+in other forms of neuralgia. The little that can be said about
+the form which is dependent upon progressively increasing
+pressure, or involvement of a nerve in malignant ulcerations,
+caries of bones or teeth, etc., falls under the heads of Diagnosis
+and Treatment, and need not detain us here. The clinical history
+of neuralgia from external violence, however, requires
+separate discussion:</p>
+
+<p>1. Neuralgia from external shock may be produced by a
+physical cause (as by a fall, a railway collision, etc.), which
+gives a jar to the central nervous system; or by severe mental
+emotion, operating upon the same part of the organism.
+Under either of these circumstances the development of the
+affection may occur at once, but by far the most frequently it
+ensues after a variable interval, during which the patient
+shows signs of general depression, with loss of appetite and
+strength. Sometimes vomiting, and in other instances paralysis,
+of a partial and temporary kind, occur. When once developed,
+the neuralgic attacks do not differ from those which
+proceed from causes internal to the organism. In the greater
+number of instances, so far as my experience goes, it is the
+fifth cranial nerve which becomes neuralgic from the effects of
+central shock. Illustrative cases will be given in the section
+on Local Classification. Meantime the important facts to note,
+in relation to the influence of constitutional states, are these:
+In the first place, the tendency of such accidents to excite
+neuralgia varies directly with the hereditary predisposition<span class="pagenum"><a name="Page_17" id="Page_17">[17]</a></span>
+evinced by the liability of the sufferer's family to neuralgic affections
+and to the more serious neuroses. Secondly, the
+likelihood of a neuralgic attack is indefinitely increased if he
+has already had neuralgia. Thirdly, although debility from
+temporary and special causes can rarely be sufficient to insure
+a true neuralgic access after a severe shock, it probably heightens,
+indefinitely, the tendency in a person otherwise predisposed.
+Delicate women are many times more liable to
+experience such consequences, from a physical or mental
+shock, than men of tolerably robust constitution.</p>
+
+<p>2. Neuralgia from direct violence to superficial nerves is
+produced by cutting or, more rarely, by bruising wounds.
+Cutting wounds may divide a nerve-trunk (<i>a</i>) partially, or (<i>b</i>)
+completely.</p>
+
+<p>(<i>a</i>) When a nerve-trunk is partially cut through, neuralgic
+pain occurs, if at all, immediately, or almost immediately, on
+the receipt of the injury. One such instance only has come
+under my own care, but many others are recorded. In my
+case the ulnar nerve was partly cut through, with a tolerably
+sharp bread-knife, not far above the wrist; partial anęsthesia
+of the little and ring fingers was induced, but at the same time
+violent neuralgic pains in the little finger came on, in fits recurring
+several times a day, and lasting about half a minute.
+Treatment was of little apparent effect in promoting a cure;
+though opiates and the local use of chloroform afforded temporary
+relief. The attacks recurred for more than a month,
+long after the original wound had healed soundly; and, for a
+long time after this, pressure on the cicatrix would reproduce
+the attacks. A slight amount of anęsthesia still remained,
+when I saw the patient more than a year after the injury.</p>
+
+<p>(<i>b</i>) Complete severance of a nerve-trunk is a sufficiently
+common accident, far more common then is neuralgia produced
+by such a cause; indeed, so marked is this disproportion
+between the injury and the special result, that I have been led
+to infer that a necessary factor in the chain of morbid events
+must be the existence of some antecedent peculiarity in the
+central origin of the injured nerve. This opinion is rendered
+the more probable because the consecutive neuralgia is in some
+cases situated, not in the injured nerve itself, but in some other
+nerve with which it has central connections. Two such cases
+are recorded in my Lettsomian Lectures, [<i>Lancet</i>, 1866], in
+which the ulnar nerve, and one in which the cervico-occipital,
+were completely divided; in all three the resulting neuralgia
+was developed in the branches of the fifth cranial. Here we
+may suppose that the weak point existed in the central nucleus
+of the fifth; and that the irritation, or rather depression, communicated
+to the whole spinal centres by the wound of a distant
+nerve, first found, on reaching this weak point, the necessary
+conditions for the development of the neuralgic form of<span class="pagenum"><a name="Page_18" id="Page_18">[18]</a></span>
+pain, which therefore would be represented to the mental perception
+as present in the peripheral branches of the fifth nerve.
+In all the cases which have come under my notice, the neuralgia
+set in at a particular period, namely, after complete
+cicatrization of the wound, and while the functions of the
+branches on the peripheral side of the wound were partly, but
+not completely, restored. The same obstinacy and rebelliousness
+to treatment are observed as in other instances of neuralgia
+from injury.</p>
+
+<p>One of the cases above referred to may here be briefly detailed,
+as it shows very completely the clinical history of such
+affections. C. B., aged twenty-four, an agricultural laborer,
+applied for relief in the out-patient room of Westminster
+Hospital, suffering from severe neuralgic pains of the forehead
+and face of the left side. Then pains were felt in the course of
+the supra-orbital, ocular, nasal, and supra-trochlear branches,
+and also in the cheek, appearing, there, to radiate from the infra-orbital
+foramen. They had commenced about three weeks
+previously to the patient's first visit to the hospital, and about
+six weeks after the accident which appeared to have started the
+whole train of symptoms. This was a cutting wound, evidently
+of considerable depth as well as external size, toward
+the back of the neck, and so situated that it must have divided
+the great occipital nerve of the left side: and, from the man's
+account of the numbness of the parts supplied by the nerve
+which immediately followed the wound, there could be no
+doubt that this had occurred. There was no acute nerve-pain,
+either during the healing of the wound, which was rapid, or
+subsequently, until more than three weeks from the date of the
+injury; at this time there was still a considerable sense of
+numbness in the skin of the occipital and upper cervical region;
+but there now commenced a series of short paroxysms of pain
+in the forehead of the same side. These at first occurred only
+about twice daily, at regular intervals; the pain was not very
+sharp, and only lasted a minute or two. The attacks rapidly
+increased in frequency and duration, however, and extended
+their area. At the time when I first saw the case the pain was
+very formidable, it recurred with great frequency during the
+day, but would sometimes leave the patient free for several
+hours together. The site of the wound was occupied by a firm
+cicatrix of about a line in breadth and an inch and a quarter
+in length; pressure on this excited only a vague and slightly
+painful tingling in the part itself, but severely aggravated the
+trigeminal pains, or reproduced them if they happened to be
+absent. The regions supplied by the great occipital nerve were
+still very imperfectly sensitive. This patient gave me a great
+deal of trouble. He continued for many weeks under my care,
+and I can scarcely flatter myself that any of the numerous
+remedies which I administered internally, or applied locally,<span class="pagenum"><a name="Page_19" id="Page_19">[19]</a></span>
+had any serious effect in checking the disorder. The subcutaneous
+injection of morphia gave some relief, as it always
+does, but this seemed to be perfectly transitory; and, although
+when the patient ceased to attend the hospital he was decidedly
+better, I cannot imagine that there was anything in it except
+the slow wearing out of the neuralgic tendency, very much
+without reference to the administration of any remedies.</p>
+
+<p>The description of neuralgia from injury would be incomplete
+without some special words on a variety of this affection
+which has only very recently been described with that fulness
+which it deserves. I refer to the pains which are produced by
+gunshot injuries of nerves, received in battle, of which no sufficient
+account had been given until the publication of the experience
+of Messrs. Mitchell, Moorehouse, and Keen, in the
+late American civil war.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a></p>
+
+<p>From the interesting treatise of the above-named writers it
+appears that not merely is neuralgia of an ordinary type a frequent
+after-consequence of wounds, but that certain special
+pains are not unfrequently produced. In the more ordinary
+instances, pain is of the darting, or of the aching kind; and
+all writers on military surgery, who have recorded their experience
+of the results of wounds received in battle, have spoken
+of affections of this kind, for the most part singularly severe
+and obstinate, and in not a few recorded instances clinging to
+the patient during the remainder of his life. These pains may
+at times leave the sufferer, but they infallibly recur when from
+any cause his health is depressed, and it is an especially common
+thing for them to be evoked in full severity under the influence
+of exposure to cold, and particularly to damp cold.</p>
+
+<p>But the American writers introduce us to another and more
+terrible neuralgia which is a, fortunately, less frequent result
+of serious injuries to nerves. They speak of it as a burning
+pain of intense and often intolerable severity; they believe that
+it seldom if ever originates at the moment of the injury, but
+rather at some time during the healing process; and it is especially
+noteworthy that it is sometimes felt not in the nerve actually
+wounded, but in some other nerve with which it has
+connections. After it has lasted a certain time, an exquisite
+tenderness of the skin is developed, and a peculiar physical
+change of skin-tissue occurs; it becomes thin, smooth, and
+glossy. It is a remarkable fact that these burning pains which
+are so definitely linked with a nutrition-change of skin are
+never felt in the trunk, and rarely in the arm or thigh, not
+often in the forearm or leg, but commonly in the foot or hand;
+and the nutrition changes of the skin are generally observed
+on the palm of the hand, the palmar surface of the fingers, or
+<span class="pagenum"><a name="Page_20" id="Page_20">[20]</a></span>
+the dorsum of the foot; rarely on the sole of the foot or the
+back of the hand. It is very interesting to remark that these
+skin-lesions correspond very nearly, not only to those observed
+in the cases of nerve-injury reported by Mr. Paget,<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> in which
+actual neuralgia was present (though the kind of pain is not
+exactly specified), but also very nearly with the nutritive
+changes observed by Mr. Jonathan Hutchinson in a number
+of cases of surgical injuries of nerves.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> The tendency of neuralgic
+pain accompanied by nutritive lesions of the skin and
+nails to seat itself in the hands and feet will be hereafter noted
+in connection with the subject of the pains of locomotor ataxy
+and of those produced by profound mercurial poisoning. And
+it will be seen in the section on Pathology, that very important
+conclusions are suggested by the coincidence.</p>
+
+<p>Joined with the burning pains, and the altered skin-nutrition,
+in the cases of gunshot injury of nerves which we are
+considering, there is nearly always a marked alteration in the
+temperature of the parts, either in one direction or the other.
+In the great majority of instances of ordinary neuralgia after
+wounds, this alteration is a very considerable reduction of the
+temperature of the parts supplied by the painful nerves; a
+change which corresponds with what appears in the vast majority
+of all cases of division of sensitive nerves, whether pain
+be set up or not. But, in all examples of the burning pain after
+injury, Messrs. Mitchell, Moorehouse, and Keen found the
+temperature of the painful parts notably elevated.</p>
+
+<p>It would appear that there is no form of neuralgia more
+dreadful, and scarcely any so hopeless, as this burning pain
+coming on as a sequel to severe nerve injuries. It exercises a
+profoundly depressing effect upon the whole nervous tone; the
+most robust men become timid and broken down, and their
+condition is compared by the American writers to that of hysterical
+women.</p>
+
+<p>There is another peculiar nutritive affection, first recognized
+as an occasional consequence of nerve injuries by Messrs.
+Mitchell, Moorehouse, and Keen, namely, an inflammation of
+joints, and, although we have no concern here with this symptom,
+it will be referred to hereafter as throwing interesting
+light on certain questions of pathology. Certain lesions of secretion
+will also be specially referred to under the heading of
+Diagnosis.</p>
+
+
+<p>II. <span class="smcap">Neuralgias of Intra-nervous Origin.</span>&mdash;As regards the
+constitutional conditions with which the several varieties of
+neuralgia that arise independently of external violence, or disease
+of extra-nervous tissues, are respectively allied, the following
+preliminary subdivisions may be made:</p>
+
+<p><span class="pagenum"><a name="Page_21" id="Page_21">[21]</a></span></p>
+<ul>
+<li>1. Neuralgias of malarious origin.</li>
+<li>2. Neuralgias of the period of bodily development.</li>
+<li>3. Neuralgias of the middle period of life.</li>
+<li>4. Neuralgias of the period of bodily decay.</li>
+<li>5. Neuralgias associated with anęmia and mal-nutrition.</li>
+</ul>
+
+<p>1. <i>Neuralgias of malarious origin</i> were formerly far more
+prevalent than they are at present, within the sphere of the
+English practitioner of medicine; with the general decline of
+malarial fevers, consequent on improved drainage and cultivation
+of lands, they have become constantly more scarce. The
+districts in which they still are found to prevail with any frequency
+are carefully specified in the interesting report of Dr.
+Whitley to the Medical Officer of the Privy Council, in the
+Blue-Book for 1863.</p>
+
+<p>Of course, however, there are a considerable number of persons
+continually returning to England from countries where
+malarious diseases are common; and these often bear about
+with them the effects of paludal poisoning which occasionally
+exhibits itself in the form of neuralgia. Till very lately, however,
+I had not happened to come across such cases, although
+at one time and another I have seen and treated a good many
+persons returned from India and Africa, whence I judge that
+neuralgia with this special history is less common than many
+seem to think. In former times, on the contrary, malarioid
+neuralgias were so common that they forced themselves on the
+notice of every practitioner. The term "brow-ague," to this
+day applied by many medical men to every variety of supra-orbital
+neuralgia, is a relic of the older experience on this
+point, as is also the very common mistake of expecting all neuralgic
+affections to present a distinctly rhythmic recurrence of
+symptoms.</p>
+
+<p>In the year 1864 I published the statement<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> that, "in a fair
+sprinkling" of the cases of neuralgia which present themselves
+in hospital out-patient rooms, ague-poisoning may be suspected;
+but I was then speaking rather from hearsay than from my
+own experience, which, in fact, had yielded no clear cases of
+this sort of neuralgia, and was till just recently unable to
+reckon up more than two undoubted and one doubtful case of
+the affection, in all of which the fifth cranial nerve was unattacked.
+The periodicity in one of the genuine cases was regular
+tertian, in the other regular quotidian. A semi-algide
+condition always ushered in the attacks; but this was gradually
+exchanged, as the pain continued, for a condition in which
+the pulse was rapid and locomotive, but compressible, and the
+strength was further depressed. In both these cases there was
+unilateral flushing of the face, and congestion of the conjunctiva,
+to a slight degree, during the attack of pain. The pain
+<span class="pagenum"><a name="Page_22" id="Page_22">[22]</a></span>
+became duller and more diffused contemporaneously with the
+lowering of arterial pressure; and, after the disappearance of
+active pain, moderate tenderness over a considerable tract
+round the course of the painful nerves remain for some time.
+There was no distinct development of painful points in the situations
+described by Valleix; but it should be remarked that the
+cases were rapidly cured with quinine, which very probably accounts
+for this circumstance.</p>
+
+<p>Till lately I had not witnessed neuralgia as an after-consequence
+of tropical malaria-poisoning, although I have had
+many cases of other diseases, the relics of hot climates, under
+my care; but within the last year I have seen a case of extremely
+severe intercostal neuralgia of a perfectly periodic type
+occurring in a patient whose constitution had been thoroughly
+saturated with tropical marsh poison, and in whom the spleen
+was still much enlarged. The neuralgia was so terrible, and
+accompanied by such severe algide phenomena at the beginning
+of the attacks, and such a sense of throbbing as the pain
+developed, as to lead to serious suspicions of hepatic abscess,
+for the moment; but the course of events soon corrected this
+idea.</p>
+
+<p>2. <i>Neuralgias of the Period of Bodily Development.</i>&mdash;By
+the "period of bodily development" is here understood the
+whole time from birth up to the twenty-fifth year, or there-abouts.
+This is the period during which the organs of vegetative
+and of the lower animal life are growing and consolidating.
+The central nervous system is more slow in reaching its
+fullest development, and the brain especially is many years
+later in acquiring its maximum of organic consistency and
+functional power.</p>
+
+<p>That portion of the period of development which precedes
+puberty is comparatively free from neuralgic affections. At
+any rate, it is rare to meet in young children with well-defined
+unilateral neuralgia, except from some very special cause, such
+as the pressure of tumors, etc. Such neuralgias as do occur
+are commonly bilateral, and are connected either with the fifth
+cranial or the occipital nerves.</p>
+
+<p>I must here mention an affection which was quite unknown
+to my experience, but was brought under my notice by the
+late Dr. Hillier, who kindly called my attention to the notes
+of two cases which were published in his interesting work on
+"Diseases of Children." The cases are those of two female
+children, aged nine and eleven respectively, in whom the
+principal symptom was violent and paroxysmal neuralgic
+headache. In both of these children the existence of cerebral
+tubercle was suspected, but this proved to be a mistake. In
+both there were intolerance of light, vomiting, tonic contraction
+of the muscles of the neck, and occasional double vision;
+but no impairment of intelligence, no amaurosis, and no paralysis<span class="pagenum"><a name="Page_23" id="Page_23">[23]</a></span>
+or rigidity of the limbs. Each of these children died
+rather suddenly, after a violent paroxysm of pain. The main,
+indeed almost the only characteristic post-mortem change was
+a marked loss of consistence of tissue, in one case in the pons
+varolii, in the other in the pons, the medulla oblongata, and
+the cerebellum. These cases are of the highest possible interest,
+as are also several other instances of headache in children recorded
+by Dr. Hillier; notably one in which severe paroxysmal
+pains were attended with general impairment of brain-power,
+and, on the occurrence of death from exhaustion, the autopsy
+revealed an amount of degeneration in the cerebral arteries (as
+also in the general arterial system) which was astonishing,
+considering that the child was only ten and a half years old.
+This case, the full significance and interest of which will be
+better seen when we come to discuss the subject of pathology,
+is an example of physical changes in the nervous system, which
+are usually delayed to an advanced period of life, occurring altogether
+prematurely, and bringing with them a kind of neuralgic
+pain which is far more common in the decline than in
+morning of life. It will be seen presently that functional derangements
+may be in like manner precociously induced, with
+the parallel effect of inducing such pains as are ordinarily the
+product of a later epoch.</p>
+
+<p>From the moment that puberty arrives all is changed in the
+status of the nervous system. In the stir and tumult which
+pervade the organism, and especially in the enormous diversion
+of its nutritive and formative energy to the evolution of the
+generative organs and the correlative sexual instincts, the delicate
+apparatus of the nervous system is apt to be overwhelmed,
+or left behind, in the race of development. Under these circumstances,
+the tendency to neuralgic affections rapidly increases.
+It will, however, be seen later that there is a great
+preponderance of particular varieties of the disease during this
+time. This period is above all things fruitful in trigeminal
+neuralgias, especially migraine.</p>
+
+<p>There remains to be noticed the fact that sexual precocity
+sometimes very much anticipates the peculiar characteristics
+of the period after puberty. It is well known that in too many
+instances children are led, by the almost irresistible influence
+of bad example, to indulge in thoughts and practices which
+are thoroughly unchildish, and which exercise a powerfully
+disturbing influence upon the nervous system. A child before
+the age of puberty ought to be distinguished (if moderately
+healthy in other respects) by the absence of any tendency to
+dwell upon his own bodily health. Under the influence of
+precocious sexual irritation he becomes hypochondriacal and
+self-centred, and often suffers, not merely from fanciful fears
+and fanciful pains, but from actual neuralgia, which is sometimes
+severe. The attacks of migraine which are a frequent<span class="pagenum"><a name="Page_24" id="Page_24">[24]</a></span>
+affection of delicate children whose puberty occurs at the normal
+time, are a much earlier torment with children who have
+early become addicted to bad practices. It is an anticipatory effect
+upon the constitution, strictly analogous to the production
+of the so-called "hysteria" in little girls under similar
+circumstances; and I suppose there is no physician who has
+not once or twice, at least, met with cases of the latter kind.
+The existence of any severe neuralgic affection in a young child,
+if it cannot be traced to tuburcle or other recognizable or organic
+brain-disease is <i>prima-facie</i> ground for suspicion of precocious
+sexual irritation; though, as Dr. Hillier's cases show, it is occasionally
+produced otherwise. Usually, there are other features
+which assist in the discovery of precocious sexualism,
+when it exists; there is a morbid tendency to solitary moping,
+and a moral change in which untruthfulness is conspicuous.</p>
+
+<p>3. <i>Neuralgias of the Middle Period of Life.</i>&mdash;By this period
+is meant the time included between the twenty-fifth and about
+the fortieth or forty-fifth year. It is the time of life during
+which the individual is subjected to the most serious pressure
+from external influences. The men, if poor, are engaged in
+the absorbing struggle for existence, and for the maintenance
+of their families; or, if rich and idle, are immersed in dissipation,
+or haunted by the mental disgust which is generated by
+<i>ennui</i>. The women are going through the exhausting process
+of child-bearing, and supporting the numerous cares of a poor
+household, in some cases; or are devoured with anxiety for a
+certain position in fashionable society for themselves and their
+children; or again, they are idle and heart-weary, or condemned
+to an unnatural celibacy. Very often they are both
+idle and anxious.</p>
+
+<p>It must not be supposed that there is a sharp line of demarcation
+between this period and the last; nevertheless, there
+are certain well-marked differences, both in their general tendencies,
+and as regards the local varieties which are commonest
+in each. We shall discuss the latter point farther on.
+At present, it is interesting to remark on the general freedom
+of the busy middle period of life from first attacks of neuralgia.
+A person who has had neuralgia previously may, and
+very likely will, during this epoch, be subject to recurrence of
+the old affection under stress of exhaustion of any kind. But
+it is very rare, in my experience, for busy house-mothers or
+fathers of families to get first attacks of neuralgia during this
+period of life. It is not the way in which a still vigorous
+man's nervous system breaks down, if it breaks down at all.
+Men frequently do break down, of course, at an age when their
+tissues generally are sound enough, and there is no reason, except
+on the side of their nervous system, why they should not
+remain in vigorous health for years. But it is greatly more
+common for the nervous collapse to take the form of insanity,<span class="pagenum"><a name="Page_25" id="Page_25">[25]</a></span>
+or hypochondriasis, or paralysis, then that of neuralgia. If a
+man has escaped the latter disease during the period when the
+growth of his tissues was active, it is not very often that he
+falls a victim to it till he begins, physiologically speaking, to
+grow old.</p>
+
+<p>4. <i>Neuralgias of Declining Bodily Vigor.</i>&mdash;The period here
+referred to is that which commences with the first indications
+of general physical decay, of which the earliest which we can
+recognize (in persons who are not cut off by special diseases) is
+perhaps the tendency to atheromatous change in the arteries.
+The first development of this change varies very considerably
+in date; but whenever it occurs it is a plain warning that a new
+set of vital conditions has arisen, and especially notable is its
+connection with the characters of the neuralgic affections
+which take their rise after its commencement. The period of
+declining life is pre-eminently the time for severe and intractable
+neuralgias. Comparatively few patients are ever permanently
+cured who are first attacked with neuralgia after they
+have entered upon what may be termed the "degenerative"
+period of existence. I mentioned the existence of commencing
+arterial degeneration as the special and most trustworthy sign
+of the initiation of bodily decay; but it is needless to say that
+this change is often not to be detected in its earliest stage.
+Something has been done of late years, however, to render its
+diagnosis more easy. Not to dwell upon the phenomenon of
+the arcus senilis, which though of a certain value is confessedly
+only very partially reliable, we may mention the sphygmographic
+character of the pulse as possessing a real value in deciding
+the physiological status of the arterial system. There
+is a well-known form of pulse-curve, square-headed, with
+marked lengthening of the first or systolic portion of the wave,
+and with an almost total absence of dicrotism, even when the
+circulation is rapid, which will often seem to assure us that
+atheromatous change of the arterial system has commenced,
+even when the physical characters of inelastic artery are not to
+be recognized with the finger in any of the superficial vessels
+by the touch of the finger. Indeed, the latter test is in all
+cases far less reliable than the sphygmographic trace, except
+when the arterial change has proceeded to a very marked degree
+of development.</p>
+
+<p>To a certain extent, the presence or absence of gray hair is
+of value in deciding whether physiological degeneration has
+begun. Like the arcus senilis, however, this is only reliable
+when joined with other indications, for it may be a purely
+local and separate change, having nothing to do with the general
+vital status of the body.</p>
+
+<p>5. <i>Neuralgias which are immediately excited by Anęmia
+or Mal-nutrition.</i>&mdash;Of the neuralgic affections which can be
+reckoned in this class, the sole characteristic worthy of note is<span class="pagenum"><a name="Page_26" id="Page_26">[26]</a></span>
+the circumstances in which they arise. It would seem that
+anęmia and mal-nutrition simply aggravate the tendency of
+existing weak portions of the nervous system to be affected
+with pain; just as they notoriously do aggravate lurking tendencies
+to convulsion and spasm. It is very common, for instance,
+for women to suffer severely from migraine, and other
+forms of neuralgia, after a confinement in which they have
+lost much blood. According to my own experience, however,
+those patients are generally, if not invariably, found to have
+previously suffered more or less severe neuralgic pain, at some
+time or other in their history, in the same nerves which now,
+under the depressing influence of hęmorrhage, have become
+neuralgic. One of the very worst cases of clavus which I ever
+saw happened after hęmorrhage in labor; the pain was so
+severe and prostrating that it appeared likely the patient would
+become insane. I discovered, on inquiry, that this woman
+had been liable for many years to headache affecting precisely
+the same region, on the occasion of any unusual fatigue or excitement.</p>
+
+<p>There is, however, one variety of neuralgia from mal-nutrition
+which deserves special consideration, viz., that which is
+occasionally produced as an after-effect of mercurial salivation.
+I have only seen one instance of this affection, but several
+are recorded. [Such, at least, is my impression, but I have
+not been able to find the reports of them.] My patient was a
+woman of somewhat advanced years when she first came
+under my notice, but her malady had (though with long
+intermissions) existed ever since she was a young girl in
+service. At that early date she was severely salivated by some
+energetic but misguided practitioner, for an affection which
+was called pleurisy, but (according to her description) might
+well have been only pleurodynia, to which servant girls are so
+very subject. At any rate, the consequences of the medication
+were most disastrous. Not only did she then and there lose
+every tooth in her head and suffer extensive exfoliations from
+the maxillę, but after this process was over she began to suffer
+frightfully from neuralgic pains in both arms and in both legs.
+Tonic medicines and a change to sea-air brought about a tardy
+and temporary cure; but from that moment her nervous system
+never recovered itself. Whenever she took cold, or was
+over-fatigued, or depressed from any bodily or mental cause,
+she was certain to experience a recurrence of the pains. At
+the time of her application to me she was suffering from an
+attack of more than ordinary severity, and which had lasted a
+long time without showing any signs of yielding. She apparently
+could not find words to express the acuteness of her sufferings.
+All along the course of the sciatic nerve in the thigh,
+all down the course of the middle cutaneous and long saphenous
+branches of the anterior crural, in the musculo-spiral,<span class="pagenum"><a name="Page_27" id="Page_27">[27]</a></span>
+radial, and the course of the ulnar nerves, and also, in a more
+generalized way, in the gastrocnemii, in the soles of the feet,
+and in the palms of the hands, the pains were of a tearing
+character, which she described as resembling "iron teeth"
+tearing the flesh. The pains recurred many times daily; her
+life was a perfect burden to her, and always had been during
+these attacks. This patient was under my observation, on various
+occasions, during several years, and I established the fact
+that cod-liver oil always did very great good. But it was evident
+that nothing would remove the tendency to the recurrence
+of the pains. I should mention, as additional proof of
+the extent to which the mercurial poison had shattered the
+nervous system of this woman, that she had violent muscular
+tremors at the time of her first attack, and on several subsequent
+occasions. A more completely ruined life was never
+seen; the poor woman had been on the highway to promotion
+in the service of a nobleman when she was mercurialized, but
+her whole prospects were blighted by the serious danger to her
+health which was caused by the preposterous antiphlogisticism
+of her medical attendant.</p>
+
+<p>I do not know that the poisonous action of any other metallic
+poison than mercury has been distinctly shown to produce
+neuralgic pains of superficial nerves. The action of lead is
+well known to produce colic, a disease which will be specially
+dwelt on elsewhere. And undoubtedly a certain amount of
+aching pain sometimes attends certain stages of lead-palsy of
+the extensor muscles of the forearm. But I know of no facts
+pointing to a true saturnine neuralgia. And the chronic
+poisonous effects of arsenic on the nervous system seem to
+produce sensory paralysis, rather than pain.</p>
+
+<p>We come now to the consideration of the local varieties of
+neuralgia. The primary subdivision of them may be made as
+follows:</p>
+
+<p>I. Superficial Neuralgias. II. Visceral Neuralgias.</p>
+
+<p>I. <ins title="Transcriber's Note: Heading added for consistency."><span class="smcap">Superficial Neuralgias.</span></ins></p>
+<p>Of superficial neuralgias a further classification may be
+made:</p>
+
+<ul>
+<li>(<i>a</i>) Neuralgia of the fifth (trigeminal, or trifacial).</li>
+<li>(<i>b</i>) Cervico-occipital neuralgia.</li>
+<li>(<i>c</i>) Cervico-brachial neuralgia.</li>
+<li>(<i>d</i>) Intercostal neuralgia.</li>
+<li>(<i>e</i>) Lumbo-abdominal neuralgia.</li>
+<li>(<i>f</i>) Crural neuralgia.</li>
+<li>(<i>g</i>) Sciatic neuralgia.</li>
+</ul>
+
+<p>This arrangement is that of Valleix, and appears to me substantially
+correct.</p>
+
+<p>(<i>a</i>) <ins title="Transcriber's Note: Heading added for consistency.">
+<i>Neuralgia of the Fifth</i></ins>.&mdash;The most important group of
+neuralgias are those of the fifth cranial nerve.</p>
+
+<p>Neuralgia of the fifth nerve always exhibits itself in the
+especial violence in certain foci, which Valleix was the first to<span class="pagenum"><a name="Page_28" id="Page_28">[28]</a></span>
+define with accuracy. These foci are always in points where
+the nerve becomes more superficial, either in turning out of a
+bony canal, or in penetrating fascię. In the ophthalmic
+division of the nerve the following possible foci are noticeable:
+(1) The supra-orbital, at the notch of that name, or a little
+higher, in the course of the frontal nerve; (2) the palpebral, in
+the upper eyelid; (3) the nasal, at the point of emergence of
+the long nasal branch, at the junction of the nasal bone with
+the cartilage; (4) the ocular, a somewhat indefinite focus
+within the globe of the eye; (5) the trochlear, at the inner angle
+of the orbit.</p>
+
+<p>In the superior maxillary division the following foci may be
+found: (1) The infra-orbital, corresponding to the emergence
+of the nerve of that name from its bony canal; (2) the malar,
+on the most prominent portion of the malar bone; (3) a vague
+and indeterminate focus, somewhere on the line of the gums of
+the upper jaw; (4) the superior labial, a vague and not often
+important focus; (5) the palatine point, rarely observed, but
+occasionally the seat of intolerable pain.</p>
+
+<p>In the inferior maxillary division the foci are: (1) The temporal,
+a point on the auriculo-temporal branch, a little in front
+of the ear; (2) the inferior dental point, opposite the emergence
+of the nerve of that name; (3) the lingual point, not a common
+one, on the side of the tongue; (4) the inferior labial point,
+only rarely met with.</p>
+
+<p>Besides these foci in relation with distinct branches of the
+trigeminus, there is one of especial frequency which corresponds
+to the inosculation of various branches. This is the
+parietal point, situated a little above the parietal eminence. It
+is small in size&mdash;the point of the little finger would cover it.
+It is the commonest focus of all.</p>
+
+<p>Neuralgia may attack any one, or all, of the three divisions
+of the nerve; the latter event is comparatively rare. Valleix,
+indeed, holds a different opinion; but this seems to me to arise
+from the fact that his definition of neuralgia was too narrow
+to include a large number of the milder cases of neuralgia,
+which are, nevertheless I believe, decidedly of the same essential
+character with the severer affections. The most frequent
+occurrence is the limitation of the pain to the ophthalmic
+division, and incomparably the most frequent foci of pain are
+the supra-orbital and the parietal.</p>
+
+<p>The most common variety of trigeminal neuralgia is
+migraine, or sick-headache, as it is often called. This is an affection
+which is entirely independent of digestive disturbances,
+in its primary origin, though it may be aggravated by their
+occurrence. It almost always first attacks individuals at some
+time during the period of bodily development. Under the influences
+proper to this vital epoch, and often of a further debility
+produced by a premature straining of the mental powers,<span class="pagenum"><a name="Page_29" id="Page_29">[29]</a></span>
+the patient begins to suffer headache after any unusual fatigue
+or excitement, sometimes without any distinct cause of this
+kind. The unilateral character of this pain is not always detected
+at first; but, as the attacks increase in frequency and
+severity, it becomes obvious that the pain is limited to the
+supra-orbital and its twigs, with sometimes also the ocular
+branches. In rare cases, as in all forms of neuralgia, the
+nerves of both sides may be affected; I have already observed
+that this seems to be relatively more common in young
+children. If the pain lasts for any considerable length of time,
+nausea, and at length vomiting, are induced. This is followed
+at the moment by an increase in the severity of the pain, apparently
+from the shock of the mechanical effect; but from
+this point the violence of the affection begins to subside, and
+the patient usually falls asleep. The history of the attacks
+negatives the idea that the vomiting is ordinarily remedial.
+This symptom merely indicates the lowest point of nervous depression;
+but it may happen that a quantity of food which has
+been injudiciously taken, lying as it does undigested in the
+stomach, may of itself greatly aggravate the neuralgia, by irritation
+transmitted to the medulla oblongata. In such a case
+vomiting may directly relieve the nerve-pain. When the
+patient awakes from sleep, the active pain is gone. But it is a
+common occurrence&mdash;indeed it always happens when the neuralgia
+has lasted a long time&mdash;that a tender condition of the
+superficial parts remains for some hours, perhaps for a day or
+two. This tenderness is usually somewhat diffused, and not
+limited with accuracy to the foci of greatest pain during the
+attacks.</p>
+
+<p>Sick headache is not uncommonly ushered in by sighings,
+yawning, and shuddering&mdash;symptoms which remind us of the
+prodromata of certain graver neuroses, to which, as we shall
+hereafter see, it is probably related by hereditary descent. In
+its severer forms, migraine is a terrible infliction; the pain
+gradually spreads to every twig of the ophthalmic division;
+the eye of the affected side is deeply bloodshot, and streams
+with tears; the eyelid droops, or jerks convulsively; the sight
+is clouded, or even fails almost altogether for the time, and
+the darts of agony which shoot up to the vertex seem as if the
+head were being split down with an axe. The patient cannot
+bear the least glimmer of light, nor the least motion, but lies
+quite helpless, intensely chilly and depressed, the pulse at first
+slow, small and wiry, afterward more rapid and larger, but
+very compressible. The feet are generally actually, as well as
+subjectively, cold. Very often, toward the end of the attack,
+there is a large excretion of pale, limpid urine.</p>
+
+<p>Another variety of trigeminal neuralgia which infests the
+period of bodily development is that known as clavus hystericus:
+clavus, from the fact that the pain is at once severe, and<span class="pagenum"><a name="Page_30" id="Page_30">[30]</a></span>
+limited to one or two small definite points, as if a nail or nails
+were being driven into the skull. These points correspond
+either to the supra-orbital or the parietal, or, as often happens,
+to both at once. But for the greater limitation of the area of
+pain in clavus, that affection would have little to distinguish it
+from migraine, for the former is also accompanied with nausea
+and vomiting when the pain continues long enough; and in
+both instances it is obvious that there is a reflex irritation propagated
+from the painful nerve. The adjective hystericus is
+an improper and inadequate definition of the circumstances
+under which clavus arises. The truth is, that the subjects of
+it are chiefly females who are passing through the trying period
+of bodily development; but there is no evidence to show that
+uterine disorders give any special bias toward this complaint.
+Both migraine and clavus are often met with in persons who
+have long passed their youth; but their first attacks have
+nearly always occurred during the period of development.</p>
+
+<p>One circumstance in connection with well-marked clavus
+appears worth noting, as somewhat differentiating it from
+migraine. It is, I think, decidedly more frequently the immediate
+consequence of anęmia than they; but it does not appear,
+from my experience, that the chlorotic form of anęmia
+is any more provocative of it than is anęmia from any other
+cause. Some of the worst cases of clavus, probably, that have
+ever been seen were developed in the old days of phlebotomy.
+It was then very common for a delicate girl, on complaint of
+some stitch of neuralgia or muscular pain in the side, to be
+immediately bled to a large extent, with the idea of checking
+an imaginary commencing pleurisy. The treatment, so far
+from curing the pain and the dyspepsia (which it produced),
+often aggravated them; whereupon the signs of inflammation
+were thought to be still more manifest, and more blood was
+taken. Under such circumstances the most complete anęmia
+was developed, and very often the patient became a martyr to
+clavus in its severest forms. One does not now very frequently
+meet with the victims of such mistaken practice; but I have
+seen one [since writing this I have seen another case (<i>vide</i> cardiac
+neuralgia, <i>infra</i>)] very severe case of clavus produced by
+loss of blood (in a subject who was doubtless predisposed to
+neuralgic affections, to judge from his family history). The
+case was that of a boy who accidentally divided his radial.</p>
+
+<p>The middle period of life is not, according to my experience,
+fruitful in first attacks of trigeminal neuralgia. But, when
+the neuralgic tendency has once declared itself, there are many
+circumstances of middle adult life which tend to recall it.
+Over-exertion of the mind is one of the most frequent causes,
+especially when this is accompanied by anxiety and worry;
+indeed, the latter has a worse influence than the former. In
+women, the exhaustion of hęmorrhageal parturition, or of<span class="pagenum"><a name="Page_31" id="Page_31">[31]</a></span>
+menorrhagia, and also the depression produced by over-suckling,
+are frequent causes of the recurrence of a migraine or
+clavus to which the patient had been subject when young.
+The middle period of life is very obnoxious to severe mental
+shocks, which are more injurious than in youth, because of the
+diminished elasticity of mind which now exists; and the same
+may be said of the influence of severe bodily accident of a
+kind to inflict damage on the central nervous system. Special
+mention ought to be made, in the case of women, of the disturbing
+influence of the series of changes which close the middle
+portion of their life, viz., the involution of the sexual
+organs. It would seem as if every evil impression which has
+ever been made on the nervous system hastens to revive, with
+all its disastrous effects, at this crisis. Latent tendencies to
+facial neuralgia are particularly apt to reassert their existence,
+and they are usually accompanied and aggravated by a tendency
+to vaso-motor disturbance, which not unfrequently
+seems to be the most distressing part of the malady. I have
+several times been consulted by women undergoing the
+"change," whose chief complaint was of disagreeable flushings
+and chills, especially of the face; and, on inquiring further,
+one has found that they were suffering from severe facial
+neuralgia, which, however, alarmed and distressed them less
+than did the vaso-motor disturbance, and the giddiness, etc.,
+which were an evident consequence of it.</p>
+
+<p>It is, however, the final or degenerative period of life which
+produces the most formidable varieties of facial neuralgia.
+Neuralgia of the fifth, which have previously attacked an individual,
+may recur at this time of life without any special
+character, except a certain increase of severity and obstinacy.
+But trigeminal neuralgias, which now appear for the first time,
+are usually intensely severe, and nearly or quite incurable.
+These cases correspond with the affection named by Trousseau
+tic epileptiforme, and it is of them, doubtless, that Romberg is
+speaking, when he says that the true neuralgias of the fifth
+rarely occur before the fortieth year of life. These neuralgias
+are distinguished by the intense severity of the pain, the lightning-like
+suddenness of its onset, and the almost total impossibility
+of effecting more than a temporary palliation of the
+symptoms. But they are also distinguished by another circumstance
+which too often escapes attention, namely, they are
+almost invariably connected with a strong family taint of insanity,
+and very often with strong melancholy and suicidal
+tendencies in the patient himself, which do not depend on, and
+are not commensurate with, the severity of the pain which he
+suffers. It may seem a strong view to take, but I must say
+that I regard a well-developed and typical neuralgia, of the
+type we are now speaking of, as an affection in which the mental
+centres are almost as deeply involved as in the fifth nerve<span class="pagenum"><a name="Page_32" id="Page_32">[32]</a></span>
+itself; though, whether this is an original part of the disease,
+or a mere reflex effect of the affection of the trigeminal nerve,
+I am not prepared to say. Other reflex affections are common
+enough in this kind of facial neuralgia, and especially spasmodic
+contractions of the facial muscles, which, indeed, often
+form one of the most striking features of the malady, the attacks
+of pain being accompanied by hideous involuntary grimaces.
+Even in the earlier stages of the disease there is usually
+some degree of the same thing, as, for instance, spasmodic
+winking. In the great majority of cases, after a little time,
+exquisitely tender points are formed in the chief foci of pain; in
+the intervals between the spasms the least pressure on these
+points is sufficient to cause agony, and a mere breath of wind
+impinging on them will often reproduce the spasm. Yet, in the
+height of the acute paroxysm itself, the patient will often frantically
+rub these very parts in the vain attempt to produce ease;
+and it has often been noticed that such friction has completely
+rubbed off the hair or whisker on the affected side: this happens
+the more easily, because the neuralgic affection itself impairs
+the nutrition of the hair and makes it more brittle, as we
+shall have occasion to show more fully hereafter. The general
+appearance of a confirmed neuralgic of the type now described
+is very distressing, and the history of his case fully corresponds
+to it. He is moody and depressed, he dreads the least movement,
+and the least current of air; he hardly dares masticate
+food at all, more especially if the inferior maxillary division of
+the nerve be implicated (as is generally the case sooner or later),
+for this movement re-excites the pain with great violence.
+Nutrition is very commonly kept up by slops, and is thus very
+insufficiently maintained: this failure of nutrition is itself a
+decidedly powerful influence in aggravating the disease. And
+there is a still further calamity which is not unlikely to occur.
+The patient may fly to the stupefaction of drink as a relief to
+his sufferings, and, if he has once experienced the temporary
+comfort of drunken anęsthesia, is excessively likely to repeat
+the experiment. But this is another and one of the most
+fatally certain methods of hastening degeneration of nerve-centres,
+and the ultimate effect, therefore, is disastrous in
+every way.</p>
+
+<p>Although the neuralgias of the degenerative period are thus
+fatally progressive, on the whole, there are some curious occasional
+anomalies. Many cases are recorded, and I have myself
+seen such, in which the attacks of pain, after reaching a very
+considerable degree of intensity, have ceased for many months,
+whether under the influence of remedies or not it is difficult to
+say with certainty, but probably far more from independent
+causes. Whatever may be the reason of these sudden arrests,
+however, certain it is that they are very seldom permanent, the
+pain returning sooner or later, like an inexorable fate.<span class="pagenum"><a name="Page_33" id="Page_33">[33]</a></span></p>
+
+<p>(<i>b</i>) <i>Cervico-occipital Neuralgia.</i>&mdash;As Valleix has remarked,
+there are several nerves (in fact, the posterior branches of all
+the first four spinal pairs) which are more or less frequently
+the seat of this affection. But among them all there is none
+comparable to the great occipital, which arises from the second
+spinal pair, for the frequency and importance of its neuralgic
+affections. This nerve sends branches to the whole occipital
+and the posterior parietal region. On the other hand, the second
+and third spinal nerves help to make up the superficial
+cervical branch of the cervical plexus which is distributed to
+the triangle between the jaw, the median line of the neck, and
+the edge of the sterno-mastoid, and those to the lower part of
+the cheek. Then there is the auricular branch, which starts
+from the same two pairs, and supplies the face, the parotid region,
+and the back of the external ear. Then the small occipital,
+distributed to the ear and to the occiput. And, finally,
+superficial descending branches of the plexus. These, altogether,
+are the nerves which at various points, where they become
+more superficial, form the foci of cervico-occipital neuralgia.</p>
+
+<p>The most typical example of this form of neuralgia which
+has fallen under my notice occurred (after exposure to cold
+wind) in a lady about sixty years of age, who had all her life
+been subject to neuralgic headache approaching the type of
+migraine, and who came of a family in which insanity, apoplexy,
+and other grave neuroses, had been frequent. The pain
+centred very decidedly in a focus corresponding to the occipital
+triangle of the neck; it recurred at irregular intervals, and in
+very severe paroxysms, lasting about a minute. It was interesting
+to follow the history of this case in one respect. It
+afforded a clear illustration of the manner in which local tenderness
+is developed; for during the first three or four days the
+patient, so far from complaining that the painful part was tender
+on pressure, experienced decided relief from pressure,
+although she experienced none from mere rest, however carefully
+the neck might be supported. But in the course of a few
+days an intensely painful spot developed itself in the occipital
+triangle, and the back of the ear became excessively tender.
+All manner of remedies had been tried in this case, without
+the slightest success and especially there was a large amount
+of speculative medication, on the theory of the probably
+"rheumatic" or "gouty" nature of the affection. Nothing
+was doing the least good to the pain, and meantime the old
+lady's digestion and general health and spirits were suffering
+very severely. Blistering was now suggested, and the affection
+yielded at once. The relief afforded must have been very
+complete, to judge by the warm gratitude which the patient
+expressed. The subsequent history of this patient illustrates
+several points which will engage our attention under the section<span class="pagenum"><a name="Page_34" id="Page_34">[34]</a></span>
+of Pathology. It may be just mentioned here, that she
+suffered, twelve months later, from a hemiplegic attack of
+paralysis.</p>
+
+<p>The tendency of cervico-occipital neuralgias is to spread
+toward the lower portions of the face, as observed by Valleix;
+in this case they become, sometimes, undistinguishable from
+neuralgias of the third division of the trigeminus. In the early
+stages of the disease, if the physician had been lucky enough
+to witness them, the true place of the origin of the pain would
+have been easily recognizable; at a later date it sometimes
+needs great care, and a very strict interrogation of the patient,
+to discover the true history of the disease. Sometimes, even,
+a cervico-occipital neuralgia which spreads in this way causes
+great irritation and swelling of the submaxillary and cervical
+glands; and I have known a case of this kind mistaken for
+commencing glandular abscess. The pain and tension were so
+great in this case, and the constitutional disturbance was so
+considerable, that the presence of deep-seated pus was strongly
+suspected, and the propriety of an incision (which would have
+been a hazardous proceeding) was seriously canvassed.</p>
+
+<p>Experience is too limited, to judge by what I have personally
+seen, and the recorded cases with which I am acquainted, to
+enable us to say anything with confidence of the conditions, as
+to age and general nutrition of the body, which specially favor
+the occurrence of cervico-occipital neuralgia. Apparently,
+however, there is much reason for thinking that the immediately
+exciting cause of it is most frequently external cold. I
+have known it produced several times in the same person, by
+sitting in a draught which blew strongly on the back of the
+neck. And I am inclined to think that it is seldom the first
+form of neuralgia which attacks a patient, but usually occurs
+in those who have previously suffered from neuralgic pains
+either of the trigeminus or of some other superficial nerve. I
+have known it once to occur in a person, thus predisposed to
+neuralgic affections, in consequence of reflex irritation from a
+carious tooth, as was proved by its cessation on the extraction
+of the latter, although there was no facial pain.</p>
+
+<p>(<i>c</i>) <i>Cervico-brachial Neuralgia.</i>&mdash;This group includes all the
+neuralgias which occur in nerves originating from the brachial
+plexus, or from the posterior branches of the four lower cervical
+nerves. The most important characteristic of the neuralgias
+of the upper extremity is the frequency, indeed almost
+constancy, with which they invade, simultaneously or successively,
+several of the nerves which are derived from the lower
+cervical pairs. The neuralgic affections of the small posterior
+branches (distributed to the skin of the lower and back part of
+the neck) are comparatively of small importance. But the
+"solidarite," which Valleix so well remarked, between the
+various branches of the brachial plexus, causes the neuralgias<span class="pagenum"><a name="Page_35" id="Page_35">[35]</a></span>
+of the shoulder, arm, forearm, and hand to be extremely
+troublesome and severe, owing to the numerous foci of pain
+which usually exist. Perhaps Valleix's description of these
+foci is somewhat over-fanciful and minute; but the following
+among them which he mentions I have repeatedly identified;
+(1) An axillary point, corresponding to the brachial plexus
+itself; (2) a scapular point, corresponding to the angle of the
+scapula. (It is difficult to identify the peccant nerve here; the
+one to which it apparently corresponds, and to which Valleix
+refers it, is the subscapular; but we are accustomed to think of
+this as a motor nerve. Still, it is certain that pressure on a
+painful point existing here will often cause acute pain in the
+nerves of the arm and forearm.); (3) A shoulder point, which
+corresponds to the emergence, through the deltoid muscle, of
+the cutaneous filets of the circumflex; (4) a median-cephalic
+point, at the bend of the elbow, where a branch of the musculo-cutaneous
+nerve lies immediately behind the median-cephalic
+vein; (5) an external humeral point, about three inches above
+the elbow, on the outer side, corresponding to the emergence
+of the cutaneous branches which the musculo-spiral nerve
+gives off as it lies in the groove of the humerus; (6) a superior
+ulnar point, corresponding to the course of the ulnar nerve between
+the olecranon and the epitrochlea; (7) an inferior ulnar
+point, where the ulnar nerve passes in front of the annular
+ligament of the wrist; (8) a radial point, marking the place
+where the radial nerve becomes superficial, at the lower and
+external aspect of the forearm. Besides these foci, there are
+sometimes, but more rarely, painful points developed by the
+side of the lower cervical vertebrę, corresponding to the posterior
+branches of the lower cervical pairs.</p>
+
+<p>The most common seat of cervico-brachial neuralgia has
+been, in my experience, the ulnar nerve, the superior and
+inferior points above mentioned being the foci of greatest
+intensity; an axillary point has also been developed in one or
+two cases which I have seen. Rarely, however, does the neuralgia
+remain limited to the ulnar nerve; in the majority of
+cases it soon spreads to other nerves which emanate from the
+brachial plexus. A very common seat of neuralgia is also the
+shoulder, the affected nerves being the cutaneous branches of
+the circumflex. I am inclined to think, also, that affections of
+the musculo-spiral, and of the radial near the wrist, are rather
+common, and have found them very obstinate and difficult to
+deal with. One case has recently been under my care in which
+the foci of greatest intensity of the pain were an external
+humeral and a radial point; but besides these there was an
+exquisitely painful scapular point. In another case the pain
+commenced in an external humeral and a radial point, but subsequently
+the shoulder branches of the circumflex became
+involved. A most plentiful crop of herpes was an intercurrent<span class="pagenum"><a name="Page_36" id="Page_36">[36]</a></span>
+phenomenon in this case, or rather, was plainly dependent on
+the same cause which produced the neuralgia.</p>
+
+<p>Median cephalic neuralgia is an affection which used to be
+comparatively common in the days when phlebotomy was in
+fashion, the nerves being occasionally wounded in the operation.
+I have only seen it in connection with this cause,
+that is to say, as an independent affection. One such
+case has been under my care. But a slight degree of it is not
+uncommon, as a secondary symptom, in neuralgia affecting
+other nerves. The traumatic form is excessively obstinate and
+intractable.</p>
+
+<p>In the neuralgias of the arm we begin to recognize the etiological
+characteristic which distinguishes most of the neuralgic
+affections of the limbs, namely, the frequency with which
+they are aggravated, and especially with which they are
+kept up and revived when apparently dying out, the muscular
+movements. In the case above referred to, of neuralgia of the
+subscapular, musculo-spiral (cutaneous branches), and radial,
+the act of playing on the piano for half an hour immediately
+revived the pains, in their fullest force, when convalescence
+had apparently been almost established.</p>
+
+<p>There is a special cause of cervico-brachial neuralgias which
+is of more importance than, till quite lately, has ever been recognized,
+namely, reflex irritation from diseased teeth. The
+subject of these reflex affections from carious teeth has been
+specially brought forward by Mr. James Salter, in a very able
+and interesting paper in the "Guy's Hospital Reports" for
+1867; and Mr. Salter informs me that he has been surprised by
+the number of cases of reflex affections, both paralytic and
+neuralgic, of the cervico-brachial nerves, produced by this
+kind of irritation, and that he agrees with me in thinking that
+a peculiar organization or disposition of the spinal centres of
+these nerves must be assumed in order to account for the fact.</p>
+
+<p>The liability of particular nerves in the upper extremity to
+neuralgia from external injuries requires a few words. The
+nerve which is probably most exposed to this is the ulnar.
+Blows on what is vulgarly called the funny-bone are not uncommon
+exciting causes of neuralgia in predisposed persons,
+and cutting wounds of the ulnar a little above the wrist are
+rather frequent causes. The deltoid branches of the circumflex
+and the humeral cutaneous branches of the musculo-spiral
+are much exposed to bruises and to cutting wounds. So far as
+I know, it is only when a nerve trunk of some size has been
+wounded that neuralgia is a probable result. Wounds of the
+small nervous branches in the fingers, for instance, are very
+seldom followed by neuralgia. I have no statistics to guide me
+as to the effect of long-continued irritation applied to one of these
+small peripheral branches, but it is probable that that might be
+more capable of inducing neuralgia. As far as my own experience<span class="pagenum"><a name="Page_37" id="Page_37">[37]</a></span>
+goes, however, it would appear that a more common result
+is convulsion of some kind, from reflex irritation of the cord.</p>
+
+<p>(<i>d</i>) <i>Dorso-intercostal Neuralgia.</i>&mdash;This is one of the commonest
+varieties of neuralgia, and yet it is very likely to be
+confounded with other affections not neuralgic in their nature.
+The disorder with which it is especially liable to be confounded
+is myalgia, which will be fully described in another
+chapter, and which, when developed in the region of the body
+to which we are now referring, is commonly spoken of as
+pleurodynia, or lumbago (according as it affects the muscles of
+the back or of the side), or muscular rheumatism. It must be
+owned that the severer forms of this affection can scarcely be
+distinguished from true intercostal neuralgia by anything in
+the character or situation of the pains. It will be seen, hereafter,
+however, that myalgia has its own specific history,
+which is very characteristic; at present, it is sufficient to remember
+that it is often extremely like neuralgia when situated
+in the dorso-intercostal region.</p>
+
+<p>Dorso-intercostal neuralgia is an affection of certain of the
+dorsal nerves. These nerves divide, immediately after their
+emergence from the intervertebral foramina, into an interior
+and a posterior branch. The latter sends filaments which pierce
+the muscles to be distributed to the skin of the back; the
+former, which are the intercostal nerves, follow the intercostal
+spaces. Immediately after their commencement they communicate
+with the corresponding ganglia of the sympathetic.
+Proceeding outward, they at first lie between two layers of intercostal
+muscles, and, after giving off branches to the latter,
+give off their large superficial branch. In the case of the seventh,
+eighth and ninth intercostal nerves, which are those most
+liable to intercostal neuralgia, the superficial branch is given off
+about midway between the spine and the sternum. The final
+point of division, at which superficial filets come off, in all the
+eight lower intercostal nerves, is nearer to the sternum; and is
+progressively nearer to the latter in each successive space
+downward. There are thus, as Valleix observes, three points
+of division: (1) At the intervertebral foramen; (2) midway in
+the intercostal space; (3) near to the sternum. And there are
+three sets of branches (reckoning the posterior division) which
+respectively make their way to the surface near to these points.</p>
+
+<p>In one of its forms, intercostal neuralgia is one of the commonest
+of all neuralgic affections. I refer to the pain beneath
+the left mamma, which women with neuralgic tendencies so
+often experience, chiefly in consequence of over-suckling, but
+also from exhaustion caused by menorrhagia or leucorrh&#339;a, and
+especially from the concurrence of one of the latter affections
+with excessive lactation. It is especially necessary, however,
+to guard against mistaking for this affection a mere myalgic
+state of the intercostal or pectoral muscles, which often arises<span class="pagenum"><a name="Page_38" id="Page_38">[38]</a></span>
+in similar circumstances with the addition of excessive or too
+long continued exertions of these muscles. "Hysteric" tenderness
+also sometimes bears a considerable resemblance, superficially,
+to true intercostal neuralgia, in cases where the genuine
+disease does not exist.</p>
+
+<p>A less common but very remarkable variety of intercostal
+neuralgia than that just mentioned, is the kind of pain which attends
+a good many cases of herpes zoster, or shingles. It is
+only of recent years that any essential connection between zoster
+and neuralgia has been suspected. The occurrence of neuralgia
+as a sequel to zoster had indeed been mentioned by
+Rayer, Recamier, and Piorry, but the essential nature of the
+connection between the two diseases was evidently not suspected
+by Lecadre, when, as late as 1855, he published his valuable
+essay on intercostal neuralgia. M. Notta was one of the
+first to present connected observations on the subject. But it
+was much more fully discussed in a paper published by M. Barensprung,
+in 1861. [<i>Ann. der Charite-Krakenhauser zer Berlin,
+ix.</i>, 2, p. 40. <i>Brit. and For. Med. Rev.</i>, January, 1862.] This
+author showed the absolute universality with which unilateral
+herpes, wherever developed, closely followed the course of some
+superficial sensory nerve, and gave reasons, which will be discussed
+hereafter, for supposing that the disease originates in the
+ganglia of the posterior roots, and that the irritation spreads
+thence to the posterior roots in the cord, causing reflex neuralgia.
+We shall have more to say on this matter. Meantime,
+it seems to be established, by multiplied researches, that,
+though unilateral herpes may and often does occur without
+neuralgia, and neuralgia without herpes, the concurrence of
+the two is due to a mere extension of the original disease,
+which is a nervous one.</p>
+
+<p>In young persons, zoster is not attended with severe neuralgia,
+but a curious half-paretic condition of the skin, in
+which numbness is mixed with formication, or with a sensation
+as of boiling water under the skin, precedes the outbreak of the
+eruption by some hours, or by a day or two. Painless herpes
+is commonest in youth. I remember, for instance, that, in an
+attack of shingles which I suffered about the age of eleven,
+there was at no stage any acute pain; only, in the pre-eruptive
+period, for a short time, I had the curious sensations referred
+to above: and the same thing has occurred in all the patients
+below puberty that I have seen, if they complained at all. From
+the age of puberty to the end of life, the tendency of herpes to
+be complicated with neuralgia becomes progressively stronger.
+The course of events varies much in different cases, however.
+In adult and later life the symptoms usually commence with a
+more or less violent attack of neuralgic pain, which is succeeded,
+and generally, though not always, displaced by the
+herpetic eruption. The latter runs its course, and after its disappearance<span class="pagenum"><a name="Page_39" id="Page_39">[39]</a></span>
+the neuralgia may return, or not. In old people it
+almost always does return, and often with distressing severity
+and pertinacity. Six weeks or two months is a very common
+period for it to last, and in some aged persons it has been known
+to fix itself permanently, and cease only with life. In these
+subjects a further complication sometimes occurs. The herpetic
+vesicles leave obstinate and painful ulcers behind them,
+which refuse to heal, and which worry the patient frightfully,
+the merest breath of air upon them sufficing to produce agonizing
+darts of neuralgic pain. I have known one patient, a
+woman over seventy years of age, absolutely killed by the exhaustion
+produced by protracted suffering of this kind.</p>
+
+<p>The foci of pain in intercostal neuralgia are always found in
+one or more of the points, already enumerated, at which sensory
+nerves become superficial. In long-standing cases acutely
+tender points are developed in one or more of these situations;
+not unfrequently the most decided of these spots is where it
+gets overlooked, namely, opposite the intervertebral foramen.
+H. G., a young woman aged twenty-six, who applied to me at
+Westminster Hospital, had suffered for twelve months from an
+irregularly intermitting but very severe neuralgia at the level
+of the seventh intercostal space of the left side. The violence
+of the pain was sometimes excessive, and when the paroxysm
+lasted longer than usual it generally produced faintness and
+vomiting. This patient had no sign of tenderness anywhere
+in the anterior or lateral regions, though the pain seemed to
+gird round the left half of the chest as with an iron chain, but
+an exquisitely tender spot, as large as a shilling, was found
+close to the spine; pressure on this always induced a strong
+feeling of nausea.</p>
+
+<p>As an illustration of the herpetic variety of dorso-intercostal
+neuralgia, running a severe but not protracted course, I may
+relate the case of a medical man whom I formerly attended.
+This gentleman was about thirty-two years of age, and a highly
+neurotic subject: inter alia, he had already suffered from a
+severe and protracted sciatica; and, very shortly before the
+herpetic attack, had been jaundiced from purely nervous
+causes. His nervous maladies were undoubtedly caused by
+over-brain-work. In this case the neuralgia developed itself
+during the latter half of the eruptive period, which was rather
+unusually lengthened. It occupied the seventh, eighth, and
+ninth intercostal spaces of the side affected with herpes, and
+was very violent and acute, so that the patient expressed himself
+as almost "cut in two" with it. The pain ceased even
+before the vesicles had perfectly healed; a rather unusual occurrence
+in my experience. I shall refer to this case hereafter,
+as an example of what I believe to be the effect of a particular
+method of treatment in lessening the tendency to after-neuralgia.
+The result of my experience is certainly this&mdash;that if a<span class="pagenum"><a name="Page_40" id="Page_40">[40]</a></span>
+case of herpes in an adult, or still more in an aged person, be
+left to itself, the amount of after-neuralgia will very closely
+correspond with the severity of the eruptive symptoms.</p>
+
+<p>There is a variety of intercostal neuralgia which is of more
+importance than the commoner kinds. Occurring mostly in
+persons who have passed the middle age, it possesses the characters
+of obstinacy and severity which belong to the neuralgias
+of the period of bodily decay. It is at first unattended with
+any special cardiac disturbance. By-and-by, however, it begins
+to attract more careful attention from the fact that the severer
+paroxysms extend into the nerves of the brachial plexus of the
+affected side, so that pain is felt down the arm. In the midst
+of a paroxysm of intercostal and brachial pain, it may happen
+that the patient is suddenly seized with an inexpressible and
+deadly feeling of cardiac oppression, and, in fact, the symptoms
+of angina pectoris, such as they will be described in a future
+chapter, become developed. A case of this kind is at present
+under my care at the Westminster Hospital. The patient is a
+man only fifty-six years of age, but whose extreme intemperance
+has produced an amount of general degeneration of his
+tissues such as is rarely seen except in the very aged; he has
+the most rigid radial arteries, and the largest arcus senilis, I
+think, that I ever saw. This man has long been subject to attacks
+of violent intercostal neuralgia, and a recent access assumed
+the type of unmistakable angina. It is very probable
+that his coronary arteries have now become involved in the degenerative
+process. In this case, before the development of
+any marked anginal symptoms, the paroxysmal pain, from
+being merely intercostal, had come to extend itself into the left
+shoulder and arm.</p>
+
+<p>Intercostal neuralgia not unfrequently accompanies, and is
+sometimes a valuable indication of, phthisis. I do not mean to
+say that the vague pains in the chest-walls, which are so very
+common in phthisis, are to be indiscriminately accounted neuralgia;
+on the contrary, they are, in the large majority of instances,
+merely myalgic, and arise from the participation of the
+pectorals, or intercostals, or both, in the mal-nutrition which
+prevails in the organism generally. But it happens, sometimes
+that a distinctly intermitting neuralgia occurs as an early symptom
+of phthisis; in fact, where there is a predisposition to neurotic
+affections, I believe that this is not very uncommon. The
+subjects are generally women; they are mostly of that class of
+phthisical patients who have a quick intelligence, fine soft hair,
+and a sanguine temperament. I have had one male patient under
+my care: this was a young gentleman aged eighteen, in
+whom a neuralgic access came on with so much severity, and
+caused so much constitutional disturbance, that the idea of
+pleurisy was strongly suggested. The paroxysms returned at
+irregular intervals for a considerable period: they were quite<span class="pagenum"><a name="Page_41" id="Page_41">[41]</a></span>
+unlike myalgic pains, not only in their character, but more especially
+with respect to the circumstances which were found to
+provoke their recurrence. They were the first symptoms
+which lead to any careful examination of the chest; it was
+then found that there were prolonged expiration and slight dulness,
+at one apex. At this period, wasting had not seriously
+commenced; but, on the other hand, there was an extraordinary
+degree of debility for so early a stage of phthisis. I am
+inclined to think that self-abuse was the principal cause both
+of the phthisis and the neuralgia, acting doubtless on a predisposed
+organism, for his family was rather specially beset with
+tendencies to consumption. I may add here, that it has appeared
+to me that young persons with phthisical tendencies are
+specially liable to neuralgic affections as a consequence of self-abuse.</p>
+
+<p>A special variety of intercostal neuralgia is that which attacks
+the female breast. The nerves of the mammę are the
+anterior and middle cutaneous branches of the intercostals;
+and they are not unfrequently affected with neuralgia, which
+is sometimes very severe and intractable. Dr. Inman has very
+properly pointed out that a large number of the cases of so-called
+"hysterical breast" are really myalgic, and are directly
+traceable to the specific causes of myalgia; but there is no
+question in my mind that true neuralgia of the breast does
+occur, and indeed is frequent, relatively to the frequency of
+neuralgias generally. There are several kinds of circumstances
+under which it is apt to occur. In highly-neurotic patients it
+may come on with the first development of the breasts at
+puberty; and it may be added that this is especially apt to
+occur where puberty has been previously induced by the unfortunate
+and mischievous influences to which we had occasion
+to refer in speaking of certain other neuralgię. A neuralgia
+of the left breast occurred in a patient of mine, who attended
+the Westminster Hospital. She was only twelve years of age,
+and small of stature, but the mammę were considerably developed.
+The face was haggard, there was an almost choreic
+fidgetiness about the child, and a very unprepossessing expression
+of countenance; the result of inquiries left no doubt that
+the patient was much addicted to self-abuse; and it seemed
+probable that to this was due the fact that menstruation had
+come on, and was actually menorrhagic in amount.</p>
+
+<p>A very painful kind of mammary neuralgia is experienced
+by some women during pregnancy; but more commonly the
+mammary pains felt at this period are mere throbbings, not
+markedly intermittent in character, and plainly dependent on
+mechanical distention of the breast: such affections are not to
+be reckoned among true neuralgię. A true neuralgia of a
+very severe character is sometimes provoked by the irritation
+of cracked nipples. I have seen a delicate lady, of highly-neurotic<span class="pagenum"><a name="Page_42" id="Page_42">[42]</a></span>
+temperament, and liable to facial neuralgia, most violently
+affected in this way. Vain attempts had been made for
+several consecutive days to suckle the infant from the chapped
+breast; when suddenly the most severe dorso-intercostal neuralgia
+set in. The attacks lasted only a few seconds each, but
+they recurred almost regularly every hour, and were attended
+with intense prostration, and sometimes with vomiting. Discontinuance
+of suckling was found necessary, for even the
+application of the child to the sound breast now sufficed to
+arouse a paroxysm of pain. Complete rest, protection of the
+breast from air and friction, and the hypodermic injection of
+morphia, rapidly relieved the sufferer.</p>
+
+<p>(<i>e</i>) <i>Dorso-lumbar Neuralgia.</i>&mdash;The superficial branches of
+the spinal nerves emanating from the lumbar plexus are considerably
+less liable to be affected with severe and well-marked
+neuralgia than are the dorso-intercostal nerves. Pains
+in the abdominal walls, which are a good deal like neuralgia,
+are not uncommon; but the majority of them will be found,
+on careful observation, to be myalgia. At least, this has been
+the case in my own experience.</p>
+
+<p>When true neuralgia of the superficial branches of the
+lumbo-abdominal nerves occurs, it develops itself in one or
+more of the following foci: (1) Vertebral points, corresponding
+to the posterior branches of the respective nerves; (2) an
+iliac point, about the middle of the crista ilii; (3) an abdominal
+point, in the hypogastric region; (4) an inguinal point, in the
+groin, near the issue of the spermatic cord, whence the pain
+radiates along the latter; (5) a scrotal or labial point, situated
+in the scrotum or in the labium majus.</p>
+
+<p>Such is the description given by Valleix; for my own part,
+I cannot say that I have seen enough cases to test its accuracy.
+I believe it to be generally correct, yet it may fairly be doubted
+whether the author might not have revised his description had
+the natural history of myalgic affections been as carefully investigated
+as it has since been. The hypogastric foci of pain of
+which he speaks are at least open to considerable suspicion, as
+it will be shown, in the chapter on Myalgia, that an extremely
+common variety of the latter affection is situated in this region,
+and the severity of the pain which it often produces might
+well cause it to be mistaken for a genuine neuralgia.</p>
+
+<p>I have, however, seen three or four cases in which the very
+complete intermittence of the paroxysms, without any perceptible
+relation to the question of muscular fatigue, left no
+doubt in my mind of the really neuralgic character of the
+malady. In one of these instances, oddly enough, the exciting
+cause appeared to be fright; and this was as severe a case
+as one often sees. The patient was a woman of middle age,
+and much depressed by the long continuance of a profuse leucorrh&#339;a.
+As she was walking along the street, a herd of<span class="pagenum"><a name="Page_43" id="Page_43">[43]</a></span>
+cattle, in a somewhat irritable and disorderly condition, came
+suddenly toward her; she immediately began to suffer pain
+just above the crest of the ilium, and at the lumber region, and,
+most acutely, in the labium majus of one side; and then pain
+returned daily, about 10 <span class="smcap">a.&nbsp;m.</span>, lasting for half an hour with
+great severity. This woman's family history was remarkable:
+her mother had been paraplegic, her sister was a confirmed
+epileptic, and two of her children had suffered from
+chorea.</p>
+
+<p>In two other cases of lumbo-abdominal neuralgia which were
+under my care, there were also very painful points in the spermatic
+cord and in the testicle. One of these cases will be referred
+to under the head of Visceral Neuralgia. Another case,
+in which severe quasi-neuralgic pain was referred to the
+groin, will be described in the chapter on the Pains of Hypochondriasis.</p>
+
+<p>(<i>f</i>) <i>Crural Neuralgia.</i>&mdash;This appears to be rare as an independent
+affection occurring primarily in the crural nerve.
+Valleix had only seen it twice in all his large experience, and
+I have never seen it myself. Neuralgic pain of the crural
+nerve is almost always a secondary affection arising in the
+course of a neuralgia, which first shows itself in the external
+pudic branch of the sacral plexus; or else occurring as a complication
+of sciatica. A remarkably severe example of the latter
+occurrence was observed in an old man who still occasionally
+attends the Westminster Hospital. He has been a martyr
+to the most inveterate bilateral sciatica for between two and
+three years; and, within the last three months, it has extended
+itself into the cutaneous branches of the curval nerves of both
+thighs. So great an aggravation of the pain is produced by
+any muscular movement, that the patient can only walk at the
+slowest possible pace, moving each foot forward only a few
+inches at a time. The bilateral distribution of the pain is remarkable
+in this case; but there can be no doubt of its really
+neuralgic character, from the truly intermittent way in which
+it recurs, and the absence of any history whatever to point in
+the direction of rheumatism, gout, or syphilis.</p>
+
+<p>The nervous supply to the skin of the anterior and external
+portion of the thigh includes: (1) The middle cutaneous, (2)
+the internal cutaneous, and (3) the long saphenous branch of
+the anterior crural nerve; (4) the cutaneous branch of the
+obturator; and (5) the external cutaneous nerve, derived from
+the loop formed between the second and third lumbar nerve.
+The sensitive twigs derived from the two latter sources, equally
+with the branches of the anterior crural, are liable to be secondarily
+affected by neuralgia, which commences in the lumbo-abdominal
+nerves; but it must be a rare event for them to be
+the seat of a primary neuralgia. The only occasion on which
+I have seen anything which looked like the latter was in the<span class="pagenum"><a name="Page_44" id="Page_44">[44]</a></span>
+case of a porter, who, in straining to lift a very heavy load,
+ruptured some part of the attachment of the tensor vaginę
+femoris. But the susceptibility of all the nerves of the front of
+the thigh to secondary or reflex neuralgia receives numerous
+illustrations. The extremely severe pain at the internal aspect
+of the knee-joint, which is such a common symptom in morbus
+coxę, is evidently a reflex neuralgia of the long saphenous
+nerve, the ultimate irritation being situated in the branches of
+the obturator nerve which supply the hip-joints. For some
+reason unexplained, it happens that this saphenous nerve is
+specially liable to be affected in a reflex manner: for instance,
+this happens in a considerable number of cases of sciatica. I
+have a lady now under my observation, in whom the secondary
+neuralgia of the saphenous nerve has become even more
+intolerable than the pain in the sciatic, which was the nerve
+primarily affected. The pain in these cases very frequently
+runs down the inner and anterior surface of the leg to the
+internal ankle. Sometimes the branches of the anterior crural
+become the seat of intensely painful points in the course of a
+long-persisting sciatica. A patient at present under my care
+has a spot, about the size of a shilling, just at the emergence
+of the middle cutaneous branch from the fascia lata, which is
+intensely and persistently tender to the touch, and the skin
+here is so exquisitely sensitive to the continuous galvanic current
+that the application of moistened sponge-conductors, with
+a current of only fifteen Daniell's cells, causes intolerable
+burning pain; whereas at every other part of the limb the current
+from twenty-five cells can be borne without much inconvenience.</p>
+
+<p>(<i>g</i>) <i>Femoro-popliteal Neuralgia, or Sciatica.</i>&mdash;This is one of
+the most numerous and important groups of neuralgia; but,
+notwithstanding that there are plenty of opportunities for
+studying it, I venture to think it is very commonly mistaken
+for different and non-neuralgic diseases, and they for it. The
+rules of diagnosis which will be laid down for all the neuralgię
+would nevertheless prevent these errors, if carefully attended
+to.</p>
+
+<p>Sciatica is a disease from which youth is comparatively exempt.
+Valleix had collected one hundred and twenty-four
+cases, and in not one was the patient below the age of seventeen,
+only four were below twenty. In the next decade there
+were twenty-two; in the next, thirty; and the largest number
+of cases, thirty-five, occurred between the ages of forty and
+fifty. This completely tallies with my own experience, and
+appears to afford some support to a suspicion I have formed,
+that the chief exciting cause of sciatica is the pressure exercised
+on the nerve in locomotion, and that this cause exercises its
+maximum influence when the period of bodily degeneration
+commences. It is further remarkable that, in elderly persons<span class="pagenum"><a name="Page_45" id="Page_45">[45]</a></span>
+(whose habits of locomotion are of course more limited), the
+proportion of fresh cases rapidly diminishes; and also that
+above the age of thirty the number of male patients greatly
+exceeds that of female patients attacked. All this seems to
+point in the same direction.</p>
+
+<p>According to my observation, there are three distinct varieties
+of sciatica. The first of these is obscure in its origin, but
+may be said, in general terms, to be connected with a nervous
+temperament of the highly impressible kind, which is more or
+less like what we call "hysteric," not only in the female, but
+also in male patients. The subjects of this kind of sciatica are
+mostly young persons, and hardly ever more than middle-aged;
+they are generally found to be liable to other forms of
+neuralgia; and the actual attack of sciatica is produced by
+some fatigue or mental distress, which at other times might
+have brought on sick headache, or intracostal neuralgia, etc.
+Very many of these patients are anęmic; and chlorotic anęmia
+seems specially to favor the occurrence of the affection.
+The greater number of the victims are females, and in very
+many, whether as cause or effect, there is impeded, or at least
+imperfect, menstruation. This kind of sciatic pain is not usually
+of the highest degree of intensity, but it generally spreads
+into a great many branches, both in a direct and a reflex manner.
+It is probable that this variety of the disease is, at least
+very often, dependent upon, or much aggravated by, an excited
+condition of the sexual organs; certainly, I have observed
+it with special frequency in women who have remained single
+long after the marriageable age, and in several male patients
+there has been either the certainty or a strong suspicion of
+venereal excess. Sciatica of this kind also occurred in the case
+of a single woman aged about thirty, who to my knowledge
+was excessively addicted to self-abuse.</p>
+
+<p>The second variety of sciatica occurs for the most part in
+middle-aged or old persons who have long been subject to excessive
+muscular exertion, or have been much exposed to damp
+and cold, or who have been subject to the combined influence
+of both these kinds of evil influence. One must also include,
+I think, in this group a considerable number of cases where the
+age is not so advanced, but the patient has been obliged, by
+the nature of his business, to maintain the sitting posture daily,
+for hours together, exercising pressure on the nerve; this is
+especially liable to happen in these persons.</p>
+
+<p>The sufferers from this variety of sciatica are mostly, as already
+said, of middle age or more; but this statement must be
+understood to be made in the comparative sense, which refers
+rather to the vital status of the individual than to the mere
+lapse of years. Many of these people have hair which is prematurely
+gray, and in some the existence of rigid arteries, together
+with arcus senilis, completes the picture of organic involution,<span class="pagenum"><a name="Page_46" id="Page_46">[46]</a></span>
+or senile degeneration. In particular cases, where
+depressing influences have been at work for a long time, or
+unusually active, these appearances rectify the false impression
+we should otherwise derive from learning the mere nominal
+age of the person; this is especially often the case with regard
+to patients who have for a long time drunk to excess. The
+prematurely and permanently gray hair (it will be seen hereafter
+that permanency of grayness is an important point), together
+with well-marked inelasticity of arteries, very often
+tells a tale which is most useful in informing us, not only of
+the vital status of the patient, but of the kind of sciatica under
+which he labors; and also influences our prognosis seriously.
+There is otherwise a somewhat deceptive air about the appearance
+of many of these degenerative cases; for instance, a ruddy
+complexion is not uncommon, nor the retention of considerable,
+or even great, muscular strength. It is probable that these
+appearances deceived Valleix and many others, or they could
+hardly have failed, as they have, to observe the frequency of
+the degenerative type among the most numerous group of sciatic
+patients, namely, those between thirty and fifty years of
+age. These persons are not truly "robust," although at a
+hasty glance they might at first seem to be so. It would be a
+serious mistake to omit the search for the important vital evidences
+which have been referred to, since these therapeutic
+and prognostic indications are of the highest value.</p>
+
+<p>A prominent feature in this kind of sciatica is its great obstinacy
+and intractability. Another, equally marked, is the tendency
+to the development of spots around the foci of severest
+pain which are intensely and permanently tender, and the
+slightest pressure on which is sufficient to set up acute pain.
+This is a symptom much less developed, if developed at all, in
+the variety of sciatica which we first discussed. The places
+which are especially apt to present this phenomenon of tenderness
+are as follows: (1) A series, or line of points, representing
+the cutaneous emergence of the posterior branches,
+which reaches from the lower end of the sacrum up to the
+crista ilii; (2) a point opposite the emergence of the great and
+small sciatic nerves from the pelvis; (3) a point opposite the
+cutaneous emergence of the ascending branches of the small
+sciatic, which run up toward the crista ilii; (4) several points
+at the posterior aspect of the thigh, corresponding to the cutaneous
+emergence of the filets of the crural branch; (5) a fibular
+point, at the head of the fibula, corresponding to the division
+of the external popliteal; (6) an external malleolar, behind
+the outer ankle; (7) an internal malleolar.</p>
+
+<p>I have already mentioned that in sciatica the pain frequently
+spreads in a reflex manner to nerves which are connected, by
+their origin from the plexus, with the sciatic. It will be remembered,
+also, that I related cases in which the formation of<span class="pagenum"><a name="Page_47" id="Page_47">[47]</a></span>
+tender points, in the course of the nerves thus secondarily affected,
+was even more distinct and remarkable than anywhere
+in the branches of the sciatic itself.</p>
+
+<p>Another circumstance which distinguishes the form of sciatica
+which we are now describing is, the degree in which (above
+all other forms of neuralgia) it involves paralysis of motion.
+[The subject of the complication of neuralgia will be treated
+in a general manner farther on; but it seems necessary to note
+here the special liability of sciatic patients to this and to the
+most material complications]. By far the largest part of the
+motor nervous supply for the whole lower limb passes through
+the trunk of the great sciatic; it might therefore be naturally
+expected that a strong affection of the sensory portion of the
+nerve would produce, in a reflex manner, some powerful effect
+upon the motor element. This effect is most frequently in the
+direction of paralysis. Complete palsy is rare, but in a large
+proportion of cases which have lasted some time there will be
+found, independently of any wasting of muscles, a positive
+and considerable loss of motor power. It is of course necessary
+to avoid the fallacy which might be produced by neglecting
+to observe whether movement was restricted merely in
+consequence of its painfulness. Not long since, I had occasion
+to test the electric sensibility in a case of sciatica, in which
+there was extremely severe pain, affecting chiefly the peroneal
+region of the leg, and great weakness of the leg, amounting to
+inability for walking. The gastrocnemius could hardly be got to
+contract at all, when the most powerful Faradic current was directed
+upon the nerve in the popliteal space of the affected limb,
+though the muscle of the sound side reacted with great vigor.</p>
+
+<p><i>Anęsthesia</i> is also a common complication of sciatica, far
+commoner, I venture to think, than it has been represented
+either by Valleix, or Notta. It is necessary, however, to be
+explicit on this point. In the early stages, both of this form
+of sciatica, and of the milder variety previously described,
+there is almost always partial numbness of the skin previous
+to the first outbreak of the neuralgic pain, and during the intervals
+between the attacks. By degrees this is exchanged, in
+the milder form, for a generally diffused tenderness around the
+foci of neuralgic pain, while other portions of the limb remain
+more or less anęsthetic. In the severer forms it sometimes
+happens that, besides an intense tenderness of the skin over
+the painful foci, there is diffused tenderness over the greater
+part or the whole of the surface of the limb. But it is important
+to remark that both in the anęsthetic and the hyperęsthetic
+conditions (so called) the tactile sensibility is very much
+diminished. I have made a great many examinations of painful
+limbs, in sciatica, and have never failed to find (with the
+compass points) that the power of distinctive perception was
+decidedly lowered.<span class="pagenum"><a name="Page_48" id="Page_48">[48]</a></span></p>
+
+<p><i>Convulsive movements of muscles</i> are met with in a moderate
+proportion of cases of sciatica in middle and advanced life,
+in which affection they are entirely involuntary. They differ
+from certain spasmodic movements not unfrequently observed
+in the milder form (and especially in hysteric women), for
+these are more connected with morbid volition, and are in
+truth, not perfectly involuntary. In several cases of inveterate
+sciatica I have seen violent spasmodic flexures of the leg
+upon the thigh. Cramps of particular muscles are occasionally
+met with. I have seen the flexors of the toes of the
+affected limb violently cramped, and in one case there was agonizing
+cramp of the gastrocnemius. It is chiefly at night, and
+especially when the patient is falling asleep, that this kind of
+affection is apt to occur.</p>
+
+<p>A third variety of sciatica is the rather uncommon one so
+far as my experience goes, in which inflammation of the tissues
+around the nerve is the primary affection, and the neuralgia is
+mere secondary effect, from mechanical pressure on the nerve,
+which, however, is not apparently itself inflamed. I believe
+that these cases are sometimes caused by syphilis, and sometimes
+by rheumatism. One of the most violent attacks of sciatic
+pain which ever came under my notice was in a syphilized
+subject, a discharged soldier, who had been the victim of
+severe tertiary affections, and had been mercilessly salivated
+into the bargain. This unfortunate man suffered dreadful agony,
+which was aggravated every night, but was never totally
+absent. The pain started from a point not far behind the great
+trochanter: pressure here caused intolerable darts of pain,
+which ramified into every offshoot of the sciatic nerve, as it
+seemed, and made the man quite faint and sick. Large doses
+of iodide of potassium, together with the prolonged use of cod-liver
+oil, completely removed the pain and tenderness. It need
+hardly be said that cases of this kind are essentially different,
+and require perfectly different principles of treatment from
+neuralgias in which the disturbance originates within the nervous
+tissues themselves.</p>
+
+<p>The chronic rheumatism does also, occasionally, affect the
+sheath of the nerve in such a manner as to produce a deposit
+which sets up neuralgic pain, must also be admitted, although I
+believe the number of such cases to be preposterously over-estimated
+by careless observers. It has several times happened
+that a patient has come under my care with so-called "rheumatic
+affection of the nerves" of the thigh and leg, and that
+on examination one has found all the symptoms and clinical
+history of a neurosis, but not the slightest valid argument for
+a diagnosis of the rheumatic diathesis. Indeed, upon this
+point, I think it is time that a decided opinion should be expressed.
+I firmly believe that a large number of sciatic patients
+have their health ruined by treatment directed to a supposed<span class="pagenum"><a name="Page_49" id="Page_49">[49]</a></span>
+rheumatic taint which is purely imaginary. The state
+of medical reasoning, suggested by the way in which too many
+practitioners decide that such and such pains are rheumatic in
+their origin, is a melancholy subject for reflection. Nearly always
+it will be found, on cross-examination, that the state of
+the urine has been made the basis of a confident diagnosis; the
+practitioner will tell you that the urine was loaded, <i>i.&nbsp;e.</i>, with
+lithtaes. He ignores the fact that nothing is more common, in
+neurotic patients who are perfectly guiltless of rheumatic propensities,
+than a fluctuation between lithiasis and oxaluria,
+neither of which phenomena, under the circumstances, indicates
+any more than a temporary defect of secondary assimilation
+of food, produced by nervous commotion. I may perhaps
+find room, on a future page, for a few further remarks on
+the subject; at present I only put in a caution against too
+ready an acceptance of the rheumatic hypothesis.</p>
+
+
+<p>II. <span class="smcap">Visceral Neuralgias.</span></p>
+<p><i>Uterine and Ovarian Neuralgia.</i>&mdash;This is an
+important group of neuralgic affections, and one which
+I cannot help thinking is strangely misappreciated, very often,
+in a therapeutic point of view. In one aspect these affections
+possess a special interest, namely this, that they are more frequently
+dependent on peripheral irritation for their immediate
+causation than any other group of neuralgias. If we consider
+the great copiousness of the nervous supply to the uterus and
+ovaries, and the powerfully disturbing character of the functional
+processes which are periodically occurring in these organs,
+we shall be at no loss to understand how this may be.
+The amount force of the peripheral influence and which are
+brought to bear upon the central nervous system by the functions
+of the uterus and ovaries are greater than any that emanate
+from the diseases and functional disturbances of any other
+organ in the body.</p>
+
+<p>The most common variety of peri-uterine neuralgia is that
+which attends certain kinds of difficult menstruation. It
+would be hardly correct to give the name of neuralgia to the
+pain existing in these very numerous cases of dysmenorrh&#339;a
+in which the suffering is apparently altogether dependent on
+the mere retention or difficult escape of the menstrual fluid,
+although the character of the pain often resembles the neuralgic
+type. There is another group of dysmenorrh&#339;al affections
+however, in which the pain may fairly be called neuralgic,
+since it is apparently independent of the circumstances of the
+discharge of menstrual fluid, and simply attends the process,
+seemingly on account of a naturally-exaggerated irritability of
+the organs concerned. There is a large class of young women
+in whom, and more especially before marriage, the time of
+menstruation is always marked by the occurrence of more or
+less severe pain. Formerly I used to believe that this pain was
+relieved on the occurrence of the discharge, but I have seen too<span class="pagenum"><a name="Page_50" id="Page_50">[50]</a></span>
+many cases of a contrary nature to retain this opinion. I now
+believe that the subjects of the kind of menstrual pain to which
+I am referring are naturally endowed with a very irritable nervous
+apparatus of the pelvic organs, and that there is a certain
+character at once of immaturity and excitability in their sexual
+organs, especially in the virgin condition. So far from these
+females being disposed to sterility, as is too often the case with
+those dysmenorrh&#339;al subjects whose troubles depend upon occlusion,
+distortion, or narrowing of the outlets, they are often
+extremely apt to the generative function; and, what is more,
+the full and natural exercise of the sexual function appears
+necessary to the health of their organs, as is shown by the fact
+that these menstrual pains lose their abnormal character, completely
+or in great part, after marriage, and especially after
+child-bearing. The contrast between the two types of dysmenorrh&#339;al
+patients is sharply brought out by the two following
+cases:</p>
+
+<p><span class="smcap">Case I.</span>&mdash;S. M., a housemaid, aged twenty-three when first
+under my notice, was the picture of physical health and
+strength, very intelligent, and a girl of excellent character
+and most industrious habits. At every menstrual period, however,
+she suffered, for some hours previously to the occurrence
+of the flow, from severe pain in the uterine region, which was
+tumefied and tender. Hot hip-baths gave some relief, apparently
+by hastening the discharge; as soon as the latter was established,
+the pain rapidly subsided. This young woman married
+a healthy and vigorous young man, but has never had any
+children, and at the date of my last inquiries still suffered periodically
+from her old troubles.</p>
+
+<p><span class="smcap">Case II.</span>&mdash;Mrs. B. was married at the age of twenty-six. Up
+to the date of her marriage she used to suffer the most severe
+pain at every menstrual period; the pain, however, bore no relation
+to the freedom of the discharge, but always lasted about
+the same length of time, under any circumstances, or was only
+less or more according as the general bodily vigor was greater
+or less at the moment. From the date of marriage these
+troubles steadily declined; a child was born at the end of
+twelve months, and the menstrual troubles have never resumed
+a serious shape up to the present time, a period of nearly
+nine years. This lady is herself a neuralgic subject, liable to
+migraine in circumstances of fatigue, and suffering horribly
+from it during her pregnancies; and she comes of a family in
+whom the nervous temperament is strongly developed.</p>
+
+<p>It must not always be concluded, because the menstrual pain
+is very severe before the discharge and is relieved at or soon
+after its appearance, that the case is one of occlusion, and not
+of neuralgia. There is a class of cases in which the affection
+appears to be a very severe ovarian neuralgia, attended with a
+vaso-motor paralysis which causes great engorgement of the<span class="pagenum"><a name="Page_51" id="Page_51">[51]</a></span>
+ovary and consequent difficulty of "ovulation." I have seen
+several instances which I could not explain in any other
+way.</p>
+
+<p><span class="smcap">Case III.</span>&mdash;One patient I particularly remember, from the
+fact that she was always attacked with dreadful pain, which
+was sometimes seated in one groin and sometimes in the other,
+but was regularly attended with large and palpable tumefaction
+of the ovary, which began to subside when the discharge
+commenced. This woman married rather late, but her <ins title="Transcriber's Note: original reads 'mensural'">menstrual</ins>
+troubles immediately became less, and she became pregnant
+and was happily delivered, nearly as soon as was possible.
+She, too, was a decidedly neuralgic subject, independently
+of her tendency to dysmenorrh&#339;al ovarian pain.</p>
+
+<p>In some women who remain single long after the marriageable
+age, ovarian or uterine neuralgia becomes a constantly-recurring
+torment, not only at the menstrual period, but at
+various other times when they are depressed or fatigued in
+body or mind. As might be expected, this tendency is
+greatly aggravated in the rarer cases where the patient's mind
+dwells in a conscious manner on sexual matters, especially if
+by an evil chance she becomes addicted to self-abuse. Among
+the many reproaches that have been thrown upon the indiscriminate
+use of the speculum in examining unmarried women,
+it has often been urged that it tends to excite sexual feelings.
+I do not for a moment doubt that this is the case, or that the
+indiscriminate use of the instrument is altogether indefensible.
+But I expect that neuralgic pain of the uterus or ovaries, in
+unmarried women, connected with an already irritable condition
+of the sexual organs, has often been the reason why such
+women have applied for advice and have consequently been examined
+with the speculum; and that the same thing has frequently
+happened in the case of women who have been left
+widows at a time of life when the sexual powers were still in
+full vigor. These patients deserve great pity.</p>
+
+<p>The peripheral irritation which gives rise to peri-uterine
+neuralgia is not always originally seated in the organs of generation.
+The following are various sources of external irritation
+which I have known to produce the affection:</p>
+
+<p>1. Ascarides in the rectum sometimes produce pelvic neuralgia.
+A woman, aged thirty-four, single, was under my care in
+King's College Hospital many years ago, under suspicions of
+ulcerated cervix. On examination, no lesion could be detected.
+It was discovered that the rectum was infested with ascarides,
+and, after the use of appropriate vermifuges and tonics, the
+patient entirely lost the uterine pains and also a tormenting
+pruritus vaginę, from which she suffered. This woman had
+at various times suffered from neuralgic headache a good deal.</p>
+
+<p>2. Profuse and intractable leucorrh&#339;a, whether associated or
+not with ulceration of the cervix, may produce peri-uterine<span class="pagenum"><a name="Page_52" id="Page_52">[52]</a></span>
+neuralgia, even of great severity, when there are strongly-marked
+neurotic tendencies. It must be noted, however, that
+many cases of pain in leucorrh&#339;al subjects, which superficially
+bear the aspect of neuralgia, turn out on closer investigation
+to be merely examples of myalgia of the abdominal muscles or
+aponeuroses.</p>
+
+<p>3. Calculus in the kidney, or in the ureter, sometimes causes
+intolerable ovarian neuralgia. In the case of a woman who was
+under my care at the Chelsea Dispensary, some years ago, this
+was the unsuspected origin of severe neuralgic pains in the left
+ovary, which recurred several times a day, and which certainly
+contributed to the patient's death by the exhaustion which they
+produced. A calculus was found tightly impacted in the
+ureter, near the kidney.</p>
+
+<p>4. Prolapsus uteri sometimes gives rise to severe peri-uterine
+neuralgia, or what appears to be such; though it is difficult
+here to draw the line between neuralgia and myalgia. The
+commonest kind of pains from prolapsus uteri are not neuralgic
+in their nature at all, but are of a "bearing down" character,
+and probably depend upon actual contractile movement of
+the walls of the uterus.</p>
+
+<p>5. The presence of tumors, either cancerous or fibroid, in
+the uterus or its appendages, gives rise, frequently, to severe
+and indeed almost intolerable pains of a distinctly intermittent
+character. In the early stages of cancerous diseases these
+pains are usually felt at the lower part of the back; in the
+later stages they are felt also in the hypogastric region, and are
+then much more severe.</p>
+
+<p>6. Ulcer of the cervix, of a non-malignant kind, probably
+sometimes gives rise to neuralgic pain of the uterus, though
+this is not so severe as in cancer.</p>
+
+<p>7. Large masses of scybalous fęces, impacted in the rectum,
+will occasionally, by the pressure which they exert on nerves,
+set up violent neuralgia of uterus or ovaries, the true nature
+of which is accidentally discovered by the use of aperients
+which unload the intestine and put an end to the suffering. No
+doubt it is chiefly in persons with neuralgic predisposition that
+this effect is produced; for, common as is the occurrence of
+extreme constipation in women, it is comparatively very rare
+for us to hear of distinctly neuralgic pain being caused by it.</p>
+
+<p>8. The condition known as "irritable uterus," ever since
+Gooch's classical description of it, is always attended with
+uterine pain, which is continuous, but is liable to periodical
+exacerbations of great severity. In this disorder there is no
+recognizable physical disease of the pelvic organs, and the patient
+will generally be found to have suffered neuralgia in other
+parts of the body on previous occasions. [There is some difference
+of opinion about this affection: some authors (<i>e.&nbsp;g.</i>, Hanfield
+Jones) considering it as distinct from the true neuralgias.]<span class="pagenum"><a name="Page_53" id="Page_53">[53]</a></span></p>
+
+<p>9. Reflex irritation, the source of which is in some quite
+distant part of the body, has in many recorded instances occasioned
+uterine neuralgia, in highly-predisposed persons. I
+have seen one case in which severe pain of this kind was
+clearly proved to have been excited by the presence of a carious
+tooth which was itself little, if at all, painful, but the removal
+of which at once cured the pelvic pain.</p>
+
+<p>Neuralgia of the urethra is an affection which is occasionally
+seen, both in males and females. I have observed it three
+times; all these cases were apparently traceable to the effects
+of excessive self-abuse. The male subject was an unmarried
+man, aged forty-two, of cadaverous appearance, much emaciated,
+with clammy, perspiring skin, and habitual coldness of
+the extremities; he suffered much from dyspepsia and palpitation
+of the heart. The pain ran along the under side of the
+penis, which was very large, with an elongated prepuce. The
+paroxysms were severe, and came on chiefly in the morning,
+soon after he awoke. No remedies did this man any permanent
+good, and he passed out of my sight, being at that time in a
+condition of wretched feebleness, and with symptoms of threatened
+dementia. Of the female subjects, one was a married
+woman, who accused her husband of impotence, and from her
+account it would certainly appear that effective connection had
+never taken place; the hymen was completely destroyed,
+however. The neuralgic pains recurred nightly in several
+paroxysms, and were especially severe about the time of the
+monthly periods. In this case the patient was, she stated, induced
+to give up her malpractices; at any rate, the pain subsided
+in a manner which could not be well accounted for by
+any direct influence of the medicinal treatment. The other
+female patient was a widow in whom the morbid habit was
+suspected from her general appearance, and from the existence
+of enlarged clitoris and other signs of irritation about the external
+parts: she became rather rapidly phthisical, and suffered
+severely from neuralgic headaches.</p>
+
+<p>Neuralgia of the bladder has been specially described by
+various writers; the pain is usually spoken of as seated at the
+neck of the bladder, and as accompanied by frequent desire to
+micturate. I have seen two cases, both in women: the first
+was eventually discovered to be an instance of malignant disease
+of the fundus of the bladder; the other was apparently
+the result of a long-continued menorrh&#339;al flux, which had
+greatly impaired the health, and produced extreme anęmia. In
+neither of these instances was the pain referred to the external
+meatus, as in the female patients above mentioned who were
+suffering from urethral neuralgia. I have never seen the
+extreme examples of vesical neuralgia described by some
+writers, in which actual paralysis of the coats of the bladder
+was secondarily produced; but the reflex influence of the<span class="pagenum"><a name="Page_54" id="Page_54">[54]</a></span>
+neuralgic affection in both the examples just mentioned appeared
+to produce great weakening of the muscular power of
+the rectum, occasioning most obstinate and troublesome constipation.</p>
+
+<p>It would appear, from recorded cases, that both the bladder
+and the uterus are liable to be affected with neuralgia from
+malarious influences; but I have never chanced to see any
+such cases.</p>
+
+<p>Neuralgia of the kidney is spoken of by several writers,
+and I suppose there is no doubt that it may exist as a
+special neurotic disease with obvious organic cause. For my
+own part, I cannot say that I have ever seen it except in instances
+where there was either the certainty, or a very strong
+suspicion, that the cause was the mechanical pressure and irritation
+of a calculus within the kidney. The diagnosis of the
+simple functional disorder must be excessively perplexing;
+for in the first place there is the greatest difficulty in making
+sure that the pain is not external, and seated either in the
+muscles of the back, or in the superficial dorsal or lumbar
+nerves, and certainly I am strongly inclined to suspect that
+this has been really the case in many examples of so-called
+renal neuralgia. That neuralgia of the kidney may arise
+secondarily, as a reflex extension of pelvic neuralgia, does,
+however, appear probable enough; for it is almost certain that
+in the latter affection at least, the vaso-motor nerves of the
+kidneys must be strongly influenced in a reflex manner; since
+the crisis or acme of a paroxysm of pelvic pain is not unfrequently
+attended with a copious secretion of pale urine.</p>
+
+<p>Neuralgia of the rectum has been carefully described by Mr.
+Ashton, but is probably not often seen except by practitioners
+who possess special opportunities of observing rectal diseases.
+In the one pure case which has fallen under my notice the
+patient complained of acute paroxysmal cutting pains extending
+about one inch within the anus, and, as these were greatly
+increased by defecation I suspected the existence of fissure.
+Nothing of the kind, however, was found on examination;
+and the pain ultimately yielded to repeated subcutaneous injections
+of atropine. This patient had got wet through, and
+had sat in his damp clothes, getting thoroughly chilled; the
+pain came on with great suddenness and severity, and the tenderness
+which has been mentioned was developed very quickly.
+Probably the influence of cold and wet is among the commonest
+causes of the complaint. Mr. Ashton also reckons as causes,
+reflex irritation from other parts of the alimentary canal, and
+the influence of malaria. He observes that the subjects of the
+affection are most frequently anęmic, and of a generally excitable
+and deranged susceptibility, and that females, who, from
+menorrhagia, or frequent child-bearing with much hęmorrhage,
+have lost a great deal of blood, are specially predisposed.<span class="pagenum"><a name="Page_55" id="Page_55">[55]</a></span></p>
+
+<p>Neuralgia of the testis (as an independent affection and not
+a mere extension of lumbo-abdominal neuralgia) is fortunately
+a much less common malady than the corresponding affection
+of the ovary; as might indeed be expected, from the much
+less degree of functional perturbation to which, in ordinary
+physiological circumstances, the former organ is exposed than
+the latter. Except from actual growths within the testis, of
+which it was a mere symptom, I have never seen neuralgia of
+the testis save from one of three causes. In one remarkable
+example it was produced as a reflex effect of severe herpes preputialis.
+Secondly, it is sometimes observed as a symptom of
+calculus descending the ureter. And, thirdly, I have seen it
+several times undoubtedly produced by excessive self abuse.</p>
+
+<p>The occurrence of testicular neuralgia, in one case of epilepsy,
+as to the cause of which I had been previously much
+puzzled, led to the discovery of the real origin of the fits. I
+should observe here that I do not believe that self-abuse is
+ever more than an immediately exciting cause of epilepsy, a
+predisposition to the disease having previously existed in all
+cases. In the patient just referred to, there was a family history
+of epilepsy, but it was difficult to explain the exciting
+cause until this was suggested by the occurrence of neuralgic
+pain in the testicle. The patient relinquished his habit, and
+both the pain and the epilepsy ceased, and, for some twelve
+months during which I had him under observation, had not
+recurred at all. A medical friend has informed me of an instance
+in which the same habit had produced a neuralgia of
+the testis so severe as to strongly tempt the patient to castrate
+himself, and he would probably have done so but that he was
+too much of a coward with regard to physical pain. The attacks
+of pain were so severe as frequently to produce vomiting
+and the greatest prostration.</p>
+
+<p><i>Hepatic Neuralgia.</i>&mdash;It must be allowed that the evidence
+even for the existence of neuralgia of the liver is at present in
+an unsatisfactory state. At the same time, there are carefully-recorded
+cases, by Trousseau and other<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a> writers of unquestionable
+authority, which leave no doubt in my mind, corroborated
+as they are by a certain amount of experience of my
+own, that such a form of neuralgia really exists. I must, of
+course, be understood to refer to something altogether different
+from the spasmodic pain which is produced by the difficult
+passage of a gall-stone toward the bowel. I have now seen
+several cases in which, as it appeared to me, there was sufficient
+evidence of neuralgic pain seated in the liver itself, and
+not dependent either on gall-stone or any so-called organic
+diseases of the viscus.</p>
+<p><span class="pagenum"><a name="Page_56" id="Page_56">[56]</a></span></p>
+<p>The subjects of hepatalgia are probably never troubled only
+by pain in the liver; they are persons of a nervous temperament,
+in whom a slight shock to, or fatigue of, the nervous
+system, habitually provokes neuralgic attacks; the pain localizing
+itself sometimes in the branches of the trigeminal, sometimes
+in those of the sciatic, sometimes in the intercostal
+nerves, etc. In one instance which has been under my observation,
+the attacks of hepatalgia alternated with cardiac neuralgia
+assuming the type of a rather severe angina pectoris.
+In another case the patient, a man aged sixty-seven, was very
+liable to attacks of intermittent abdominal agony, in which
+one could hardly doubt that the pain was located in the colon,
+and was attended with paralytic distention of the bowel; the
+peculiar feature of the case being the sudden way in which
+the symptoms would appear and depart, independently of any
+recognizable provocation or the use of any remedies. On two
+separate occasions this patient was attacked with pain of a
+precisely similar kind, but limited to the right hypochondrium,
+attended with great depression of spirits, and followed by a
+well-pronounced jaundice. So remarkable was the conjunction
+of symptoms in these two attacks that a strong suspicion
+of biliary calculus was raised, but not the slightest confirmation
+of this idea could be obtained; and indeed one symptom&mdash;vomiting&mdash;which
+nearly always attends the painful passage of
+a biliary calculus, was altogether absent.</p>
+
+<p>Putting aside a considerable number of cases in which
+"pain in the liver" was vaguely complained of by patients
+who were plainly hypochondriacal, and whose account of
+their own sufferings could not be relied on, I have altogether
+seen five instances of what I regard as genuine hepatalgia.
+The first of these was very remarkable in its history and in all
+its features. The patient was a respectable girl of eighteen,
+subject to migraine, who had reason to fear that she had become
+pregnant, though this proved, ultimately, not to be the
+case. Under these circumstances she was attacked with intermittent
+pains, in the right hypochondrium, of intolerable
+severity; resembling, in fact, the pain of biliary calculus,
+but without the sense of abdominal constriction, and
+without any vomiting. These recurred daily at about
+the same hour in the morning, for about ten days; when
+rather suddenly, a jaundiced tint appeared upon the face,
+and very shortly the whole skin was colored bright yellow;
+there was intense mental apathy; the urine was loaded with
+bile-pigment, and the fęces clay-colored. This state of things
+lasted only about a week and then very rapidly disappeared;
+but as the jaundice subsided there was a partial recurrence of
+the neuralgic pains, which, for a day or two, were as severe as
+they had ever been; The other four cases of hepatalgia which
+I have seen, including that of the man above mentioned, have<span class="pagenum"><a name="Page_57" id="Page_57">[57]</a></span>
+all been in persons in advanced life; but, except the latter,
+neither of them displayed any symptoms of disordered biliary
+secretion; and the diagnosis (as to situation, for the character
+of the attacks was manifestly neuralgic) rested mainly on the
+fact that the pain radiated to the shoulder.</p>
+
+<p>There remains to be noticed one clinical feature of the disease,
+which, I believe, is characteristic; namely, the peculiar
+mental depression which attended all the cases I have seen,
+but was most marked in the two in which jaundice occurred.
+In the girl above referred to, the apathy, during the period
+when there was jaundice but no pain, was even alarming; it
+reminded one of the mental state in commencing catalepsy;
+during the painful stages it was more like the gloom of suicidal
+melancholia. Of course, the acute mental anxiety which this
+patient had suffered would account for a good deal of this; but
+the symptom was as distinct, though less severe, in the case of
+an elderly lady, whom I have attended on another occasion
+for migraine; here there was no recognizable source of anxiety;
+and, on the other hand, there was no reason to suspect the retention
+of bile-elements in the blood. It seems, therefore, as
+if an essentially depressing influence on the mind was excited
+by hepatic neuralgia; or else, that emotional causes are the
+chief source of the malady.</p>
+
+<p><i>Neuralgia of the Heart.</i>&mdash;If there be any hesitation in treating
+this disease as exactly conterminous with angina pectoris,
+it can, I think, be only reasonably justified on two grounds:
+In the first place, it may be urged that acute pain of the neuralgic
+type is not always present in angina pectoris; and,
+secondly, it may be urged that many cases of painful neurosis
+of the heart have been observed, in which the recurrence of
+pain with some amount of cardiac embarrassment has gone on
+for years, whereas the popular conception of true angina almost
+necessarily involves rapid fatality.</p>
+
+<p>There is doubtless some force in these objections, especially
+in the second, for it does seem rather inconvenient to call by
+the same name so deadly a disorder as the worst form of angina,
+and so comparatively harmless a malady as some of those
+instances of chronic tendency to spasmodic pain of the heart
+which are not very uncommon, and in which the patient survives,
+perhaps, to an old age. Yet, after all, there is the
+greatest difficulty in drawing any rational line of distinction;
+for the basis of the affection seems the same in every case,
+whether pain or spasm be the predominant feature, and
+whether the course of the disease be long or short. All that
+appears to be necessary for its production is a certain originally
+neurotic temperament (with possibly some congenital
+weakness or some post-natal disease of that part of the spinal-cord
+centres which Von Bezold has described as furnishing
+three-fourths of the propulsive power of the heart) and the<span class="pagenum"><a name="Page_58" id="Page_58">[58]</a></span>
+presence of almost any kind of difficulty or embarrassment of
+the action of the heart. The most common source of this embarrassment
+is perhaps failure of nutrition in the muscular
+walls of the heart, from disease of the coronary arteries. Indeed,
+it is not known that any organic change of the heart or
+great vessels, even of the slightest kind, is necessary to the
+production of angina; on the contrary, there is every reason to
+think that mere fatigue and depression may bring on the attacks
+in persons of a strongly nervous temperament. For my
+own part, I am inclined to believe, however that there really
+always is disease somewhere in the cardiac centre of the spinal
+cord, though that disease may consist in no more than a disposition
+to minute interstitial atrophy. But we shall say more
+about this presently.</p>
+
+<p>It is at any rate certain that cardiac neuralgia is always a
+most grave complaint, from the almost total uncertainty
+whether succeeding attacks will not involve a fatal amount of
+spasm. As for the expression angina pectoris, it is just one of
+those mischievous terms which, arising out of the mystified
+ignorance in which the elder physicians found themselves as
+to the pathology of internal diseases, have since been attached
+in turn to various definite organic changes, with none of which
+they had any essential connection; and it is therefore much to
+be wished that it could be altogether done away with. At the
+same time, there is so much that is peculiar in the case of
+cardiac neuralgia, owing to the importance of the organ affected,
+that it will be necessary here to treat not merely its
+symptoms, but also its diagnosis, prognosis, etiology, pathology,
+and treatment, in a separate and continuous manner.</p>
+
+<p><i>Clinical History and Symptoms.</i>&mdash;Cardiac neuralgia
+usually shows itself for the first time with considerable abruptness.
+The patient may or may not have been consciously ill before
+the actual seizure, but it rarely happens, even when the
+heart has notoriously been the subject of some organic disease,
+that there has been any thing to lead him to expect the kind of
+attack from which he now suffers. In the midst of some little
+unusual effort, or even without this kind of provocation, suddenly
+the patient is attacked with severe pain, usually at the
+lower part of the sternum; this pain darts through to the back
+and left shoulder, and nearly always runs down the left arm.
+Sometimes, indeed, it is felt acutely over a large area of the
+chest, and runs down both arms; this is the case in a patient
+now under my care, in whom the affection is more obviously
+a neurosis, and less attended with coarse organic changes, than
+is usually the case. Along with the pain, which is always very
+distressing, but varies greatly in severity in different cases,
+there is a variable amount of another sensation which can be
+compared to nothing but cramp, or rather compression; the
+patient usually describes it as feeling as if some one were grasping<span class="pagenum"><a name="Page_59" id="Page_59">[59]</a></span>
+the heart in his hands, and, when this sensation is at all
+prominent, the idea of impending death is most strongly impressed
+on the sufferer's mind. His outward appearance seems
+to confirm the idea. In cases where the sense of compression
+is great, the face is of an ashen gray; the lips white, with a
+faint livid tinge; the pulse small, feeble, and unrhythmical, or
+imperceptible, at the wrist; cold perspiration breaks out upon
+the face; in short, all the signs of approaching dissolution are
+present. In cases where the suffering is chiefly or entirely
+confined to severe pain, of a darting or burning character,
+the state of the circulation is often different. The heart bounds
+against the ribs, in rapid and painful palpitation, the face is
+flushed deep crimson, the pulse at the wrist is large, bounding,
+but very compressible; in fact, the outward appearance of the
+patient is so different from that of one who suffers from the
+more depressing kind of angina, that it is difficult to consider
+the two affections as essentially similar. But there can be no
+question, if we carefully examine the matter, that they are
+mere varieties of the same disorder, especially as they both may
+successively occur in the same person.</p>
+
+<p>The course of cardiac neuralgia varies extremely. Supposing
+the malady to be purely neurotic, and not complicated with
+organic disease, which forms a constant source of cardiac embarrassment,
+then the patient may only experience one or two
+attacks, under some special circumstances of exhaustion, which
+may never recur; or, on the other hand, he may develop a
+strong tendency to cardiac neuralgia which may beset him during
+almost any number of years. In the latter case, it is an
+even chance whether the patient will at last sink from the anginal
+affection; for, even supposing him to escape any fatal intercurrent
+disease of an independent nature, the fatal event
+may be at last produced by cerebral softening, or by apoplexy,
+or other central nervous disease. In fact, the frequency with
+which the latter kind of termination occurs is very significant
+of the essential nature of the disease.</p>
+
+<p>The manner in which cardiac neuralgia commences varies
+very greatly. In the celebrated case of Dr. Arnold, the first
+attack did not occur till he was forty-seven years of age; it at
+once assumed full intensity, and proved fatal in two hours and
+a half. There is also reason to believe that Dr. Arnold's father
+died in a first attack of angina. I have myself known a first
+attack prove fatal in the course of an hour; there was very
+considerable ossification of the coronary arteries and fatty degeneration
+of the heart-walls. Again, there are many cases
+which commence gradually, and with great mildness, and with
+little appearance of danger to life in the first attacks; but the
+subsequent attacks are progressively more severe and dangerous
+up to a fatal result, after weeks, months, or years. On
+the other hand, I have known three instances in which the<span class="pagenum"><a name="Page_60" id="Page_60">[60]</a></span>
+first attacks of spasmodic heart-pain very nearly proved fatal,
+but the subsequent fits were milder (in one there was no second
+attack): all those patients are living, six, eight, and three
+years respectively, after their first attacks.</p>
+
+<p>It can hardly be doubted that neuralgic spasm is the true
+cause of sudden death in some cases of stenosis of the aortic
+orifice, which, but for some accidental circumstances, would
+not have died suddenly at all, but would have gone through a
+long and gradual course of deterioration. I particularly remember
+an instance in which extreme and calcareous constriction
+of the aortic orifice, in a boy not yet come to puberty, was
+entirely unsuspected, until one day, in running fast, he
+screamed out and fell down, and was almost instantaneously
+dead. I remember another case very similar, in which extreme
+mitral constriction produced almost as sudden death, apparently
+from painful spasm, under the same kind of exertion.
+On the other hand, sudden death, when produced by the form
+of heart-disease which (as Dr. Walshe points out) is most
+likely to cause such a catastrophe, viz., aortic regurgitation
+pure, without hypertrophy, does not seem to be due to painful
+spasm, but to simple and complete failure of the muscular
+power, and is perhaps partly of the nature of paralysis from a
+syncopal condition of the brain, the unhypertrophied heart
+having become for the moment unable to supply blood enough
+to the brain to carry on nervous function at all.</p>
+
+<p>A good instance of the form which angina takes, when the
+element of organic cardiac change is well pronounced, was
+afforded by the case of a young gentleman recently under my
+care. He was twenty-one years of age, and from early boyhood
+had been accustomed to a great deal of muscular exercise;
+in fact, it is probable that he had undermined his health by the
+frequent and extraordinarily long walks which he took, for
+his frame was particularly small and slight, and the muscles
+small and soft. He came of a family in whom the tendency to
+neurotic disorders is obviously very strong; both his father
+and his brother are subject to bad attacks of migraine, and he
+had himself repeatedly suffered from the same thing. The
+family disposition, altogether, is highly nervous and excitable.
+The remarkable circumstance in this young gentleman's case
+is, that although he had taken for years an extraordinary
+amount of pedestrian exercise (including mountain-climbing),
+and latterly had exchanged this for the even more trying exertion
+of rowing, he had never suffered from any noticeable
+symptom of cardiac distress up to the very day of his anginal
+attack. For some months, however, he had been growing
+thin and pale, and I had given him certain cautions, and had
+made him take cod-liver oil and steel, as I entertained some
+fears of his becoming phthisical. On the day of the attack
+there was nothing particular in his appearance, but he complained<span class="pagenum"><a name="Page_61" id="Page_61">[61]</a></span>
+of a slight cold, and had no appetite for his six o'clock
+dinner. He retired to rest at eleven o'clock, having taken a
+small dose of laudanum and chloric ether for his cold. In less
+than half an hour he awoke out of his sleep in fearful agony;
+so severe and prostrating was the anginoid pain that he had
+the greatest difficulty in crawling out of bed to unlock his door.
+I found him bathed in cold sweat, pale as a sheet, and with
+livid lips. He groaned with pain, which he described as
+"cutting him across" from the sternal notch to the nipple, and
+going down the left arm; and there was so marked a catching
+of the breath as to make it almost certain that there was
+diaphragmatic spasm; in fact, it was this which alarmed him,
+and made him say that he was certainly dying. The heart,
+however, appeared to be pushed up somewhat, and it was
+thought that this might be partly due to stomachic distention,
+but a mustard emetic produced little effect. The heart-sounds
+were so weak that the presence or absence of bruit could not be
+safely predicated; meantime, the pulsations intermitted in a
+most alarming manner. Large doses of brandy and sulphuric
+ether at length (after several relapses) seemed to subdue the
+pain and spasm, and in an hour and a half from the commencement
+of the attack the patient, though utterly worn out,
+sank into a tolerably quiet sleep. The spasms did not recur,
+but for the next three or four days he was in a state of great
+exhaustion. When his tranquillity of mind had been somewhat
+restored, a careful physical examination was made, and it was
+discovered that there was a moderately loud and somewhat
+thrilling systolic bruit at the site of the aortic valves, and extending
+some distance into the vessels. The pulse still remained
+strikingly intermittent, and, though of fair volume,
+was very compressible. Percussion indicated considerable enlargement
+of the heart, and the physical signs pointed, on the
+whole, to dilatation without hypertrophy. Some doubtful
+signs of consolidation were observed at both apices of the lungs.</p>
+
+<p>It is remarkable that, notwithstanding the serious degree of
+cardiac mischief indicated by the above signs, the patient, a
+very few days later, took a walk of some ten miles, and,
+though much exhausted, suffered no recurrence of his formidable
+spasmodic symptoms in consequence of this imprudence.
+He was sent to the mild climate of Mentone, and subsequently
+to Nice; the angina never recurred, but the patient remained
+weak, and liable to more or less dyspn&#339;a for fifteen or sixteen
+months; now he lives an ordinary life, doing his duty as a
+Swiss citizen and officer. The cure of some hęmorrhoids,
+about twelve months after the anginal attack, seemed greatly
+to benefit him. What the future of this case may be it is
+impossible to say, but of course there is no security against
+the angina recurring on extraordinary excitement or over-exertion.<span class="pagenum"><a name="Page_62" id="Page_62">[62]</a></span></p>
+
+<p>Of the purely neurotic variety of angina it is impossible to
+determine the frequency; but it seems certain that the affection
+is common, and I suspect that it occurs more often than is
+supposed, as a sequel to asthma. The probable relationship
+between the two affections was long ago indicated by
+Kneeland.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a> I have certainly seen several cases of asthma in
+which spasmodic pain of the heart has occurred on various occasions
+after or during a very severe asthmatic paroxysm.
+One case was that of a gentleman, of a highly delicate and
+neurotic temperament, who had suffered for fifteen or sixteen
+years from well-marked spasmodic asthma: this case is remarkable
+as an illustration of several points which will be
+dwelt upon in other parts of this volume. For some time before
+the outbreak of cardiac neuralgia, he had suffered repeatedly
+from severe facial neuralgia, and these attacks on more
+than one occasion culminated in facial erysipelas, or what was
+entirely indistinguishable from that affection. He then began
+to suffer from cardiac pain and spasm after his asthmatic paroxysms,
+and these new symptoms speedily assumed the form of
+a very severe intermittent angina: in several of the attacks he
+appeared about to die. The pain in these attacks is very severe;
+it occupies a large area in the centre of the chest, and runs
+down both arms; and, what is strange, the arms become remarkably
+swollen and hot after an unusually long bout of
+pain, I presume from vaso-motor paralysis. At present (nearly
+five years from the commencement of the cardiac neuralgia)
+the cardiac attacks, though of frequent occurrence, are decidedly
+more tolerable than they were at first, and the sense of
+squeezing or pressure, though never quite absent, does not
+amount to the dreadful sort of feeling which used to convince
+the patient that he was at the point of death. In this case, the
+heart has been repeatedly explored without any positive result,
+and the pulse has been frequently tested by the sphygmograph.
+The latter instrument is the only mode of examining by which
+I have been able to elicit even suspicious evidence that there is
+any organic change of the heart; by means of it I have lately
+obtained some grounds for suspecting that there is slight dilatation
+of the heart, but it is uncertain whether anything of the
+kind existed at the commencement of the anginal symptoms.
+In this case I am inclined, on the whole, to doubt whether the
+angina will ever prove fatal, unless the bronchitis, with which
+the patient's asthma has for some time past been liable to be
+complicated, should occur in a severe form; in that case it is
+likely that the additional embarrassment of the heart's action
+may bring on fatal spasms.</p>
+
+<p>One of the best examples I ever saw of cardiac neuralgia
+(ultimately proving fatal) was one of which the origin was entirely
+<span class="pagenum"><a name="Page_63" id="Page_63">[63]</a></span>
+nervous. It occurred in a gentleman in the prime of
+life, and naturally of a powerful physique, whose very active
+and capacious mind had been greatly overwrought. The
+whole weight of responsibility for an undertaking of national
+importance, and which involved great difficulties and much
+anxiety, for a long time rested on his shoulders. Under these
+influences he broke down, and never effectually recovered himself.
+At first, the symptoms were those of mere ordinary nervous
+exhaustion, but after a time he became subject to frequently
+recurring attacks of agonizing spasmodic heart-pain,
+with a sense of impending dissolution; from these he was invariably
+relieved by the inhalation of a small amount of chloroform.
+Not the slightest organic heart mischief could be detected,
+either during life or after death.</p>
+
+<p><i>Pathology.</i>&mdash;Angina stands in so peculiar a position that I
+deem it well to discuss it as a whole, and not merely its clinical
+history, in this place. As I have already said, there is nothing
+in the morbid appearances found after death which is characteristic
+of fatal angina, and in the milder kinds of cardiac neuralgia
+we are driven back upon the general probabilities
+which we deal with in reasoning as to the origin of neuralgias
+in general. As to morbid changes, it is impossible to say any
+thing more exhaustive of the facts known than the following
+words of Dr. Walshe:<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> "First, there are few, if any, structural
+diseases either of the heart, its orifices, and its nutrient
+arteries, or of the aorta, found recorded in the narratives of the
+post-mortem examination of different victims of angina pectoris.
+Secondly, there is no conceivable disease of these structures
+and parts which has not in various individuals reached the
+highest point of development, without anginal paroxysms, even
+of a slight kind, having occurred during life; to this proposition
+extensive calcification of the coronary arteries perhaps furnishes
+a solitary exception. Thirdly, the organic changes most
+frequently met with have been fatty atrophy and flabby dilatation
+of the heart; obstructive disease of the coronary arteries
+by atheroma and calcification of the orifice and arch of the
+aorta. Fourthly, the rarest have been hypertrophy and
+hypertrophy with dilatation. In truth, it may be doubted
+whether these conditions in their genuine form, without any
+combination of fatty atrophy, have ever been the sole morbid
+states present." From all this Dr. Walshe concludes that
+the fundamental mischief of angina is neurotic; and,
+while he believes that some textural change in the heart
+is necessary as an irritant to generate this neurotic susceptibility
+to dynamic disturbance from slight causes, he recognizes
+only one common quality in these various cardiac
+lesions, viz., that they indicate mal-nutrition and weakened
+<span class="pagenum"><a name="Page_64" id="Page_64">[64]</a></span>
+power. Dr. Walshe does not appear to believe the neurotic
+disturbance can arise without the kind of irritation which
+is kept up by such cardiac changes. In spite, however of
+the great authority of this author, it certainly seems very
+probable that organic cardiac change is by no means necessary
+to the occurrence of angina, and this for two reasons: In the
+first place, though full reliance may be placed on the details of
+the post-mortem examinations made by Dr. Walshe himself,
+they are very few (twelve or fourteen) in number; and other
+observers who have recorded cases are as little trustworthy,
+considering their evident tendency to find some disease where
+none exists, as the older narratives which Dr. Walshe naturally
+distrusts were unreliable when they declared that no
+morbid change was present. And, secondly, his view hardly
+takes it into account that there are still two other alternatives,
+even supposing that one or other of the above changes is always
+present: (<i>a</i>) it is possible that the neurotic disturbance and the
+cardiac lesions might both be the result of a common cause; and
+(<i>b</i>) it is even possible that the alterations of tissue in the heart
+and vessels are due to a morbid influence proceeding from a
+diseased nervous centre, either spinal or sympathetic.</p>
+
+<p>As for the state of the muscular fibre which immediately
+causes death, Dr. Walshe is of opinion that it is paralytic rather
+than spasmodic; and he urges in favor of this view the fact
+that in his large experience he has never known the pulse to
+intermit during the attack&mdash;it was always regular, however
+feeble. In this respect he is in opposition to some distinguished
+authors, however, and, as he allows that he has not seen original
+attacks in their height, but only when they were subsiding,
+it would be possible that the spasm stage had subsided. However
+Dr. Walshe admits that there may be exceptional cases in
+which spasm, or cramp (<i>i.&nbsp;e.</i>, spasm with rupture or dislocation
+of fibre), really occurs, and suggests that this is very probable
+in the rare cases where death is attended by general tetanic
+spasm of the muscles. As far as my own opinion is worth anything,
+I could insist that at least Dr. Walshe must be right
+as against Dr. Latham and Dr. Inman, in affirming that
+cardiac cramp, if it occurs, is the consequence and not the
+cause of the neuralgic pain.</p>
+
+<p><i>Causes.</i>&mdash;In some respects it is impossible to deal with the
+etiology of angina apart from the pathology, just as we remarked
+with regard to neuralgias in general. But there are
+certain special features in the causation of angina pectoris
+which require separate notice, just as there are special features
+in its pathology.</p>
+
+<p>Of predisposing causes, the majority are the same as those of
+which we have spoken in our general remarks on the etiology
+of neuralgia. A family history of a tendency to the graver
+neuroses is I believe universal, and, indeed, direct inheritance<span class="pagenum"><a name="Page_65" id="Page_65">[65]</a></span>
+of angina from father to son, as in Arnold's case, has happened
+in many recorded instances. A very remarkable fact is the
+time of life at which the disease originally appears: Walshe
+says it is rare before the age of fifty, but excessively rare before
+forty. This is very interesting, as placing angina in the same
+category with the severe and intractable forms of facial and
+other neuralgias which are so highly characteristic of the
+period of bodily degeneration. One may even gather a suspicion,
+though it goes but a short way toward proof, that the
+essence of angina is an atrophy either of the cardiac plexus or
+of the nucleus of the vagus, or of that part of the spinal cord,
+already mentioned, which seems to be the centre of the major
+part of the propulsive force of the heart.</p>
+
+<p>On the other hand, there is a fact, even more remarkable
+than the influence of age, which tells somewhat in a contrary
+direction. There is a most extraordinary preponderance of
+males among the victims of angina. Sir John Forbes found
+eighty males among eighty-eight patients suffering from this
+disease. On the first blush it would seem natural, indeed
+almost necessary, to explain this by supposing that, as men
+take a much larger amount of strong physical exercise than
+women, they will furnish a much larger proportion of subjects
+in whom an ill-nourished heart will break down under its
+work and be seized either with paralysis or cramp (for the two
+states are, after all, not opposed to each other, but only varying
+shades of debility.) Upon this theory one would have to
+believe that the origin of angina was far more peripheral than
+central, if we are to suppose that spasm is the ordinary condition
+of the heart during the anginal paroxysm. But we do
+not know that this is the case; indeed, there are many arguments
+against it; and at any rate we must suppose that in a
+considerable number of cases the muscular state is one of relaxation
+from want of power. And certainly it is infinitely
+more probable that paralysis or spasm of a muscular viscus
+should occur as a reflex consequence of neuralgia occurring in
+a nerve whose central nucleus was closely connected with the
+motor centre of the organ, than that mere paralysis of the viscus
+should convey a reflex impression to sensitive nerves which
+should express itself in the form of acute pain. It must be
+confessed that the matter hangs in doubt; but the evidence is,
+on the whole, very strong for the belief that central nervous
+mischief is the most important element in angina.</p>
+
+<p>Another very important class of predisposing causes of
+angina is the mental emotions. It is notorious that the disease
+is one not common in humble life; it chiefly assails the more
+cultivated class, and especially men who are much engaged in
+affairs in which great mental anxiety or emotion is mingled
+with severe toil of intellect. Thus the professional class has
+always shown a sad predominance in tendency to this disease;<span class="pagenum"><a name="Page_66" id="Page_66">[66]</a></span>
+a large number of the victims have been found among overworked
+clergymen, lawyers, doctors, engineers, etc. The
+various forms of heart-lesion which have been already mentioned
+must doubtless be considered highly predisposing, when
+there is already a neurotic susceptibility, more especially those
+which, like fatty degeneration of the muscular structure,
+greatly enfeeble the heart's action. I do not believe that these
+diseases will cause angina in a person who is free from the
+peculiar nervous susceptibility.</p>
+
+<p>The immediately exciting causes are very various. The
+most common of all is doubtless some exertion of body, or distress
+of mind, which at once agitates and embarrasses the
+heart's action; and, where the tendency to cardiac neuralgia
+has once declared itself by an actual attack, very slight excesses
+of this kind will usually suffice to re-excite the paroxysm.
+Sexual excitement is particularly provocative of the attacks, in
+the predisposed. But much slighter causes suffice, in those
+cases where the irritability of the cardiac nerves has become
+very intense: thus a mere puff of cold air upon the face, and
+other similar slight peripheral impressions, by acting in a reflex
+manner, have frequently produced the paroxysm. I have seen
+an extremely severe anginal attack brought on by the slight
+shock of the sudden slamming of a door. And it would even
+appear that some peripheral excitements of a powerful kind
+may operate with such force as to generate angina in persons
+who are merely in weak health, but who cannot be supposed to
+be specially predisposed to angina; it is in this way, I presume,
+that we must explain the extraordinary occurrence, reported
+by Guelineau,<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a> of an epidemic outbreak of angina, in which
+numbers of men, belonging to a ship's crew, were simultaneously
+affected. The men had been badly fed, and their
+quarters were very unhealthy; but the powerful exciting cause
+seemed to be the rapid change from a very hot to a very cold
+climate. Not only were there many cases of severe angina,
+but other forms of neuralgia, and severe colics, were observed
+in others of the crew. Among the sources of peripheral irritation
+which ought to be particularly considered, in relation to
+angina, are the diseases and injuries which produce powerful
+irritation of the branches of the trigeminus. Lederer's cases<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a>
+of violent vomiting and cardiac pain, from the operation of
+pivoting teeth, and Remak's instances<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a> of violent palpitation
+and cardiac distress, produced by disease of the last molar
+tooth, seem to show that, both through the vagus and the sympathetic,
+<span class="pagenum"><a name="Page_67" id="Page_67">[67]</a></span>
+the most powerful reflex action may be produced in
+the heart and stomach by irritation of the fifth cranial.</p>
+
+<p>Another occasional excitant of angina is an interesting link
+in the chain of proof that angina is <i>au fond</i> a neuralgia,
+namely, the malarial poison, which has in a good many well-observed
+cases distinctly induced the disease.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a> Finally, the
+occasional influence of excessive tobacco-smoking in producing
+anginal attacks, in persons not affected with any discoverable
+organic heart-disease, affords the strongest corroborative
+evidence of the essentially neurotic character of angina
+pectoris. M. Beau<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a> has recorded many serious, and some
+fatal, cases from this cause. Probably in both the malarial
+cases and those induced by tobacco-poisoning the special
+neurotic tendency existed already.</p>
+
+<p><i>Diagnosis.</i>&mdash;The diagnosis of angina pectoris, in those severe
+forms with which the popular idea of the disease is chiefly connected,
+can hardly be a matter of much difficulty. When we
+see an elderly man lying in a state of deathly collapse, which
+has suddenly come on, with cold sweats and nearly extinguished
+pulse, gasping for breath, and complaining of intolerable pain
+in the chest and arm, and a sense of oppression more dreadful,
+even, than the pain, we can hardly doubt that the case is angina
+in its worst form. On the other hand, when a young person,
+especially a young female, complains even of very severe
+pain in the cardiac region, together with breathlessness, especially
+if the heart be palpitating and the face flushed, the
+diagnosis, though not immediately certain, already very
+strongly indicates the probability that the case is not one of
+primary cardiac neuralgia at all. These are extreme instances,
+however. In more doubtful cases, the following are the principal
+materials for decision:</p>
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="4" summary="Affirmative Negative signs">
+<tr><td align="center" width="50%"><i>Affirmative Signs.</i></td><td align="center" width="50%"><i>Negative Signs.</i></td></tr>
+<tr><td class="topleft">1. Age over forty.</td><td class="topleft">1. Age under forty.</td></tr>
+<tr><td class="topleft">2. Male sex.</td><td class="topleft">2. Female sex.</td></tr>
+<tr><td class="topleft">3. Nervous temperament (personal and family) without marked hysteria or hypochondriasis.</td><td class="topleft">3. Temperament either not nervous at all, or markedly hysterical or hypochondriacal.</td></tr>
+<tr><td class="topleft">4. Existence of arterial degeneration.</td><td class="topleft">4. No signs of arterial degeneration.</td></tr>
+<tr><td class="topleft">5. Existence of valvular disease of the heart.</td><td class="topleft">5. No discernible valvular disease.</td></tr>
+<tr><td class="topleft">6. Extension of the pain to one or both arms.</td><td class="topleft">6. Heart sounds clear and strong.</td></tr>
+<tr><td class="topleft">7. Vivid sense of approaching dissolution.</td><td class="topleft">7. Pain fixed to one spot and increased or relieved by muscular movements of the painful parts.</td></tr>
+<tr><td class="topleft">&nbsp;</td><td class="topleft">8. Pain running round one side, but not extending to shoulder or arm.</td></tr>
+</table></div><p><span class="pagenum"><a name="Page_68" id="Page_68">[68]</a></span></p>
+
+<p>It is scarcely necessary to say that no single one of the above
+signs is individually of positive worth for the decision, which
+must be made after a careful review of the comparative arguments,
+<i>pro</i> and <i>con</i>. The disorders with which angina is most
+likely to be confused are (1) Myalgia of the intercostal or pectoral
+muscles; (2) intercostal neuralgia; (3) acute commencing
+pleurisy. Either of these may very perfectly simulate the
+more formidable disease, as regards the two elements of acute
+pain and catching of the breath; but the condition of the circulation,
+taken together with the consideration of the above
+named points, will generally decide the question. Especially
+important is the deep persuasion of impending dissolution,
+when present, as a positively affirmative symptom.</p>
+
+<p>It should be born in mind that, if we are summoned to a patient's
+assistance, and have no previous history to guide us, our
+diagnosis, to be useful, must be rapid; and it is always better to
+err on the side of angina than in other directions, and to employ
+remedies boldly in that sense, if there be any reasonable
+ground for believing the case to be of that nature. A more
+mature and careful diagnosis may be made when the patient
+has recovered from the severe symptoms of the paroxysm.</p>
+
+<p><i>Prognosis.</i>&mdash;The prognosis of cardiac neuralgia is at best
+doubtful, and, in many cases, positively bad in the highest degree.
+If the attacks occur for the first time in a patient who
+has passed middle life, and is physiologically old for his age, <i>i.&nbsp;e.</i>,
+shows tendency to degenerative changes of vessels, arcus senilis,
+gray hair etc., they are of very gloomy import; more especially
+if any signs exist which make a fatty change in the
+ventricle probable, or if there be serious valvular lesions. The
+probability here is greatly in favor of a speedy fatal termination;
+if the first attack does not kill, a second or third very probably
+will; at any rate, the patient is not likely to survive any considerable
+number. If the attack occurs in a younger person, in
+whom there is not much likelihood that arterial degeneration
+has seriously commenced, or the heart-muscles become fatty,
+more especially if the attacks have been brought on by such an
+accidental circumstance as a very exhausting bout of mental or
+physical toil, then there is considerable reason to hope that the
+disease may soon wear itself out. Even patients who have
+serious valvular lesions may, with young and undegenerated
+tissues in their favor, quiet down again into a regular habit of<span class="pagenum"><a name="Page_69" id="Page_69">[69]</a></span>
+semi-health, in which they may live for a long time without
+any recurrence of cardiac neuralgia. The more purely neurotic
+form, again, especially when it develops gradually out of
+some pre-existing chronic neurosis, such as asthma, is usually
+slow in its progress; and it may well happen, in such cases,
+that the danger to life is more on the side of serious nervous
+lesions than from the anginal attacks themselves. At the same
+time, it must be remembered that, even in the milder cases,
+any very unusual excitement, bringing on an unwontedly severe
+attack, may produce fatal results at any period of the
+disease.</p>
+
+<p>There is some reason to believe that cardiac neuralgia is occasionally
+produced in a reflex manner in consequence of a
+severe existing intercostal neuralgia. I cannot say that I have
+witnessed any thing which can be considered as completely
+proving this; but it certainly seems likely that, in some of the few
+cases of excessively painful herpes zoster which have proved fatal
+(of which I have given one example), cardiac spasm or paralysis
+may have been secondarily induced, and may have occasioned
+the catastrophe. It is likely enough that, if this was
+the case, the reflex irritation operated upon motor centres
+which themselves were predisposed to take on the morbid
+action; but this again is a fresh illustration of the uncertainties
+to which prognosis is liable in a disease like angina, the
+very fundamental character of which is that, upon increase of
+the irritation, the gravity of the resulting functional affection
+is liable to be indefinitely and most rapidly increased.</p>
+
+<p><i>Treatment.</i>&mdash;The treatment of cardiac neuralgia is (1) prophylactic,
+and (2) palliative of the attacks.</p>
+
+<p>As regards the prophylactic treatment, it is unnecessary to
+repeat the remarks which we have made elsewhere upon the
+general principles of tonic and nutritive medication in neuralgias
+of every kind. One especial prophylaxis, in the case of
+this formidable variety of neuralgia, is concerned with the
+preservation of the heart from certain disturbing influences
+which would render the occurrence of the fit more probable.
+All violent emotions and all strong physical exercise (but especially
+such forms of it as, like boating, are well known to
+"pump" the heart severely) are to be carefully avoided. Even
+indigestion and flatulence are to be carefully guarded against
+since these are quite capable of embarrassing the action of the
+heart to a degree which, though it might be trivial in the case
+of ordinary health, may prove fatal by exciting a flabby ventricle
+to irregular and embarrassing contraction. It is even
+possible that the strong irritation set up by some varieties of indigestible
+food might propagate an irritation to the spinal cord
+which would produce an interbitory paralysis at once.</p>
+
+<p>But besides these obvious precautions against interference
+with the regular and tranquil action of the heart, there are<span class="pagenum"><a name="Page_70" id="Page_70">[70]</a></span>
+some special medicinal remedies which deserve particular notice.
+Whether we really possess any means of so influencing
+the nutrition of the muscular tissue of the heart as to prevent
+its lapsing into a fatty degeneration, it is impossible to say;
+but this may be affirmed with some confidence, that, in cases
+where awkward threatenings of cardiac neuralgia have occurred,
+and simultaneously it has been noticed that the heart-sounds
+become weak and the circulation languid, a most
+marked improvement has been produced in all respects by the
+administration of iron and strychnia. I usually give tincture
+of sesquichloride of iron, ten minims, and strychnia, one-fortieth
+of a grain, three times a day. Still better, where it
+can be borne, is the syrup of the triple phosphate of quinine,
+iron, and strychnia, which undoubtedly has an extraordinary
+influence upon tissue nutrition, as exemplified in its remarkable
+effects in many cases of phthisis. It must be observed,
+however, that it is not every neuralgic patient who will bear
+the combination of quinine with iron; it has occurred to me to
+meet with several in whom the union of these two remedies
+proved violently disturbing to the nervous system, causing distressing
+headache and palpitation of the heart, which could
+not be attributed to any want of care in the apportioning of the
+dose, or in the mode of administration. Iron is more especially
+indicated, of course, in cases where there is anęmia; but
+there are some cases in which strychnia given alone seems to
+produce a very beneficial influence. (<i>vide</i> Chapter V., on
+"Treatment.")</p>
+
+<p>By far the most important prophylactic tonic against cardiac
+neuralgia, however, is arsenic. That this drug should prove
+useful in cardiac neuroses might readily be anticipated from
+its very great utility in many cases of asthma, a disease which,
+as already remarked, has a close relationship to the former.
+Dr. Philipp has recently recorded a case which is perhaps an extreme
+instance of this beneficial influence of arsenic, but is
+none the less encouraging, especially as it only corroborates
+what has been advanced by other observers. Given in doses of
+from three to five minims of Fowler's solution, twice or thrice
+daily, arsenic is an invaluable remedy in cardiac neuralgia;
+the one objection to it being that some neurotic patients possess
+such an irritable intestinal canal that the remedy cannot be
+borne, as it produces diarrh&#339;a. Even here we may sometimes
+succeed by combining it with very small doses of opium. It
+is more especially with regard to those cases in which the neurotic
+character of the disease is very prominent&mdash;<i>i.&nbsp;e.</i>, in which
+the nervous temperament of the patient betrays itself in other
+ways besides the tendency to spasmodic embarrassment of the
+heart's action, that arsenic holds such a very high place as a
+remedy. And it should be carefully remarked that the prophylaxis
+of angina extends itself, in such cases, beyond the<span class="pagenum"><a name="Page_71" id="Page_71">[71]</a></span>
+limits of actually-declared and well-defined angina, which is,
+of course, an uncommon disease. This remedy is important,
+and may be most usefully employed in the far larger group of
+cases in which a marked tendency to spasmodic pain in the
+chest, on the occurrence of some comparatively trifling excitement,
+is observed in patients who either have some organic
+heart-disease, or who are liable to severe attacks of asthma.
+It cannot be too often repeated that there is no intelligible separation,
+except one of degree, between these cases and the malignant
+forms of angina. It may be added that, in my experience,
+I have found the whole group of cases to be bound together
+in a singular way by the tolerance of arsenic which,
+with certain exceptions already referred to, they display. Commencing
+with the small doses above mentioned, I have found
+it possible, in many cases, to advance to the administration of
+twice or thrice the quantity, and to continue this medication
+for months together, not only with no evil effect, but
+with the best results.</p>
+
+<p>Of zinc, as a prophylactic tonic in cardiac neuralgia, I
+know but little. Truth to say, it is a nervine tonic of occasional
+great value, but which, on the whole, I have found so
+unreliable that I am somewhat prejudiced against it; and perhaps
+have not given it a fair trial in those milder cases of
+cardiac pain to which it might be suited. It does appear, however,
+to have some preferential action on the vagus, and
+might therefore be possibly more useful than I am at present
+inclined to think it.</p>
+
+<p>The treatment of the acute neuralgic stage itself is a matter
+in which we are sadly limited by the exigencies of the case.
+Relief must be excessively rapid if we are to save life in
+the most threatening cases, or to deliver the patient from a
+most prostrating agony, which might have lasted for hours,
+in other instances.</p>
+
+<p>The remedy which the highest authority, Dr. Walshe, seems
+to put first in efficacy is opium; and he directs the dose to be
+measured by the intensity of the pain, as much as forty to sixty
+drops of laudanum being given in a severe case. He says, however,
+that it should be given with an antispasmodic, such as
+brandy, or ether, or sal-volatile; and I confess that I believe
+the antispasmodic treatment to be by far the most important.
+Indeed, so marked is the success which I have found to attend
+the use of ether in the paroxysm, that till lately I scarcely
+cared to make further experiments, with drugs, for the relief
+of the patient at this stage. One teaspoonful of ether in two
+ounces of thickish mucilage should be given at once, and repeated
+in a short time if the patient does not rally.</p>
+
+<p>In a few instances, angina seems to be provoked by the irritation
+of indigestible food, and when there is good reason to
+suspect this an emetic should be given. I strongly recommend<span class="pagenum"><a name="Page_72" id="Page_72">[72]</a></span>
+that mustard should be used for this purpose, for the effect of
+a mustard-emetic is by no means merely to empty the stomach,
+it has a powerfully rousing influence on the heart.</p>
+
+<p>Upon the subject of the inhalation of chloroform for cardiac
+neuralgia, I have only to say that, though I have seen it usefully
+employed, I should not, with my present experience,
+ever think of employing it myself. Every possible advantage
+which it could give is obtained by the internal use of ether,
+and many serious dangers are avoided, which would attend
+the use of chloroform. For it must be remembered that the
+only kind of chloroform inhalation which would be useful
+would be that in which a carefully measured small dose of a
+weakly impregnated atmosphere should be inhaled, and, without
+large experience in the administration of chloroform, the
+practitioner will be unable to secure this effect with certainty.
+And the effect of a powerfully-charged atmosphere, breathed
+only once or twice even, would be instantaneously fatal.</p>
+
+<p>Hot epithems to the epigastrium are probably of some use,
+and besides this the temperature of the body should be carefully
+kept up by hot bottles to the feet, hot tins to the epigastrium,
+etc. Brandy should be freely administered during the
+attack, if we cannot immediately obtain either ether or a
+remedy now to be mentioned. I refer to the nitrite of amyl,
+which, at the time when the first part of this chapter was
+written, I had not had the opportunity of testing.</p>
+
+<p>Nitrite of amyl is a highly-vaporizable fluid, which possesses
+the following remarkable physiological action: the inhalation
+even of a very small quantity is followed, after a
+minute or so, by a sudden acceleration of the heart's action,
+accompanied by intense crimson congestion of the vessels of
+the face and conjunctiva, and a sense of enormous fulness in
+the head; these phenomena are extremely fugitive, passing
+away completely in two or three minutes, unless the inhalation
+is renewed. These characteristic effects had for some years
+been experimentally exhibited by Dr. Fraser and others, but
+the practical application of amyl to the treatment of angina
+was first suggested, I believe, by Dr. Brunton, in the case of a
+patient under the treatment of Dr. Maclagon and Dr. Bennett,
+in the Edinburgh Royal Infirmary. The angina was
+in this case symptomatic, there being advanced valvular
+disease of the heart. Comparative examinations with
+the sphygmograph, during the intervals and during the
+paroxysms, made strikingly manifest the fact that, during
+the attacks, there was an increase of arterial tension which was
+directly proportionate to the severity of the pain and cardiac
+embarrassment. It was thus suggested to Dr. Brunton's mind
+that nitrite of amyl, by relaxing the systemic arteries, might
+remove the unnatural tension, and give relief to the pain;
+and the result confirmed this hope. Doses of five and ten drops<span class="pagenum"><a name="Page_73" id="Page_73">[73]</a></span>
+were inhaled from a towel, with the uniform result of at once
+quieting the pain; it might return in a few minutes, but a
+second dose usually removed it entirely for many hours. Various
+other cases have since been reported, in which similar
+relief was obtained, and I had occasion to employ it myself in
+one instance. The gentleman whose case has been related
+above (see page 101), as an example of the relief obtainable by
+the use of ether began to suffer rather more severely from his
+attacks than had been the case for some time, toward the end
+of the year 1869. I now determined to try the amyl, and accordingly
+left a small bottle containing half an ounce of it in
+his possession, with exact instructions to the following effect:
+On the first symptoms of a paroxysm of angina, he was to get
+the bottle open, and as soon as their character was fully declared
+he was to put the bottle to one nostril (closing the other
+with the finger, and keeping the mouth shut) and take one
+long, powerful inspiration. The result of his first experiment
+was very remarkable: the first sniff produced, after an interval
+of a few seconds, the characteristic flushing of the face and
+sense of fulness of the head; the heart gave one strong beat,
+and then at once he passed from the state of agony to one of
+perfect repose and peace, and at his usual bedtime slept naturally.
+This experience was repeated on several occasions, and
+for a considerable time the patient retained such full confidence
+in the remedy that he discarded all use of ether, and greatly
+reduced his allowance of stimulants, with very marked benefit
+to his appetite and general health. The new remedy did
+not lose any of its power by repetition, but unfortunately the
+patient at last conceived a horror of it, which caused him to
+abandon its use. So distressing and alarming to him was the
+sense of fulness in the head produced by the amyl, that, notwithstanding
+his certain knowledge that he could at once cut
+short a paroxysm, he could not persuade himself to continue
+its use, and for some time past he has returned to the use of
+the ether and (though in less quantities than previously) of the
+brandy, for this purpose. And here it must be remarked that
+this objection, although probably needless in the case of this
+particular patient, may have real importance in certain circumstances.
+The admirable physiological researches of Dr.
+Brunton leave no doubt that the effect of inhalation of amyl
+is to relax, very suddenly, the tonic contraction of the systemic
+arteries, and in the case of the brain it would appear
+that a serious strain must be suddenly thrown upon the capillary
+net-work. This being the case, it appears likely that,
+where the atheromatous change has considerably invaded
+these delicate vessels, they might prove too brittle to stand the
+sudden distention, and a rupture and consequent cerebral
+hęmorrhage might ensue. This suspicion, then, that such
+pathological changes exist, ought to seriously affect our judgment<span class="pagenum"><a name="Page_74" id="Page_74">[74]</a></span>
+as to the administration of amyl; and this suspicion
+ought to be always entertained, <i>prima facie</i>, in the case of
+patients who have much passed the age of fifty, more especially
+if they have gray hair and an arcus senilis, or if the sphygmograph
+yields a pulse-trace of the decidedly square-headed type,
+or if they have been long addicted to alcoholic intemperance.
+In such patients I should be disinclined to allow the use of
+amyl.</p>
+
+<p>[Although I have thought fit here to give an outline of angina
+pectoris as a connected whole, I shall have occasion to
+recur to the subject again under the heads of Pathology and
+Treatment of Neuralgias in General.]</p>
+
+<p><i>Gastralgia.</i>&mdash;Neuralgia seated in the stomach itself is not to
+be distinguished with accuracy from neuralgic pains occupying
+one or other of the neighboring nervous plexuses. It must be
+remembered that not merely is the stomach itself copiously
+supplied by the pneumogastric nerves with afferent fibres, but
+the great solar plexus is close behind it, the c&#339;liac plexus
+springs from the fore part of the latter, and these, with the
+coronary and superior mesenteric plexus, may all be said to be
+well within the region in which "gastralgic" pain is felt. It
+is not particularly important, however, in my opinion, to
+make any very exact diagnosis here, as to the site of the pain,
+since all these neuralgias must be considered to belong to the
+pneumogastric nerve, the branches supplied from which are
+probably the sole means by which these plexuses become the
+seat of neuralgia.</p>
+
+<p>Abdominal pneumogastric neuralgia is an extremely distressing
+and occasionally a very intractable disorder. The
+subjects of it are almost invariably in a state of marked and
+evident debility, and inquiry generally elicits the fact that
+they have suffered at other times from neuralgia elsewhere
+than in its present seat. By far the most common history of
+previous affections of this kind is that of trigeminal neuralgia,
+especially of the supra-orbital branch; and it has several
+times occurred to me to observe the direct sequence of a
+gastralgia upon a unilateral browache. Anęmia is a specially
+frequent attendant of gastralgia, more so than of other neuralgias.
+Women are, by the general consent of authors, more
+liable to gastralgia than men.</p>
+
+<p>The special mark of true neuralgic pain in the abdominal
+pneumogastric, as distinguished from other deep-seated pains
+in the epigastrium, is the remarkably direct relation of its
+severity to the patient's exhaustion, particularly in regard to
+the weakness induced by want of food. While the great majority
+of dyspeptic pains are increased by filling the stomach,
+gastralgia, on the contrary, is invariably relieved by food,
+often most strikingly and completely. Pressure from without,
+also, while it aggravates most pains dependent on local organic<span class="pagenum"><a name="Page_75" id="Page_75">[75]</a></span>
+mischief, nearly always more or less relieves gastralgia. Equally
+striking is the comfort given by stimulants, especially by hot
+brandy-and-water; in this respect gastralgia resembles colic.
+There is something special in the degree of mental depression
+which attends gastralgic pain. In this it resembles the pains
+of hypochondriasis, but there is a resilience of the spirits
+when the pain has been relieved which is not seen in the latter
+affection. A very frequent complication of gastralgia is
+severe palpitation of the heart, but during the paroxysm itself
+the pulse, whether rapid or not, is commonly small, at first
+tense, and afterward soft, but not acquiring any considerable
+volume till the pain has ceased.</p>
+
+<p>So severe is the pain, and so complete the mental and physical
+prostration in bad attacks of gastralgia, that the first aspect
+of the patient might suggest&mdash;indeed often has suggested&mdash;the
+occurrence of gastric or duodenal perforation; but, as soon as
+the paroxysm is over all the alarming appearances vanish,
+leaving only a certain amount of tenderness on deep pressure.
+In the more typical cases there are no signs of dyspepsia
+whatever, no fulness nor excessive redness of the tongue, no
+nausea, regurgitation of food, nor pyrosis. Occasionally the
+neuralgic affection is complicated with more or less gastric
+catarrh; but this is a much rarer occurrence, in my experience,
+than some writers would lead one to believe; and, moreover,
+where a certain amount of organic disorder of the stomach is
+observed, it is usually a mere secondary result of the neuralgia.
+The most severe example of gastralgia which I ever saw
+was entirely unaccompanied by dyspepsia; this patient absolutely
+attempted suicide to escape from his agonizing pains,
+which recurred with the greatest frequency and obstinacy, but
+were at last entirely removed by strychnia. In another patient
+whose very interesting case will be again alluded to under the
+head of Complications of Neuralgia, violent abdominal pneumogastric
+pain was succeeded by a severe attack of trigeminal
+neuralgia, accompanied by inflammation of the eye, which inflicted
+irreparable damage; here, too, the gastralgia was entirely
+uncomplicated by any other stomach-symptoms.</p>
+
+<p><i>Cerebral Neuralgia.</i>&mdash;We enter, here, on an extremely obscure
+and doubtful subject: Can there be pain in the central
+masses of the encephalon? There are undoubtedly a not inconsiderable
+number of cases of pain, neuralgic in type on the
+whole, in which the suffering cannot be referred to any recognizable
+superficial nerve. It seems deeply situated within the
+cranium. I have also quoted cases of Dr. Hillier's in which
+not merely was there deep-seated headache in children, but
+there was something like a characteristic general change observed
+in the brain-tissues after death, viz., a great moisture
+and softness of texture. Notwithstanding all this, I am not
+convinced, nor indeed much disposed to believe, that pain is<span class="pagenum"><a name="Page_76" id="Page_76">[76]</a></span>
+ever felt in the structure of the brain; I rather believe that, in
+the cases where this seems to occur, the pain is either in the intracranial
+portion of the nerve trunks, or, far more probably,
+in the twigs of nerves that are distributed to the cerebral membranes.
+In that case they are, strictly speaking, only varieties
+of neuralgia of the fifth nerve, and might have been properly
+discussed under that heading; but it is more convenient to
+speak of them apart, since their phenomena present considerable
+differences from those of the external neuralgias of the
+head and face.</p>
+
+<p>I have now seen several of these cases of intracranial neuralgias,
+and very perplexing and (at first sight) alarming they
+certainly are. The first of these cases came under my care in
+1868. The patient was a single lady who had greatly over-tasked
+an intellect that was not, perhaps, originally very
+strong, by trying to do hack literature on conscientious principles;
+insisting, for instance, on knowing something about
+every subject she wrote upon. Her age was thirty-eight when
+she applied to me; menstruation was scanty but regular; and,
+on the whole, she could not be said to have passed an unhealthy
+life, although "nervous-headaches" and "sick-headaches"
+had occasionally beset her. This time the trouble seemed to be
+more serious. Ten days before applying to me, she had awaked
+in the morning with a feeling that something was very wrong
+in her head; there was not so much pain as a dull, brooding
+sort of weight, felt deeply within the cranium, and rather anteriorly.
+This had not lasted many hours when she was seized
+with a sensation of intense cold, amounting almost to rigors,
+and then before long was suddenly attacked with acute splitting
+pain in the same situation as the feeling of weight already
+mentioned had occupied. This pain, which came and went, or
+rather intensified and remitted, without ever completely ceasing,
+lasted about two hours, and then rather suddenly disappeared,
+leaving the patient with a deep "bruised and sore feeling
+in her brains." The pain recurred about the middle of the
+next day, lasting for several hours, and again leaving behind it
+the sore feeling. Day by day the paroxysms returned, and, on
+the day before her visit to me, the patient had, she told me,
+been driven frantic by her sufferings and had become actually
+delirious. Her appearance, when I first saw her, was wretched;
+the face haggard, both eyes sunken and surrounded with deep
+rings of dusky pigment, both conjunctivę bloodshot, the whole
+face almost earthy in its pallor. At that hour (11 <span class="smcap">a.&nbsp;m.</span>) the
+pain had not positively recommenced, but she was in momentary
+dread of its recurrence. She complained of giddiness,
+muscę volitantes, and great feebleness of vision, and dreaded
+attempting to read, as the mere effort of fixing her eyes on
+anything intently caused flashes of fire before them. It was
+difficult at first to believe that there was not some serious organic<span class="pagenum"><a name="Page_77" id="Page_77">[77]</a></span>
+brain-mischief; but on the whole I concluded that there
+was an absence of any genuine symptoms of such disease. At
+the same time, the pain was decidedly not referred to any cutaneous
+sensory nerve; and on the whole it appeared probable
+that the affection was intracranial. There remained the diagnosis
+of meningeal neuralgia, and to this I provisionally made
+up my mind. The opinion that the pain did not depend on any
+fixed organic disease was decisively justified by the results of
+treatment. One-sixth of a grain of morphia was injected on
+the occasion of the first visit, and this was repeated every day,
+and sometimes twice a day, for a fortnight; by this sole means,
+with rest, quietude, and light nourishing food, the patient was
+brought to comparative convalescence. The injections were
+then gradually discontinued, and she got quite well.</p>
+
+<p>In a second case, which presented itself in the out-patient
+room at Westminster Hospital, a young man of markedly-nervous
+temperament, who had been somewhat given to drink,
+complained of similarly deep-seated intermittent pain, which
+he referred, however, to a point nearer the back of the head.
+He suffered, also, from vertigo, especially after unusually long
+paroxysms. Blisters to the nape of the neck, and a few subcutaneous
+injections of morphia, removed the pain and the vertigo
+completely.</p>
+
+<p>A third example was that of a gentleman, aged thirty-four,
+who was sent over from the neighborhood of Sydney, Australia,
+to see me. Here, also, there was deep-seated intracranial
+neuralgic pain of the most severe kind, which greatly alarmed
+his local medical attendants; and it was only after a great
+many remedies had been tried that one medical man gave the
+opinion that the disease was "neuralgia of the membranes of
+the brain," and employed the hypodermic injection of morphia.
+This treatment at once gave great relief, though the pain
+had been so severe as to cause delirium on several occasions.
+In order to get thoroughly re-established, he was sent to England,
+and desired to consult me. As was expected, the voyage
+proved of the greatest service, as he hardly suffered at all
+while on the water. On arriving in England he was at first
+well, but in a week or two began to feel somewhat below par,
+and one morning, feeling an attack of pain coming on, he
+came to me. He was a tall and strongly-built man, with nothing
+peculiar in his appearance except a certain languor and
+heaviness of the eyes. He appeared to have lived somewhat
+freely and to have smoked decidedly to excess. His description
+of the attacks left no doubt of their neuralgic character,
+and in other respects they seemed quite analogous to the other
+cases mentioned above, except in one thing, that there seemed
+a good deal of evidence tending to show a bad local influence
+in the air of that part of Australia where he usually resided.
+Almost any change from that had always done him good,<span class="pagenum"><a name="Page_78" id="Page_78">[78]</a></span>
+though nothing had done anything like so much as the voyage
+to England. On the occasion of his first visit to me I injected
+him with one-sixth grain acetate of morphia, thereby stopping
+the pain. I prescribed muriate of iron and minute doses of
+strychnia, which he took for some little time, but the pain
+never recurred during his stay in England and on the Continent.
+Unfortunately, as he was anxious to return to Australia,
+I permitted him to do so, after a stay in the Old World of
+only three or four months; but, very shortly indeed after his
+return to Sydney, his old complaint attacked him. This time,
+unhappily, the hypodermic morphia has proved merely palliative,
+and I have latterly heard very bad accounts from him;
+still, there has been nothing to throw doubt on the neuralgic
+character of the disease.</p>
+
+<p>In reflecting upon the anatomy of the nervous branches to
+the dura mater, I have formed the opinion that there are two
+situations, one anterior and the other posterior, in which intracranial
+neuralgia may occur; the former at the giving off of
+Arnold's recurrent branch from the ophthalmic division, near
+the sella turcica, the other in the peripheral twigs of this same
+branch, distributed to the tentorium cerebelli.</p>
+
+<p><i>Pharyngeal Neuralgia.</i>&mdash;A rather common and extremely
+troublesome form of neuralgia is that which attacks the
+pharynx. It is very much more common in women than in
+men, and especially in hysterical persons. The pain commonly
+commences in a not very acute manner; it may be felt
+for some days, or even weeks, as a dull aching, coming and
+going pretty much in accordance with the patient's state of
+fatigue, or of reinvigoration after meals, etc. Some trivial
+circumstance, such as a slightly extra degree of exhaustion, or
+the influence of some depressing emotion, will then change the
+type to that of decided neuralgia, which may become extremely
+severe. Nothing is more annoying, and even distressing,
+than the suffering itself, besides which there are abnormal sensations
+in the throat which almost irresistibly compel the
+patient to believe that there are severe inflammation and
+ulceration, and that the throat is in danger of being closed up.
+Although the pain is usually one-sided, it sometimes affects
+both sides, and is felt also at the back of the pharynx. The
+act of swallowing being painful, there is the greater suspicion
+of inflammation or ulceration, but careful observation shows
+that a large bolus of food is swallowed with as little, if not less,
+pain than a small mouthful of solids or even liquids.</p>
+
+<p>Pharyngeal neuralgia must, I think, be considered mainly
+an affection of the glosso-pharyngeal nerve; the evidence for
+this is found in the distribution of the pain. A slight degree
+of the neuralgia will only involve some one or two points in or
+behind the tonsil; but, when the pain is strongly developed, it
+will be found to radiate into the tongue, in one direction, and<span class="pagenum"><a name="Page_79" id="Page_79">[79]</a></span>
+into the neck (following the course of the carotid) in another,
+besides spreading well into the region occupied by the pharyngeal
+plexus. One disagreeable reflex effect of severe pharyngeal
+neuralgia consists in involuntary movements of the
+muscles of deglutition, another is seen in the copious outpouring
+of thick mucus similar to that which collects in the
+pharynx and &#339;sophagus when a foreign substance has become
+impacted.</p>
+
+<p><i>Laryngeal neuralgia</i> concentrates itself mainly in the twigs
+of the superior laryngeal branch of the pneumogastric which
+are distributed to the arytęno-epiglottidean folds, the epiglottis,
+and the chordę vocales; more rarely a neuralgia is developed
+lower down, within the cavity of the larynx, apparently in
+one or more of the scanty twigs to the mucous membrane supplied
+by the recurrent laryngeal.</p>
+
+<p>Pure neuralgias of the larynx, like those of the pharynx, are
+more common in women, and especially in weakly hysterical
+women, than in men. They are easily excited and greatly
+aggravated by movements of the parts, and thus it happens
+that, among men, by far the most numerous subjects of laryngeal
+neuralgia are found among clergymen, professional
+singers, and others whose occupation compels them to strenuous
+and fatiguing employment of the laryngeal muscles. It is
+rather a singular and striking fact, however, that the so-called
+"clergyman's sore-throat," which is characterized by most unpleasant
+sensations, and by a more or less complete loss of
+voice, is not, in the majority of cases, attended with any distinct
+laryngeal neuralgia. It seems that a predisposition to
+neuralgia is a necessary element in the latter affection.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="comp" id="comp"></a>CHAPTER II.</h2>
+
+<h3>COMPLICATIONS OF NEURALGIA.</h3>
+
+
+<p>The secondary affections which may arise as complications
+of neuralgia form a deeply interesting chapter in nervous
+pathology, and one which has only been explored in quite
+recent years. The excellent treatises of Valleix and Romberg,
+written only thirty years ago, make but most cursory and
+superficial mention of these complications, and do not attempt
+to group them in a scientific manner. The reflex convulsive
+movement of the facial muscles in severe tic-douloureux had
+of course been long observed; and Valleix added the correct
+observation that gastric disturbance was often secondarily provoked
+in facial neuralgia, thus improving greatly on the old
+view, which supposed that, where trigeminal neuralgia and<span class="pagenum"><a name="Page_80" id="Page_80">[80]</a></span>
+stomach disorder coexisted, the latter must have been the antecedent
+and the cause of the former. Still, he did not explain
+the pathological connection. And as regards certain other
+most interesting results of neuralgia, which he could not avoid
+meeting with from time to time, <i>e.&nbsp;g.</i>, lachrymation, flux from
+the nostril, salivation, altered nutrition of the hair, he only
+speaks of these as occasional phenomena, and in no way
+classifies them, or explains their relation to the neuralgia itself.</p>
+
+<p>There did exist, however, one too little known work of some
+years earlier date, which, though not dealing specifically with
+neuralgia, and though based upon the necessarily very imperfect
+knowledge of the functions of the nervous system prevalent
+in its day, had nevertheless done much to lay the foundation
+of a comprehensive view of the complications of neuralgia;
+we refer to the work of the brothers Griffin, on "Functional
+Affections of the Spinal Cord and Ganglionic System," published
+in 1834. In this most interesting treatise, the record of
+acute and extensive observations made in a quiet and unpretending
+way by two Irish practitioners, numerous examples are
+cited in which neuralgic affections were seen to be inseparably
+united with secondary affections of the most various organs,
+with which the neuralgic nerves could have no connection except
+through the centres, by reflex action. The authors, while
+firmly grasping the fact of the common connection of the
+nerve-pain and the other phenomena (convulsions, paralysis,
+altered special sensation, changes in secretion, changes even in
+the nutrition of particular tissues) with the central nerve system,
+were doubtless in error in thinking that they could detect
+the precise seat of the original malady, by discovering certain
+points of tenderness over the spinal column. But their facts were
+observed with the greatest care, and can now be interpreted
+more intelligently than was possible at the time. Here, for
+example, is a case which forestalls one of the most interesting
+pieces of information which more recent research has made
+generally known:</p>
+
+<p>"<span class="smcap">Case XXIV.</span>&mdash;Kitty Hanley, aged fourteen years, catamenia
+never appeared; about six months ago was attacked
+with pain in the right eye and brow, occurring only at night,
+and then so violently as to make her scream out and disturb
+every one in the house; it afterward occurred in the infra-orbital
+nerve, and along the lower jaw in the teeth, and there
+was inflammation of the cornea, with superficial ulceration
+and slight muddiness. Tenderness was found at the upper
+cervical vertebrę, pressure on any of them exciting severe
+pain in the vertex and brow; but none in the eye or jaws,
+where it is never felt except at night."</p>
+
+<p>The above is a well-marked example of neuralgia of the
+trigeminus causing secondary inflammation and ulceration of
+the eye of a precisely similar kind to that which had been experimentally<span class="pagenum"><a name="Page_81" id="Page_81">[81]</a></span>
+produced by Magendie by section of the fifth, at
+or posterior to its Gasserian ganglion. We shall see, hereafter,
+how extremely important are this and similar facts, not only
+in regard to the clinical history, but also to the pathology of
+neuralgia in general.</p>
+
+<p>The first regular attempt, I believe, to classify the complications
+of neuralgia, was made by M. Notta, in a series of elaborate
+papers in the "Archives Generales de Medecine" for 1854.
+We may specially mention his analysis of a hundred and
+twenty-eight cases of trigeminal neuralgia, which is well fitted
+to impress on the mind the frequency, though, as we shall
+presently see, it does not adequately represent the seriousness,
+of these secondary disorders. As regards special senses, Notta
+says that the retina was completely or almost completely paralyzed
+in ten cases, and in nine others vision was interfered
+with, partly, probably, from impaired function of the retina,
+but partly, also, from dilatation of the pupil or other functional
+derangement independent of the optic nerve. The sense of
+hearing was impaired in four cases. The sense of taste was
+perverted in one case, and abolished in another. As regards
+secretion, lachrymation was observed in sixty-one cases, or
+nearly half the total number. Nasal secretion was repressed
+in one case, in ten others it was increased on the affected side.
+Unilateral sweating is spoken of more doubtfully, but is said
+to have been probably present in a considerable number of
+cases. In eight instances there was decided unilateral redness
+of the face, and five times this was attended with noticeable
+tumefaction. In one case the unilateral tumefaction and redness
+persisted, and were, in fact, accompanied by a general
+hypertrophy of the tissues. Dilatation of the conjunctival
+vessels was observed in thirty-four cases. Nutrition was
+affected as follows: In four cases there was unilateral hypertrophy
+of the tissues; in two, the hair was hypertrophied at
+the ends, and in several others it was observed to fall out or to
+turn gray. The tongue was greatly tumefied in one case.
+Muscular contractions, on the affected side, were noted in fifty-two
+cases. Permanent tonic spasm, not due to photophobia,
+was observed in the eyelid in four cases, in the muscles of
+mastication four times, in the muscles of the external ear once.
+Paralysis affected the motor oculi, causing prolapse of the
+upper eyelid, in six cases; in half of these there was also outward
+squint. In two instances the facial muscles were paralyzed
+in a purely reflex manner. The pupil was dilated in
+three cases, and contracted in two others, without any impairment
+of sight; in three others it was dilated, with considerable
+diminution of the visual power. Finally, with regard to common
+sensibility, M. Notta reports three cases in which anęsthesia
+was observed. Hyperęsthesia of the surface only occurred
+in the latter stages of the disease.<span class="pagenum"><a name="Page_82" id="Page_82">[82]</a></span></p>
+
+<p>To Notta's list of complications of trigeminal neuralgia must
+be added the following, all of which have been witnessed, and
+several of them in a large number of instances: Iritis, glaucoma,
+corneal clouding, and even ulceration; periostitis,
+unilateral furring of the tongue, herpes unilateralis, etc. In
+writing on this subject three or four years ago, I mentioned
+that all these secondary affections had been seen by myself,
+except glaucoma. That is now no longer an exception; indeed,
+my attention has been so forcibly called to the connection between
+glaucoma and facial neuralgia, that I shall presently
+examine it at some length.</p>
+
+<p>The trigeminus is, of all nerves in the body, that one whose
+affections are likely to cause secondary disturbances of wide
+extent and various nature, owing to its large peripheral expanse,
+the complex nature of its functions, and its extensive
+and close connections with other nerves. Moreover, its relations
+to so important and noticeable an organ as the eye tends
+to call our attention strongly to the phenomena that attend its
+perturbations. But there is every reason to think that all
+secondary complications which may attend trigeminal neuralgia
+are represented by analogous secondary affections in neuralgias
+in all kinds of situations; and we may classify them in the
+principal groups which correspond to disturbance of large sets
+of functions:</p>
+
+<p>1. First, and on the whole, probably, the most common of
+all secondary affections, we may rank some degree of vaso-motor
+paralysis. It may be doubted if neuralgia ever reaches
+more than a very slight degree without involving more or less
+of this; for so-called points douloureux are themselves pretty
+certainly, for the most part, a phenomenon of vaso-motor
+palsy; and the more widely-diffused soreness, such as remains
+in the scalp, for instance, after attacks of pain, even at an
+earlier stage of trigeminal neuralgia than that in which permanently
+tender points are formed, is probably entirely due
+to a temporary skin-congestion. The phenomenon presents
+itself in a much more striking way in the condition of the
+conjunctiva seen in intense attacks of neuralgia affecting the
+ocular and peri-ocular branches of the fifth; one sometimes
+finds the whole conjunctiva deeply crimson; and, in one remarkable
+instance that I observed, the same shade of intense
+red colored the mucous membrane of the nostril of the same
+side. In several instances, I have seen a more than usually
+violent attack of sciatic pain followed by the development of
+a pale, rosy blush over the thinner parts of the skin of the leg,
+especially of the calf, which were then extremely tender, in a
+diffuse manner, for some time after spontaneous pain had
+ceased.</p>
+
+<p>2. Not merely the circulation, however, but the nutrition of
+tissues, becomes positively affected, in a considerable number<span class="pagenum"><a name="Page_83" id="Page_83">[83]</a></span>
+of cases. It is difficult to judge, with any exactness, in what
+proportion of neuralgic cases this occurs, but its slighter degrees
+must be very common. It has very frequently happened
+to me, quite accidentally, in examining with some care the
+fixed painful points, which are so important in diagnosis, to be
+struck with the decided evidence to the finger of solid thickening,
+evidently dependent on hypertrophic development of
+tissue-elements; in severe and long-standing cases, I believe
+this condition will always be found. Probably the change is,
+more usually than not, sub-inflammatory; but it is certain, on
+the other hand, that there are great variations in the kind of
+tissue-changes complicating neuralgia, and that inflammation
+is no necessary element in them. This subject has greatly
+engaged my attention, and I find myself able to give what is
+probably a fuller account of the matter than any yet published
+connectedly.</p>
+
+<p>The following tissues have been seen by myself to become
+altered under the influence of neuralgia in nerves distributed
+to them, or to the parts in their immediate neighborhood.</p>
+
+<p>(<i>a</i>) The hair has changed in color in many cases. Of twenty-seven
+patients suffering from neuralgia of the ophthalmic
+division of the fifth, eleven had more or less decided localized
+grayness of hair on that side. The amount of this varied
+greatly, from mere patches of gray near the roots of the hair
+to decided grayness of the majority of the hairs over the larger
+part of half the head, nearly to the vertex; but in each
+case it was a change of color that did not exist on the
+other side of the head. In four of these cases there was
+also grayness of part of the eyebrow on the affected side.
+A very remarkable phenomenon, which I have sometimes
+identified, is fluctuation of the color, the grayness notably increasing
+during, and for some time after, an acute attack of
+pain, and the same hairs returning afterward more or less to
+their original color. My attention was first called to this
+curious occurrence in my own case. I have so often related
+this case [see, for instance, my article on Neuralgia in "Reynolds's
+System of Medicine," vol. ii.] that I shall merely recall
+the fact that, when pain attacks me severely, the hair of
+the eyebrow on the affected side displays a very distinct patch
+of gray (on some occasions it has been quite white) opposite
+the tissue of the supra-orbital nerve, and that the same hairs
+(which can be easily identified) return almost to the natural
+color when I am free from neuralgia. I must, however, add
+the very curious fact, which I observed accidentally in experimenting
+(as regards urinary elimination) on the effects of
+large doses of alcohol, that a dose sufficiently large to produce
+uncomfortably narcotic effects invariably caused the same temporary
+change of color in the hair of the same eyebrow, even
+when no decided pain was produced, but only general malaise.<span class="pagenum"><a name="Page_84" id="Page_84">[84]</a></span>
+The subject will be again referred to under the heading of
+Pathology.</p>
+
+<p>Change in the size and texture of the hairs, in neuralgia, has
+been noted by Romberg and Notta, and has been several times
+observed by myself. Occasionally the individual hairs near
+the distribution of the painful nerve become coarsely hypertrophied;
+at times the number of hairs appears to multiply,
+but I imagine this is only a case of more rapid and exuberant
+development of hairs that would be otherwise weak and small.
+In one very remarkable instance of sciatica this came under
+my observation; the whole front of the painful leg, from the
+knee nearly to the ankle, became clothed, in the course of
+about six months, with a dense fell of hair, which strongly
+reminded me of similar abnormal hair-growths that have been
+occasionally seen in connection with traumatic injuries to the
+spinal cord. More commonly, the effect of neuralgia upon
+hair is to make it brittle, and to cause it to fall out in considerable
+quantities; one young lady, who consulted me for a
+severe migraine, was seriously afraid of having a good head of
+hair completely ruined in this way, but the hair gradually grew
+again after the neuralgia had disappeared.</p>
+
+<p>(<i>b</i>) The periosteum of bone and the fibrous fascię in the
+neighborhood of the painful points of neuralgic nerves not unfrequently
+take on a condition of subacute inflammation, with
+marked thickening and tenderness on pressure. The most
+striking instance of this that I have seen was in a lady suffering
+from severe cervico-brachial neuralgia. In the neighborhood
+of the emergence of the musculo-spiral nerve at the outer
+side of the arm, there was developed what looked for all the
+world like a large syphilitic node, except that the skin was
+brightly reddened over it; this disappeared altogether some
+little time after the neuralgia had been relieved by ordinary
+treatment. I must say that, but for the peculiar circumstances
+of the case, putting syphilis out of the question, I could not
+have avoided the suspicion, at first, that the swelling was specific.
+But I have several times seen similar, though less
+developed, swellings in neuralgia, and in one case I noticed
+the occurrence of such a swelling on the malar bone, in an old
+woman in whom the neuralgic pain was limited to the auriculo-temporal
+and the supra-orbital branches of the fifth.</p>
+
+<p>A very important point is to be noted in connection with
+these sub-inflammatory swellings in connection with neuralgia.
+Pressure on them will, frequently, not merely excite the
+neuralgic pains in the branches of the affected nerve, but send
+a powerful reflex influence through the cord to distant organs,
+causing vomiting, for instance, or affecting the action of the
+heart in a very perceptible manner. I shall show, when I come
+to speak of the phenomena of so-called spinal irritation, that
+this circumstance has led to erroneous influences in many<span class="pagenum"><a name="Page_85" id="Page_85">[85]</a></span>
+cases. These exquisitely tender points are often found where
+Trousseau places his neuralgic <i>point apophysaire</i>, namely,
+over, or very near, the spinous processes of the vertebrę. The
+tenderness is quite unlike that which is known as hysterical
+hyperęsthesia; it is much severer, and is limited to one, two,
+or three points, corresponding, in fact, to the superficial part
+of the posterior branches of as many spinal nerves.</p>
+
+<p>(<i>c</i>) The nutrition of the skin over neuralgic nerves is sometimes
+notably affected even when the process does not reach
+the truly inflammatory stage, which will be more particularly
+mentioned presently. A certain coarseness of texture of the
+skin has struck me much, in several cases of long-standing
+facial neuralgia. And there is a most curious phenomenon
+(which will be especially considered hereafter in regard to the
+singular influence of the constant galvanic current upon it),
+the distribution of a greater or less amount of dark pigment to
+the skin near the painful part. This phenomenon is much
+more marked during the paroxysms, and in the slighter cases
+entirely disappears in the intervals, but in old-standing severe
+cases it becomes more or less permanent.</p>
+
+<p>(<i>d</i>) The mucous membranes, in situations where we can observe
+them, not unfrequently show interesting changes, the
+nutrition of the epithelium of parts covering the painful nerve
+being exaggerated. It has been noted by various observers,
+in neuralgia affecting the second and third divisions of the
+trigeminus, that the half of the tongue corresponding to the
+painful nerve was covered with a dense fur. This is by no
+means universally the case, but I have seen it occur several
+times. In my own case, in which the neuralgia is limited for
+the most part to the ophthalmic division, and only rarely spreads
+even to the second division of the nerve, this does not usually
+occur, but I have noticed it on one or two occasions. And I
+once made the still more singular observation that a large
+narcotic dose of alcohol, which was sufficient to cause comparatively
+free elimination of unchanged alcohol in the urine,
+caused furring of the tongue, which was decidedly thicker
+on the side of the affected nerve than on the other half of the
+tongue.</p>
+
+<p>(<i>e</i>) We come now to a group of complications of neuralgia
+which are exceedingly important, and by no means adequately
+appreciated as yet, viz., the acute inflammations which directly
+result from neuralgic affections in a certain percentage of cases,
+probably much larger than has been at all generally suspected.</p>
+
+<p>The most familiar of the inflammatory complications of
+neuralgia is herpes zoster, the favorite seat of which is the
+skin which covers one or more of the intercostal spaces: the
+eruption, as occurring in this situation, is so well known that
+it would be waste of time to describe it. In young subjects
+zoster is commonly painless, at least the sensations are those of<span class="pagenum"><a name="Page_86" id="Page_86">[86]</a></span>
+heat, pricking, and irritation, rather than of acute pain; but
+from puberty onward there is an increasing tendency, especially
+in those otherwise predisposed to neuralgia, for zoster to
+be preceded, accompanied, or followed by neuralgia of the intercostal
+nerves corresponding to the distribution of the eruption.
+Most commonly, the eruptive period is, in my experience,
+nearly or quite free from neuralgia, but it often recurs,
+or breaks out for the first time, when the vesicles are drying
+up, but more especially if, as is sometimes the case, especially
+in elderly people, the scabs fall off and leave superficial ulcers.
+Neuralgia may last, after herpes zoster, for any time from a few
+days to many weeks, and I have known it so agonizingly severe
+and so persistent as actually to kill an aged woman from sheer
+exhaustion. In spite of sundry objections that have been
+raised to the theory of the nervous origin of zoster, it appears
+to me that the evidence in favor of it is overwhelming, more
+especially now that it is proved that the disease, with all the
+same characteristics presented by it when seen on the chest or
+abdomen, may occur on the face (following the branches of the
+trigeminus), or on the forearm (following the course of nerves
+from the brachial plexus). Two of the severest cases of neuralgia
+attending herpes that I have ever seen were in private
+patients (whose family history, unfortunately, I had no means
+of ascertaining) who were affected, respectively, in the facial
+and in the brachial nerve-territories.</p>
+
+<p>A far more formidable occasional complication of neuralgia
+is inflammation affecting the eye. Mr. Jonathan Hutchinson
+records several cases in which neuralgic herpes zoster of the
+face was attended with iritis, with serious or even irremediable
+damage to the organ. For my own part, I have witnessed
+several instances in which neuralgia of the first and second
+divisions of the fifth has been attended with skin-inflammation,
+but only in one of these (just alluded to) did the inflammation
+present the characteristic appearances of herpes: in all
+the rest it far more closely resembled erysipelas. The skin was
+excessively reddened in an almost or quite continuous patch
+over the whole territory through which ran the painful nerves;
+by no means only linearly in the course of the nerves, though
+accurately limited to the district of the first or first and second
+divisions of the fifth. In the first case I saw (a woman, aged
+thirty-two), nothing could be more startling than the rapidity
+with which an irregular patch of the skin, including half of
+one cheek, the side of the nose, and a large part of the forehead
+and scalp on the same side, became converted into the
+dense, fiery-red, brawny tissue, with minute vesicles scattered
+over its surface, which looks so characteristic of erysipelas;
+this commenced immediately on the subsidence of severe neuralgic
+pain. During the erysipelatoid inflammation, though
+there was no spontaneous pain, the neuralgia could be instantly<span class="pagenum"><a name="Page_87" id="Page_87">[87]</a></span>
+lighted up for a moment by pressure on the infra-orbital foramen,
+on the supra-orbital notch, or upon the malar bone, about
+its centre. Since that time I have seen several cases of a
+similar character; two of these, which were reported in the
+<i>Lancet</i> for 1866, I shall here reproduce: [Extensive inquiries
+convinced me that the tendency to erysipelatous complication
+of facial neuralgia is exceedingly common. Eulenburg expressly
+confirms my original statement to this effect, and extends
+it to all neuralgias.]</p>
+
+<p><span class="smcap">Case I.</span>&mdash;A woman, aged sixty-three, presented herself in
+the out-patient room at Westminster Hospital, suffering from
+neuralgia of ten days' standing (which for the present, however,
+seemed to have abated considerably), but asking advice
+chiefly for an erysipelatoid inflammation which had come on a
+day or two before, and occupied the area of the painful nerve-district.
+The neuralgia had affected the supra-orbital nerve,
+running up toward the vortex, and the auriculo-temporal
+branch of the third division of the fifth; although there was no
+very acute pain present at this time, pressure over the supra-orbital
+notch, or at a point just in front of the ear, would at
+once cause a brief paroxysm of pain. It was curious to find
+that there was a thickened and tender spot over the malar bone
+(and corresponding to the exit of some nerve filaments from
+the bone) which had never been the seat of spontaneous neuralgia,
+but pressure here sent a dart of pain into the auriculo-temporal
+and supra-orbital nerves. The inflammation was
+markedly limited to the general area of distribution of the
+twigs of the auriculo-temporal and of the ophthalmic division;
+it was of a continuous deep-red color, and attended with much
+thickening of the skin. The conjunctiva was intensely congested,
+and there were lachrymation and very marked
+photophobia, but there were no signs of iritis, and no corneal
+clouding.</p>
+
+<p><span class="smcap">Case II.</span>&mdash;M. W., a woman, aged forty-two, well-nourished
+and healthy-looking, married and had one child; had never
+suffered any serious ailment except once, about five years previously.
+She then had a decided attack of "erysipelas," very
+accurately limited to the right half of the face. Five months
+before coming to me she sustained a severe shock from being
+thrown out of a chaise, without suffering any external or
+visible damage. An hysterical tendency, which she had always
+possessed, became more marked; it revealed itself by palpitations,
+occasional dysphagia, and a disposition to weep causelessly.
+The menses were flowing at the time of the accident;
+they ceased abruptly soon after (they had been scanty for some
+time previously), and did not recur till four months later. The
+hysteric disturbance progressively increased during a fortnight,
+and then the patient was attacked with violent intermittent
+neuralgia, commencing in the eyeball and spreading over the<span class="pagenum"><a name="Page_88" id="Page_88">[88]</a></span>
+district supplied by the branches of the first and second divisions
+of the trigeminus. The pain was accompanied by intense
+conjunctival congestion and photophobia [Dr. Handfield Jones
+remarks that photophobia, in his experience, is only a rare
+accompaniment of facial neuralgia. I have latterly come to
+the same opinion. Redness of the eye and lachrymation are
+very common; true photophobia uncommon. Notta's experience
+would seem to have been similar]. It lasted on the
+first day fourteen hours, and returned daily for the next
+fifteen or sixteen days. An attack of erysipelas, strictly
+limited to the district of the painful nervous branches, then
+set in. From that moment the neuralgic attacks became less
+frequent and severe. A second similar onset of erysipelas
+occurred some three or four weeks after the first. Finally, the
+neuralgia disappeared about four months after its first occurrence,
+and the menses reappeared in tolerable abundance about
+the same time. About a fortnight before this the patient had
+discovered that her right eye was dim; as the photophobia had
+previously disabled her from opening the eye, she could not be
+sure how long this dimness had existed. At the time of her
+visit to me the cornea was blurred with a large patch of interstitial
+lymph, with the remains of a superficial ulcer in the
+centre; the iris was turbid and discolored, showing the traces
+of recent but past iritis; the pupil was regular in form and
+active to light; the conjunctiva was slightly congested.
+Ophthalmoscopic observation was attempted by a skilled observer,
+but could not be satisfactorily carried out, from the
+turbid state of the media. The conjunctiva was slightly congested.
+In place of the lachrymation that had prevailed during
+the neuralgic period, there was a remarkable insensibility of
+the lachrymal apparatus, for the patient had noticed that the
+smell of onions, which would make the other eye weep profusely,
+had no influence on the affected one.</p>
+
+<p>The family history of this patient is a most remarkable one.
+All the members of her mother's family, for two generations
+back, had died at middle age, either from apoplexy or some
+disease involving hemiplegia. This case has, by a mistake, not
+been added to the list of twenty-two private cases in which the
+family history was carefully investigated, that will be found
+in the chapter on Pathology; this arose from the fact that the
+patient was not properly under my care, but was sent to me as
+a medical curiosity; the notes of her case were therefore taken
+in a different book from the others. The case certainly ought
+to be taken as a counterpoise to such a one as No. XVI. in the
+list, which is that of a gentleman who suffered from the most
+complicated neurotic maladies (asthma, angina pectoris, facial
+neuralgia, more than once attended with erysipelas), but whose
+family history, so far as it was known, presented no traces of
+tendency to neurotic disease.<span class="pagenum"><a name="Page_89" id="Page_89">[89]</a></span></p>
+
+<p>To these two cases of inflammation, secondary to neuralgia, I
+shall add a third, which is even more interesting, and which
+came under my notice not long since.</p>
+
+<p><span class="smcap">Case III.</span>&mdash;H. T., watchmaker's assistant, aged forty-two,
+suffered for about three weeks with very severe remittent abdominal
+pain, entirely unconnected with dyspepsia, constipation,
+or diarrh&#339;a. It was intermittent in character, but
+observation soon showed that the times at which it came on
+were simply those at which the stomach had gone longest
+without food, especially the early morning, and that nourishment
+never failed to relieve it. The suffering was great, and
+the man failed considerably in general health, notwithstanding
+that his appetite and digestion were unimpaired. He had only
+been under my care about ten days when he presented himself
+one day at the hospital, and stated that the pains in the stomach
+had entirely left him, but that he suffered the most frightful
+pains in and around the right eye. I found a well-marked
+conjunctival congestion and lachrymation, but there were as
+yet no tender points; the neuralgia was felt most severely in
+the globe of the eye and in one tolerably straight line, darting
+up toward the vertex from the brow. The iris seemed clear
+and free, and the cornea was not cloudy. I gave the man a
+subcutaneous injection of one-sixth grain acetate of morphia,
+for present ease, and ordered him muriate of iron and small
+doses of strychnia three times a day. When he next appeared,
+four days later, I was alarmed to perceive that unmistakable
+iritis had fully developed itself, the iris was already turbid and
+discolored and the pupil irregular, from a serious amount of
+adhesions. By this time there were fully-developed tender
+points, supra-orbital and parietal; besides this, pressure on the
+globe caused paroxysms of pain, in all the branches of the ophthalmic
+division, but there was not much spontaneous pain.
+I dropped atropine in the eye, applied blistering fluid to the
+back of the neck, [the nape of the neck is the point most suitable
+for blistering which is intended to affect the eye, and the
+ophthalmic division of the fifth, generally,] and desired the
+man to come to see me at my own house next day, intending
+to take him to an ophthalmic surgeon. Unfortunately he failed
+to do this, and three days later, when he came to see me at the
+hospital, the cornea was studded with opacities, the pupil was
+almost closed with effused lymph, there was violent ocular
+pain, and a great and increasing sense of tension. I begged
+him to go without loss of time to the Eye Hospital, as my own
+ophthalmic colleague was not at Westminster that day; and I
+have never heard any more of the patient.</p>
+
+<p>Glaucoma is a still more serious disease of the eye, which I
+think there is now sufficient evidence to show is sometimes
+entirely, and very often in considerable part, neuralgic in its
+origin. Since my attention was directed, some six years ago,<span class="pagenum"><a name="Page_90" id="Page_90">[90]</a></span>
+to the frequent connection between the so-called rheumatic
+iritis and neuralgia, I have taken much interest in the subject
+of acute eye-affections; and the occurrence of one or two cases
+of glaucoma in personal friends of my own has made this interest
+even painfully strong. I am necessarily without the
+means of personally observing glaucoma on the large scale,
+but I have now seen two cases in which, if I possess any faculty
+of clinical observation whatever, the whole genesis of the disease
+was a neuralgic disorder of the trigeminus; and it was to
+me a melancholy reflection that nothing better than iridectomy
+in one case, and excision of the eyeball in the other,
+could be done in the present state of ophthalmic science.
+There are now a good many recorded instances of neuralgic
+glaucoma, and Mr. R. Brudenell Carter, of St. George's, and the
+South London Ophthalmic Hospital, recently assured me that
+nervous aspect of some form of glaucoma presents itself the
+strongly to his mind, though he does not commit himself to
+any theory. Two cases were reported by Mr. Hutchinson, in
+Ophthalmic Hospital Reports IV. and V.; but the most complete
+and interesting cases that I have met with are recorded
+by Dr. Wegner;<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a> they are two out of four that occurred within
+a very short time in the clinic of Prof. Horner at Zurich, and
+they form the basis of some researches by Wegner into the
+nature of the influence of the trigeminus upon ocular tension,
+which will be referred to, along with others, in the chapter on
+Pathology. The second of these cases is so important that I
+shall reproduce it in full.</p>
+
+<p>A. Hediger, aged twenty-four, a moderately strongly-built
+young woman, seen first in August, 1860. From her own and
+her mother's account, it seemed she had long suffered from
+convulsive attacks that did not appear to have been truly epileptic.
+Some days previously her left eye became very painful,
+and the sight failed, without any inflammatory symptoms.
+On inspection the pupil was somewhat dilated, the eye somewhat
+hypermetropic, fundus normal; No. 5, Jager's type, was
+read with difficulty. Wegner could not explain the condition.
+At the end of October the eye was much worse; after severe
+paroxysms of pain, No. 16 type was the smallest legible, the
+field of vision was decidedly limited in all directions, but especially
+on the inner and upper portions. An unusually
+long hysteric attack was now observed. The patient
+was for twenty-four hours in a half-sleep, the extremities,
+meantime, were much jerked, the speech sometimes
+coherent and sometimes incoherent; she cried out to her
+friends, etc., but had no severe convulsion-fit with spasm of
+glottis. She was removed to the hospital, where she stayed six
+weeks. The hysteria improved under treatment with valerian
+<span class="pagenum"><a name="Page_91" id="Page_91">[91]</a></span>
+and morphia (Prof. Greisinger had confirmed the opinion that
+there was no true lesion of the centres), but the neuralgia of
+the globe was extraordinarily severe, both day and night.
+From January to June, 1861, Wegner saw her occasionally.
+The visual power of the left eye fluctuated between 15 and 19
+Jager. Field of vision very limited. Pupil very dilated and
+insensitive, the globe painful to the touch, and injected. The
+right eye weakly hypermetropic; normal field of vision, normal
+pupil, no pain. The scene suddenly changed on the 29th
+of June. She was attacked with fearful pain, and an enormous
+mydriasis with extreme amblyopia of the right eye; the fingers
+could hardly be counted when placed quite close. The optic
+disc appeared somewhat cloudy, with very evident venous
+pulsation. The mydriasis, amblyopia, and neuralgia lasted
+some time, while simultaneously the left eye could only read
+19-17 type, but was painless. The pathology seemed quite obscure,
+and the surgeon remained almost passive till August,
+when he performed paracentesis on the left eye. The patient
+could distinguish fingers at that time at a foot's distance with
+the right eye; with the left read No. 11, but suffered fearful
+pains. These diminished after the puncture; the eye could
+read No. 20 next day, and improved after that to 19; the pains
+recurred in the next day, but for the first time ceased to disturb
+sleep. The scene again changed in the most surprising
+manner on the 27th of August. The most frightful pain again
+attacked the left eye. The pupil was dilated to the maximum
+(far beyond what occurs in oculo-motor paralysis); the globe
+was extremely painful on touch, visual power fallen to 19
+Jager. On the other hand, the right eye had a normal pupil,
+was painless, and could read No. 12. Paracentesis of the left
+eye improved its vision and diminished pain, but only temporarily,
+so that it had to be repeated at short intervals. The condition
+was so far stationary toward the end of October that the
+right eye continually gained visual power, but the left stood
+still and fluctuated from worse to better, with the greater or
+less severity of the neuralgic paroxysms. Pupils always in
+extreme dilatation. In the end of October and beginning of
+November (the patient had worn a large seton for a month) remarkable
+changes occurred; the neuralgia of the left globe diminished
+steadily, the pupil got smaller, the visual power increased,
+the neuralgia now was only on the lower lid, which
+was slightly red and painful to the touch, and had continual
+spontaneous pain. Visual power of right eye No. 3, of left eye
+No. 5. Visual field intact; with full illumination by weak light
+there is a peripheral torpor, but only in a narrow zone. The
+hyperęmia now extended more and more over the lower lid
+and the upper part of the cheek; this was apparent during the
+paroxysms, which were very severe, and destroyed sleep; it
+did not allow the skin to be touched; the color was deep (with<span class="pagenum"><a name="Page_92" id="Page_92">[92]</a></span>
+high temperature) and extended to the angle of the mouth.
+This phenomenon lasted till the beginning of December, when
+neuralgia again attacked the left globe, with strong mydriasis
+and diminution of visual power (15 to 20 Jager), till at last the
+movements of the hand could hardly be distinguished, and
+this state of things continued with fluctuations up to the end
+of the month. The seton had been taken off just before the
+new outbreak; it was put in again on December 31st. In January
+the pains continued severe in the eye, with only one remission
+(from the 17th to the 20th), when the hyperęmia recurred
+in the cheek. On the 26th the pupil was very dilated,
+and fingers could not be seen at half a foot's distance. Visual
+field very limited, globe hard. A large upper iridectomy was
+made. After this the pupil was contracted, the pains diminished,
+visual power 10 Jager, field seven inches. In the middle
+of February the hysterical attacks recurred with great
+force; the patient was unconscious half the day; she was clear
+enough in senses when awake, but complained of buzzing in
+her head, as if a cock-chafer were inside it. From this till the
+middle of March, the left eye did not alter, the impairment of
+vision remained, with normal pupil and no pain in the globe,
+and the iridectomy seemed at least to have done good in one
+direction; but on the 13th of March the operated eye was again
+attacked with pain, visual power fell to No. 17, pupil became
+dilated, and after a few days the swelling, heat, and tenderness
+of the cheek recurred. During the years 1862 and 1863 the
+condition remained pretty much the same; <i>i.&nbsp;e.</i>, the right eye
+sound, the left painful (in spite of the iridectomy) with dilated
+pupil, concentrically narrowed visual field, visual power fluctuating
+between No. 15 and mere finger-counting without any
+ophthalmoscopic appearances. A number of paracentesis and
+subcutaneous injections of morphia (which last were the more
+indicated as the supra-orbitalis was tender on pressure) always
+brought relief merely for a few hours. On the 19th of April,
+1864, vision being complete in right eye, and No. 19 in left,
+Wegner punctured the latter. On the 2d of May the eye read
+No. 10 slowly, the pains had gone and not returned, the pupil
+became smaller. On the 31st of March, 1865, the patient was
+pronounced well; the eye was painless, the pupil somewhat
+larger than the other; the finest type could be read when
+looked at very close.</p>
+
+<p>3. The next group of affections secondary to neuralgia are
+the paralysis of muscles. These are pretty common; I find
+them in twenty-eight of the hundred cases which have been
+referred to. But of these twenty-eight instances of paralytic
+affections no less than twelve were connected with neuralgia
+of the trigeminus, and in most of these it was one or more of
+the muscles connected with the eye that were affected. Sciatica
+is nearly always attended with much weakening of voluntary<span class="pagenum"><a name="Page_93" id="Page_93">[93]</a></span>
+power of the muscles of the thigh and leg; and in some
+instances this reaches to decided or even complete paralysis.
+In looking for this phenomenon we must be very careful that
+we do not mistake the mere reluctance to move the limb, on
+account of the painfulness of all movements, for true paralytic
+weakness of nerve and muscle. And it is also necessary to
+bear in mind, in prolonged cases, the probability that much of
+the weakness may have been caused by degeneration of the
+muscles owing to forced inaction. Still, there is a class of secondary
+paralyses that are in no way to be confounded with
+such effects as these: for instance, it occasionally happens,
+almost in the very first onset of severe sciatic pain, that the limb
+hangs absolutely helpless; and in one such case lately, being
+struck with the completeness of the loss of power, I tested the
+Faradic irritability by directing a sharp current on comparatively
+exposed portions of the painful nerve (<i>e.&nbsp;g.</i>, in the popliteal
+space, and behind the head of the fibula), and elicited
+only the most feeble contractions, entirely unlike what the
+same current evoked in the opposite limb. I regret that I have
+as yet found it impossible to carry out a regular inquiry as to
+the sensibility to the different currents of motor nerves which
+are centrally connected with neuralgic sensory nerves.</p>
+
+<p>Muscular viscera which are composed of unstriped fibre, like
+the intestines, or of a mixture of striped and unstriped, like
+the heart, are probably very liable to a secondary paralytic influence
+from certain special neuralgię. It is ascertained that
+the pain of a certain degree of severity in the branches of the
+fifth may absolutely stop the heart's action for a moment&mdash;an
+effect which is succeeded, usually, by violent and disorderly
+pulsations. I have myself once known the operation of "pivoting"
+a tooth, which gave frightful pain, cause instantaneous
+and most alarming arrest of the heart's motion, which for a
+minute or two seemed as if it were going to be fatal. But the
+variety of visceral paralysis which is probably far the most
+frequent is secondary paralysis of the bladder, from neuralgia
+in one or other of the pelvic organs, or of the external genitalia;
+and next to this comes paralytic distension of the cęcum,
+colon, or rectum, secondary to various abdominal and pelvic
+neuralgic affections. In one instance of acute ovarian neuralgia
+that I saw, the paralytic distention of the colon was by far
+the most remarkable circumstance, so enormously was it developed;
+and for some days after the neuralgia had ceased, and
+when the flatulence had nearly disappeared, the intestine remained
+absolutely torpid.</p>
+
+<p>4. Convulsive actions of muscles, as every one knows, are
+very common complications of neuralgia. In trigeminal neuralgias
+these may be observed (according to the division or divisions
+of the nerve that are affected) in the proper muscles of
+the eye, or in those supplied by the fourth and sixth nerves, or<span class="pagenum"><a name="Page_94" id="Page_94">[94]</a></span>
+(perhaps only when two or three divisions of the fifth are neuralgic
+at once) by the portio dura. It is curious, however, that
+those formidable spasmodic affections of the face which belong
+to the same order as torticollis and writer's cramp, are not frequently,
+if ever, directly associated with trigeminal neuralgia.
+The only connection between them seems to be that these peculiar
+spasmodic affections are only developed in highly-neurotic
+families, some of whose members are almost sure
+to be found suffering from some form of regular neuralgia.
+In severe sciatica it has several times happened to me to
+see convulsive action of the flexors, bending the leg spasmodically
+upon the thigh. And in a very large proportion of all
+neuralgias, wherever situated, attentive observation of the
+patient during the paroxysms will detect the existence of local
+twitching or local spasm of muscles, though these may be
+slight in degree.</p>
+
+<p>Among the convulsive affections must be reckoned convulsive
+movements and tonic spasms of various portions of the
+alimentary canal. Vomiting is a common example of this; in
+migraine it is the regular and necessary climax of attacks
+which last with severity for a certain time; indeed, any severe
+attack of neuralgia involving the ophthalmic division of the
+fifth may excite vomiting. Convulsive action of the pharyngeal
+muscles, as a complication of pharyngeal or laryngeal
+neuralgia, occasionally occurs to such an extent as to render
+deglutition difficult or impossible for the time. And I have seen
+what I do not doubt to have been a spasmodic condition of the
+rectum induced by peri-uterine neuralgia. The genito-urinary
+organs are also not unfrequently affected spasmodically in consequence
+of a neuralgic affection either peri-uterine or pudendal.
+I have seen spasmodic stricture of the male urethra thus
+produced, and likewise vaginal spasm.</p>
+
+<p>5. Impairments of sensation, both common and special, are
+very frequent attendants of neuralgia. As regards the special
+sensations, we may first mention that of touch; this is almost
+constantly impaired, immediately before, during, and some
+little time after a neuralgic paroxysm, in the skin supplied by
+the painful nerves. I was first led to make this observation by
+my own experience; the skin all round the inner angle of my
+right eye is permanently less sensitive to distinctive impressions
+than that of the opposite side, and this impairment is always
+decidedly greater, and spreads over a larger surface, before,
+during, and for some time after, the attacks of pain. More extended
+observation has convinced me that a certain amount of
+bluntness of distinctive skin-sensation accompanies nearly
+every neuralgia. As regards the sense of taste, I have found
+this decidedly perverted, at the time of an attack, even in my
+own case, although the neuralgia never extends into the third
+branch of the nerve. It is interesting to notice, in connection<span class="pagenum"><a name="Page_95" id="Page_95">[95]</a></span>
+with this, that the epithelium of my tongue has been seen, on
+one occasion, to be exaggerated on the side of the neuralgic
+affection, showing a probability that there is perturbed function,
+at any rate of certain fibres, of the third division. But I
+have seen much more decided alteration, indeed temporary entire
+abeyance of the power to distinguish between the tastes of
+different substances, with the affected side of the tongue, in a
+case of severe epileptiform tic in which the third division was
+strongly affected with neuralgia; and Notta records a similar
+instance. As regards vision, besides minor perversions and
+disturbances, I have observed more or less complete amaurosis
+in several instances of ophthalmic neuralgia; in one case it was
+absolute, and lasted, with but slight improvement in the intervals
+between the paroxysms, for nearly a month, but disappeared
+entirely, though somewhat gradually, after the final
+cessation of the neuralgia. As regards hearing, I have noticed
+serious impairment only in five cases, all of them of a severe
+type of trigeminal neuralgia, involving all three divisions of
+the nerve. Smell, I have never observed to be more than
+doubtfully impaired, except in one case (<i>vide</i> Chapter III),
+where it was completely destroyed.</p>
+
+<p>Common sensation was reported by Notta as affected in only
+three cases out of a hundred and twenty-eight; but my own
+experience has afforded a much larger proportion of instances
+in trigeminal neuralgia. Indeed, in all situations neuralgia
+appears to me to involve this effect, in the larger number of
+instances, in the early stages; later, it is supplanted in part by
+great tenderness on pressure in the well known <i>points douloureux</i>,
+and sometimes the tenderness becomes diffused over a
+considerable surface. I agree with Eulenburg in thinking that
+anęsthesia is more frequent in sciatica than in other neuralgias.</p>
+
+<p>6. Secretion is often very notably affected in neuralgia; the
+phenomena are necessarily more easily observed in connection
+with affections of the trigeminal than of other nerves. In the
+great majority of cases the affection is in the direction of increase;
+at least, the watery elements of secretion are often
+poured out in profusion. Thus, profuse lachrymation is exceedingly
+common in ophthalmic neuralgia; in a large number of
+cases there is also copious thin nasal flux on the affected side;
+sometimes, however, the secretion, though copious, is semi-purulent,
+or bloody. Increased salivation has been noticed, by
+a large number of observers, in neuralgia involving the lower
+division of the fifth. In a smaller number of instances, the
+secondary effect on secretion is precisely opposite; thus both
+Notta and myself have observed complete dryness on the nostril
+on the affected side in ophthalmic neuralgia.</p>
+
+<p>I might expand this chapter on the complications of neuralgia
+to a very much greater length; but, as regards the clinical
+history of these affections, it is perhaps better not to occupy<span class="pagenum"><a name="Page_96" id="Page_96">[96]</a></span>
+more time and space. It will, however, be necessary to return
+to the consideration of the subject in connection with Pathology.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="path" id="path"></a>CHAPTER III.</h2>
+
+<h3>PATHOLOGY AND ETIOLOGY OF NEURALGIA.</h3>
+
+
+<p>The pathology and the etiology of neuralgia cannot be considered
+apart; they must be discussed together at every step. I
+do not mean to say that neuralgia is singular among diseases
+in this respect; it seems to me merely a case in which the intrinsic
+defects of the conventional system of separating the
+"causes" of disease from its pathology happen to be more glaring
+and more easily demonstrable than usual.</p>
+
+<p>Neuralgia possesses no "pathology," if by that word we intend
+to signify the knowledge of definite anatomical changes
+always associated with the disease, in a manner that we can
+exhibit or exactly describe. It also possesses no demonstrable
+causes, if we employ the word "causes" in the old metaphysical
+sense. And yet I am very far from admitting, what seems to
+be so generally taken for granted, that we know less about the
+seat, the nature, and the conditions of neuralgia than of other
+diseases. On the contrary, I believe, with all deference to the
+supporters of the ordinary opinion, that we know more about
+neuralgia, in all these respects, than we do about pneumonia,
+only our knowledge is not of the superficial and obvious
+kind, but requires the aid of reason and reflection to develop
+and turn it to account. It has long been a matter
+of surprise to me, that even able writers have been content
+to talk about this disease (as, indeed, they have been content
+to speak of many nervous diseases) with an inexplicable
+looseness of phraseology. They speak of its "protean" forms;
+whereas, in my humble judgment, its forms are by no means
+specially numerous. They insist on the mysterious and unintelligible
+manner of its outbreaks, remissions and departure;
+but I shall try to show that, although, in the investigation of
+<ins title="Transcriber's Note: original reads 'neralgi'">neuralgia</ins>, we are continually stopped in particular lines of
+inquiry by what seems to be ultimate facts, susceptible of no
+further immediate solution, the channels of information open to
+us are so unusually numerous as to enable us to accumulate a
+mass of information which, upon further reflection, will be
+found to furnish the materials of a synthesis of the disease singularly
+clear and effective for every practical purpose of the
+physician. In one important particular I especially hope to
+convince the reader that a large proportion of the mystification<span class="pagenum"><a name="Page_97" id="Page_97">[97]</a></span>
+as to the pathology of neuralgia is gratuitous, and the result
+of great carelessness in estimating the comparative value of
+different facts. I hope to show clearly that, as regards both
+the seat of what must be the essential part of the morbid process,
+and the general nature of the process itself, we possess
+very definite information indeed. I expect, in short, to convince
+most readers that the essential seat of every true neuralgia
+is the posterior root of the spinal nerve in which the pain
+is felt, and that the essential condition of the tissue of that
+nerve-root is atrophy, which is usually non-inflammatory in
+origin. This doctrine seems, at first sight, presumptuous,<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a> in
+the confessed absence or extreme scarcity of dissections which
+even bear at all upon the question. But one source of the
+extraordinary interest which the pathology of neuralgia has
+long possessed for me resides in this very fact, that I am convinced
+we can demonstrate the above apparently difficult theorem
+by means of pathological observations on the living subject,
+taken in conjunction with physiological experiments, and
+with only the aid of a very few isolated facts of positive morbid
+anatomy. I need hardly say that I am none the less anxious
+for that further assurance which we shall one day, perhaps,
+obtain by means of greatly-improved processes for
+microscopic detection of minute changes in nerve-centres; but,
+looking to the necessary rarity of opportunities for post-mortem
+examinations of the nervous system in any but the most
+advanced stages of neuralgias, it will hardly be disputed that,
+if I am right in my main position, we are singularly fortunate
+to be so unusually independent of the need for this source of
+information.</p>
+
+<p>1. The first fact which strikes me as of decided importance
+is the position of neuralgia as an hereditary neurosis; and this
+character of the disease is so pregnant with significance, that
+I shall take some considerable pains to put the fact beyond
+doubt in the reader's mind.</p>
+
+<p>There are two series of facts which support the theory of the
+inheritance of the neuralgic tendency: (<i>a</i>) instances in which
+the parent of the sufferer had also been affected with the disease;
+and (<i>b</i>) instances in which the family history of the
+patient being traced out more at large it appeared that, among
+the members of two or more generations, while one, two, or
+more individuals had been actually neuralgic, other members
+had suffered from other serious neuroses (such as insanity,
+<span class="pagenum"><a name="Page_98" id="Page_98">[98]</a></span>
+epilepsy, paralysis, chorea, and the tendency to uncontrollable
+alcoholic excesses), and, in many instances, that this neurotic
+disposition was complicated with a tendency to phthisis.</p>
+
+<p>(<i>a</i>) The question of the direct transmission of neuralgia
+itself from the parent seems the easiest of decision, though even
+this cannot always be satisfactorily cleared up by the hospital
+patients, among whom one collects the largest part of one's
+clinical materials. However, I have been at the pains of
+investigating a hundred cases of all kinds of neuralgia, seen in
+hospital and private practice, with the following results:
+twenty-four gave distinct evidence that one or other parent had
+suffered from some variety of neuralgia; fifty-eight gave a distinctly
+negative answer; and eighteen would not undertake to
+give any answer at all. Among the twenty-four affirmatives
+are inserted none in which the history of the parent's affection
+did not clearly specify the liability to localized pain, of intermitting
+type, but recurring always in the same situation during
+the same illness. In three of these twenty-four instances,
+the patient stated that both parents had suffered from such
+attacks, and, in one of these, it appeared that the grandfather
+had likewise suffered.</p>
+
+<p>(<i>b</i>) The question of the tendency of a family, during two or
+more generations, to severe neuroses of more or less varying
+kinds, including neuralgia, is difficult to work out perfectly,
+though in a large number of instances we may get enough
+information to be very useful. I have spent much time and
+trouble in endeavoring to collect such information; but there
+are two main difficulties in connection with all such attempts.
+From hospital patients you frequently can get no reliable information
+whatever respecting any members of the family farther
+back than the immediate parents; and, even respecting
+uncles and aunts and first cousins, it is often impossible to learn
+any thing. And when you get to a higher class of society,
+especially when you approach the highest, although the information
+may exist, it may be withheld, or you may be purposely
+mystified. One would doubt beforehand, under these
+circumstances of difficulty, whether it would be possible to
+obtain affirmative evidence of the neurotic temperament of the
+families of neuralgic patients in general; but, in truth, the
+evidence is so overwhelming in amount, that more than enough
+can be obtained for our purpose. I shall give, first, the results
+of one special inquiry which, by the kindness of a patient, I
+have been able to carry out with more than usual completeness;
+it relates to the medical genealogy of a sufferer from sciatica;
+the account is fairly complete for four generations. The
+great-grandfather was a man of splendid physique (an only
+son), who lived very freely, but died an old man. His children
+were three sons, one of whom (though strictly temperate)
+was a man of eccentric and somewhat violent temper, and<span class="pagenum"><a name="Page_99" id="Page_99">[99]</a></span>
+suffered from a spasmodic facial affection. This one, the
+grandfather of my patient, married a lady who died of phthisis,
+and among the ten children she bore him, two sons died of
+phthisis, two sons became chronically insane, one son died,
+probably of mesenteric tubercular disease (aged fifty-six), two
+sons are still alive at very advanced ages, and have always
+been perfectly healthy and strong; one daughter died in middle
+age, it is not certain from what cause; one daughter lived
+healthily to the age of eighty, and then was attacked by facial
+erysipelas, followed by violent and intractable epileptiform tic,
+which clung to her for the remaining four years of her life;
+and the remaining daughter, an occasional sufferer from
+migraine, died at the age of sixty-seven, almost accidentally,
+from exhausting summer diarrh&#339;a. The fourth generation, in
+this branch of the family, consisted of thirty-one individuals;
+of whom seven have died of phthisis, or scrofulous disease; one
+from accidental violence, one from rheumatic fever, one from
+scarlet fever; and among the surviving twenty-two one has
+been insane, but recovered; two are decided neuralgics; one is
+occasionally migraineuse, and once had a smart attack of facial
+erysipelas, corneitis, and iritis, as the climax to a severe neuralgic
+attack; one has been a sufferer from chorea; one has
+become phthisical; one developed strumous disease, but has
+fairly recovered from it. The remaining fifteen enjoy good
+health, but are distinguished, almost without exception, by a
+markedly neurotic temperament, indicated by an anxious tendency
+of mind, quickness of perception, ęsthetic taste, disposition
+to alternations of impulse and procrastination. Of the
+young fifth generation growing up, there have been twenty-five
+children, of whom only one has died (from fever), the rest
+are apparently healthy (most of them specially so); but, as few
+have yet reached the age for the development either of phthisis
+or of neurotic diseases, the future of this generation can only
+be guessed at. [It is unnecessary to trace the other descendants
+of the second generation, but I may state that their medical
+history, also, strongly supports the theory of inheritance of the
+neurotic tendency, and of the influence of an imported element
+of phthisis in aggravating the latter.] I suspect that, as
+regards the young children now growing up, everything will
+depend on the care with which they are fed, and the kind of
+moral influences brought to bear on them, two subjects which
+will be fully dwelt on in the chapter on Treatment.</p>
+
+<p>Of less perfect inquiries on the subject of neurotic disposition
+inherited by neuralgic patients, I have made a great number,
+though I regret to say that I have not attempted the task in the
+whole number of those from whom I inquired as to direct inheritance
+of neuralgia from their parents. However, in eighty-three
+cases this was done with all possible care, and any deficiency
+of completeness in the results is not my fault. I shall<span class="pagenum"><a name="Page_100" id="Page_100">[100]</a></span>
+take first those that were private patients, twenty-two in number,
+respecting whom, I may say, that the evidence is of the
+best, as far as it goes, since I was better able to discriminate as
+to the worth of statements, than in dealing with hospital
+patients, and have rejected every case in which the informant
+did not seem intelligent enough, or otherwise to have the
+means, to give a thoroughly reliable account.</p>
+
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="4" summary="patient list">
+<tr><td class="topright">I.</td><td class="topleft">Neuralgia cervico-brachialis; in a lady, aged seventy-one. Mother suffered from epileptiform facial tic; uncle was paralyzed; patient herself eccentric to the verge of insanity.</td></tr>
+<tr><td class="topright">II.</td><td class="topleft">Bilateral sciatica of great severity; in a gentleman, aged seventy-three. Gout, paralysis, and neuralgia, have been frequent in the family.</td></tr>
+<tr><td class="topright">III.</td><td class="topleft">Cardiac neuralgia; in a man, aged twenty-four. Father epileptic and a drinker; grandfather died of softening of the brain, aged thirty-eight.</td></tr>
+<tr><td class="topright">IV.</td><td class="topleft">"Cerebral" neuralgia; in a single lady, aged thirty-eight. Mother has been insane; first cousin epileptic.</td></tr>
+<tr><td class="topright">V.</td><td class="topleft">Lumbo-abdominal neuralgia; in a gentleman, aged fifty-two. Father a drinker; mother insane; maternal grandfather phthisical.</td></tr>
+<tr><td class="topright">VI.</td><td class="topleft">Severe neurotic angina pectoris; in a gentleman, aged fifty. Almost every one of the graver neuroses among patient's near relations.</td></tr>
+<tr><td class="topright">VII.</td><td class="topleft">Migraine and cervico-occipital neuralgia; in a young lady, aged twenty-five. Immediate causes, brain-work, and influence of cold weather. Father and brother both epileptic; father's family much affected with neurotic diseases.</td></tr>
+<tr><td class="topright">VIII.</td><td class="topleft">Sciatica; highly-nervous temperament. Father died insane from drink; and probably other members of the family also nearly or quite insane.</td></tr>
+<tr><td class="topright">IX.</td><td class="topleft">Auriculo-temporal neuralgia; in a married lady, aged twenty-eight. Father's family markedly phthisical and neuralgic.</td></tr>
+<tr><td class="topright">X.</td><td class="topleft">Intercostal neuralgia; in a girl (phthisical), aged twenty-four. Mother and two uncles phthisical; maternal grandfather epileptic and a drinker.</td></tr>
+<tr><td class="topright">XI.</td><td class="topleft">Facial neuralgia (third branch trigeminal); in a gentleman, aged fifty-four, a great whiskey-drinker. Drinking hereditary for three generations; father died insane; grandfather epileptic; sister phthisical; two brothers very "eccentric."</td></tr>
+<tr><td class="topright">XII.</td><td class="topleft">Migraine, severe; in a lady, aged thirty-three. Grief was the immediate cause. Mother hemiplegic at forty-second year; first cousin insane; two aunts (maternal) epileptic.</td></tr>
+<tr><td class="topright"><span class="pagenum"><a name="Page_101" id="Page_101">[101]</a></span></td></tr>
+<tr><td class="topright">XIII.</td><td class="topleft">Extremely severe sciatica and cervico-brachial neuralgia of the left side, with singular inflammatory consequences; in a lady, aged fifty-two. A family history remarkably free from neurotic diseases and from phthisis. The neuralgia was probably caused partly by excessive ptyalism, partly by over brain-work.</td></tr>
+<tr><td class="topright">XIV.</td><td class="topleft">Migraine; in a young lady, aged sixteen; very profuse menstruation, which had lasted for two years. Family history very free both from phthisis and neuroses.</td></tr>
+<tr><td class="topright">XV.</td><td class="topleft">Frontal and nasal neuralgia; in a man. Repeated attacks of localized facial erysipelas; drinking-habits for some years; fatal acute insanity in middle age. Father insane, committed suicide; mother subject of violent epileptiform tic.</td></tr>
+<tr><td class="topright">XVI.</td><td class="topleft">Angina pectoris (neurotic); spasmodic asthma, twenty years; facial neuralgia and erysipelas; in a gentleman, aged fifty. Family medical history scanty and imperfect; but, as far as it goes, entirely without evidence of either phthisis or neuroses.</td></tr>
+<tr><td class="topright">XVII.</td><td class="topleft">Neuralgia of testis, immediately caused by local irritation. Father died of phthisis; paternal uncle epileptic and insane.</td></tr>
+<tr><td class="topright">XVIII.</td><td class="topleft">Ovarian neuralgia; in a girl, aged twenty-six, liable to occasional migraine. Mother has suffered sciatica; brother died of phthisis.</td></tr>
+<tr><td class="topright">XIX.</td><td class="topleft">Gastralgia; in a man, aged twenty-seven; highly intellectual and nervous. Family history very free from neuroses; but some evidence of phthisis, in two previous generations, on mother's side.</td></tr>
+<tr><td class="topright">XX.</td><td class="topleft">Sciatica; in a lady, aged sixty; second attack. Ancestors, on both sides, for some generations, clever, and in several instances decidedly eccentric, if not insane; much neuralgia in the family.</td></tr>
+<tr><td class="topright">XXI.</td><td class="topleft">Migraine; in a young lady, aged seventeen; menstrual difficulties. No neurotic nor phthisical family history.</td></tr>
+<tr><td class="topright">XXII.</td><td class="topleft">Sciatica; in a married lady, aged twenty-seven; first pregnancy; had rheumatic fever and subsequent chorea in childhood. Paternal uncle epileptic; mother had rheumatic fever and cardiac disease; paternal grandfather suffered from sciatica late in life.</td></tr>
+</table></div>
+
+
+<p>No one, I think, can look down the above list and fail to be
+struck with the great preponderance of cases in which the general
+neurotic temperament plainly existed in the patients' families;
+and let me add that, in not a few of these cases, the
+neuralgia in the individual under observation might have been
+easily set down as dependent merely upon peripheral irritation,
+which, indeed, plainly did act as a concurrent cause.<span class="pagenum"><a name="Page_102" id="Page_102">[102]</a></span></p>
+
+<p>Fortunately, however, I am not dependent upon my own
+evidence alone, for the proofs of the proposition that neuralgia
+is eminently a development of hereditary neuroses. The great
+French alienists, Morel and Moreau of Tours, some years ago
+laid the foundations of the doctrine of hereditary neurosis.
+They enforced this chiefly with reference to the manner in
+which insanity is transmitted through a chain of variously-neurotic
+members of a family stock; and Moreau laid special
+stress on the deeply interesting connection of the phthisical
+with the neurotic tendency. Since then various observers have
+insisted on the same thing. Of late, Dr. Maudsley has worked
+out this subject with great ability, in his work "On the Physiology
+and Pathology of Mind," and in his recent "Gulstonian
+Lectures;" and Dr. Blandford dwells on it with emphasis in
+his interesting "Lectures on Insanity." [Dr. Blandford does
+not, however, admit that the phthisical diathesis has any such
+close and causal relation with neuroses as has been imagined
+by some recent pathologists; and, on the other hand, he points
+out that phthisis in neurotic subjects, <i>e.&nbsp;g.</i>, the insane, must,
+in a large measure, be considered the product of the accidentally
+unhealthy circumstances in which they pass their
+lives. In the latter opinion I entirely agree.] Indeed, it may be
+taken as a recognized fact, among the more advanced students
+of nervous diseases, that hereditary neurosis is an important
+antecedent of neuralgia, in at least a very large number of
+instances. I shall conclude this part of the argument by stating
+the general results of my inquiries respecting sixty-one
+hospital patients. Of these cases, twenty-two were migraine,
+or some other affection of the ophthalmic division of the fifth
+nerve; seven were sciatica; two were epileptiform facial tic;
+ten were neuralgias affecting chiefly the second and third divisions
+of the fifth nerve; three were intercostal neuralgias pure;
+one was intercostal neuralgia plus anginoid pain; seven were intercostal
+neuralgias with zoster; three were brachial neuralgias;
+and five were abdominal neuralgias (hepatic, gastric, mesenteric,
+etc.) Of eighty-three hospital and private patients [It must be
+understood that the respective numbers do not indicate with
+any accuracy the relative frequency of the different neuralgias
+as seen in my practice. (Sciatica, <i>e.&nbsp;g.</i>, was proportionally
+more frequent.) They represent but a small part of the neuralgic
+patients whom I have seen during fourteen years of dispensary,
+hospital, and private practice, and they were selected
+for inquiry merely because I happened to be able to give the
+time for the necessary questions. Every one who knows out-patient
+practice will understand how seldom this happened.]
+I obtained evidence of the presence, among blood-relations, of
+the following diseases: Epilepsy, fourteen cases (eight were
+examples of migraine); hemiplegia or paraplegia, nine cases;
+insanity, twelve cases; drunken habits, fourteen cases; "consumption,"<span class="pagenum"><a name="Page_103" id="Page_103">[103]</a></span>
+eighteen cases; "St. Vitus's dance," four cases. I
+am well aware that these figures must be taken with caution,
+and that considerable doubt must rest on the accuracy of some
+of these details, more especially with regard to "epilepsy," as
+it was impossible, with the greatest care, to be sure that this
+was not given, by mistake, for hysteria in some cases; and the
+same may apply to the statement that relations had suffered
+from "consumption." The facts are given for what they are
+worth, and with the express reservation that their total reliability
+is far less than that of the accounts obtained respecting
+private patients belonging to the more educated classes. But,
+in one respect, viz., as regards drunken habits, it is possible
+that a truer estimate is gained from the statements of hospital
+patients than from those of private patients, who would usually
+be more prone to reticence on such a topic.</p>
+
+<p>The evidence as to the hereditary character of neuralgia assumes
+a yet higher importance when supplemented by the facts
+respecting the alternations of neuralgia with other neuroses as
+the same individuals. Every practitioner must be aware how
+frequent is the latter occurrence. Nothing is more common,
+for example, than to see insanity developed as the climax of
+minor nervous troubles, especially of neuralgia. And there is
+one form of neuralgia, the true epileptiform tic, which is intimately
+bound up with a mental condition of the nature of melancholia,
+and even with the markedly suicidal form of the latter
+affection. I have lately had under my care a lady in whom
+the prodromata of a severe facial neuralgia were mental; the
+disturbance commenced with frightful dreams, and there was
+great mental agitation even before the pain broke out; this
+disturbance of mind, however, continued during the whole
+period of the neuralgia, and was relieved simultaneously with
+the cessation of the attacks of pain. This is contrary to what
+happens in some cases; thus, Dr. Maudsley quotes the case of
+an able divine who was liable to alternations of neuralgia and
+insanity, the one affection disappearing when the other prevailed.
+Dr. Blandford has met with several instances in which
+neuralgia has been followed by insanity, the pain vanishing
+during the mental disturbance, and reappearing as the latter
+passed away. And he remarks that, in the transition of a neuralgia
+(to mental affection), we may well believe that the neurotic
+affection is merely changed from one centre to another,
+from the centres of sensation to those of mind. He says that
+the ultimate prognosis of such cases is bad; a point to which
+we shall have to refer again.</p>
+
+<p>The prominent place which quasi-neuralgic pains hold in the
+earlier history of locomotor ataxy is a fact that cannot but
+engage attention. In this volume we have not treated these
+pains as belonging to the truly neuralgic class, for the very
+practical reason that they are but incidents in a most important<span class="pagenum"><a name="Page_104" id="Page_104">[104]</a></span>
+organic disease, and that in a diagnostic and prognostic
+point of view it is necessary to dwell on their connection with
+that disease. But, in considering the pathological relations of
+neuralgia, it would be improper to omit the consideration of
+the pains of locomotor ataxy, which bear a striking semblance
+to neuralgic pains. The fact that they are an almost if not
+quite constant feature of a disease which is from first to last an
+atrophic affection (mainly of the posterior columns of the cord),
+in which the posterior roots of the nerves are almost always
+deeply involved, has a bearing on our present inquiry too
+obvious to need further remark.</p>
+
+<p>Equally important to our investigation is the fact that pains,
+closely resembling neuralgia, are not very uncommonly a part
+of the phenomena of commencing, and more frequently of
+receding, spinal paralysis. I have the notes of three cases of
+partial recovery from paraplegia, in all of which the patients
+remained for years, in one case for nearly twenty years (ending
+with death), the victims to a singularly intractable neuralgia
+of both lower extremities. In the worst of the cases the
+patient was the victim of excessive and continuous labor at literary
+work of a kind which hardly exercised the mental powers,
+but was extremely exhausting to the general power of the
+nervous system; he broke down at about the age of fifty, but
+dragged on a painful existence for the long period above mentioned.</p>
+
+<p>We are also certainly entitled to adduce the example of the
+so-called neuralgic form of chronic alcoholism as an instance
+of the close relationship of neuralgia to other central neuroses.
+I refer to those cases, more common perhaps than is generally
+admitted, in which pains in the extremities, often quite resembling
+neuralgia in their intermittence, are either superadded
+to or take the place of the muscular tremors and general restlessness
+that are more popularly considered as the essential
+nervous phenomena of chronic alcoholic poisoning. That the
+pains are usually bilateral, and more diffuse in their character
+than those of ordinary neuralgia, is a fact which it is not difficult
+to explain by the <i>modus operandi</i> of the cause; but we
+shall have more to say on the general relations of alcoholic
+excess to neuralgia presently. The pains themselves will be
+fully described in the second part of this book, which treats of
+the affections that simulate neuralgia; here we need only
+remark that it is not uncommon for them to occur interchangeably
+with true neuralgia in the same person.</p>
+
+<p>The occasional interchangeability of migraine with epilepsy
+is a well-known fact; every practitioner who has seen much
+of the latter disease will have seen some cases in which the
+patient had been liable, at some point of his medical history,
+to "sick-headaches" of a truly neuralgic kind; although it is
+quite true, as Dr. Reynolds points out, that the kind of sensorial<span class="pagenum"><a name="Page_105" id="Page_105">[105]</a></span>
+disorder specially premonitory of the attacks consists rather
+in indefinable distressing sensations, than in actual pain. The
+<ins title="Transcriber's Note: from 1871 ed. See full note at end.">genealogical</ins> connection between migraine and epilepsy is, as
+I have already stated, apparently very close. Such instances
+as one mentioned by Eulenburg are rightly explained by him;
+it is the case of a girl who suffered at an unusually early age
+(nine) from migraine; her mother had been a migraineuse,
+and her sister was epileptic; the strong neurotic family tendency
+is believed by Eulenburg to account for the appearance of
+migraine at such a period of life.</p>
+
+<p>This seems the fitting place to introduce some special remarks
+on migraine in its relations to other neuralgias of the head,
+because Eulenburg has mentioned and combated my view,
+according to which migraine is a mere variety of neuralgia of
+the ophthalmic division of the fifth nerve. I call it my view,
+because, though several other authors had previously expressed
+it, I was first lead to entertain it by observations made before
+I had studied their works, and especially by the impressive
+teaching of my own case, as to which more will be presently
+said. Eulenburg, though he fully allows that migraine is a
+neuralgia, urges a series of objections to the identification of
+migraine with ophthalmic neuralgias; of which objections one,
+based on the doctrine of Du Bois Reymond as to the action of
+the sympathetic in migraine, must be reserved for consideration
+when we discuss the general pathology of the vaso-motor complications
+of neuralgia. The other grounds of distinction that
+he urges are the following: In the first place, he remarks that
+the site of the pain is by far less distinctly referred to definite
+foci on the outside of the skull than in trigeminal neuralgia;
+the patient's sensations very usually lead him to declare that
+the pain is in the brain itself. Secondly, he says that the
+points douloureux (in Valleix's sense) are almost constantly
+absent in true migraine. Thirdly, he specifies the character of
+the pain in migraine&mdash;dull, boring, straining, etc.&mdash;as differing
+from that of trigeminal neuralgia, which is ordinarily
+much more acute and darting. Fourthly, he notes the long
+duration of individual attacks of migraine, and the long intervals
+(very commonly three or four weeks) between them.
+Fifthly, he dwells on the frequent prodromata of migraine
+referable to the organs of sense (flashes before the eyes, noises
+in the ears), or to the stomach (nausea), or more generally to
+the reflex functions of the medulla oblongata (<i>e.&nbsp;g.</i>, convulsive
+rigors, excessive yawning, etc.)</p>
+
+<p>Now, I should have nothing to say against the accuracy of
+this description, did it apply merely to the distinctions between
+highly-typical cases of the "sick-headache" of the period of
+bodily development, and highly-typical cases of the ophthalmic
+neuralgias which are commonest in the middle and later
+periods of life; nor indeed should I greatly care if it were<span class="pagenum"><a name="Page_106" id="Page_106">[106]</a></span>
+finally decided that migraine and clavus should be separated
+from the true trigeminal neuralgię, provided the following
+points were well impressed on the minds of practitioners. In
+the first place, I must insist that in my own experience the
+great majority of undoubtedly neuralgic headaches, which subordinate
+stomach disturbance, are far less sharply separated
+than the above description would allow from the unmistakable
+trigeminal neuralgias; it is only a minority of cases that wear
+this extreme type, and a far larger number shade imperceptibly
+away toward the type of ophthalmic neuralgia pure and simple.
+And so, again, of the so-called clavus there is every variety,
+from a form bordering closely on the migraine type to another,
+differing in nothing from an unusually severe ocular and
+frontal neuralgia of the fifth, except in the presence of a tremendously
+painful parietal focus. But the fact on which I
+would most particularly insist is one that was first taught me
+by my personal experience, viz., that migraine is, with extraordinary
+frequency, the primary or youthful type of a neuralgia
+which, in later years, entirely loses the special characters
+of sick-headache, and assumes those of ordinary frontal neuralgia,
+with or without complications. In my own case, the
+"sick-headache" character of the affection was strongly
+marked during the first two or three years, after which time it
+gradually but steadily lost all tendencies to stomach complications,
+and, what is more, the type of the recurrence became
+entirely changed. Yet it is quite impossible to believe that the
+malady is now a different one, in any essential pathological
+point, from what it was at first; if any disproof of this were
+needed, it might be remarked that the singular series of secondary
+trophic changes which have complicated my case have
+been impartially distributed between the respective periods
+when the affection was frankly migraineuse, when it was
+mixed, and when it was simply ophthalmic neuralgia (as it is
+at present;) indeed, some of the most decided of these trophic
+complications (orbital periostitis, corneal ulceration, fibrous
+obstruction of the nasal duct) occurred within the period in
+which every attack of pain, unless I succeeded in getting to
+sleep very shortly, ended in violent vomiting. The experience
+thus gained has made me very attentive to the past history of
+those who, in later life, complain of frontal neuralgia without
+stomach complication, and it is surprising to find in how many
+cases patients, who at first declare that they never had neuralgia
+before, on reflection will recall the fact that they were
+often "bilious" in their youth; which "biliousness" turns out
+to have been regularly preceded by one-sided headache, and to
+have been severe in proportion to the severity and duration of
+that previous headache.</p>
+
+<p>I ask the reader to dwell with fixed attention on this fact of
+the exclusiveness, or almost exclusiveness, with which the neuralgias<span class="pagenum"><a name="Page_107" id="Page_107">[107]</a></span>
+of the anterior part of the head are represented during
+the period of bodily development, and especially in the years
+just succeeding puberty, by migraine or by clavus. When this
+fact has thoroughly entered the mind, we can hardly help
+joining with it that other and most important fact already
+noticed, of the close connection between the predisposition to
+migraine and the predisposition to epilepsy, and reflecting
+further on the strong tendency which epilepsy likewise shows
+to infest the earlier years of sexual life. In view of these things,
+it is difficult to avoid the inference that both the epileptic and
+the neuralgic affections of this critical period of life are the
+expression of a morbid condition of the medulla oblongata, in
+which the sensory root of the trigeminus has its origin; and
+further, that this morbid condition (tending to explosive and
+atactic manifestations of nerve-force) must have its basis in
+defective nutrition. For, be it remembered, the epoch of sexual
+development is one in which an enormous addition is being
+made to the expenditure of vital energy; besides the continuous
+processes of the growth of the tissues and organs generally, the
+sexual apparatus, with its nervous supply, is making by its
+development heavy demands upon the nutritive powers of the
+organism; and, it is scarcely possible but that portions of the
+nervous centres, not directly connected with it, should proportionally
+suffer in their nutrition, probably through defective
+blood-supply. When we add to this the abnormal strain that
+is being put on the brain, in many cases, by a forcing plan of
+mental education, we shall perceive a source not merely of
+exhaustive expenditure of nervous power, but of secondary
+irritation of centres like the medulla oblongata, that are probably
+already somewhat lowered in power of vital resistance,
+and proportionably irritable. Let us suppose, then, that to all
+these unfavorable conditions there was added the circumstance
+that the structure of the medulla oblongata, or of parts of it,
+was congenitally weak and imperfect; then surely it would be
+scarcely possible for these loci minimę resistentię to escape
+being thrown into that state of weak and disorderly commotion
+which eminently favors pain in the sensory, and convulsion
+in the motor apparatus.</p>
+
+<p>2. We have so far been mainly considering the relations to
+the production of neuralgia of certain conditions of the central
+nervous system which indisputably are inherent from
+birth. Let us now pass quite to the other extreme, and consider
+a class of momenta which take a decided part in producing
+many neuralgię, but which are altogether accidental and
+factitious, and cannot be included among the necessary hostile
+conditions of life. To push the contrast to the utmost, let us
+inquire first, what amount of influence in the production of
+neuralgia can be given by such a purely "functional" influence
+as educational misdirection of intellect and emotion?<span class="pagenum"><a name="Page_108" id="Page_108">[108]</a></span></p>
+
+<p>It is somewhat strange, though every one accepts as a mere
+truism the maxim that sudden emotional shock may produce
+almost any degree or variety of nervous disorder, the slower
+but far surer influence of long-continued mental habit is often
+practically ignored. It cannot, indeed, be left out of sight as
+a cause of disorders of the mind itself, nor are there many who
+would deny that such diseases as cerebral softening are, in a
+considerable number of cases, the premature ending to a life
+that has been broken down by harassing work and anxiety.
+But what is far less appreciated is the tendency of certain
+unfortunate mental surroundings and modes of mental life to
+produce a generally neurotic condition, which may express
+itself in a variety of functional disorders, among which not
+the least common is neuralgia.</p>
+
+<p>I may fairly hope to be acquitted of any predisposition to lay
+exaggerated stress on this kind of influence in the production
+of neuralgia, considering all that I have said of the importance
+of that inevitable cause, the neurotic inheritance, and all
+that I shall have to say presently as to the effects of a variety
+of external influences of a totally different kind. But I confess
+that, with me, the result of close attention given to the
+pathology of neuralgia has been the ever-growing conviction
+that, next to the influence of neurotic inheritance, there is no
+such frequently powerful factor in the construction of the
+neuralgic habit as mental warp of a certain kind, the product
+of an unwise education. This work is not intended as a
+treatise either on religion or psychology, and yet it is impossible
+for me to avoid some few words that may seem to trench
+on the province of each: for I believe that there are certain
+emotional and spiritual and intellectual grooves into which it
+is only too easy to direct the minds of young children, and
+which conduct them too often to a condition of general nervous
+weakness, and not unfrequently to the special miseries of
+neuralgia. As regards the working of the intellect, it is easier
+to speak in a free and unembarrassed manner than respecting
+the other matters. There can be no doubt that, of intellectual
+work, that sort which exhausts and harasses the nervous system
+is the forced, the premature, and the unreal kind; and this
+it is which predisposes, among other nervous maladies, to neuralgia.
+It is more difficult to speak the truth about emotional
+influences generally, and especially about those which are
+concerned with the highest spiritual matters; but I should do
+wrong were I to suppress the statement of my convictions on
+this point. I believe that a most unfortunate, a positively poisonous
+influence upon the nervous system, especially in youth,
+is the direct result of efforts, dictated often by the highest
+motives, to train the emotions and aspirations to a high ideal,
+especially to a high religious ideal. It is not the object that is
+bad, but the machinery by which it is sought to be attained.<span class="pagenum"><a name="Page_109" id="Page_109">[109]</a></span>
+In modern society there are two principal methods which are
+popularly employed for this purpose; I shall describe them,
+by two epithets which are selected with no offensive intention,
+as the Conventual and the Puritan methods of spiritual training.
+By the former is meant that kind of education which
+deliberately dwarfs the nervous energy, with the hope of preserving
+the mind from the contamination of unbelief and of
+sinful passion. It is a system which is not peculiar to the
+Roman Church, nor even to the Christian religion, and it need
+the less detain our attention, as its effects, so far as they are
+evil, are mainly seen in general nervous and mental enfeeblement,
+rather than in the outbreak of explosive nervous disorders,
+such as convulsion, insanity, or neuralgia. There are
+doubtless exceptions to the rule; but that is the rule. It is far
+otherwise with the spiritual education which is here called
+Puritan, but which is confined to no party in the Church. This
+is a system which seeks to purify and exalt the mind, not by
+enforcing obedience to a series of spiritual rules for which
+another mind is responsible, but by compelling it to a perpetual
+introspection directed to the object of discovering whether
+it comes up to a self-erected spiritual standard. The reader
+will understand that I have not the remotest intention to
+depreciate either a true and manly self-restraint in obedience
+to the direction of "pastors and masters," or an honest watchfulness
+over one's own conduct and thoughts. But the lessons
+which our psychologists are rapidly learning, as to the evil
+effects on the brain of an education that promotes self-consciousness,
+are sorely needed to be applied to the pathology of
+nervous diseases generally, and of neuralgia among the rest.
+Common sense and common humanity, when united with the
+physician's knowledge, cry out against the system under which
+religious parents and teachers subject the feeble and highly
+mobile nervous systems of the young to the tremendous strain
+of spiritual self-questioning upon the most momentous topics.
+More especially is such a practice to be condemned in the case
+of boys and girls who are passing through the terrible ordeal
+of sexual development&mdash;an epoch which, as we have already
+seen, is peculiarly favorable to the formation of the neurotic
+habit, and I must emphatically state my belief that among the
+seriously-minded English middle classes, more especially,
+whose life is necessarily colorless and monotonous, the mischief
+thus worked is both grave and widely spread.</p>
+
+<p>Perhaps the maximum of damage that can be inflicted
+through the mind upon the sensory nervous centres is effected
+when to the kind of self-consciousness that is generated by an
+excessive spiritual introspection there is added the incessant
+toil of a life spent in sedentary brain-work, and checkered
+with many anxieties, and many griefs which strike through the
+affections. Doubtless, such a combination of morbid mental<span class="pagenum"><a name="Page_110" id="Page_110">[110]</a></span>
+influences is sufficient of itself to generate the neuralgic disposition
+in its severest forms, without any hereditary neurotic
+influence, and without any other peripheral irritations; I have
+more than one such instance in my mind at this moment. But,
+if they can do this, much more can such influences arouse
+inherent tendencies to neuralgia; to persons who are predisposed
+in this manner they are most highly deleterious.</p>
+
+<p>3. We come now to the peripheral influences which in a
+more obvious manner become factors in the production of neuralgia.
+Of such influences there are an immense variety, and
+the only common quality that can be predicated of all is the
+tendency directly to depress the life of the sentient centre upon
+which their action impinges.</p>
+
+<p>If we search among the external influences which contribute
+to the production of neuralgia for one that is apparently trivial
+as to the amount of material disturbance which it can cause,
+and yet is very frequently effective, we may select the agency
+of cold. The effect of a continuous cold draught of air impinging
+on the naked skin for some time is comparatively frequently
+seen in the provocation of neuralgic attack: we say comparatively,
+because this influence is more frequently effective
+than blows, wounds, or temporary irritations of any kind,
+applied to the peripheral ends of sensory nerves. But if neuralgia
+be a more frequent consequence of cold than of these
+other influences, a moment's reflection will show that it is by
+no means an absolutely common result. One has only to
+think of the numerous omnibus-drivers, engine-drivers, cab-drivers,
+etc., etc., who pass their whole working lives in presenting
+the (more or less) naked expanse of their trigeminal
+and their cervico-occipital nerves to every variety of wind, to
+perceive that, were this sort of influence very potent in itself,
+male neuralgic patients should swarm as thick as bees in our
+hospital and dispensary out-patient rooms; which is notoriously
+quite contrary to the fact. The same remarks, in both directions,
+may be applied to the direct influence of atmospheric
+moisture, either with or without the effect of wind (of course
+I am not speaking of the more recondite effects of damp soil on
+the persons who live about it). [Among the hundred patients
+who formed the basis of the inquiries mentioned in this work,
+forty-one accused external cold of producing the attack, but
+many of these produced insufficient evidence that such was
+the case.] In short, the direct effects of atmospheric cold
+would seem to be these. Mere lowness of temperature goes for
+something, but not much; [The most marked instance of the
+effect of cold, <i>per se</i>, that I have seen, was exhibited by a
+young lady who was under my care during the past severe
+winter (1870-'71). During much of the time she was confined
+to a carefully-warmed apartment, on penalty of a violent paroxysm
+if she left it.] for about as much, perhaps, as it does in<span class="pagenum"><a name="Page_111" id="Page_111">[111]</a></span>
+the way of aggravating all neurotic tendencies. Cold joined
+with wind is much more powerful. And the maximum of
+ill-effect seems reached by very cold wind mingled with sleet
+or driving rain, which keeps the skin sodden. But the conclusion
+at which I long ago arrived is, that none of these
+influences ever take more than a small (though it is sometimes
+an important) part in the production of neuralgia; and that in
+the majority of cases there is no pretence for supposing that
+they had the slightest share in its causation.</p>
+
+<p>A word or two must be said as to the <i>modus operandi</i> of
+cold and cold wind, as these are the most frequent of external,
+so-called "exciting" causes. The popular use of such phrases
+as the latter has an extraordinary influence in disguising the
+plain fact, which is, that these influences operate wholly in the
+direction of robbing the nerves of force. The continuous
+abstraction of heat from the surface, which of course is materially
+aided by rapid movement of the air, must necessitate a
+readjustment of the distribution of energy, the only result of
+which must be to drain the sensory nervous centre of its reserve
+of force. But, in fact, there is an experiment, ready performed
+to our hands, which may amply satisfy us as to the kind of
+influence exerted by cold on superficial nerves, viz., the sensations
+experienced in recovering from frost-bite, which has been
+severe enough to paralyze the nerves without causing actual
+gangrene of the tissues. The passage of the nerves back from
+temporary death to full functional life is marked by a half-way
+stage in which there is agonizing pain.</p>
+
+<p>4. We must next consider the effects of a class of peripheral
+influences which act, where they exist, in a more constant
+manner than any others; viz., those in which the trunk or
+periphery of a sensory nerve either receives a severe injury, or
+becomes more or less engaged in inflammatory processes, or
+compressed or otherwise damaged by the growth of tumors or
+the spread of destructive ulcerations.</p>
+
+<p>With regard to ordinary nerve-wounds as a cause of neuralgia,
+we have already said (<i>vide</i> Chapter II.) nearly as much
+as it is necessary to say; we need only here point out that, like
+the influence of cold applied to superficial nerves, that of
+wounds must necessarily be a depressing one to the centre with
+which the wounded nerve is connected, and the resulting neuralgia
+must be regarded as an expression of impeded and
+imperfect nerve-energy, not of heightened nerve-function.
+The pain is set up during the process of nerve-healing; that is
+to say, at a stage intermediate between those of abolished function
+and completely restored function; and there can be little
+doubt that the obstinacy with which it is often protracted is
+due to the slowness with which a wounded nerve recovers
+its full functional activity; when once the latter is completely
+restored there is an end of neuralgic pain. It is exactly analogous
+to the course of events in recovery from freezing.<span class="pagenum"><a name="Page_112" id="Page_112">[112]</a></span></p>
+
+<p>There remain for consideration, however, (a) a small class
+of cases of nerve-wounds in which the healing process is not
+simple; but the lesion is followed by the development of a
+tumor of the kind denominated true neuroma. The process
+consists of hyperplastic changes in the nerve-fibres; its commonest
+examples are seen in the extraordinarily painful swellings
+that occur on the ends of nerves left in stumps after
+amputations; but, in fact, a neuroma of this kind may occur
+after any kind of severe nerve-injury, as, <i>e.&nbsp;g.</i>, a cut from
+broken glass, the impaction of foreign bodies, etc. The true
+neuromata are composed mainly of nerve-tissue, with a relatively
+small element of connective tissue: the nerve-fibres can
+be traced directly to the nerve-tumor. Besides the traumatic
+neuromata which form permanent tumors, incapable of being
+got rid of except by actual excision, a minor variety of the
+same kind of change has in several cases been known to take
+place in consequence of an abiding local irritation from the
+impaction of a foreign body, on the removal of which the
+neuromatoid enlargement completely disappeared. (b) There
+are likewise a certain number of cases in which a tumor is
+developed from the neurilemma, and does not consist of nervous
+tissue; these are distinguished as false neuromata, and may be
+of various kinds, the fibromatous and gliomatous being far the
+most common, but cysts and cystic tumors also sometimes
+occurring.</p>
+
+<p>The case of the neuromata is well worth reflecting upon, in
+the course of our endeavors to clear up the Pathology and
+Etiology of Neuralgia. If ever we could find a merely peripheral
+influence which would of itself be invariably competent
+to excite neuralgic pains, it would surely be found in neuroma;
+but the case is not merely not so, it is strikingly contrary.
+Just as wounded and inflamed nerves frequently go through
+the whole processes of disease and recovery without once
+eliciting a neuralgic pang, so is it with neuromata; they are
+not unfrequently quite indolent, and neither excite neuralgia,
+nor are themselves at all particularly tender to the touch.
+And what is most remarkable is, that, as Eulenburg correctly
+remarks, among the pseudo-neuromata the kind of tumor
+which is most frequently associated with neuralgia is by no
+means the dense fibroma or glioma, which might be expected
+by its mechanical pressure to excite inevitable neuralgic pain,
+but the far softer and more yielding cystic tumors. I do not
+know how the facts may affect the reader, but to me they suggest
+the strongest possible arguments against the belief that
+peripheral irritation can of itself produce neuralgia without
+the intervention of some centric change. The tendency to such
+change (from inherent constitution) in the sensory root of the
+nerve must surely be the reason why neuroma causes neuralgia
+in a given number of subjects, instead of letting them go scot-free,
+as it does other persons.<span class="pagenum"><a name="Page_113" id="Page_113">[113]</a></span></p>
+
+<p>The same remarks apply to the result of observations on the
+effect of tumors commencing in tissues altogether unconnected
+with the nerve, and merely coming to involve it, secondarily,
+in pressure. It has been often noted that, among these tumors,
+fluid-containing cysts and soft medullary cancers are far more
+frequently the cause of decided and distressing neuralgia than
+the denser and less yielding neoplasms. Of kinds of tumors
+that are specially apt to produce severe and even intolerable
+neuralgia by the pressure on nerves, it has been remarked that
+aneurisms are among the worst: here every pulsation often
+sends a dart of agony through the nerve. There is a reason
+here, however, which is often left out of sight; not merely is
+the perpetually varying pressure specially harassing and
+exhausting to the nerve, but in many of these cases there is
+general arterial degeneration, and the sensory root of the nerve
+is exceedingly likely to be very badly nourished. [This result
+will be more directly brought about when the aneurism
+happens to press on the ganglion of a posterior root.] We pass
+now to the consideration of the influence exerted by other
+great series of peripheral impressions in the production of neuralgia.
+These impressions are connected chiefly with the functions
+of the digestive and of the genito-urinary organs, the
+functions of the eye, and the nutrition of the teeth.</p>
+
+<p>To take the least important of these first, I may surprise
+some readers by the statement, which I nevertheless make with
+much confidence, that irritation of any part of the alimentary
+canal is, on the whole, a rare concurrent cause, even in the
+production of neuralgia. There are, as has been already fully
+explained, cases of neuralgia seated in these viscera themselves
+(or the plexuses in their immediate neighborhood), although
+their number is immensely smaller than that of the neuralgias
+of superficial nerves. But it is not at all common&mdash;it is even
+exceedingly rare&mdash;for irritation conveyed from the alimentary
+canal to take any important part in setting up neuralgia of a
+distant nerve, even when that nerve has close connections,
+through the centres, with those coming from the irritated portion
+of the alimentary canal. Valleix had the great merit to
+perceive this, even in the case of neuralgias of the head, where
+appearances are so likely to lead the observer to a contrary
+opinion. And it is not a little remarkable that this should be
+the case, when we consider the close central connections which
+the vagus, the great sensory nerve of a large portion of the
+alimentary canal, has with the sensory root of the trigeminus.
+In fact, however, there are certain peculiar forms of gastric
+irritation which do react upon the trigeminus; for instance, a
+lump of unmelted ice, suddenly swallowed, almost invariably
+produces acute pain in the supra-orbital branch of the fifth, on
+one side or the other, and occasionally (as in a case cited by Sir
+Thomas Watson) in other nerves. But that common dyspeptic<span class="pagenum"><a name="Page_114" id="Page_114">[114]</a></span>
+troubles at all frequently or importantly contribute to the production
+of neuralgia, I do not for a moment believe: it needs
+some very powerful irritation, such as that just mentioned, or
+as impaction of great masses of scybalę in the intestines, or
+severe irritation from worms, to produce such an effect.</p>
+
+<p>It is far otherwise with the genito-urinary apparatus; in a
+large number of cases, irritations proceeding from these organs
+do undoubtedly contribute to the production of neuralgia,
+though by no means in the important degree which many
+authors seem to have assumed. There can be no doubt, for
+example, that the irritation of a calculus, either within the
+kidney itself, in the ureter, or in the bladder, may set up violent
+neuralgia, which for the most part is localized in the
+branches of the lumbo-abdominal nerves. The instance of the
+eloquent Robert Hall is an example of renal calculus acting
+in this way: he suffered the most excruciating agony for
+years, and was obliged to take enormous quantities of opium
+in order to make life endurable. An instance of calculus
+impacted in the ureter, in a gentleman somewhat past middle
+age, occurred in my own practice; the lumbo-abdominal neuralgia
+occurred in frequent paroxysms of dreadful severity;
+and another case, already referred to was that of a woman,
+in whom ovarian neuralgia was undoubtedly in great part
+due to the irritation of an impacted calculus in the ureter.
+These cases, however, are very rare in comparison with others
+in which the peripheral source of the neuralgia is either the
+uterus or ovary, or the external genitals. I have no means of
+ascertaining, with anything like accuracy, the frequency with
+which the internal sexual organs are the starting-point of neuralgia,
+because the majority of such cases pass, naturally, to
+the care of physicians who practice chiefly in the diseases of
+women, and consequently not adequately represented either in
+my hospital or my private practice; still, I have seen a good
+many of these affections, and, though I speak with the reserve
+necessitated by the circumstances just named, I am much
+inclined to believe that even such powerful centripetal influences
+as those of the states of commencing puberty, of pregnancy,
+of the change of life, and uterine diseases generally, are
+very rarely the cause of true unilateral neuralgia, except in
+subjects with congenital tendencies to neuralgia. But in predisposed
+subjects there can be no doubt that these influences
+assist most powerfully in producing the malady.</p>
+
+<p>Of the power of irritation of the external genitalia to act as
+a so-called "exciting cause" of neuralgia, there is abundant
+evidence. I would especially call attention to the remarkable
+monograph of M. Mauriac, ["<i>Etude sur les Nevralgies
+Reflexes symptomatiques de l'Orchi-epididymite blenorrhagique</i>"
+Par C. Mauriac, Medecin de l'Hospital du Midi. Paris,
+1870.] on the neuralgias consecutive to blenorrhagic orchi-epididymitis,<span class="pagenum"><a name="Page_115" id="Page_115">[115]</a></span>
+as illustrating this with a force that was to me,
+for one, surprising. I shall, perhaps, have further occasion to
+these researches; here it will be enough to mention that M.
+Mauriac's enormous experience of blenorrh&#339;a and orchitis at
+the Midi has shown that, in an exceedingly large number of
+cases, certainly not less than four per cent., this combination
+is followed by reflex neuralgias, of which a large number are
+not seated in the genital apparatus, but affect the track of some
+distant sensory nerve, through the intermediation of the spinal
+centres; and that with these reflex pains there is often profound
+general disturbance, including very often an extremely
+profound general anęmia. The most frequent kind of these
+neuralgias is rachialgia, <i>i.&nbsp;e.</i>, pain in the superficial posterior
+branches of spinal nerves; next comes lumbo-abdominal neuralgia;
+then sciatic and crural, visceralgic (abdominal), etc.;
+and besides all these there are numerous instances of neuralgia
+in the testis. As to the nervous "reflection," more hereafter.</p>
+
+<p>It has surprised me, somewhat, that while M. Mauriac has
+seen so many reflex neuralgias set up by orchi-epididymitis, he
+does not appear to have noticed cases of trigeminal neuralgia
+from this source; because, in the very analogous instance of
+the peripheral irritation produced by excessive masturbation,
+we undoubtedly do frequently get a development of the tendency
+to migraine, and also to other forms of neuralgia of the
+fifth: moreover the effect of such local irritation can be occasionally
+traced with much distinctness in the trigemini, by a
+tendency to certain forms of eye-disease without positive neuralgia.
+This was remarkably exemplified in a case which was
+under my care some years ago, and in which both eyes were
+greatly damaged by vaso-motor and trophic changes; partial
+insanity also supervened with hallucinations of sight and hearing.</p>
+
+<p>We come now to one of the most powerful sources of peripheral
+irritation tending to set up neuralgia; viz., functional
+abuse of the eye. This is one of the very few peripheral influences
+which occasionally we see producing neuralgia unaided
+by hereditary predisposition, or any other observable cause
+whatever, and in a far larger number producing it with the
+sole aid of more or less defective general nutrition. The latter
+occurrence is well exemplified by a case which Mr. Carter sent
+me the other day, and which also illustrates (second attack) the
+effect of the superaddition of syphilitic taint:</p>
+
+<p>Matilda W&mdash;&mdash;, aged thirty-three, married, and has three
+very healthy children. Comes of a remarkably healthy family,
+of which she told me the entire history for three generations,
+with unusual intelligence and clearness. No neuroses,
+properly so-called, in any of her relatives during all this time.
+She herself was a very strong and hearty girl until the age of
+seventeen; between this date and her marriage, three years<span class="pagenum"><a name="Page_116" id="Page_116">[116]</a></span>
+later, she was obliged to work tremendously hard at fine sewing,
+by which means she gained a very scanty livelihood.
+After a comparatively short period of this work she began to
+suffer from typical attacks of migraine, very severe, and recurring
+every three or four weeks, but in no particular connection
+with the menstrual function, which was normal. On her
+marrying and ceasing to do needle-work, the migraine entirely
+disappeared, and she retained perfect health till the commencement
+of 1871. At this time she had suckled a very hearty
+baby for ten months, and was not able to furnish such good
+living as usual. She was attacked early in January, with violent
+neuralgia affecting all three branches of the right fifth, and
+she the more readily applied for advice because she soon found
+that the neuralgia was becoming complicated with dimness of
+vision in the eye of the affected side, "as if she was going to
+have a cast." Was quite unconscious of ever having had
+syphilis. The medical man encouraged to believe that the
+whole malady was nervous, and would soon disappear under
+appropriate remedies, and gave her quinine, under which
+treatment she declares that she was rapidly improving, both as
+to pain and vision, but that her resources came to an end, and
+she could no longer pay for the medicine. She then neglected
+herself, and rapidly got worse in all regards, till at last she
+was compelled to apply to the South London Ophthalmic Hospital,
+whence Mr. Carter sent her to me, on the 6th of April.
+At this time the paroxysms were excessively violent and frequent,
+though brief. On examination, tender points were
+found at the supra-orbital notch, at the infra-orbital foramen;
+in front of the ear; in the temporal region; in the parietal
+region, and the inferior dental region. There was strongly
+marked anęsthesia of the skin of the right half of the face,
+of the gums, and of the side of the tongue. The teeth
+were absolutely perfect: not one spot of caries could be seen.
+Taste was completely destroyed in left half of anterior part of the
+tongue. Smell was totally lost on both sides, and had been so,
+the woman declared, from a very early period in the illness.
+The right eye showed complete paralysis of the levator palpebrę
+and of the external rectus; nearly complete paralysis of
+the superior and inferior rectus, rather less marked paralysis
+of the internal rectus. Pupil normal, conjunctiva moderately
+congested, lachrymation profuse, photophobia partial.
+The functions of the retina were perfect. Accommodation
+was affected in the following degree and manner. The
+vision of the affected eye was perfect at long distances,
+very imperfect at short distances. With both eyes open
+she saw every thing double, but could still count all
+the bricks in a whitewashed wall at sixteen feet distant.
+There was no secondary disturbance of the stomach
+whatever. On the first visit she assuredly had no visible signs,<span class="pagenum"><a name="Page_117" id="Page_117">[117]</a></span>
+in skin or throat, of syphilis; the perfect health of her children,
+and absence of abortions, made syphilis the less probable.
+But on her second visit she complained of sore throat, and a
+week later a palpably specific sore appeared on the soft
+palate. She declared, with apparent sincerity, that it was the
+first symptom of the kind she had ever had. The neuralgia
+rapidly disappeared under thirty grains of iodide of potassium
+daily. The lesions of taste and smell disappeared exactly pari
+passua with the trigeminal pains. The ocular paralysis
+threaten to be much slower in departing. I think we must
+believe that this woman contracted syphilis after the birth of
+her last child. It is at any rate certain that the migraine of
+her youth was perfectly unconnected with syphilis, being as
+unlike the pains evoked by the latter as it is possible for two
+kinds of pain to be. In all probability she was infected during
+her last lactation.</p>
+
+<p>Last among the peripheral influences of sufficient importance
+to be specially mentioned as effective factors in the production
+of neuralgia, must be mentioned caries of the teeth, and the
+comparatively rare accident of the mal-position or abnormal
+growth of a "wisdom-tooth." It is an undoubted fact that
+these things may cause neuralgia even of a very serious type,
+and attended with extensive complications; as in Mr. Salter's
+cases, already mentioned, of reflex cervico-brachial neuralgia
+from carious teeth. Looking to the extreme frequency of
+caries, however, as compared with the rarity of true neuralgia
+(not mere toothache) as a consequence of it, it is impossible
+not to suppose that the share of the carious teeth in the production
+of such neuralgia must be very small, compared with that
+of other influences.</p>
+
+<p>5. The next influence which we shall mention as undoubtedly
+very effective in assisting the production of neuralgia in
+certain cases is that of anęmia and mal-nutrition generally;
+but it is not necessary to dwell on this at any length. The
+fact is notorious that severe loss of blood is always followed
+by headache; and if there be the least predisposition to neuralgia,
+this headache will very commonly take the form of the
+severest clavus. And, in like manner, chronic states of anęmia
+and of mal-nutrition undoubtedly aggravate every existing
+neuralgia, and bring out lurking tendencies to the disease.
+But I do not believe that anęmia, or starvation pure and simple,
+ever generates true neuralgia by its sole influence.</p>
+
+<p>6. The question how far, and in what way, the neuralgic
+tendency is helped by certain constitutional diatheses, such as
+rheumatism and gout, and by certain toxęmię, such as malaria,
+alcoholism, lead-poisoning, etc., is a very much more difficult
+one than might be supposed from the off-hand manner in
+which many writers speak of the "rheumatic," the "gouty,"
+or the "alcoholic" forms of "neuralgia." We may, however,<span class="pagenum"><a name="Page_118" id="Page_118">[118]</a></span>
+simplify it a good deal. In the first place, it seems obvious to
+me that the only manner in which alcohol helps the production
+of true neuralgia is by its tendency, after long abuse, to
+produce degeneration of the nervous centres: it will therefore
+be considered, shortly, under another division of the present
+subject. Lead-poisoning, again, only produces so highly
+special a form of neuralgia (if colic be neuralgia at all) that it
+need not detain us here. The influence of malaria is, for the
+most part, an utter mystery to us, but by so much as we can see
+it appears plain that one of the most important features in the
+disease is a powerful disturbance of the spinal vaso-motor centres.
+But the most interesting consideration that we have to
+deal with is the question of the supposed relations of the rheumatic
+and the gouty diatheses, and the syphilitic dyscrasia, to
+the neuralgic tendency. On this point I am obliged to disagree
+<i>in toto</i> with the popular view that assigns these diatheses
+among the most frequent predisposing causes of neuralgia.</p>
+
+<p>To take the case of rheumatism first, I am willing to allow
+that there are a number of facts which superficially appear to
+countenance the idea of a close connection of this disease with
+neuralgia. But of these facts a considerable proportion
+consist only of examples of inflammation of the nerve-sheath,
+with a certain amount of effusion within and
+around it, occurring in persons who have never shown
+any symptoms which warrant the assumption of a general
+rheumatic diathesis; and these local phenomena really differ
+in nothing from many trophic and vaso-motor changes which
+have been already described as plainly secondary to ordinary
+neuralgia in which there could be no pretence of a rheumatic
+pathology except on the slender foundation of a suspicion
+that the affection was immediately excited by the influence of
+cold, which is really no argument at all. Such patients will
+be found to have exhibited, not special rheumatic, but special
+neuralgic tendencies in their past history. On the other hand,
+there undoubtedly are a certain number of patients who, having
+previously given signs of a tendency to generalized rheumatic
+inflammation of fibrous membranes, are, on some particular
+occasion, attacked with similar inflammation extending
+over a more or less considerable tract (not a small limited spot)
+of a nerve sheath. But so far from agreeing with those who
+think that this is a frequent case, my experience teaches me
+that it is quite exceptional; nor do I believe that the common
+opinion could ever have arisen had it not been for the rage that
+exists for connecting every disease with a special diathesis
+which the profession flatters itself that it understands. Few
+persons have taken more pains than myself to ascertain the
+frequency with which neuralgic patients show a history of previous
+rheumatism, whether in the so-called "fibrous," or in<span class="pagenum"><a name="Page_119" id="Page_119">[119]</a></span>
+the synovial form; but it is remarkable how seldom I have
+found this to be the case&mdash;a result which surprised me, because
+it happened that I, a neuralgic subject, had suffered in youth
+from regular acute rheumatism, and had fancied that I should
+discover a close connection between rheumatism and neuralgia.
+Eulenburg states that neuralgia caused by cold more frequently
+attacks the sciatic nerve than any other, and thinks that the
+tendency to sciatica is characteristic of the relations of rheumatism
+to sensory nerves. For my own part, I see no reason
+to call in the rheumatic diathesis as a <i>deus ex machina</i> to explain
+the frequency with which sciatica follows comparatively
+trifling peripheral impressions like that of cold. The true reason
+I believe to be, that what would have been a slight and
+trivial neuralgia elsewhere, becomes a serious affection in the
+instance of the sciatic nerve, by reason of the strong muscular
+pressure end dragging which are always going on in the thigh
+in locomotion. I shall return to this subject when speaking of
+Treatment.</p>
+
+<p>As regards the relations, of gout to neuralgia, I can hardly
+express my own view better than by quoting the words of
+Eulenburg:<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a> "Much more doubtful is the influence of gout,
+which in rare cases, perhaps, produces neuralgia directly, by
+means of neuritis, or by the deposit of tophus-like calcareous
+concretions in the nerve-trunks. Gout has been reckoned as a
+great influence among the causes of superficial neuralgias
+(sciatica), and also of visceral neuralgia (angina pectoris, etc.,)
+but this influence is more probably only an indirect one, operating
+through circulation changes which are often produced by
+chronic liver-diseases or by diseases of the heart and
+vessels, (<i>e.&nbsp;g.</i> Valvular diseases and narrowing of the
+coronary arteries in angina)." To which I will add this argument
+against any close connection of gout with neuralgia, that
+it is exceedingly seldom that colchicum effects any decided
+good, a fact which is as unlike the relations of colchicum to
+true gout as any thing could be. For, whatever may be thought
+of the advantages or disadvantages, on the whole, of employing
+colchicum against gout, at least no one with any experience
+will deny that in the immense majority of cases of true gouty
+pain, it gives rapid relief to the acute suffering. I doubt if it
+ever<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">[18]</a> acts in that way in real neuralgia, though I have
+occasionally seen it apparently useful in a more limited way,
+as will be said hereafter.</p>
+
+<p>As regards the relation of the syphilitic dyscrasia to neuralgia,
+I agree in general with Eulenburg. "Syphilis," he says,
+"may be the direct cause of neuralgia, either by the development
+<span class="pagenum"><a name="Page_120" id="Page_120">[120]</a></span>
+of specific gummata in the nerve-trunks or in the
+centres, or by arousing chronic irritative processes in the nerve
+sheaths, the membranes of the brain and spinal cord, or,
+especially, in the bones and periosteum (syphilitic osteitis and
+periostitis)." The case of periostitis, however, is a doubtful
+one: it may be questioned whether this affection (which will
+be among the diseases discussed in Part II. of this work) ever
+give rise to true neuralgia. Persons who are, by inheritance,
+highly predisposed to neuralgia, may from the mere general lowering
+of their health produced by constitutional syphilis, become
+truly neuralgic simultaneously with, or subsequently to, the
+appearance of painful nodes on their bones. And as regards
+the whole relations of syphilis to neuralgia, I must, from my
+experience, conclude that the former is, after all, but rarely
+concerned in the production of the latter. Syphilis has a
+strong specialty for producing limited motor paralyses, but a
+much weaker one for producing limited affections of the sensory
+system.</p>
+
+<p>7. We now come to the discussion of a group of momenta
+whose influence in the production of neuralgia is at once very
+powerful, and of the highest significance as regards the general
+pathology of the disease. These are the degenerative
+changes of the arterial and capillary systems which are a part
+of the normal phenomena of old age, but may occur at earlier
+periods of life, in consequence either of certain constitutional
+diseases, especially gout, or of special toxic influences on nutrition,
+of which persistent alcoholic excess is very far the most
+important.</p>
+
+<p>The reader does not need to be told the familiar story of the
+degenerative changes in the vessels which, commencing usually
+some time during the fifth decenniad, by degrees convert the
+elastic arterial coats, and the almost membranous walls of the
+capillaries, into more or less rigid tubes; nor does he need to be
+informed that the tendency of these changes, as they operate
+in the great motor and intellectual centres, is notoriously to
+produce innutrition of the tissues that depend for their blood
+supply on the affected vessels, whence cerebral softening so
+commonly results. That analogous changes take place in the
+vessels supplying the spinal centres is certain; but it is a
+remarkable fact that these do not very commonly produce
+motor paralysis. What they do produce is rather a slow
+enfeeblement both of (spinal) sensation and motion, but where
+the process of decay has been prematurely forced, or the inheritance
+of neurotic weakness is very marked, the process of
+sensorial decay (the decline, that is, of true sensorial function)
+is apt to be mingled with pain. That this pain should be
+localized, often in a single nerve, is no more surprising than the
+fact that the degenerative process itself should vary so greatly in
+the degree of its development at one point from that which it<span class="pagenum"><a name="Page_121" id="Page_121">[121]</a></span>
+shows at others. I have already insisted (<i>vide</i> Chapter I.) on the
+marked correspondence between the period of life in which
+degenerative changes commence and progress (the last third,
+roughly speaking, of a fairly long life), and that in which the
+most severe, intractable, and progressively increasing neuralgias
+are developed. I must here notice a singular statement of
+Eulenburg's, that neuralgia never attacks people who are over
+seventy. That statement shows that persons of a greater age
+than seventy are rare in this world, and that no such patient
+happened to come under Eulenburg's notice; for I have (by
+mere chance, doubtless) seen several instances of first attacks
+occurring after seventy; and almost the worst case of epileptiform
+tic I ever saw began when the patient was eighty; she was
+a member of a highly neurotic family whose medical genealogy
+is given at a previous page. In general terms, it may be said
+that every additional year of life after fifty increases the probability
+that a neuralgia, should such arise, will be severe and
+rebellious to treatment; and in the very aged the cure of such
+affections is probably impossible.</p>
+
+<p>8. This seems the proper place to introduce such facts as have
+been observed, and they are very few, that directly illustrate
+the material changes occurring in neuralgia.</p>
+
+<p>Very much the most important of these facts is the history of
+a remarkable case recorded by Romberg. ["Diseases of Nervous
+System," Syd. Soc. Trans., vol. i.] The patient, a man
+sixty-five years old at the time of his death, had suffered for
+several years from the most violent and intractable epileptiform
+trigeminal neuralgia, complicated with interesting trophic
+changes of the tissues. Post-mortem examination showed that
+the pressure of an internal carotid aneurism had almost
+destroyed the Gasserian ganglion of the painful nerve, that the
+trunk and posterior root of the nerve were in a state of
+advanced atrophic softening, and the atrophic process had
+extended in less degree to the nerve of the opposite side. Now,
+the value of this case is by no means restricted to the fact that
+it records the existence of a particular anatomical change in
+one example of neuralgia. Its most striking teaching is the
+fact that the acutest agonies of neuralgia can be felt in a nerve,
+the central end of which is reduced to such a pitch of degeneration
+that conduction between centre and periphery must very
+shortly have entirely ceased had the patient lived. And hardly
+less important is its illustration of the fact that permanent
+injury to the ganglion of the posterior root of a spinal nerve
+impairs the vitality of the posterior root itself&mdash;a fact which
+has been independently made out by the physiological
+researches of Bernard and of Augustus Waller.</p>
+
+<p>On the other hand, if we examine the tolerably numerous
+histories of cases in which the painful nerves have been examined
+at the apparent site of pain, we discover nothing to lead<span class="pagenum"><a name="Page_122" id="Page_122">[122]</a></span>
+us to connect neuralgia definitely with any one sort of change.
+Assuredly, for example, local neuritis is by no means universally,
+it is probably even not commonly, present in the early
+stages of neuralgia; it has also been repeatedly detected in
+nerves that had been wholly free from neuralgia; and, on the
+other hand, it has been entirely absent in nerves that have
+been the seat of the severest pains. Moreover, many facts
+which have been put down without reflection, as showing a
+local peripheral cause for neuralgia, are at least open to
+another and, as I believe, truer explanation; as (<i>e.&nbsp;g.</i>) in
+the following remarks of Eulenburg on mechanical irritations
+of nerves as causes of neuralgia: "Diseases of
+bones are extraordinarily frequently the cause of neuralgias
+in consequence of compression or secondary disease, which
+affects the branches of nerves passing through canals,
+foramina, fissures, or over processes of bone. The appearances
+which the opportunities of resections of the
+trigeminus for facial neuralgia have permitted to be discovered,
+have given us valuable information in that direction. Flattening
+and atrophy of nerves from periostitis, or from concentric
+hypertrophy in narrowed bony canals, have frequently
+been discovered. The neurilemma at the narrowed parts was
+often seen reddened, ecchymosed, infiltrated with serum, or
+surrounded with fibrous exudation; occasionally inflammation
+had been followed by partial thickening of the neurilemma
+(fibrous knots) and turbidity (Trubungen) of the nervous cord
+at the corresponding spot. Similar appearances have been
+noted in other neuralgias (neuralgia-brachialis, sciatica)."
+For my own part, I believe that the above description represents
+the facts from an erroneous point of view. True neuralgia,
+if by that we understand a pain of intermittent character
+limited to one or more nerves, is in my experience an
+extremely uncommon result of periosteal disease, or of inflammation
+of the linings of bony canals; but in a great number
+of instances such diseases appear to be set up as the secondary
+consequence of the neuralgic process (whatever the essential
+nature of that may be) going on in sensory nerves which supply
+the parts when these inflammations appear. And it must
+be remembered that the specimens obtained by resection of
+nerves are comparatively few in number, and are taken universally
+from old-standing and desperate cases of disease; in
+short, from cases which are just in those advanced stages of
+neuralgia in which, as has already been amply shown, these
+secondary inflammations are almost always present. On the
+other hand, I have myself had one opportunity of examining
+the local condition of an intercostal nerve, which during life,
+and quite up to death, had been the site of the most pronounced
+neuralgia, which, however, had only existed for a
+few days. The patient, a young man, aged twenty-seven, was<span class="pagenum"><a name="Page_123" id="Page_123">[123]</a></span>
+probably insane, and had attempted suicide. Not a trace of
+inflammation, either in the nerve itself or in any of the tissues
+to which it was distributed, could be detected. (This was
+a case in which I greatly regretted the impossibility of getting
+a family history that was at all reliable.) The spinal cord,
+unfortunately, could not be examined. And I strongly believe,
+from the marked absence of tenderness on pressure which is
+almost universally observed in ordinary cases of neuralgia at
+an early stage, that primary inflammation of neurilemma,
+periostem, etc., as a cause of neuralgia, is altogether exceptional;
+so much so, that we are entitled to believe it can never
+be more than a concurrent, and then not the most important,
+cause.</p>
+
+<p>It is necessary here to inquire, more particularly than we
+have yet done, into the nature of the "painful points" first
+signalized by Valleix as a distinctive symptom of neuralgia.
+Very great differences of opinion have prevailed among subsequent
+writers, both as to the frequency and the significance
+of these points. It may be said, however, to be now quite
+settled that the presence of definite points, painful on pressure,
+and also corresponding to the foci of severest spontaneous
+pain, is far from universal in neuralgia. Upon this
+point there is probably no reason to doubt the correctness of
+Eulenburg's observations made in the surgical clinic of Greifswald
+and the polyclinic of the University of Berlin; he says
+that he discovered the existence of tender points in "Valleix's
+sense," in rather more than half the cases of superficial neuralgia,
+but in the rest he could not by any means discover
+them. In many other cases, however, he found more indefinite
+points of tenderness, not accurately corresponding to
+nerve-branches, but affecting individual portions of skin,
+bone, or joints; the relation of these to the neuralgic symptoms
+was difficult of explanation. Eulenburg lays down the
+principle that "hyperęsthesia" may depend on three sorts of
+causes&mdash;(1) On local disease of the peripheral ends of nerves;
+(2) on alterations of the psychical centres; and (3) on morbidly
+exaggerated conduction in the nerve-trunks themselves;
+and it is to this third source that he attributes many of the
+phenomena of the neuralgic painful points, and especially
+their multiplicity, in many cases. The <i>locus in quo</i> of the
+mischief which sets up this exaggerated conduction of sensory
+impression is, upon this theory, between the psychical centre
+and the main point of branching of the nerves; hence a large
+number of peripheral nerve-termini might be practically sensitive
+to touch, because the mischief, though localized in a
+comparatively small spot, might easily affect many bundles of
+fibres, which diverge widely from each other in their course.
+It will be seen presently with what limits and for what reasons
+we believe this to be a true theory. But to return to the question<span class="pagenum"><a name="Page_124" id="Page_124">[124]</a></span>
+of painful points in Valleix's sense, we must state one or
+two facts which seem certain from our own experience, but
+have not been adequately recognized, we believe, by others.
+The first is, that localized tender spots, accurate pressure on
+which will set up or aggravate the neuralgic pain, are not
+early phenomena, save in neuralgias of exceptional severity
+of onset; but that a certain persistence and severity of neuralgia
+are always followed by the formation of one or more true
+points douloureux. The second fact relates to the clinical history
+of migraine. Roughly speaking, it is true, as Eulenburg
+states, that, in pure migraine, painful points in Valleix's sense
+are not to be found; in place of them we observe, after the
+paroxysms have passed away, a more generalized soreness of
+considerable tracts of the scalp, forehead, etc., or diffuse tenderness
+of the eyeball. But I must here again refer to the
+fact, first observed in my own case, and afterward verified in
+many others, that migraine may be only the youthful prelude
+to a regular trigeminal neuralgia attended with the formation
+of characteristic localized painful points at a later period.
+And the third fact that must be specially mentioned is that
+the true Valleix's point, when it has become established for
+some time, is not a mere spot of sensitive nerve, but is the
+scene of trophic changes, involving hyperęmia and thickening
+of parts surrounding the nerve. To give one example,
+it is quite a frequent thing to find a patch of tender and sensibly
+thickened periosteum of irregular shape, but equal sometimes
+to a square inch in size, over the frontal bone at and
+immediately above the inner end of the eyebrow, in cases
+where supra-orbital neuralgia has recurred frequently during
+some years, although no such thing was present when the neuralgia
+first commenced. In my own case, the bone has become
+sensibly thickened at that point.</p>
+
+<p>The general result of such post-mortem and clinical information
+as can be had seems clearly to be that positive anatomical
+changes, either of nerve-terminals or superficial nerve-branches,
+are but casual and infrequent factors in the first
+production of neuralgia, and, in particular, it would seem
+that inflammation of a nerve itself by no means necessarily
+produces neuralgic pain, but (far more commonly) simple
+paralgesia or anęsthesia of the parts external (peripheral) to
+the lesion. The one marked exception to this general proposition
+is to be found in the case of the severe and peculiar injuries
+inflicted on the trunks of nerves by gunshot-wounds
+which, as we have seen (from the American experiences), can
+produce some of the most dreadful forms of neuralgia. But
+the nature of the injury here inflicted is, it must be remembered,
+quite different from any thing which either disease or
+accident in civil life would produce, save in the most exceptional
+instances. For the chief material element in the production<span class="pagenum"><a name="Page_125" id="Page_125">[125]</a></span>
+of the neuralgias of ordinary life we are really driven,
+by exclusion, to the condition of the posterior roots of special
+nerves, in some cases, perhaps, to the (spinal) ganglia on
+which the nutrition of these roots probably is considerably
+dependent.</p>
+
+<p>With the field thus narrowed for us, it is surely legitimate,
+in the necessary scarcity of anatomical records referring
+directly to the state of the nerve-roots in ordinary neuralgia,
+to place great weight on the facts of a disease like locomotor
+ataxy, in which the main anatomical change is a progressive
+atrophy of the posterior columns which usually falls with
+peculiar severity on the posterior nerve-roots, or on the parts
+of the gray matter immediately adjoining these, and in which
+neuralgia may be said, for practical purposes, to be a constant
+and most characteristic phenomenon. If any one desires to
+see how strikingly the connection of the neuralgic phenomena
+with the anatomical-change comes out, I recommend him to
+study Dr. Lockhart Clarke's papers on locomotor ataxy (<i>vide</i>
+"St. George's Hospital Reports, i." 1866; <i>Lancet</i>, June, 10 1865;
+"Med.-Chir. Soc. Transactions," 1869), or the excellently
+reported case by Nothnagel (<i>Berlin Klin. Wochensch.</i>, 1865).
+It is really not too much to say that the only important difference
+between the clinical aspect of the pains of locomotor
+ataxy and those of ordinary neuralgia is simply such as depends
+on the fact that the anatomical change in the former case is
+bilateral, and usually affects the roots of several, sometimes of
+a great many pairs of nerves. I infer, from a conversation
+with Dr. Clarke, that he fully recognizes the force of the analogy,
+and the great strength of the presumption which it sets
+up in favor of an atrophic change of the posterior roots in
+neuralgia.</p>
+
+<p>It may, of course, be urged, against the view that neuralgia
+depends on any change analogous to those which occur in
+ataxy, that quantities of cases of the former recover speedily,
+and must be supposed to be either independent of material change
+altogether or, at any rate, to have involved only very trivial
+anatomical changes, not formidable diseases, like atrophy of
+nerve-centres. I find it impossible to admit that this argument
+has the slightest force. Are we to suppose that the posterior
+nerve-roots alone, of all tissues and organs of the body,
+are incapable of minute and partial changes in the direction of
+molecular death which may be perfectly recovered from in
+weeks, months, or even days? I, for one, cannot doubt, that
+such changes are of frequent occurrence, in all parts of the
+central nervous system, when I can consider the absolute
+dependence of these portions of the organism upon a perfect
+blood-supply, and the immense number of possible causes of
+temporary interference with that source of nutrition. And I
+can see no probable difference, except in degree and persistence<span class="pagenum"><a name="Page_126" id="Page_126">[126]</a></span>
+between the effects on sensation which would be produced by
+such a change of the posterior roots as this, and that which
+would result from the more serious and fatally continuous
+change which is involved in locomotor ataxy.</p>
+
+<p>9. We come now to a most important but most complex and
+difficult portion of the argument respecting the <i>locus in quo</i> of
+the essential pathological process (if such there be) in neuralgia;
+viz., as to the paths and the character of the so-called "reflex"
+influences which intervene in the causation, both of neuralgia
+itself, and also of the numerous complications with which we
+have seen that neuralgia is liable to be attended. The clinical
+facts which confront us here, and demand explanation, are
+the following: (1) Irritation so called, of sensory fibres may
+apparently evoke pains attributed to the site of the irritation,
+or to the parts on the peripheral side which are supplied by the
+same sensory nerves. (2) Peripheral irritation of a particular
+sensory nerve may evoke neuralgic pains in nerves connected
+with that irritated only through the spinal centre. (3) Neuralgia
+in a sensory nerve may (and almost always does, to
+some extent) produce secondary vaso-motor paralyses: these
+paralyses may affect fibres which run in the same branch of
+the nerve as that which is painful, or fibres that run in another
+branch of the same nerve, or fibres that run with another
+sensory nerve, or the ganglionic chain of the sympathetic
+itself. (4) In like secondary manner, neuralgia may produce vaso-motor
+spasms in any of the directions just specified; this is usually
+a short-lived phenomenon, giving place quickly to paralysis;
+but Du Bois Reymond's often-quoted analysis<a name="FNanchor_19_19" id="FNanchor_19_19"></a><a href="#Footnote_19_19" class="fnanchor">[19]</a> of his own sufferings
+from migraine seems to show that spasm-producing irritation
+of the trunk of the sympathetic may last during some
+hours. (5) Neuralgia in a sensory nerve may increase, alter,
+or (more rarely) suspend the secretions of glands supplied
+by fibres bound up either in the same branch, or in another
+branch of the same nerve, or in a different nerve with which
+it is connected only through the centre or (possibly) only
+through a plexus. (6) Neuralgia in a sensory nerve can produce
+paralysis of muscles supplied by motor fibres bound up
+with the painful branch, or with another branch of the same
+nerve, or in muscles supplied by a totally distinct nerve connected
+only through the centre. (7) It may produce convulsion
+and spasms of muscles, in all the above directions;
+this usually alternates with great weakness, or actual paralysis
+of the same muscles. (8) It may produce partial or complete
+loss of common or special sensation in nerve-fibres that run
+either with the same branch, or with another branch of the
+same nerve. (9) It may produce trophic changes, either in
+the direction of simple atrophy or of subacute inflammation
+<span class="pagenum"><a name="Page_127" id="Page_127">[127]</a></span>
+with proliferation of lowly-vitalized tissue (<i>e.&nbsp;g.</i>, connective) in
+the parts with which are supplied with sensation by the painful
+branches or by other branches of the same nerve.</p>
+
+<p>It is necessary to go over again the proof of these facts; they
+are given pretty copiously in the chapter on Complications;
+and could have been made much more numerous. But the
+point to which I desire to compel the reader's attention is the
+impossibility as it seems of me, of accounting for the variety
+and complexity of these phenomena, except by the supposition
+that there is in every case of neuralgia a central
+change, which is the one most important factor in the producing
+both of the pain and of the secondary phenomena.
+For the result of my experience is that neuralgia, unless very
+slight and brief, is never unattended by these complications
+and in the great majority of cases involves several different
+secondary alterations of function which must (so to speak)
+radiate from the central end of the sensory nerve, and from
+no other place whatever. And it must be remembered that the
+most elaborate "<i>symptome-complexe</i>" is found equally in
+cases where no suggestion of any peripheral origin of the pain
+can be made, and in cases where, at first sight, one might
+fancy there was a very obvious peripheral cause for pain. I am
+quite willing to admit, with Eulenburg and others, that the
+evidence, powerful and varied though it be of the relations of
+neuralgia to hereditary neuroses, to alcoholic and senile degeneration,
+etc., only raises a strong probability that some part
+of the central nervous system is the <i>locus in quo</i> of the essential
+morbid processes in the majority of neuralgias. But the
+case stands far otherwise now that we are able to show, not
+merely that the majority of neuralgic patients suffer from such
+influences as those above mentioned, but that every variety of
+neuralgia is liable to be complicated with secondary affections
+of the most divergent nerves, the only common meeting-place
+of which is in the spinal centre of the painful nerve; and when
+we find moreover, that many of these secondary affections can
+equally be produced by undoubted atrophic changes (as in
+ataxy of those same posterior roots).</p>
+
+<p>At this point we must introduce a remark relative to the true
+nature of so-called "reflex" effects. The word is constantly
+used, and is also much abused, as Eulenburg remarks. We all
+understand, of course, what is intended by the commonest use
+of the word: the case of sneezing produced by the irritation
+of snuff applied to the peripheral branches of the fifth nerve
+in the nose is a stock example. But another application of the
+phrase, of much more questionable propriety, is that where it
+is employed to designate functional nervous actions, which
+merely arise simultaneously with or subsequently to sensory
+phenomena as to which there is no proof whatever that they
+were produced by peripheral irritation. This particular inaccuracy<span class="pagenum"><a name="Page_128" id="Page_128">[128]</a></span>
+of customary speech has probably contributed largely
+to the inveteracy with which writers on nervous disease have
+insisted on assuming a peripheral origin in every case for neuralgia
+itself. In the case of sciatica, for example, complicated,
+secondarily, with paralysis of the flexors of the limb, it seemed
+easy and scientific to speak both of the neuralgia and the paralysis
+as "reflex" effects of a local peripheral mischief&mdash;gouty,
+rheumatic, or the like; and it appears to have been perfectly
+forgotten by many that the whole phenomena might be
+explained by an original morbid action in the sensory root of
+the nerve, extending subsequently to the motor root, without
+any intervention of peripheral irritation whatever, or under
+the influence only of the ordinary peripheral impressions,
+which, in health, evoke no painful nor paralytic symptoms.
+It is by this kind of extension of a central morbific process,
+leading to radiation of the perturbing influence centrifugally
+along divers nervous paths, that I believe we must explain the
+facts observed in complicated cases.</p>
+
+<p>Take, for example, the following case, which, in its history
+of twenty-three years, presents a fair example of a type of
+trigeminal neuralgia which I believe to be the rule rather than
+the exception, though the trophic changes were somewhat unusually
+varied and interesting. The following would be the
+pathological order of events, according to the radiation theory:
+First or true migrainous stage; failure of nutrition of a portion
+of the sensory root of the right fifth nerve within
+medulla oblongata, lesser degree of the same condition in the
+adjoining and closely-connected vagus root (hence supra-orbital
+pain, local anęsthesia and vomiting); extension of the
+morbid process to the motor root (hence vaso-motor paralysis
+and secretory and trophic changes in the cornea, superciliary
+periosteum, etc). Second period: recovery, to a large extent,
+of the nutrition of the posterior root of the trigeminus, complete
+recovery of the root of the vagus (hence alteration of
+the type of recurrence of the pains, which now occur at
+increasingly long intervals, and needed special provocation,
+<i>e.&nbsp;g.</i>, excessive fatigue, to bring them on; hence, also, disappearance
+of the stomach symptoms); continuance of the affection
+of the motor portion of the nerve (hence, continuance of
+the tendency to trophic, secretory, and vaso-motor changes);
+development of the true points douloureux during and after
+the paroxysms, instead of the diffused tenderness following
+the old attacks of migraine. Third stage: neuralgic attacks
+become rare and comparatively unimportant; tendency to
+trophic changes greatly lessened; local anęsthesia persists.
+Presumption, that the nutrition of the nerve-centre has nearly
+recovered itself, but that that centre is still the <i>locus minimę
+resistentię</i> of the central nervous system, liable to suffer from
+any cause of general nervous depression.<span class="pagenum"><a name="Page_129" id="Page_129">[129]</a></span></p>
+
+<p>Now, in interpreting the above phenomena, as I do, upon
+the theory of one essentially uniform nutritive change affecting
+the fifth nerve within the medulla oblongata, I shall be
+met with the following objections: First, there is the common
+and superficial difficulty that pain and paralysis of sensation
+must be opposite states, and that it is impossible to refer them
+both to one and the same pathological process. I have already
+in many places given instances how constantly pain and sensory
+paralysis interchange in a manner which is totally incomprehensible
+except upon the supposition that their physiological
+basis is essentially the same; but the most satisfactory evidence,
+perhaps, that could possibly be produced on this point
+is to be found in the perusal of a group of cases observed by
+Hippel,<a name="FNanchor_20_20" id="FNanchor_20_20"></a><a href="#Footnote_20_20" class="fnanchor">[20]</a> and entitled by him "Anęsthesia of the Trigeminus,"
+the loss of sensation being the most remarkable feature.
+The cases are so deeply interesting that I would
+gladly transfer them bodily to these pages, but must abstain
+from want of space. Suffice it to say here, that, in the first
+place, the anęsthesia was accompanied, in every one of these
+cases, by a most distinct and typical neuralgia; and, secondly,
+that trophic changes occurred which most interestingly (though
+not with absolute completeness) reproduced the phenomena
+observed after complete section of the trigeminus at the Gasserian
+ganglion.</p>
+
+<p>The second objection sure to be raised to the theory of a simple
+spreading of a nutritive central change, as the cause of all
+the phenomena in such a case as the above, is this: It will be
+asked how the process extended itself to the motor root, which,
+in the case of the fifth nerve, is removed by a somewhat formidable
+anatomical distance from the sensory root. I am, of
+course, well aware of the latter fact, and it is an additional
+reason for selecting neuralgia of the fifth, as an extra difficult
+test of the value of my theory. A few words must be premised,
+reminding the reader of the physiological anatomy of
+the nerve.</p>
+
+<p>The trigeminus is in all its characters a spinal nerve; but it
+has sundry peculiarities both of structure and of connections
+with other nerves. Its posterior or sensory root is enormous,
+and, as Schroder van der Kolk showed, takes a direction from
+behind downward and forward, which is intended to facilitate
+its numerous and important connections with the nuclei of
+other nerves: of these the most notable are its connections
+with the vagus, facial, glosso-pharyngeal, and hypo-glossal
+nuclei. The motor root, much smaller than the sensory, was
+shown by Lockhart Clarke to be traceable as low as the inferior
+<span class="pagenum"><a name="Page_130" id="Page_130">[130]</a></span>
+border of the olivary body, as a column of cells which occupies
+a situation corresponding to that of the anterior course of
+the spinal gray matter.</p>
+
+<p>As this column passes onward in the medulla oblongata, on
+a level with the glosso-pharyngeal nerve, it forms a group of
+cells of large size. Besides numerous other connections which
+it forms, Clarke describes the motor root as sending processes
+forward, like tapering brushes or tails of fibres, in connection
+with more scattered cells lying in their course, which may be
+frequently seen to communicate with the transverse bundles
+which traverse the "gray tubercle" and the sensory roots of
+the fifth contained therein. In this way the sensory root,
+though seemingly much separated from, is really in very
+direct connection with, the motor root.</p>
+
+<p>Now, proofs, which must be considered almost positive, have
+recently been adduced to show that the nerve-fibres concerned
+in those peculiar alterations in the tissues supplied by the
+ophthalmic division of the fifth, which occur in section of the
+trigeminus, come entirely from the motor root of the fifth, and
+form a very small band in the inner or medial margin of the
+ophthalmic trunk. The observation of Meissner<a name="FNanchor_21_21" id="FNanchor_21_21"></a><a href="#Footnote_21_21" class="fnanchor">[21]</a> goes to show
+that it is possible (by good luck) to divide the trunk in such a
+partial manner as to cut only the inner fibres, and thereby
+produce the trophic eye-changes without any anęsthesia, or
+only the sensory fibres, and thereby induce anęsthesia without
+any trophic changes; and it must be owned that this really
+affords the only reasonable explanation of the discrepancy
+between the experimental results obtained by Magendie and
+Bernard; and also the facts of such cases as those related by
+Mr. Hutchinson,<a name="FNanchor_22_22" id="FNanchor_22_22"></a><a href="#Footnote_22_22" class="fnanchor">[22]</a> who in two instances found that a completely
+anęsthetic eye recovered perfectly well from the wound
+made in a surgical operation. The nature of the nervous influence
+(whether ordinary vaso-motor only, or a special trophic
+function) has been greatly disputed. Dr. Wegner,<a name="FNanchor_23_23" id="FNanchor_23_23"></a><a href="#Footnote_23_23" class="fnanchor">[23]</a> from
+observing the remarkable group of glaucomatous cases under
+Horner (of which one has been related), made experiments,
+from which he concluded that the augmentation of intra-ocular
+pressure in glaucoma was a phenomenon dependent
+upon the sympathetic, which was irritated by reflection
+<span class="pagenum"><a name="Page_131" id="Page_131">[131]</a></span>
+from the trigeminus. But the researches of Hippel and
+Grunhagen, especially their latest,<a name="FNanchor_24_24" id="FNanchor_24_24"></a><a href="#Footnote_24_24" class="fnanchor">[24]</a> give a different explanation,
+excluding the sympathetic; they found that irritation of
+the medulla oblongata, in the neighborhood of the trigeminus
+root, produced a lasting and very pronounced augmentation
+of intra-ocular blood-pressure, an effect which, they remark,
+could not depend on irritation of the vaso-motor centre, since
+that must produce contraction of the vessels and lowering of
+the blood-pressure. They conclude that "the trigeminus contains
+specific fibres which possess the property of actively dilating
+the blood-vessels of the eye;" and in reference to the secretion
+of the fluid humors of the eye, they conclude also that
+"the trigeminus also plays the part of an (active) nerve of
+secretion."</p>
+
+<p>Of these conflicting opinions I can have no difficulty in at
+any rate rejecting that of Wegner; for the clinical phenomena
+of the complications attending trigeminal neuralgia, such as
+they are described in my last chapter (and could have been
+described at much greater length), seem to me utterly to
+exclude vaso-motor spasm except as a temporary phenomenon
+at the commencement of the attacks of acute pain. Vaso-motor
+palsy undoubtedly is very often present, in fact every
+attack of neuralgia of a certain severity is thus complicated;
+and there is no reason to doubt that this paralysis could be
+caused by lesions within the medulla. Are we, then, to admit
+functions of active dilatation of vessels, and active impulse to
+secretion in certain fibres of the fifth? It is necessary at any
+rate to clear the ground in one respect: it must not be supposed
+that I for a moment entertain the idea that there can be direct
+active dilatation, <i>i.&nbsp;e.</i>, that there can be any system of muscular
+fibres (and nerve-fibres stimulating them) whose office is to
+open the calibre of the vessels; the idea is wildly improbable&mdash;in
+fact almost inconceivable by any one who reflects on the
+necessary machinery&mdash;and there is not a single observed
+anatomical fact to give it support. If, then, I speak of the
+possibility of "active" dilatation, it must be understood that I
+refer to a theory of "inhibition," which supposes certain fibres
+to be gifted with the power of paralyzing or inhibiting the
+vaso-motor nerves. It is my duty to speak with all reasonable
+reserve on that most difficult <i>quęstio vexata</i>, the existence of
+special inhibiting systems of nerves, and the extent to which a
+double series of opposed nervous actions is generalized in the
+body; but it is impossible to avoid the subject altogether, and
+I offer the following remarks, with deference, to our professional
+physiologists. The strongest instances of the apparent
+inhibiting action are probably afforded by the <i>nervi
+erigentes</i>, as shown by Loven, the cardiac depressor, by Ludwig
+<span class="pagenum"><a name="Page_132" id="Page_132">[132]</a></span>
+and Cyon, and the splanchnics (upon the intestine), by
+Pfluger. But there is not a single one of these examples that
+has not been challenged by experimenters of repute. Thus the
+theory of the distinctive restraint-action of the splanchnics
+upon the intestine, and of the vagus upon the heart, has been
+especially controverted by Piotrowski, who, indeed, rejects the
+whole theory of special inhibitory nerves.<a name="FNanchor_25_25" id="FNanchor_25_25"></a><a href="#Footnote_25_25" class="fnanchor">[25]</a> And, from another
+point of view, Mr. Lister long ago attacked the views of
+Pfluger, maintaining that it was possible to produce exactly
+opposite effects through the medium of the very same nerves,
+according as the experimental irritation applied to them was
+weak or strong. To Dr. Handfield Jones<a name="FNanchor_26_26" id="FNanchor_26_26"></a><a href="#Footnote_26_26" class="fnanchor">[26]</a> this seems a still
+unanswerable objection to the inhibitory theory. And in the
+remarkably able and judicial summary of the "Physiology
+and Pathology of the Sympathetic or Ganglionic System,"<a name="FNanchor_27_27" id="FNanchor_27_27"></a><a href="#Footnote_27_27" class="fnanchor">[27]</a>
+by Dr. Robert T. Edes, a less decided but still tolerably strong
+acquiescence is given to Mr. Lister's criticisms of this theory.
+Personally, I must express very strongly the distrust (which is
+probably felt by many others) of doctrines which assert an
+exact opposition between the functions of any two nerves, on
+the basis of an observation that the same apparent effects may
+be produced by section of the one and galvanization of the
+other; both processes seem far too pathological, and too remote
+from the conditions of ordinary vitality, to admit of any such
+absolute deductions from their results.</p>
+
+<p>In the present state of our information I am inclined to
+explain all the congestive complications of trigeminal neuralgia
+on the basis of vaso-motor paralysis. And I further believe
+that the cause of that paralysis is a direct extension of the original
+morbid process from the sensory root to the motor, affecting
+the origin of fibres in the latter, which are destined to
+govern the calibre as ocular and facial vessels. These fibres I
+suppose it is that Meissner succeeded in dividing when he partially
+cut the trigeminus, and got nutritive and vascular changes
+without anęsthesia.</p>
+
+<p>There must be more than this, however, to account for the
+whole of the trophic phenomena; for there is a great body of
+evidence to show that mere vaso-motor paralysis does not produce
+any phenomena of such an actively morbid kind as those
+we are endeavoring to explain. The phenomena on the side
+of secretion might indeed be possibly explained by vaso-motor
+paralysis. [It must be remembered that I am speaking of such
+<span class="pagenum"><a name="Page_133" id="Page_133">[133]</a></span>
+augmented secretion as is seen in neuralgia. I agree with
+Prof. Rutherford (Lectures on Experimental Physiology,
+Lancet, April 29, 1871) that it is difficult thus to explain the
+effects of galvanization of the chorda tympani on the submaxillary
+gland.] Consisting as they do (a), in the great
+majority of cases, of a mere outpour of what seems little more
+than the aqueous part of the secretion, and (b) in a few cases of
+arrested secretion, a phenomenon otherwise by no means
+unfamiliar as the result of sudden, passive engorgement of
+glands. But the mere cessation of vaso-motion will not account
+for such facts as the rapid and simultaneous development of
+erysipelatous inflammation, of corneal clouding and ulceration,
+of iritis and glaucoma, of nutrition-changes in hair and
+mucous membrane. I must, for the present, be content to
+believe it probable that there is a special set of efferent fibres in
+the trigeminus, emanating from the motor-root, whose office it
+is in some unknown way to preside over the equilibrium of
+molecular forces in the tissues to which the nerve is distributed;
+trophic nerves, in fact, though not active dilators of blood-vessels.</p>
+
+<p>It seems to me that, without enlarging further on this almost
+endless topic, I should be justified in assuming that I had
+shown the very high probability that the common starting-point
+both of the neuralgia and of its vaso-motor secretory, and
+trophic complications, was in the sensory root of the trigeminus.
+But the argument is greatly strengthened when we consider
+the fact that loss of peripheral common, and also tactile
+sensation, to a greater or less degree, is constantly observed to
+occur simultaneously with the pain and with the other complications.
+When we observe a patient suffering from racking
+supra-orbital and ocular neuralgia, and discover that at
+the very same period the skin round the eye is markedly insensitive
+to impressions, except in the <i>points douloureux</i>, what
+can we rationally suppose, except that both pain and insensibility
+are the result of one and the same influence, which radiates
+from the sensory centre?</p>
+
+<p>Nor are we likely to reach a different conclusion, if we test
+the matter by the consideration of a rarer, but still sufficiently
+common kind of case, such as I have described in Chapter I.,
+in which a very strong peripheral influence (traumatic) produces
+neuralgia, accompanied by vaso-motor and secretory phenomena,
+and by anęsthesia, but not in the district of the painful
+nerve, but in the territory of a quite different nerve. How
+can we doubt, in the case, <i>e.&nbsp;g.</i>, of a trigeminal neuralgia thus
+complicated, the exciting cause of which was a wound of the
+ulnar nerve, that the morbid influence, traveling inward from
+the lesion, would have passed without any special consequences
+(as happens in thousands of such nerve-wounds), had it
+not, in its passage along the medulla, encountered a <span class="pagenum"><a name="Page_134" id="Page_134">[134]</a></span><i>locus
+minoris resistentię</i> in the roots of the trigeminus? It seems
+impossible to account for the phenomena on any other theory.
+[Eulenburg says, in reference to my reported cases of the kind:
+"<i>Solche Falle begunstigen in hohem Grade die Annahme
+pradisponirender Momente, die in der ursprunglich schwacheren
+Organisation einzelner Abschnitte des centralen Nerven-apparates
+beruhen.</i>" <i>Op. cit.</i>, p. 56.]</p>
+
+<p>It is necessary, in the next place, to consider a very important
+question, how far irritation can pass over from one nerve
+to another, without reflection through a spinal centre, solely
+in virtue of a connection through the medium of a nervous
+plexus. The case which apparently presents such phenomena
+in the most unmistakable way is that of <i>angina pectoris</i>.</p>
+
+<p>The site to which the essential heart-pain is referred in this
+disease is probably the cardiac, or this and the aortic plexus;
+in a comparatively small number of cases the pain does not
+extend farther. But much more frequently it spreads in various
+directions, and we have to account for its presence (<i>a</i>) in
+intercostal nerves, (<i>b</i>) cervical nerves, (<i>c</i>) nerves springing
+from the brachial plexus.</p>
+
+<p>Before we inquire into the mechanism by which this extension
+of the pain takes place, we ought in strictness to ask ourselves
+whether the essential heart-pain is felt only in the
+spinal sensory branches, or whether the sympathetic fibres are
+themselves capable of feeling pain. The latter supposition,
+notwithstanding all that has been argued in its favor from the
+supposed analogies of the pain of colic, gall-stone, etc., seems
+to me very doubtful. It would appear more probable that
+both the latter pains, and also those of angina, are really connected
+with branches either of the vagus or of other spinal
+nerves. And there is no need to invoke the sympathetic as a
+sensory nerve, to account either for the essential heart-pain
+of angina, or for its extension into arm, chest-wall, and neck.
+For the plexus cardiacus receives spinal branches, both from
+the vagus and also (through the medium of the sympathetic
+ganglia of the neck) from the whole length of the cervical and
+the uppermost part of the dorsal cord-centres. And, in this
+way, it would seem quite possible intelligibly to account for
+the pain radiating into intercostal, cervical, and brachial
+nerves, merely by extension of a morbid process essentially
+seated in the cord. Usually, however, one sees it explained
+not in this way, but by the inter-communications that exist
+outside the spine, between the branches from the cervical ganglia
+and the lower cervical and upper dorsal nerves; and the
+pain in the arm is especially explained by the connection
+(outside the spinal canal) of the inferior cervical ganglion, on
+the one hand with the lower cervical nerves, which go to the
+brachial plexus, and, on the other hand, with the heart itself.
+There remains to be explained, however, the singular tendency<span class="pagenum"><a name="Page_135" id="Page_135">[135]</a></span>
+of the arm-pain to be one-sided (this happens in at least four
+cases out of five); and this explanation seems to me insuperably
+difficult, on the theory that the transference of morbid action
+to the brachial nerves takes place through external anastomoses.
+It appears greatly more probable that angina is essentially
+a mainly unilateral morbid condition of the lower
+cervical and upper dorsal portion of the cord; liable of course
+to be seriously aggravated by such peripheral sources of irritation
+as would be furnished by diseases of the heart, and especially
+by diseases of the coronary arteries; the latter affection
+probably involving constant mechanical irritation of the cardiac
+and the aortic plexuses. It is noteworthy that the arm-pain
+is sometimes (I do not know how often) accompanied by
+vaso-motor paralysis in the limb; this phenomenon could also
+certainly be more easily accounted for on the supposition of
+radiation from a spinal vaso-motor centre (to which the morbid
+process had extended from a posterior nerve-root) than on
+that of communication between painful sensory nerves and
+vaso-motor nerves; through either of the plexuses independently
+of the spinal centres.</p>
+
+<p>In truth, I suspect that, whatever part the plexuses, with
+their reenforcing ganglionic cells, may play during physiological
+life, they are not often the channels of mutual pathological
+reaction of one kind of nerve with another. It would be
+possible to argue this even more strongly in the case of trigeminal
+neuralgias; but I must not unnecessarily expand this
+already too lengthy discussion.</p>
+
+<p>From the varied considerations which have now been
+adduced, the reader, unless I altogether miscalculate the value
+of the facts, will probably have arrived at the following conclusions:
+(1) That the assumption of a positive material centric
+change as the essential morbid event in neuralgia is almost
+forced upon us; (2) that, whereas the morbid process, if
+centric, is <i>a priori</i> infinitely more likely to be seated in the
+posterior root of the painful nerve, or the gray matter immediately
+connected with it, than anywhere else; so, again, the
+assumption of this locality will explain, as no other theory
+could explain, the singular variety of complications (all of them
+nearly always unilateral, and on the same side as the pain)
+which are apt to group themselves around a neuralgia; and
+some of which are very seldom absent in neuralgia of any
+considerable severity. To this we may certainly add that it is
+extremely probable that the vast majority of neuralgic patients
+inherit the tendency to this localized centric change; in support
+of this we may finally mention two considerations derived
+from the sex and the ages most favorable to neuralgia.
+Eulenburg saw a hundred and six cases of neuralgia of all
+kinds, of which seventy-six were in women and only thirty in
+men; my own experience is very similar; namely, sixty-eight<span class="pagenum"><a name="Page_136" id="Page_136">[136]</a></span>
+women and thirty-two men out of a hundred hospital and private
+patients. The strong connection between the hysteric and
+the neuralgic temperament in women, and the great preponderance
+of women among neuralgics, strengthen in no small
+degree the probability of inherent tendencies to unstable equilibrium
+as a very common predisposing factor in neuralgia.
+And, on the subject of age, I need only recall what I have said so
+strongly about the coincidence of neuralgia with particular
+epochs in life, as affording evidence of the most powerful kind
+that neuralgics are, save in exceptional instances, persons with
+congenitally weak spots in the nervous centres, which break
+down into degeneration, temporary or permanent, under the
+strains imposed by one or other of the physiological crises of
+the organism, or the special physical or psychical circumstances
+which surround the patient's life.</p>
+
+<p>Having thus decidedly expressed my belief in the essential
+material participation of the nerve-centre in neuralgia, it
+remains for me to discuss two points: first, as to the character
+of the material change in the nerve-root, and next, as to the
+extent to which mere peripheral influence, without special
+inherited tendencies, may suffice to set this process
+going.</p>
+
+<p>The morbid change in the nerve-centre is probably, in the
+vast majority of cases, an interstitial atrophy, tending either
+to recovery, or to the gradual establishment of gray degeneration,
+or yellow atrophy, of considerable portions of the whole
+of the posterior root, and the commencement of the sensory
+trunk as far as the ganglion.</p>
+
+<p>It is probable, however, that in a certain number of cases, the
+atrophic stage may be preceded by a process of genuine inflammation,
+and that this inflammation is centripetally produced
+in consequence of inflammations of peripheral portions of the
+nerve. The considerations which make this probable are
+chiefly derived from the analysis of cases in which a more or
+less chronic, but severe, visceral disorder has been followed by
+so-called reflex paralysis, but in which neuralgic phenomena,
+have been conspicuous. In reference to this subject I recommend
+to the reader's attention the very interesting paper on
+"Reflex Paralyses" by Prof. Leyden, of Konigsberg.<a name="FNanchor_28_28" id="FNanchor_28_28"></a><a href="#Footnote_28_28" class="fnanchor">[28]</a> He is
+immediately commenting upon a case in which dysenteric
+affection of the bowel were followed by the symptoms of myelitis,
+attended with febrile exacerbations, and also with severe
+pains in the region of the sacrum, in the course of the dorsal
+intercostal nerves of the right side, and in the knees, and semi-paralytic
+weakness of the lower extremities, and with pains
+between the shoulder-blades and the left arm. Leyden discusses
+the doctrine of reflex paralyses in general, starting from
+<span class="pagenum"><a name="Page_137" id="Page_137">[137]</a></span>
+the cases of urinary paraplegia brought forward by Stanley, in
+1835, and tracing the growth of opinion through the phases
+represented by Graves, Henoch, and Romberg, by Valentine
+and Hasse, then by Pfuger, and other professors of the inhibitory
+doctrine; by Brown-Sequard (in his well-known, and now
+very generally discredited, theory of spasm of the vessels in
+the nervous centres), by Jaccoud in the "Erschopfung"
+(exhaustion) theory, down to the more careful and reliable
+researches of Levisson on the temporary reflected paralyses
+induced by experimental squeezing of the kidney or uterus of
+animals; and then gives the history of the more recent doctrine
+of a positive material change in the cord centripetally
+introduced. Gull<a name="FNanchor_29_29" id="FNanchor_29_29"></a><a href="#Footnote_29_29" class="fnanchor">[29]</a> (1856) may be said to have inaugurated the
+new doctrine of a morbid process transmitted along the pelvic
+nerves to the cord, and causing material changes there.
+Remak,<a name="FNanchor_30_30" id="FNanchor_30_30"></a><a href="#Footnote_30_30" class="fnanchor">[30]</a> on the other hand, suggested a material change operating
+in the opposite direction; <i>a neuritis descendens</i>, starting
+in the very nerves (within the pelvis) which showed the paralysis
+in the extremities. The symptoms are supposed by him to
+be distinctive, inasmuch as there is both violent pain in the
+nerves of the soles of the feet, and also tenderness of the same.
+On the other hand, Remak said that myelitis, with neuritis,
+might be the origin of paraplegia and simultaneous palsy of
+bladder and rectum. The theory of neuritis descendens was
+supported by Kussmaul,<a name="FNanchor_31_31" id="FNanchor_31_31"></a><a href="#Footnote_31_31" class="fnanchor">[31]</a> in the record of a case where disease
+of the bladder was complicated with pelvic inflammation, atheromatous
+degeneration of the arteries, and consequent fatty
+degeneration of the sciatic nerves, causing direct paraplegia.
+We return to the centripetal theory of urinary paralysis with
+Leyden's own cases, published in 1865; of three patients with
+urinary paraplegia, two died, and the existence of a secondary
+(centripetal) myelitis seems to have been established, and by
+all analogy it must have existed in the third case, which recovered.
+The only puzzle and doubt that ensued was caused by
+the fact that there was an absence of neuritis in the different
+nerves themselves; though it seemed plain that the starting
+point of the myelitis was at the entrance of these nerves into
+the cord. This mystery seemed to be cleared up by the important
+experiments of Tiesler, ("Ueber Neuritis" Konigsberg,
+1860) a pupil of Leyden's. This observer excited local traumatic
+inflammation in the sciatic nerve of rabbits and dogs;
+the rabbit became paraplegic and died three days afterward.
+At the site of the artificial irritation there was a localized formation
+of pus, and there was a second similar formation
+within the vertebral canal at the point where the posterior
+<span class="pagenum"><a name="Page_138" id="Page_138">[138]</a></span>
+roots of the sciatic enter the cord; but there was no neuritis
+of the intervening portion of the nerve.</p>
+
+<p>Upon this and similar evidence is based the modern doctrine
+of a neuritis migrans, with centripetal tendencies, upon which
+it is supposed that a very large proportion, at least, of the
+urinary, dysenteric, and uterine paraplegias, miscalled
+"reflex," depend; and it is clear that the application of the
+word "reflex" in such a case is a grave abuse, tending to produce
+such confusion of thought and error in practice. In relation
+to the subject of our own inquiry&mdash;neuralgia&mdash;it is obviously
+of the highest consequence to investigate the question
+whether peripheral irritations, analogous to those which produce
+urinary paraplegia, are at all frequently the cause of the
+changes in the posterior roots which produce true neuralgia;
+for of course an inflammation may be the beginning of an
+atrophy which may presently exhibit no distinction whatever
+from one of which the origin was altogether non-inflammatory.
+I think that there is strong reason for thinking that this is not
+at all frequently the case. In the first place, all the evidence
+that exists respecting these centripetal inflammations of the
+cord is opposed to the idea that, save in the rarest instances,
+the inflammatory process limits itself to one small segment of
+the cord. Secondly, the description of the pains that have
+usually accompanied such inflammations of the cord is considerably
+different from the strictly localized, frankly intermittent
+character of a true neuralgia; in fact, all we know of the
+history of myelitis (except when complicated with a large
+amount of meningitis) forbids us to suppose that severe pain
+would be an immediate symptom. But, thirdly, a far more
+important objection to the theory of an origin in localized centripetal
+myelitis, the result of a neuritis migrans, is the rarity
+of motor paralysis as an early symptom, instead of which we
+ought to find a very distinct history of decided paralysis (much
+more decided than those secondary paralyses which actually do
+occur in some neuralgias) of the muscles supplied by the anterior
+roots of the painful nerve, in every case in which such a
+peripheral origin could be assumed. Again, the totally feverless
+commencement of neuralgias, a character which is maintained
+throughout the progress of the milder cases, is entirely
+opposed to the idea of a direct connection between myelitis and
+neuralgia. The superficial appearance of pyrexia is sometimes
+given by a local vaso-motor paralysis, which makes the neuralgic
+part, after a long bout of pain, hot and red; but of general
+pyrexia there is nothing.</p>
+
+<p>Taking every thing into consideration, one is inclined to
+say that there is a probability that in a very limited number
+of cases peripheral irritation does cause actual limited myelitis,
+which escapes recognition at the time, but which issues
+in an atrophy, the subjective expression of which is actual<span class="pagenum"><a name="Page_139" id="Page_139">[139]</a></span>
+neuralgic pain. We may well ask ourselves, also, whether
+there is not some likelihood that a peripheral irritation, which
+stops short of producing an actual neuritis migrans capable of
+centripetally exciting a myelitis, may not, by a lower degree of
+centripetal irritation, give a bias toward certain forms of non-inflammatory
+atrophy in cells of posterior nerve-roots which
+are congenitally of weak organization. I am inclined to
+believe strongly that this does occur. For example, I should
+explain thus the majority of the peripheral cases of ciliary
+neuralgia, migraine, etc., that we meet with in poor young
+needle-women, especially the hypermetropic, who, at an age
+when they can ill afford the strain, work so constantly and
+strenuously at an occupation which fearfully taxes the
+eye.</p>
+
+<p>I would also go farther, and express the opinion that peripheral
+influences of an extremely powerful and continuous
+kind, where they occur with one of those critical periods of
+life at which the central nervous system is relatively weak and
+unstable, can occasionally set going a non-inflammatory
+centric atrophy which may localize itself in those nerves upon
+whose centres the morbific peripheral influence is perpetually
+pouring in. Even such influences as the psychical and emotional,
+be it remembered, must be considered peripheral&mdash;that
+is, they are external to the seat and centre of the neuralgia.
+And there are probably few practitioners of large experience
+who have not seen a patient or two in whom the concurrence
+of some unfortunate psychical with some other noxious peripheral
+influence, the whole taking place at some critical period
+of life (especially in the years between puberty and marriage),
+seems to have totally deranged the general balance of nervous
+forces, and induced morbid susceptibilities and morbid tendencies
+to some particular neurosis. It is a comparatively frequent
+thing, for example, to see an unsocial solitary life (leading
+to the habit of masturbation), joined with the bad influence
+of an unhealthy ambition, prompting to premature and
+false work in literature and art. The bad peripheral influence
+of constant fatigue of the eyes in study may so completely
+modify a young man's constitution as to make a wreck of him
+in a very few years, changing him from the state of habitual
+and conscious health to that of chronic neurosis of one sort or
+another. And, though it is doubtless on persons with congenital
+tendencies to nervous diseases that such a combination
+of bad influences produces its most serious effects, yet there
+unquestionably are a few persons in whom they appear to
+entirely generate the neurotic constitution. I have already
+touched upon the part that misdirected psychical influences,
+especially religious and other forms of emotional excitement,
+may play in this unfortunate perversion of the natural
+and healthy nervous functions, more especially in youth;<span class="pagenum"><a name="Page_140" id="Page_140">[140]</a></span>
+and need only add, here, that perhaps the most fatal combination
+of all the bad influences is the melancholy union
+of highly-strained religious sentiment with peripheral sexual
+irritation, which is, unfortunately, a too common phenomenon
+under certain systems of education. The most
+frequent neurotic consequences of the class of influences
+which have now been referred to are probably neuralgia&mdash;in
+the form either of migraine, of nervous angina, or of sciatica&mdash;or
+else asthma.</p>
+
+<p>But, if the combination of several such centripetal influences
+may generate the neurosis unaided, even a single one of
+them operating powerfully for a long period may produce
+most serious consequences in those who are hereditarily predisposed.
+The influence of prolonged fatigue of the eyesight,
+independently of any special intellectual or emotional strain,
+was strongly illustrated in my own case about three years ago.
+I was then engaged upon a piece of scientific writing which
+demanded no great intellectual effort, but was being done
+against time, and by working, night after night, many hours
+by gas-light. My neuralgic (trigeminal) attacks came on with
+great severity, accompanied by vertiginous sensations of so
+alarming a kind as to make me fear the invasion of some
+serious brain-mischief. I broke off all work, and went to the
+sea-side, but was greatly disappointed to find, for the first few
+days, that the symptoms were not in the least mitigated. The
+mystery was soon explained. The weather had been such as
+to confine me a good deal to the house, and, thinking it would
+do no harm, I amused myself with reading newspapers and
+novels. At last I suspected that the use of my eyes in reading
+was altogether mischievous; I desisted from reading any
+thing, and in forty-eight hours every symptom had vanished.</p>
+
+<p>Among peripheral influences of a more mechanical kind
+there is one cause of neuralgia, the force of which has been
+variously estimated, but which some authors rate as very
+important, viz.: the influence of the pressure, and especially
+of the varying pressure, of blood-vessels, or other hollow
+viscera, upon the trunks of the nerves. We must set aside
+one such action which is undoubtedly very powerful, as essentially
+differing from the others; I mean the pressure of dilated
+blood-vessels, especially aneurisms, when this happens to be
+exerted upon the ganglion of the sensory trunk. Here there
+can be no doubt of the mischief; for the pressure, if at all
+severe, gradually destroys the life of the ganglion, upon
+which, as was proved by Waller, the nutrition of the posterior
+nerve-root hangs with very intimate dependence, and the pulsations
+of the vessel seem greatly to aggravate both the irritation
+and the centripetal tendency to atrophy. In short, it is
+plain that such lesion of a ganglion may be the whole and<span class="pagenum"><a name="Page_141" id="Page_141">[141]</a></span>
+sufficient cause of a neuralgia of the most desperate and incurable
+kind. It is another matter when we are asked to believe
+that the mere varying pressure of intestines, in different states
+of fullness, or plexuses of pelvic veins liable to temporary
+congestions, can so affect the sciatic nerves as to set up neuralgia.
+Considering the extreme frequency of cases in which
+such momenta must be partially coming into operation, especially
+in women&mdash;a frequency altogether out of proportion to
+that of sciatica&mdash;I cannot admit the probability that this
+influence is more than an occasional and very secondary
+factor, and that only in cases where the disposition to neuralgia
+is uncommonly strong.</p>
+
+<p>A sufficiently complete explanation of my theory as to the
+pathology and etiology of neuralgia has now been given,
+although the subject might be elaborated at far greater length;
+and I hope it will be apparent to the reader that the view now
+advocated is at once important, and also vouched for by strong
+evidence. I claim for it that the whole argument shall be
+taken together, for it is a case of cumulative proof; every link
+must be weighed and tested, before the remarkable strength of
+the chain can be felt. And it may fairly be said that, if the
+proof of a definite kind of material change in a definite organ,
+as the essential factor in neuralgia, has been established upon
+reasonable grounds, an important step has been taken toward
+removing a serious opprobrium and difficulty in practical
+medicine. Although the true neuralgias are not among the
+most frequent of human diseases, they form a class of enormous
+practical importance, for they are sufficiently common to
+be sure to occur in considerable numbers in the practice of
+every medical man, and, both from the suffering which they
+inflict, and the rebelliousness which they often show to treatment,
+they are among the gravest sources of anxiety which
+the practitioner is likely to encounter. There are probably
+few disorders which so often occasion mortification and loss of
+professional credit to the physician. The helplessness which
+men, who do not enjoy special opportunities of seeing those
+diseases with frequency, so often show in dealing with them, is
+largely caused by the extreme timidity and vagueness with
+which the standard treatises on medicine deal with the
+question of their pathology; and a very unfair advantage has
+thus been given to the specialists, who, by the mere force of
+opportunity, and continual blind "pegging away" in an
+entirely empiric manner, have acquired a certain rude skill in
+the treatment of these maladies which enables them to outshine
+practitioners who often have far more in them of the veritable
+<i>homme instruit</i> as regards general scientific education and
+habits of mind. It will be evident, as a mere abstract proposition,
+that the enunciation of a reasonable pathology of the
+disease, and the sweeping away of a mass of unmeaning<span class="pagenum"><a name="Page_142" id="Page_142">[142]</a></span>
+phrases about "mysterious functional affections" and the
+like, must be a distinct gain to practitioners of plain common-sense
+and good general knowledge, to whom neuralgia is
+merely one of a vast number of different diseases among which
+their attention and study are divided. And I hope that, in the
+further remarks on Diagnosis, Prognosis, and Treatment, yet
+to be made, the value of clear pathological ideas of disease will
+be brought more practically and clearly into view. [The
+reader will find, at the end of Part I. of this volume, a note
+which contains a brief discussion on the "Erschopfung" theory
+of Jaccoud, and the doctrines of Dr. Handfield Jones respecting
+inhibition, with which I thought it best not to encumber the
+text of the present chapter.]</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="diag" id="diag"></a>CHAPTER IV.</h2>
+
+<h3>DIAGNOSIS AND PROGNOSIS OF NEURALGIA.</h3>
+
+
+<p><i>Diagnosis.</i>&mdash;This subject is much simplified and shortened,
+in regard to our present purpose, by the plan of the present
+work, which, by separately describing (in Part II.) the other
+disorders which resemble neuralgia, and are liable to be confounded
+with it, avoids the necessity for stating here the
+negative diagnosis of neuralgia itself. We are only concerned
+here to give a clear picture of the positive signs which it is
+necessary to verify before we can suppose disease to be neuralgia.
+The special modes of searching for these are interesting,
+and in some respects peculiar;</p>
+
+<p>(1) The first and most essential characteristic of a true neuralgia
+is, that the pain is invariably either frankly intermittent,
+or at least fluctuates greatly in severity, without any sufficient
+and recognizable cause for these changes.</p>
+
+<p>(2) The severity of the pain is altogether out of proportion
+to the general constitutional disturbance.</p>
+
+<p>(3) True neuralgic pain is limited with more or less distinctness
+to a branch or branches of particular nerves; in the
+immense majority of cases it is unilateral, but when bilateral
+it is nearly always symmetrical as to the main nerve affected,
+though a larger number of peripheral branches may be more
+painful on one side than on the other.</p>
+
+<p>(4) The pains are invariably aggravated by fatigue or other
+depressing physical or psychical agencies.</p>
+
+<p>The above are characteristics which every genuine neuralgia
+possesses, even in its earliest stages; if they be not present, we<span class="pagenum"><a name="Page_143" id="Page_143">[143]</a></span>
+must at once refer the diagnosis to one or other of the affections
+described in Part II. of this work.</p>
+
+<p>Supposing the above symptoms to be present, we expect to
+find&mdash;</p>
+
+<p>(5) In by far the largest number of instances that the
+patient has either previously been neuralgic, or liable to other
+neuroses, or that he comes of a family in which the neurotic
+disposition is well marked. Failing this, we are strongly to
+doubt the neuralgic character of the malady, unless we detect
+that there has been&mdash;</p>
+
+<p>(6) A poisoning of the blood by malaria (but this very
+rarely causes neuralgia, save in the congenitally predisposed);
+or&mdash;</p>
+
+<p>(7) A powerfully operating or very long-continued peripheral
+irritation centripetally directed upon the sensory nucleus of
+the painful nerve; which irritation may be (<i>a</i>) "functional,"
+as where the eye has been persistently and severely over-strained
+and trigeminal pain results, or a sudden severe shock
+has been received; or, (<i>b</i>) coarsely material, as where inflammation,
+ulceration, etc., of surrounding tissues involve the
+periphery of the painful nerves in a perpetually morbid action,
+or chronic but profoundly depressing psychical influences;
+or&mdash;</p>
+
+<p>(8) A constitutional syphilis. In this case there will either
+be marked syphilitic local affection of the trunk of a nerve, or
+if, as is more common, the syphilitic change is in the nerve-centre,
+there will most likely be other syphilitic centric mischiefs,
+leading to scattered motor or vaso-motor paralyses,
+characteristic modifications of special sense-functions, etc.</p>
+
+<p>If the neuralgia be of some standing and a certain degree of
+severity, there will inevitably be found&mdash;</p>
+
+<p>(9) Some of the fixed tender points of Valleix, in such situations
+as have been described in Chapter I.; and&mdash;</p>
+
+<p>(10) Secondary affections (<i>a</i>) of secreting glands, or (<i>b</i>) vaso-motor
+nerves; or (<i>c</i>) of nutrition of tissues; or secondary localized
+paralyses of muscles, or localized anęsthesia of a somewhat
+decided though not complete kind, as described in Chapter
+II.; any one or any number of these various complications may
+be present.</p>
+
+<p>I must insist that the above picture includes only the essentials
+for a diagnosis of neuralgia; if the painful affection will
+not answer to the conditions therein included, we have no
+right to call it a neuralgia&mdash;it belongs, for every practical purpose,
+to some other category of disease. Let me add one more
+essential characteristic, which is, that the pain begins and
+assumes its characteristic type before any other of the phenomena
+appear, with the single and partial exception of anęsthesia.</p>
+
+<p>There are some special modes of diagnosis of the varieties<span class="pagenum"><a name="Page_144" id="Page_144">[144]</a></span>
+of neuralgia, developed of late years, that require notice here;
+they are chiefly the result of the researches of Moriz Benedikt.</p>
+
+<p>As regards the quality of the pain, Benedikt says that the
+curve of intensity has an intimate relation to the <i>locus in quo</i>
+of the neuralgia (<i>i.&nbsp;e.</i>, whether in the periphery, trunk, or
+roots). An inflammatory irritation set up at the periphery of
+a nerve (by a joint-inflammation, for instance) produces a continuous
+pain; the same kind of irritation, attacking a nerve-trunk
+(<i>e.&nbsp;g.</i>, in the bony canals), produces a paroxysmal pain;
+an inflammation spreading from the vertebrę to the nerve-roots
+or the cord-centres produces momentary lancinating
+pains. The latter characteristic he supposes to be especially
+characteristic of the centrally-produced neuralgias; and I may
+observe, as so far confirmatory of this idea, that this is especially
+the character of the pains in locomotor ataxy. There are
+sundry special cases to be considered, however: thus, Benedikt
+himself remarks that the pain set up by the pressure of a pulsating
+aneurism is, from the nature of things, lancinating from
+moment to moment. Eulenburg,<a name="FNanchor_32_32" id="FNanchor_32_32"></a><a href="#Footnote_32_32" class="fnanchor">[32]</a> moreover, says that Benedikt's
+tests of the locality of the primary mischief only hold
+good under the following circumstances: (1) When the irritability
+and the exhaustibility of the nerves are in a normal condition
+during the neuralgia; (2) when the irritation that calls
+forth the paroxysm is either identical with the original cause
+of the disease, or at least operates upon the same spot. The
+two conditions, however, do not concur. The irritability and
+exhaustibility may be sometimes excessive in neuralgias, sometimes
+normal, and perhaps, in certain cases, beneath the normal
+standard; by which means the form of the curve of intensity
+must be considerably modified. Moreover, the irritation
+that provokes an attack may from the periphery attack the
+primary seat of the disease, even when this is central, on
+account (says Eulenburg) of exaggerated conductivity of the
+nerves (his second cause<a name="FNanchor_33_33" id="FNanchor_33_33"></a><a href="#Footnote_33_33" class="fnanchor">[33]</a> of "hyperęsthesia"), as is, in fact,
+very frequently the case. He also thinks the distinction
+between paroxysmal and lancinating pains too indefinite to
+serve as a sufficiently reliable basis of diagnosis, especially considering
+the endless <i>nuances</i> of the form which the pain is apt
+to take. I agree with Eulenburg upon this point; and am convinced,
+from my own observations, that such a distinction as
+that between lancinating and paroxysmal pains is illusory, [I
+have taken some pains to investigate the character of the pains,
+not only in neuralgia, but in locomotor ataxy. It is true
+that the lancinating character predominates, on the whole,
+in the latter disease; but there are great differences in
+different individuals, and even in the same patient at various
+<span class="pagenum"><a name="Page_145" id="Page_145">[145]</a></span>
+times, which plainly depend on subjective influences. Compare
+for instance, Dr. Headlam Greenhow's report on an
+ataxic patient, with a report on the same man by Dr. Buzzard
+and myself. ("Trans. Clin. Soc.," vol. i., 1868, pp. 152-162.)]
+the two kinds being frequently found alternate in the same
+case. The only useful distinction, in my opinion, is Benedikt's
+first one: he is probably right in saying that, where such an
+affection as an inflamed joint forms the source of peripheral
+irritation that immediately provokes a neuralgia, the pain is
+apt to be unusually continuous.</p>
+
+<p>The extent to which the pain of neuralgia spreads into different
+termini of the same nerve has been made the basis of
+distinctions as to the seat of the original mischief. For example,
+it has been said that pain in the mental branch of the third
+division of the trigeminus, which does not invade the auriculo-temporal
+branch, can hardly depend on an irritation operating
+on the trunk of the inferior dental; it must be distinctly
+peripheral, or else it must act upon limited portions of the central
+origin of the fifth nerve. But the fact seems rather to be
+that, whether the neuralgia was excited by lesions at the periphery,
+in the nerve-trunk, or in the centre, it is equally possible
+that either a small or a large part of the peripheral expanse
+of the nerve may become the seat of the pain: this almost necessarily
+follows from the entire independence of individual fibres
+in nerves.</p>
+
+<p>As regards the evidence afforded by the motor, vaso-motor,
+and trophic complications, there is this very positive diagnostic
+value in them&mdash;that they enable us to say, with greater assurance
+than we could otherwise do, that the disease is a real neuralgia.
+But, the only evidence that they afford as to the situation
+of the mischief is, that they uniformly point to the central
+end of a particular nerve; and accordingly I have already
+shown, in the chapter on Pathology, that the attentive study
+of these very complications furnishes us with some of the most
+powerful arguments upon which rests my theory that in neuralgia
+there is always centric mischief. What share in the
+production of the malady, in any given case, has been taken
+by the centric disease, and what if any by a peripheral irritation,
+the existence of these complications in no way helps us
+to determine; far less does it enable us to localize a peripheral
+lesion which may have acted as a concomitant cause; on the
+contrary, I believe that there is no more fertile source of erroneous
+judgment on this very point, than some of these complications,
+especially the vaso-motor and trophic. I suspect that
+it has happened, in hundreds of instances, that a localized congestion
+or inflammation, which is a mere secondary phenomenon,
+produced in the centrifugal manner already so fully
+explained, has been taken for the veritable <i>fons et origo</i> of
+the malady: hence the neuralgia has been confidently reckoned<span class="pagenum"><a name="Page_146" id="Page_146">[146]</a></span>
+as one peripherally produced, and, what is even worse,
+the whole energy of treatment has been directed to a mere outlying
+symptom, under the idea that the primary source of mischief
+was being attacked.</p>
+
+<p>The application of electricity as a test of the nature of a
+neuralgia has been employed by Benedikt,<a name="FNanchor_34_34" id="FNanchor_34_34"></a><a href="#Footnote_34_34" class="fnanchor">[34]</a> who lays down certain
+laws as the result of his researches. He says that (<i>a</i>) in
+idiopathic peripheral neuralgias the nerves are not sensitive to
+the current; (<i>b</i>) in neuralgias dependent on neuritis or hyperęmia
+of the nerve-sheath there is general electric tenderness
+of the nerve; (<i>c</i>) in cases where the pain has been set up by
+morbid processes in tissues surrounding the nerve, there is electric
+tenderness only at the site of these changes. I may, in
+general terms, express concurrence in these statements; but I
+must add that, as diagnostic rules they apply only to the early
+stages of neuralgia; for the occurrence of secondary complications
+may and does altogether change the condition of electric
+sensitiveness. It need hardly be said that the above remarks
+on diagnosis apply for the most part only to the superficial
+neuralgias, which, however, include an immense majority of
+the cases of neuralgias. The diagnosis of visceral neuralgias
+is, it need hardly be said, in most cases, a far more difficult and
+complicated matter. In these diseases we have often little
+more to guide us, in the actual symptoms, than (<i>a</i>) the intermittence
+of the pain, and (<i>b</i>) the absence of commensurate
+constitutional disturbance, especially the complete freedom
+from sense of illness in the intervals between the pains. We
+shall be obliged to rely greatly on such historical facts as the
+presence or absence of neurotic tendencies in the patient and
+his family; the possibility of his having been exposed to blood-poisoning
+(<i>e.&nbsp;g.</i>, from malaria or chronic alcoholic excess, or
+extreme over-smoking); the circumstance that he has been
+habitually overworked, or greatly exposed to agitating psychical
+influences; perhaps that he has been subject to a combination
+of several of these morbific momenta. To say truth, the
+diagnosis of visceral neuralgias must, at the best of times, be a
+difficult and anxious matter, and we can hardly ever thoroughly
+satisfy ourselves until we have procured some decided
+results from treatment; fortunately, however, it happens
+tolerably often that we can do this, and sometimes in a very
+striking way.</p>
+
+<p><i>Prognosis.</i>&mdash;The prognosis of neuralgia varies exceedingly,
+according to the form and situation of the disease, and many
+other considerations. There are, of course, in the first place,
+certain neuralgias in which the prospect is perfectly hopeless
+as to cure; such are the cases in which the nerve is involved
+in a continuously growing tumor (especially within a rigid
+<span class="pagenum"><a name="Page_147" id="Page_147">[147]</a></span>
+cavity, like the skull), or a slow but persistent ulcerative process.</p>
+
+<p>Supposing, however, that the case is none of these, the very
+first prognostic consideration is that of age.</p>
+
+<p>Of the neuralgias of youth, the majority either disappear
+altogether after a first attack, or recur a certain number of
+times during some years, the neuralgic tendency either disappearing
+or becoming greatly mitigated when the process of
+bodily consolidation is over. In another group the neuralgic
+tendency is never lost, but the form of the attacks changes, and
+there is far less spontaneity in the manner of their production.
+It is exceedingly common to see delicate boys and girls between
+puberty and the age of eighteen or twenty, attacked with typical
+migraine, which recurs regularly every three or four weeks
+for perhaps two or three years, then ceases to occur at regular
+periods, then loses the tendency to stomach complication; and,
+by the age of twenty-five or somewhat later, has left, as its
+only relic, a tendency to attacks of ophthalmic neuralgia, which
+come on when the patient is excessively fatigued, or encounters
+the close air of a theatre, or undergoes an unusual strain of mental
+excitement or anxiety, etc.; but which never come on without
+some such special provocation. So, again, there is a variety of
+sciatica which belongs mainly to the period between puberty
+and the twenty-fifth to thirtieth year, and which seems really
+to belong, pathologically, to the age of unsettled and irregular
+sexual function, the tendency to it usually disappearing after
+the patient has settled down happily in married life. Ovarian
+and mammary neuralgia have very commonly a similar
+history.</p>
+
+<p>On the other extreme we find the neuralgias of the period of
+bodily decay: these are of very bad prognosis. A neuralgia
+which first develops itself after the arteries and capillaries have
+begun to change decidedly in the direction of atheroma is
+extremely likely, even if apparently cured for a time, to recur
+again and again, with ever-increasing severity, and to haunt
+the patient for the remainder of his days. It therefore becomes
+exceedingly important, in a prognostic point of view, to assure
+ourselves as soon as possible whether this arterial degeneration
+has decidedly commenced; and for this purpose I am in the
+habit of insisting to pupils on the great importance of sphygmographic
+examination for all neuralgic patients who have
+passed the middle age. Where we get the evidence which is
+furnished by the formation of a distinctly square-headed radial
+pulse-curve, even though there be no palpable cord-like rigidity
+of superficial arteries, we are bound to be exceedingly cautious
+of giving a favorable prognosis.</p>
+
+<p>In women the period of involution of the sexual apparatus
+forms a crisis which, in regard to neuralgias, is of great prognostic
+importance. On the one hand, if the general vital status<span class="pagenum"><a name="Page_148" id="Page_148">[148]</a></span>
+be good, and the arterial system fairly unimpaired, we may
+look to the completion of the process of involution as a probable
+time of deliverance from neuralgic troubles that have
+hitherto beset a woman; we know that she will probably suffer
+a temporary aggravation of her pains, but we hope to see her
+lose them altogether. On the other hand, if it should happen
+that she enters on the period of sexual involution with her
+general nutrition considerably impaired and her arterial
+system decidedly invaded by atheroma, it is only too likely
+that neuralgias recurring now, or attacking her for the first
+time, will assume the worst and least manageable type.</p>
+
+<p>Of almost or quite equal importance with the question of the
+physiological age of the patient is that of his personal and
+family history with regard to the tendency to neuralgia and to
+other severe neuroses. Upon this subject I have dwelt so very
+fully in other parts of this work, that it is merely necessary
+here to repeat, that the balance of chances is most heavily
+swayed to the bad side by all evidence tending to prove congenital
+neurotic tendencies in the patient and vice versa.</p>
+
+<p>Of prognostic hints that are to be gathered from our knowledge
+of the immediate causes of the attack, there are none so
+valuable as those which we gather from the detection of a
+malarial or a syphilitic factor in the production of the malady.
+In the former case, we hope to cure the patient either with
+quinine or arsenic, with almost magical certainty and rapidity;
+in the latter, we expect an almost equally brilliant result from
+iodide of potassium.</p>
+
+<p>The particular nerve in which the neuralgia is seated does
+not so decidedly influence the prognosis, according to my experience,
+as is stated by some authors; nevertheless, there are
+differences of this kind. For instance, sciatica, though by no
+means so frequently a mild and trifling complaint as Eulenburg
+would make it to be, is certainly, on the whole, more
+curable than the trigeminal neuralgias taken as a group. I,
+however, cannot share Eulenburg's opinion as to the rarity of
+a central cause for sciatica, nor his consequent explanation of
+its more frequent curability; the latter I explain by the fact
+that it is possible far more completely to remove the concomitant
+causes in sciatica than in trigeminal neuralgia. By
+simply keeping a sciatic patient in the prone posture, shielded
+from cold and from pressure on the nerve, we have it in our
+power to remove nearly all peripheral sources of irritation;
+but in trigeminal neuralgia there are many influences, particularly
+psychical ones, which cannot be shut out, and which will
+continue to act with disastrous effect in many cases. With all
+this, however, we see a sufficiently large number of incurable
+sciaticas, on the one hand, and of severe trigeminal neuralgia
+cured on the other. It is only the genuine epileptiform tic,
+occurring in subjects whose arterial system is an advanced<span class="pagenum"><a name="Page_149" id="Page_149">[149]</a></span>
+stage of degeneration, that stands out clearly and unmistakably
+pre-eminent among neuralgias for rebelliousness to treatment
+of every kind.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="trea" id="trea"></a>CHAPTER V.</h2>
+
+<h3>TREATMENT OF NEURALGIA.</h3>
+
+
+<p>I now approach what is really the most difficult portion of
+my task; for, although it would be easy enough to write copiously
+on the treatment of neuralgia, it is extremely difficult to
+keep a just medium between the opposite extremes of undue
+meagreness and of useless profusion of detail in the handling
+of this subject. There are also difficulties connected with the
+present uncertain and transitional state of opinion, even
+among high authorities, as to the value of particular remedies,
+and even of large groups of remedial agents, altogether there
+has been more hesitation in my mind as to this part of the
+present work than about any other, and the present chapter
+has been rewritten more than once. I mention this only to
+account for what there may very likely be found in it&mdash;an
+imperfect literary style such as too commonly marks work which
+has been repeatedly patched and corrected. At the same time,
+it should be said that my hesitation does not apply to the main
+principles of treatment which will be recommended below; it
+proceeds rather from the fear of seeming to ignore from carelessness
+modes of treatment which are still much used, but
+which I have really rejected, because, after full trial, they
+appeared to me valueless. Space is, after all, limited, and a
+complete account of all the remedies for neuralgia in vogue,
+in English and Continental clinics, would of itself fill a large
+volume.</p>
+
+<p>The treatment of neuralgia may be divided into four
+branches: (1) Constitutional remedies; (2) narcotic-stimulant
+remedies; (3) local applications; (4) prophylaxis.</p>
+
+<p>1. Constitutional treatment must be subdivided, as (<i>a</i>) dietetic,
+(<i>b</i>) anti-toxic, and (<i>c</i>) medicinal tonic.</p>
+
+<p>(<i>a</i>) The importance of a greatly-improved diet for neuralgic
+patients is a matter which is more fully appreciated by the
+English school of medicine than by either the French or the
+German; it has, for instance, very much surprised me to
+notice the almost entire silence of Eulenburg on this topic.
+For my part, the opinions expressed three years ago<a name="FNanchor_35_35" id="FNanchor_35_35"></a><a href="#Footnote_35_35" class="fnanchor">[35]</a> on this
+matter have only been modified in the direction of increasing
+<span class="pagenum"><a name="Page_150" id="Page_150">[150]</a></span>
+certainty; I have learned by further experience that the principle
+is even more extensively applicable than I had supposed.</p>
+
+<p>That neuralgic patients require and are greatly benefited by a
+nutrition considerably richer than that which is needed by
+healthy persons, is a fact which corresponds with what may
+be observed respecting the chronic neuroses in general; and it
+gives me much satisfaction to point out this position of neuralgia
+as belonging to this large class of disorders, not merely
+by its pathological affinities, but by its nutritive demands. In
+a very excellent and suggestive paper by Dr. Blandford<a name="FNanchor_36_36" id="FNanchor_36_36"></a><a href="#Footnote_36_36" class="fnanchor">[36]</a> it is
+stated, as the result of a large experience in mental and other
+nervous disorders, that the greater number of chronic insane
+and hypochondriacal cases, as well as neuralgic patients, are
+remarkably benefited by what might seem at first sight almost
+a dangerously copious diet. Occasionally it happens that the
+patients discover this by the teaching of their own sensations,
+and the apparent excesses in eating which some epileptic and
+hypochondriacal persons habitually commit are looked on by
+many practitioners as the mere indications of a morbid <i>bulimia</i>
+which represents no real want, but only the craving of a perverted
+sensation which ought to be interfered with and allayed
+rather than encouraged. It is now many years since I began
+to doubt the justice of this opinion; the particular instance
+which called my attention to it being that of epilepsy, of which
+disease I saw a considerable number of cases, within a short
+period of time, that were distinguished by the presence of
+enormous appetite for food; and I finally came to the conclusion
+that, so far from this symptom being of evil augury, and
+likely to lead to mischief, it is, with certain limitations, a most
+fortunate occurrence. It is hardly necessary to say that over-eating,
+such as produces dyspepsia and distention of a torpid
+intestine with masses of fęces, may distinctly aggravate the
+convulsive tendency; but the truth is that, with a little careful
+direction and management of the unusual appetite, these bulimic
+patients can in most cases be allowed to satisfy their desires
+without harm of this kind following; a larger portion of food
+really gets applied to the nutritive needs of the body, and the
+nervous system unmistakably benefits thereby, the tendency
+to atactic disorder being visibly held in check.</p>
+
+<p>That which I have thus observed in the case of epilepsy, and
+which Dr. Blandford more particularly affirms concerning
+chronic mental diseases and the large number of neuroses that
+hover on the verge of insanity, has been most distinctly verified
+in my experience of the treatment of neuralgia. It is,
+unfortunately, by no means a frequent occurrence that the
+sufferer from this malady is inclined to eat largely, but the
+few patients of this type that I have seen were, in my judgment,
+<span class="pagenum"><a name="Page_151" id="Page_151">[151]</a></span>
+distinctly the better for it. Far more common in neuralgia
+is a disposition of the patient to care little for food, to
+become nice and dainty, and in particular to develop an aversion&mdash;partly
+sensational and partly the result of morbid fear
+about indigestion&mdash;for special articles of diet. Dr. Radcliffe
+pointed out the special tendency of neuralgics to neglect all
+kinds of fat; partly from dislike, and partly because they
+believe it makes them "bilious;" and I have had many occasions
+to observe the correctness of this observation. In fact,
+by the time patients have become sufficiently ill with neuralgia
+to apply to a consulting physician, they have already, in
+the great majority of cases, got to reject all fatty foods, and
+have cut down their total nutriment to a very sufficient standard.
+Young ladies suffering from migraine are especially apt
+to mismanage themselves, to a lamentable extent, in this direction:
+this is natural enough, because the stomach disorder
+seems to them the origin of the pain, instead of being, as it is,
+a mere secondary consequence of the neurosis. But it is not
+only the sufferers from sick-headache in whom we find this
+tendency to insufficient eating, especially of fat; not to mention
+that all severe pain usually tends to disorder appetite and
+make it fastidious, there is nearly always some wiseacre of a
+friend at hand, ready to suggest that neuralgia is something
+very like gout, that gout is always aggravated by good living,
+and, <i>ergo</i>, that the patient should be "extremely cautious as
+to diet;" the end of which is that the poor wretch becomes a
+half-starved valetudinarian, but, so far from his pain getting
+better, it steadily becomes worse. I cannot too strongly express
+the benefits that I have seen accrue, in the most various kinds
+of neuralgic cases, from persistent efforts to remedy this state
+of things, and to convert the patient from a valetudinarian to
+a hearty eater; and I wish particularly to say that this success
+has always been most marked when I have from the first
+insisted on fat forming a considerable element of the food.
+Cod-liver oil is the form in which I much prefer to give it, if
+this be possible; there can be no mistake about the relatively
+greater power of this than of any other fatty matter, I believe
+simply from its great assimilability. But the very cases in
+which we most urgently desire to give fat are often those in
+which the patient's fantastic stomach openly revolts at the
+idea of the oil; we must then try other fats; and we should go
+on trying one thing after another&mdash;butter, plain cream, Devonshire
+cream, even olive or cocoanut oil (though these are the
+poorest things of the sort we can use)&mdash;till we get the patient
+well into the way of taking a considerable, if possible a decidedly
+large, daily allowance of fat, without provoking dyspepsia.
+It is surprising what can be done in this way by perseverance
+and tact, and it is no less striking to observe the good
+effects of the treatment. Nothing is more singular than to see<span class="pagenum"><a name="Page_152" id="Page_152">[152]</a></span>
+a girl, who was a peevish, fanciful, and really very suffering
+migraineuse, brought to a state in which she will eat spoonful
+after spoonful of Devonshire cream, and at the same time lose
+her headaches, lose her sickness, and develop the appetite of a
+day-laborer; and, though such very marked instances as this
+are uncommon, they do sometimes occur, and a minor but
+still important degree of improvement is very frequent.</p>
+
+<p>As for the <i>modus operandi</i> of the fatty food, there is no certainty.
+Dr. Radcliffe believe it acts as a direct nutrient of the
+nervous centres; and I also cannot help feeling that there is
+some evidence in favor of this idea. But, whether this be so
+or not, there is another kind of action of fat that is more simple
+and obvious; namely, it seems to be certain that the enrichment
+of the diet by fat greatly assists the assimilation of
+food in general, and thus the patient's nutrition is altogether
+improved.</p>
+
+<p>It is not merely, however, by increasing any one element of
+food that we should seek to enrich the diet of neuralgics, but
+rather by such a steady and persistent effort as Dr. Blandford
+describes, to increase the total quantity of nutriment to perhaps
+as much as one-third more than the patient would probably
+have taken in health. To those who from prejudice are incredulous
+of the propriety of this method, I would say, "Try
+it, and I venture to say your incredulity will disappear."
+More especially I would urge the great importance of this
+system in modifying the nervous status of very young, and
+also of aged, sufferers from neuralgia; it is the indispensable
+basis of a sound treatment for such patients.</p>
+
+<p>This seems the proper place for such remarks as must be
+made upon the function of alcohol in neuralgia; for, though
+this agent is a true narcotic when given in large doses, it is not
+under that aspect that I can recommend its use in neuralgia at
+all. I have written so much on this subject lately, that I shall
+here content myself with an emphatic repetition of my protest
+against the use of alcoholic liquors as direct remedies for pain.
+They ought only to be given, in neuralgia, in such moderate
+doses, with the meals, as may assist primary digestion without
+inducing any torpor, or flushing of the face, or artificial exhilaration.
+I cannot too expressly reprobate the practice of
+encouraging neuralgics, especially women, to relieve pain and
+depression by the direct agency of wine or spirit; it is a system
+fraught with dangers of the gravest kind.</p>
+
+<p>(<i>b</i>) The anti-toxic remedies include agents addressed to the
+modification of a special condition of the blood and tissues
+induced by the presence of morbid poisons, of which syphilis,
+malaria, and (more doubtfully) gout and rheumatism, are the
+representative examples.</p>
+
+<p>Of syphilitic neuralgia the treatment may be summed up in
+a few words: Give iodide of potassium in doses rapidly<span class="pagenum"><a name="Page_153" id="Page_153">[153]</a></span>
+increased up to a daily quantum of twenty to thirty grains. If
+this fails, give one-twelfth of a grain of bichloride of mercury
+thrice daily.</p>
+
+<p>Of malarial neuralgia I can only speak from such a limited
+experience that I am by no means in a position to give an
+exhaustive account of the treatment. Quinine is, of course,
+the remedy that should first be tried; and, as the paroxysms
+are usually regular in their recurrence, I prefer to give the
+drug after the plan which is, I think, incontestably the best in
+ordinary ague&mdash;<i>i.&nbsp;e.</i>, to administer one large dose (five to
+twenty grains) about an hour before the time when the attack
+is expected. With a few exceptions the malady, unless it had
+taken very deep root before we were consulted, will yield to a
+few doses given in this way; after the morbid sequence has
+been thus interrupted, it will be proper to continue the action
+of quinine in smaller and more frequent doses, given for three
+or four weeks continuously. For the comparatively rare cases
+in which quinine fails, the prolonged use of arsenic (Fowler's
+solution, five to eight minims three times a day), especially
+with the simultaneous employment of cod-liver oil, is to be
+recommended.</p>
+
+<p>The part which gout may play in inducing neuralgia is, as I
+have already said, a far more doubtful question than the popular
+medical traditions assume it to be; and treatment directed
+to gout as a cause is an extremely uncertain affair. The direct
+relief of neuralgic pain by the administration of colchicum, for
+example, is, in my experience, a very rare occurrence, even
+where the gouty diathesis is unmistakably present; and, on
+the other hand, the depressed vitality which gouty neuralgics
+usually show in a marked degree, renders it very doubtful
+whether the relief of the pain may not be too dearly purchased
+at the cost of the general lowering effects of colchicum. It is
+probable that neuralgia occurring in gouty subjects is more
+safely, and equally effectually, treated upon general principles.
+At the same time it may be admitted that, in the subordinate
+function of an adjuvant to the aperients which it is sometimes
+advisable to give, small doses of the acetic extract of colchicum
+seem to possess some value.</p>
+
+<p>The question of treatment addressed to a supposed rheumatic
+element in neuralgia will, of course, be differently judged
+according to the respective ideas of various practitioners as to
+the pathological affinities of the two diseases; and the reader
+already knows that I believe these affinities to be different in
+kind from what is generally believed. The utmost that I
+should concede is, that in a certain very limited number of
+cases the peripheral factor in neuralgia is an inflammation of
+the nerve-sheath, or surrounding tissues, which forms part of a
+chain of phenomena of local fibrous inflammations in different
+parts of the body. Iodide of potassium, in five or ten grain<span class="pagenum"><a name="Page_154" id="Page_154">[154]</a></span>
+doses three times a day, is the proper treatment for such cases.
+I have never found alkalies do any direct good to the pain.</p>
+
+<p>(<i>c</i>) The medicinal tonic variety of constitutional treatment is
+more especially represented by the use of iron and arsenic in
+cases where poverty of the blood seems to exist in a marked
+degree, and by the administration of certain tonics&mdash;quinine,
+phosphorus, strychnia, and zinc&mdash;which are supposed to exert
+a specially restorative influence upon the nervous tissues.</p>
+
+<p>The use of quinine as an anti-malarial agent has been already
+referred to; its employment in non-malarial cases is of much
+more restricted scope and benefit. Experience has taught me
+to agree in general with the opinion of Valleix, that it is a
+very unreliable agent; the one marked exception to this being
+the case of ophthalmic neuralgias. What the reason may be
+I cannot in the least say, but it is a fact that quinine does benefit
+these neuralgias, in cases where there is no room for suspicion
+of malaria, with a frequency which is very much greater
+than in the treatment of the painful affections of any other
+nerve in the body. The quantity given should be about two
+grains three times a day.</p>
+
+<p>The preparations of phosphorus which I have employed in
+the treatment of neuralgia are the phosphuretted oil, the hypophosphite
+of soda (five to ten grains three times a day), and
+pills of phosphorus (according to Dr. Radcliffe's recommendation)
+containing one-thirtieth of a grain, given twice or thrice
+daily. Either of the two last will do all that phosphorus can
+do, but its utility is not very extensive or reliable. I have
+found it to do most good in cases where there was a high
+degree of anęsthetic complication.</p>
+
+<p>Preparations of zinc have, in my hands, done no particular
+good, although I have tried them in all manner of doses.</p>
+
+<p>Strychnia, on the other hand, is a remedy which I have
+learned to prize much more highly during the last few years
+than previously. Its most decided efficacy has been shown in
+some of the visceralgię, especially gastralgia, and (to a less
+extent) angina pectoris. Its internal use for these complaints
+is best effected by giving doses of five to ten minims of tincture
+of nux-vomica three times a day; but a method which I have
+several times employed with good effect is the subcutaneous
+injection of very small doses of strychnia (one-eightieth to one-fiftieth
+of a grain) twice daily. For the superficial neuralgias,
+on the other hand, I generally administer one-fortieth of a
+grain, with ten or fifteen minims of tincture of sesquichloride
+of iron, by the stomach, three times a day; this is a very powerful
+prophylactic remedy to prevent the recurrence of the
+attacks when once the sequence of them has been broken
+through by other means.</p>
+
+<p>Of iron generally, as a remedy in anęmic cases, I have only
+to remark that, in order to get its full benefits, it is necessary<span class="pagenum"><a name="Page_155" id="Page_155">[155]</a></span>
+to use large doses. I give the saccharated carbonate in twenty-grain
+doses twice or three times a day.</p>
+
+<p>But of the sesquichloride of iron I am inclined to say something
+more; it has seemed to me that, besides its effects on the
+blood, it has a marked and direct influence upon the nervous
+centres, which is different from anything which one observes
+in the action of other preparations of iron. It is certain that
+the action of sesquichloride of iron, in those cases of chlorosis
+which are distinguished by profound nervous depression, is
+something quite peculiar; and the effect which it produces in
+the anęmic neuralgias, more especially of young women, is
+equally remarkable. I cannot help alluding here to the
+striking effects which large doses of the tincture, as recommended
+by Dr. Reynolds, produce in acute rheumatism; the
+severest pain is often checked within twenty-four hours after
+the commencement of this treatment. Both in this disease and
+in neuralgia, I employ the old-fashioned tincture: if given
+alone it should be used in large doses (thirty or forty minims
+three times a day); but an excellent combination is that,
+already mentioned, of ten-minim doses of this tincture with
+one-fortieth of a grain of strychnia. There is something in the
+revivifying effects of this mixture that is quite peculiar. I
+have very lately employed it in the case of a gentleman, aged
+thirty-five, who was the subject of frontal neuralgia complicated
+with paralysis of the internal rectus, and who was
+decidedly anęmic, and greatly depressed and worried in mind
+by the consciousness of his inability to overtake professional
+work which had accumulated upon him. This patient improved
+with great rapidity, and in the course of three weeks lost, not
+merely his neuralgia, but also his strabismus, almost entirely;
+but he then got into a condition which, though not of permanent
+importance, was sufficiently undesirable to make me
+mention it here, especially as I have seen the same thing in
+more than one patient besides him. It is a peculiar state of
+restlessness during the day and sleeplessness at night, without
+any positive exaltation of reflex excitability such as one used
+to see from strychnia in the days when mischievously large
+doses of that drug were very commonly given, and patients
+used to complain of decided twitchings and startings of the
+limbs. It is clearly not a strychnia effect pure and simple,
+nor an iron effect only; it is a <i>tertium quid</i> compounded of
+the actions of both drugs.</p>
+
+<p>The direct effects of arsenic in the improvement of the
+quality of the blood seem to me incontestable; and its use for
+this purpose in anęmic neuralgias is certainly something over
+and above its special neurotic action. No one, who has
+employed it much in the cases of anęmic children suffering
+from chorea after rheumatism, can have failed to observe its
+frequently striking influence upon blood-formation even long<span class="pagenum"><a name="Page_156" id="Page_156">[156]</a></span>
+before the nervous ataxia is materially reduced. The misfortune
+is, however, that we possess no indications by which to
+judge beforehand whether we may reckon on its most favorable
+action in any given (non-malarious) case, with certain
+special exceptions. In angina pectoris it has a most direct
+effect, which is rarely altogether missed, and is sometimes
+surprising: the cases in which it succeeds best are those distinguished
+by anęmia, but we may well suppose, from its
+remarkable action upon other neuroses of the vagus, that it is
+something more than an action on the blood-making process
+which produces such powerful effects in allaying the tendency
+to recurrence of the paroxysms. My attention was called to
+its action in this disease chiefly by the remarkable case published
+by Philipp;<a name="FNanchor_37_37" id="FNanchor_37_37"></a><a href="#Footnote_37_37" class="fnanchor">[37]</a> this was a purely neurotic angina, but one
+of the severest type, and the influence of arsenic was very
+striking. Since that time I have employed it in several cases,
+and, after trying various forms of administration, I conclude
+that nothing is better than Fowler's solution, in doses of three
+minims (gradually increased, if the remedy be well tolerated,
+up to eight or ten) three times a day. Unfortunately, there
+are some neurotic patients who cannot bear arsenic, the irritability
+of their alimentary canal is such that the drug always
+provokes vomiting, or diarrh&#339;a, or both; this was the case
+with one of my patients, in whose case I had allowed myself to
+hope for the very best results from arsenical treatment. But
+where the patient tolerates it&mdash;and usually he tolerates it
+extremely well&mdash;the prolonged use of arsenic seems really to root
+out the anginoid tendency, or at least to confine it to the more
+trivial and manageable manifestations. I believe that in at least
+three patients, I have so completely broken down a succession
+of cardiac neuralgic attacks as to substitute for them a mere
+remnant of a tendency to "tightness at the chest" after any
+severe bodily exertion or mental emotion. It might be a question,
+in cases where the stomach does not tolerate the
+ordinary administration of the agent, whether it would
+not be worth while to try the effect of subcutaneous
+injection (two to four minims of Fowler), or inhalation of the
+smoke of arsenical cigarettes. But, in truth, it is not certain
+that even in this case we escape the characteristic effects of
+the drug upon those persons who are abnormally sensitive to it.</p>
+
+<p>A remarkable instance of the beneficial influence of arsenic
+occurred in the case of a woman, aged forty-six, the solitary
+example of severe angina in a female that I have ever seen.
+[It is by no means uncommon, however, to see the milder
+forms of cardiac neuralgia in women; the remarkable statistics
+of Forbes, quoted in Chapter I., must certainly have been
+taken exclusively from cases of the severest type of the disease.]
+<span class="pagenum"><a name="Page_157" id="Page_157">[157]</a></span>
+This was a hospital patient, who had always suffered much
+from hysteria, and from childhood had been liable to hemicranic
+headache; she had entered on the period of "change"
+at the time the attacks began, but menstruation, though irregular,
+still continued, and, in fact, did not cease till four years
+later, long after the anginal attacks had been subdued. The
+patient had been attacked for the first time at the end of a
+heavy day's washing; she dropped on the ground with the
+sudden agony and faintness, and thought she should "never
+come to life again." The paroxysms returned five times within
+the next month, though not always so severely as on the first
+occasion; but the poor woman lived in a constant state of
+terror. On the occasion of her second visit to me, she had a
+most severe attack in the waiting-room at the hospital: being
+called to her I found her very nearly pulseless, gasping, and
+with the kind of complexion which is so suggestive of approaching
+death. She was recovered by a large dose of ether. It
+was a rather uncommon feature in this case that the pain was
+only at and around the lower end of the sternum, except that
+occasionally it shot along the sixth intercostal space. The
+employment of Fowler's solution (in doses gradually mounting
+to twenty-one minims daily) for six months completely eradicated
+the anginal tendency; the proof that it was a real therapeutic
+effect was given by the result of an attempt to leave the
+medicine off at the end of eight weeks' treatment; the patient
+immediately began to suffer again. When she really left off,
+at the end of six months' treatment, she had had no tendency
+to heart-pang for more than a month, and, besides this, looked
+quite another creature in her improved vitality and vigor.
+Yet the menstrual troubles went on, and the function was not
+finally suppressed for a long time afterward.</p>
+
+<p>I suspect, however, that the most frequent successes with
+arsenic will, after all, be made in the cases of more or less
+anęmic male patients who are attacked with the neurotic
+form of angina in the midst of a career (as is especially the
+case with some professional careers) that implies not merely
+incessant labor, but great anxiety of mind. The drug does
+little good, however, if not positive harm, in that form of
+angina pectoris minor which is not the result purely of these
+causes, but of these, or some of these, plus the morbid action
+of the alcoholic excess, to which the patient has fled in order
+to relieve mental harassment and the fatigue that comes from
+overwork, especially overwork at tasks that are not congenial
+to his natural disposition; there is usually in such cases a
+heightened irritability of the alimentary canal, which is
+almost sure to cause arsenic to disagree: the really useful treatment
+is quinine for the first few days, and then, when the
+stomach will bear it, cod-liver oil in increasing doses, up to a
+large daily amount given for a long time together.<span class="pagenum"><a name="Page_158" id="Page_158">[158]</a></span></p>
+
+<p>On the whole, arsenic, from its singularly happy combination
+of powers as a blood-tonic, a special stimulant of the nervous
+system, and withal as a special opposer of the periodic
+tendency, must be regarded as one of the most powerful
+weapons in the physician's hands, and (although it seems to
+act best in the neuralgias of the vagus and of the fifth) there
+is a possibility of its proving the most effective remedy in
+almost any given case which may come before us.</p>
+
+<p>2. The narcotic-stimulant treatment for neuralgia includes
+some of the most powerful remedies for the disease which we
+possess. These remedies have very different properties, but
+they all agree in this, that in small doses they appear restorative
+of nerve-function&mdash;in large doses depressors of the same.</p>
+
+<p>Four very different types, at least, of narcotic-stimulant
+drugs are useful in neuralgia: (<i>a</i>) There is the opium type, by
+which pain is very directly antagonized, and, besides this,
+sleep is also directly favored. (<i>b</i>) There is the belladonna
+type, by which pain is also much relieved, though with far
+greater certainty in some regions than in others (<i>e.&nbsp;g.</i>, much
+the most powerful effect is seen in cases of pelvic visceralgia),
+but sleep is by no means so certainly or directly produced as
+by opium. (<i>c</i>) There is the chloral type, which is almost
+purely hypnotic; it is represented almost solely by chloral
+itself, which is resembled by scarcely any other drug. (<i>d</i>)
+There is bromide of potassium, which stands alone for its
+powerful action on the cerebral vaso-motor nerves, and which
+is useful in neuralgia simply by its power to check psychical
+excitement directly (through the circulation) and indirectly
+(through the production of sleep).</p>
+
+<p>(<i>a</i>) Opium and the remedies that resemble it are, for the treatment
+of neuralgia, fully represented by the hypodermic use
+of morphia, which is the only kind of opiate treatment that
+ought ever to be employed, save in very exceptional instances.
+The great reasons for the preference of the subcutaneous
+administration over the gastric are, the economy of the drug
+which it affects and the much smaller degree of disturbance
+of digestion which it causes. The hypodermic injection of
+morphia, if conducted on correct principles, enables us, when
+necessary, to repeat the dose a great number of times with but
+little loss of the effect, and consequently with a much smaller
+rate of progressive increase of the quantity required; and the
+absence of depressive action on digestion enables us to carry
+out simultaneously that plan of generous nutrition which has
+already been shown to be so important a part of treatment.
+Indeed, the case is hardly expressed with sufficient strength,
+when we say that hypodermic morphia is usually harmless to
+the digestive functions; for in a great number of instances it
+will be found actually to give an important stimulus both to
+appetite and digestion; and the patient, who without its aid<span class="pagenum"><a name="Page_159" id="Page_159">[159]</a></span>
+could hardly be persuaded to take food at all, will not unfrequently
+eat a hearty meal within half an hour after the injection.</p>
+
+<p>The remarkable effects of hypodermic morphia have, however,
+caused it to be rashly and indiscriminately used, and so
+much harm has been done in this way that it is necessary to
+be exceedingly careful in the rules which we lay down for its
+employment. Upon these grounds I must hope to be excused
+if, in order to render this work complete, I repeat a good deal
+of what I have already said in other places. In the first place,
+I shall speak of the mode of administration, and then of the
+dose.</p>
+
+<p>As regards the mode of administration, I prefer the use of a
+solution of five grains of acetate of morphia to the drachm of
+distilled water; if the acetate be a good specimen, this will
+dissolve easily (and keep some time without precipitation)
+without the use of any other solvent. With a solution of
+this strength we require nothing elaborate in the form of the
+syringe; a simple piston arrangement does well; only it is
+advisable that the tube shall have a solid steel triangular
+point, and a lateral opening. As regards the place of injection,
+I must repeat the opinion<a name="FNanchor_38_38" id="FNanchor_38_38"></a><a href="#Footnote_38_38" class="fnanchor">[38]</a> which I have already published,
+that Mr. Hunter's plan of injection at an indifferent
+spot is, in the great majority of instances, fully as effective as
+the local injection would be; nevertheless, there is one consideration
+which in some cases may properly induce us to
+adopt the latter plan. Very nervous and fanciful patients
+will sometimes be much more readily brought to allow the
+operation when it seems to go directly to the affected spot,
+when they would be sufficiently incredulous of the benefits of
+an injection performed at a distance to indulge their dislike of
+incurring pain by refusing to submit to it. And there is one
+class of cases in which it is likely that there are real physical
+advantages in the local injection; in instances of old-standing
+neuralgia with development of excessively tender "points,"
+which are also the foci of the severest pain, it will sometimes
+be advisable to inject into the subcutaneous tissue at these
+points. There is undeniable reason for thinking that the sub-inflammatory
+thickening of tissues around a certain point of
+nerve delays the transit of the morphia into the general circulation,
+and enables it to act more directly and powerfully on
+the nerve, which it thus renders insensitive to external impressions;
+an important respite is thus gained, during which the
+nerve-centre has time to recover itself somewhat. At the
+same time it must be remarked that this immediate injection
+<span class="pagenum"><a name="Page_160" id="Page_160">[160]</a></span>
+of a tender point is apt to be exceedingly painful, and it may
+be absolutely necessary to apply ether-spray before using the
+syringe. In early stages of neuralgia, before the formation of
+distinct tender points, there is no advantage whatever (except
+the indirect one above mentioned) in the local injection. And,
+on the other hand, it is often of great consequence not to run
+the chance of disfiguring such a part as the face, the neck,
+etc., when the injection can easily be done over the deltoid, or
+in the leg, or in some other part which even in women is
+habitually covered by the dress.</p>
+
+<p>The dose to be employed is an exceedingly important
+matter, and one as to which practitioners are still very often
+injudicious. We ought never to commence with a larger dose
+than one-sixth of a grain; but very often as little as one-twelfth
+of a grain will give effective relief, and in not very severe
+cases it is well worth while to try this smaller quantity.
+When no larger quantity than one-sixth of a grain is employed
+we commonly observe no narcotic effects, <i>i.&nbsp;e.</i>, there is no
+contraction of pupil, no heavy stupor, and, although the
+patient very often falls asleep, on waking he does not experience
+headache, nor is his tongue foul. I cannot too strongly
+express the opinion that it is advisable by all means to content
+ourselves with this degree of the action of hypodermic morphia,
+unless it fails to produce a decided impression on the pain.
+But in very severe cases our small doses will fail; and then,
+rather than allow the patient to continue having severe paroxysms
+unchecked, we must frankly admit the necessity of
+using a narcotic dose from one-quarter to one-half of a grain,
+according to circumstances. Whatever actual dose be
+employed, it is important not to repeat it with unnecessary frequency;
+once a day in the milder, and twice a day in the more
+severe cases, will be all that is advisable, save in very exceptional
+cases: the point being to administer it as quickly as possible
+after the commencement of an exacerbation. If by these
+means we can prevent the patient having any severe pains
+during a period of several days, we often give time to the
+affected nerve to recover itself so completely, especially with
+the aid of other measures to be presently mentioned, that the
+tendency to neuralgia is completely broken through, and we
+can drop the injections, either at once or by rapid diminution
+of the dose, and thereafter treat the case merely with tonics,
+and with the precautionary measures to be dwelt upon under
+the heading of Prophylaxis. But, if we have been driven to
+the use of distinctly narcotic doses, and these do not very
+speedily break the chain of neuralgic recurrence, it will not do
+to continue to rely upon hypodermic morphia; it will be best to
+try some of the local remedies (blistering, galvanism) with it.
+If this combination fails, we should then try the effect of atropine,
+the sulphate of which, hypodermically injected, fully<span class="pagenum"><a name="Page_161" id="Page_161">[161]</a></span>
+represents for all useful purposes the mydriatic class of narcotics.</p>
+
+<p>(<i>b</i>) The commencing hypodermic dose of atropine should be
+one-one hundred and twentieth grain; it is not often that so
+small a quantity will do any good, but it is necessary to use
+this agent with great precaution, as we occasionally meet with
+subjects in whom extremely small doses provoke most uncomfortable
+symptoms of atropism, as dry throat, dilated pupil,
+delirium, and scarlet rash. Commonly we shall find ourselves
+obliged to increase the dose to one-sixtieth, one-fiftieth, or one-thirtieth
+of a grain; and in a very few cases it may be necessary
+to go even as high as the one-sixteenth or one-twelfth.
+In my experience such instances are excessively uncommon;
+and I cannot but suppose that the practitioners who use the
+high doses frequently must inject in such a manner as to fail
+to get the whole dose taken up. [Absolutely inexplicable to
+me is the statement of the illustrious Trousseau&mdash;that hypodermic
+remedies are "less active" (!) than gastric remedies&mdash;except
+on his hypothesis.]</p>
+
+<p>The most remarkable effects that I have seen from hypodermic
+atropia were obtained in cases of peri-uterine neuralgia,
+especially dysmenorrh&#339;al neuralgia. Speaking generally of
+atropine, it must undoubtedly be counted far inferior to morphia
+as a speedy and reliable reliever of neuralgic pain, but for
+all pelvic neuralgias it appears to me on the whole to surpass
+morphia. And besides this, in other neuralgias, where opiates
+altogether disagree (as with some subjects they do), it is not
+uncommon to find that atropia acts with exceptionally good
+effect. And to some extent I am inclined to confirm Mr. Hunter's
+opinion, that, where atropia does stop neuralgia, it does so
+more permanently than morphia.</p>
+
+<p>There is another special use of hypodermic atropine which I
+have not seen mentioned by any one but myself, but which is
+probably very important, namely, in ophthalmic neuralgia
+where acute iritis, or especially glaucoma, seems coming on.
+I may be mistaken, but I believe that in three cases I have succeeded,
+by prompt injection of sulphate of atropine (one-sixtieth
+to one-fortieth of a grain), in saving a neuralgic eye from
+damage, and possibly from destruction, from impending
+glaucoma.</p>
+
+<p>(<i>c</i>) The class of cases for which merely hypnotic remedies
+are of much value is limited; nevertheless, in the milder kinds
+of migraine and clavus, especially when they have been brought
+on or are kept up by mental worry or hysterical excitement,
+these remedies will sometimes prove very useful. In former
+days, before we knew chloral, I used to employ camphor for
+this purpose; three or four grains being administered every two
+hours: and in hysterical hemicrania of a not very severe type
+this not unfrequently produced a short sleep, from which the<span class="pagenum"><a name="Page_162" id="Page_162">[162]</a></span>
+patient awoke free from the pain. But chloral infinitely transcends
+in value any agent of this kind that was known before.
+Perfectly valueless for the really severe neuralgias, it is of the
+greatest possible use as a palliative in migraine and clavus,
+where the great object, for the moment, is to get the patient to
+sleep. A single dose of twenty to thirty grains will often
+effect our object: it may be repeated in two hours if sleep has
+not been induced; it should be given as soon as the pain has at
+all decidedly commenced.</p>
+
+<p>And here I wish to make some special remarks on the subject
+of "palliation," and the relation it bears to "cure." Nothing
+is more common than to read serious admonitions, in
+medical works, about the folly of trusting to remedies which
+only palliate for the moment but leave the root of evil
+untouched; and, of course, there is a certain respectable modicum
+of the fire of truth behind all this orthodox smoke. In
+the case of neuralgia, however, it is most important to understand
+that mere palliation, that is, stopping of the pain for the
+moment, may be either most useful or highly injurious, according
+to the way in which it is done. The unnecessary induction
+of narcosis for such a purpose, doubtless, is most reprehensible;
+but if it were possible simply to produce sleep from
+which the patient should awake refreshed, without any narcotic
+effects, then, certainly, that sort of palliation must be good.
+That is precisely what the judicious use of chloral does; and I
+may mention, as resembling though not equalling it, the action
+of Indian hemp, which has been particularly recommended by
+Dr. Reynolds. From one-fourth to one-half of a grain of good
+extract of cannabis, repeated in two hours if it has not produced
+sleep, is an excellent remedy in migraine of the young.
+It is very important, in this disease, that the habit of long
+neuralgic paroxysms should not be set up; and if the first two
+or three attacks are promptly stopped, by the induction of
+sound, non-narcotic sleep, we may get time so to modify the
+constitution, by tonics and general regimen and diet, as to
+eradicate the neuralgic disposition, or at least reduce it to a
+minimum. But I would decidedly express the opinion that
+such remedies as either opium or belladonna are mostly unsuited
+to this purpose. If the migraine of young persons does not
+yield to chloral, to cannabis, or to muriate of ammonia (in
+twenty or thirty grain doses), it will not be advisable to ply the
+patient with any remedies of the narcotic-stimulant class, but
+to trust to tonic regimen and the use of galvanism.</p>
+
+<p>The mention of muriate of ammonia, which, for migraine
+and clavus and the milder forms of sciatica, not unfrequently
+proves useful in stopping the violence of a paroxysm and
+enabling the patient to get some refreshing sleep, leads me to
+notice that not only may a variety of the milder narcotic-stimulants
+be employed in this way, but the external stimulus<span class="pagenum"><a name="Page_163" id="Page_163">[163]</a></span>
+of heat to the extremities (very hot pediluvia) greatly assists
+the action of any such remedies; especially if mustard-flour be
+added, so that a mild vapor of mustard rises with the steam
+and is inhaled. Perhaps the ideal medication, to arrest a bad
+sick-headache, is to give twenty grains of chloral, and make
+the patient plunge his feet in very hot mustard-and-water and
+breathe the steam. He can hardly fail to fall asleep for a
+longer or shorter time, and awake free from pain.</p>
+
+<p>(<i>d</i>) The use of bromide of potassium in neuralgia is a subject
+of great importance, and which requires much attention
+and discrimination. In common with, I dare say, many others,
+I made extensive trial of this agent when it first began to be
+much talked of, but was so much disappointed with its effects
+in neuralgias, that at one time I quite discarded it in the treatment
+of those affections. Renewed experience has taught me
+however, that, though its use is restricted, it is extremely
+effective if given in appropriate cases and in the right manner.
+For the great majority of neuralgias it is quite useless, and,
+what is more, proves often so depressing as indirectly to
+aggravate the susceptibility of the nervous system to pain.
+The conditions, <i>sine quis non</i>, of its effective employment seem
+to be the following: The general nervous power, as shown by
+activity of intelligence, and capacity of muscular exertion and
+the effective performance of co-ordinated movements, must
+be fairly good, find the circulation must be of
+at least average vigor; the patient must not have entered on
+the period of tissue-degeneration. Among neuralgics who
+answer to this description, those who will benefit by the
+bromide are chiefly subjects&mdash;especially women&mdash;in whom a
+certain restless hyperactivity of mind and perhaps of body also,
+seems to be the expression of Nature's unconscious resentment
+of the neglect of sexual functions. That unhappy class, the
+young men and young women of high principle and high
+mental culture to whom marriage is denied by Fate till long
+after the natural period for it, are especial sufferers in this way
+and for them the bromide appears to me a remedy of almost
+unique power. But I wish it to be clearly understood that it is
+not to the sufferers from the effects of masturbation that I
+think the remedy specially applicable: on the contrary, it is
+rather to those who have kept themselves free from this vice,
+at the expense of a perpetual and almost fierce activity of mind
+and muscle. The effects of solitary vice are a trite and vulgar
+story; there is something far more difficult to understand
+and at the same time far more worth understanding
+in the unconscious struggles of the organism of a pure minded
+person with the tyranny of a powerful and unsatisfied sexual
+system. It is in such cases, which it heeds all the physician's
+tact to appreciate, that it is sometimes possible to do striking
+service with bromide of potassium; but it will be necessary to<span class="pagenum"><a name="Page_164" id="Page_164">[164]</a></span>
+accompany the treatment with strict orders as to generous
+diet, and, very likely, with the administration of cod-liver
+oil.</p>
+
+<p>Having decided that bromide of potassium is the proper
+remedy, we must use it in sufficient doses. Not even epilepsy
+itself requires more decidedly that bromide, to be useful, shall
+be given in large doses. It is right to commence with moderate
+ones (ten to fifteen grains), because we can never tell,
+beforehand, that our patient is not one of those peculiar subjects
+in whom that very disagreeable phenomenon&mdash;bromic acne&mdash;will
+follow the use of large doses. But we must not expect
+good results till we reach something like ninety grains daily.
+Let me add that it is not so far as I know, by reducing any
+"hyperęsthesia" of the external genitals, of which the patient
+is aware, that the remedy acts; I have not seen such a nexus
+of disease and remedy in these cases.</p>
+
+<p>3. Local Measures.&mdash;The external remedies which may be
+applied for the treatment of neuralgia may be divided into (<i>a</i>)
+skin-stimulants; (<i>b</i>) paralyzers of peripheral sensory nerves;
+(<i>c</i>) remedies adapted to diminish local congestion; (<i>d</i>) remedies
+adapted to diminish arterial pulsation; (<i>e</i>) electricity; (<i>f</i>)
+mechanical means of protection.</p>
+
+<p>(<i>a</i>) Among the skin-stimulants blisters hold the highest
+place as a remedy for neuralgia; indeed the assertion of Valleix,
+that they are the best of all remedies, is still not very wide
+of the truth. They are by no means universally applicable,
+and the degree to which their action should be carried varies
+materially in different forms of the disease, but they
+are of the greatest possible service in a large number of
+instances.</p>
+
+<p>It is possible to view the action of blisters in neuralgia in
+more than one way. When applied in such a manner as to
+vesicate decidedly, and especially if kept open and suppurating
+for some time, they cause considerable pain of a different kind
+from that of neuralgia itself and the mental effect of this,
+operating as a diversion of the patient's thoughts from his
+original trouble, may be thought to assist in breaking the chain
+of nervous actions by which he is made to feel neuralgic pain.
+There may be something in this, but I confess that I do not
+believe this kind of effect goes for much in genuine neuralgia.
+It is rather in the pain of hypochondriasis, and the so-called
+spinal irritation (to be described in the second part of this
+work), that such an action of blisters proves useful.</p>
+
+<p>Another action of blisters, which some authors hold to be
+perhaps the most effective portions of their agency, is that
+which is produced by the drain of fluid, specially when they
+are kept open, by which means a kind of depletion is set up,
+and the morbid irritation that causes the nerve pain removed.
+I cannot at all assent to this view. In the first place, I believe<span class="pagenum"><a name="Page_165" id="Page_165">[165]</a></span>
+that any one who has large experience of blistering in neuralgia
+will ultimately come, as Valleix did, to believe that prolonged
+drain from a blister is rarely or never useful, and that a
+far better plan is that of so-called flying blisters, renewed at
+intervals if necessary. The most genuine successes that I have
+procured from blistering have certainly been got in this way.
+But I should go further, and say that the prolonged drain and
+the peculiar kind of chronic irritation produced by a suppurating
+blistered surface can very decidedly aggravate a neuralgia;
+this is more especially the case when the blister is applied
+immediately over the focus pain.</p>
+
+<p>The view which I am strongly convinced alone explains the
+beneficial action of blisters is that which supposes them to
+act as true stimulants of nerve-function. In order that this
+effect shall be produced, it will be necessary that the skin-irritation
+be either produced at some distance from the seat of the
+greatest pain, or that, if applied in that spot, it shall be comparatively
+mild in degree. And accordingly, I have been led, in my
+observations to apply the blister at some distance from the
+focus of pain. An indifferent point, however, will not do&mdash;there
+must be an intelligible channel of nervous communication
+between the irritated portion of skin and the painful nerve.
+This object is accomplished by placing the blister as close as
+may be to the intervertebral foramen from which the painful
+nerve issues; the effect of this is probably a stimulation of the
+superficial posterior branches, which is carried inward to the
+central nucleus of the nerve. I must say that the results
+which I have derived from this plan of treatment have been far
+more satisfactory than those which I used to obtain when I habitually
+applied the vesication as near as might be to the focus of
+peripheral pain; and I think that this result tallies well with the
+idea that the essential mischief in neuralgia consists in an enfeebled
+vitality of the central end of the posterior root. An exceedingly
+interesting confirmation of this idea as to its <i>modus
+operandi</i> has been afforded me by the fact that not merely
+neuralgic pain, but also trophic and inflammatory complications
+attending it, have been sensibly relieved, in several cases
+that I have seen, by this mode of reflex stimulation. This has
+been particularly the case in herpes zoster, where the process of
+inflammation and vesiculation has been very promptly checked
+by the application of a tolerably powerful blister by the side of
+the spine at the proper level; and I am gratified to mention that
+Dr. J. K. Spender, of Bath, pointed out this fact<a name="FNanchor_39_39" id="FNanchor_39_39"></a><a href="#Footnote_39_39" class="fnanchor">[39]</a> at a time
+when he had only seen my statement that the pain could be
+relieved in this way. In the case of the trigeminus, the same
+kind of reflex stimulation is most effectively obtained by applying
+the blister over the branches of the cervico-occipital, at the
+<span class="pagenum"><a name="Page_166" id="Page_166">[166]</a></span>
+nape of the neck; and it is remarkable what powerful effects
+are sometimes thus produced, even in cases that wear the most
+unpromising aspect. For example, in the desperate epileptiform
+tic of old age, I have more than once seen a complete
+cessation of suffering, which lasted for a very long time&mdash;so
+long, in fact, as to make me hope against hope that it might
+never return. I do not now entertain any such expectations
+from this remedy; still, its value is very great.</p>
+
+<p>There are curious differences between the effects of blistering
+in trigeminal or intercostal neuralgia and in sciatica. On
+the whole, it would appear that blistering in the neighborhood
+of the spine is less frequently effective in the latter, and we
+sometimes, after failing with this method, obtain immediate
+success by two or three repetitions of the flying blister, somewhere
+over the trunk of the nerve, especially just outside the
+sciatic notch. I have one lady patient in whom this series of
+phenomena has several times been observed; and I have seen
+it occur in a particular attack, in other patients, in whom,
+nevertheless, on another occasion the spinal blistering has
+been promptly effective.</p>
+
+<p>I consider blistering of the posterior branches to be an
+important, and usually an essential, element in the treatment
+of all cases of sciatica in the middle period of life which have
+reached some severity and lasted long enough to become complicated
+with decided secondary affections.</p>
+
+<p>In all cases where blistering is employed it is advisable to
+adopt the simultaneous use of hypodermic morphia or atropine;
+this combination of remedies is exceedingly powerful.</p>
+
+<p>Lastly, it must be said of blistering, that, on the whole, it is
+a remedy not well fitted to be applied to aged subjects; and in
+its severer forms it should never be applied to patients who
+are greatly prostrated in strength. For it must be borne in
+mind that the remedy may miss its aim of relieving the neuralgia,
+in which case it is necessary to remember, more accurately
+than many practitioners appear to do, what a very
+serious element of misery and prostration will be introduced
+into the case by the vesication itself.</p>
+
+<p>I am not convinced that any of the other forms of severe
+skin-irritation (<i>e.&nbsp;g.</i>, tartar-emetic inunction, or the use of
+veratrine-ointment to such a degree as to produce not the
+anęsthetic but the irritant effects) are of any particular value;
+if blistering failed, I should not expect to see them succeed.</p>
+
+<p>A milder degree of skin-stimulation is represented by rubefacient
+liniments of various kinds, which may be briskly
+rubbed into the skin along the track of the painful nerve,
+without any danger of producing vesication. Among this
+class I continue to prefer chloroform diluted, with six or seven
+parts of chloroform, to any other; in the milder forms of neuralgia,
+especially in young persons and first attacks, it is surprising<span class="pagenum"><a name="Page_167" id="Page_167">[167]</a></span>
+how frequently the paroxysm may be greatly relieved,
+if not arrested. Still, this can only be regarded as the merest
+palliative; and in severer cases such applications are useless.
+Occasionally, when chloroform-liniment has failed, a mustard
+plaster will do good.</p>
+
+<p>The mildest degree of skin-stimulation is represented by the
+continuous application of moist warmth, which is best effected
+by the simple application of moistened spongio-piline; so far
+as I have observed, however, it is rather in cases of myalgia
+than in true neuralgia that this does good; in the latter it is
+probably little more than a mere protector against cold.</p>
+
+<p>(<i>b</i>) A variety of agents can be employed with the object of
+temporarily interrupting the conductivity of the painful nerve;
+by this means a period of rest is obtained during which the
+centres&mdash;sensory and psychical&mdash;have time to regain a juster
+equilibrium, and the habit of pain is, <i>pro tanto</i>, broken
+through.</p>
+
+<p>There is one agent of this class which for general purposes I
+do not think is worth retaining on our list of sensory paralyses&mdash;namely,
+cold. Cold, to be of any value, ought to be of the
+degree which is represented by ice allowed to melt slowly in
+contact with the skin; and for the majority of neuralgias this
+is decidedly inferior to other remedies that can be applied by
+painting or inunction. The one case in which ice is supremely
+useful is in neuralgia of the testis; here I make no doubt that
+it is almost, if not quite, the most useful remedy we can
+employ, although of course other means must be taken to
+modify the neuralgic temperament. It should be applied the
+moment an attack comes on.</p>
+
+<p>Far more useful, in neuralgias generally, is the external
+application of aconite or of veratrine. Aconite may be
+employed in the milder or the stronger form; in the former
+case, we simply paint the ordinary tincture on the skin over
+the painful nerves (avoiding any cracks or sores); in the latter,
+we rub in an ointment containing one grain of the best hydrate
+of aconitine to the drachm of lard, about twice a day, and to
+such an extent as to maintain complete numbness of the parts
+continuously, for two, three, or four days. I do not believe
+that this will ever, by itself, cure a true neuralgia of any considerable
+severity; but I have more than once known its intervention,
+at a crisis in treatment when it seemed that other
+remedies might fail, produce a striking change in the progress
+even of a very bad case.</p>
+
+<p>A milder, but still very useful form of the same kind of
+action, is produced by veratrine-ointment. I would recommend,
+however, as a rule, that it be employed, at any rate at
+first, of weaker strength than that recommended in the Pharmacop&#339;ia,
+for with some persons it is easy to pass the anęsthetic,
+and to enter on the irritant, action of veratrine upon<span class="pagenum"><a name="Page_168" id="Page_168">[168]</a></span>
+the skin. This leads me to give a caution that should properly
+have come earlier, when I was speaking of skin-stimulants. In
+aged subjects, especially, we rather frequently meet, in neuralgia,
+with a specially irritable state of the skin, even although
+there may be at the same time some loss of common and tactile
+sensation; and the practitioner must be warned against the
+danger of producing an amount of skin-irritation which will
+fearfully annoy his patient. I speak feelingly, having by
+such an indiscretion lost the richest patient who ever favored
+my consulting-room with his presence!</p>
+
+<p>The inunction of mild veratrine-ointment is extremely useful,
+as an adjunct to other treatment, in migraine and supra-orbital
+neuralgias of suckling women, and of chlorotic girls.
+I have also seen it do much good in mammary neuralgia.</p>
+
+<p>The last division of the subject of paralyzing agents in the
+treatment of neuralgia includes the surgical operations for
+division or resection of a painful nerve. Upon this question
+there is much difficulty in speaking decidedly. I admit at
+once, of course, that surgical interference is evidently indicated
+when, along with decided and intractable neuralgic pain,
+there is plain evidence either of the existence of a neuromatous
+tumor, or the presence of a foreign body impacted, or a
+tight cicatrix pressing upon a nerve. I admit, also, though
+with much greater qualifications, that carious teeth may need to
+be extracted before we can cure a neuralgia; but even here I
+should put in the decided caveat that we must consider whether
+the system is in a state to bear the shock, and that in any case
+we probably ought to mitigate the effects of the operation by
+performing it under chloroform. And I need hardly tell any
+one, who is familiar, either practically or from reading, with
+the subject, that thousands of carious teeth have been
+extracted from the mouths of neuralgic patients, not only without
+benefit, but with the effect of distinctly aggravating the
+disease. And I am yet more doubtful as to the advisability of
+such surgical procedures as the division or the resection of a
+piece of the painful nerve. Theoretically, as the reader will
+understand from the strong opinion I have given as to the
+mainly central origin of neuralgias, I never could anticipate
+that such a procedure would be more than temporarily successful;
+on the contrary, the mischief in the central end of the
+nerve remaining, I should suppose that the trying process of
+the reunion of the nerve (which always takes place) would be
+almost certainly attended with a revival of the neuralgia, too
+probably in an aggravated form. The only two cases of
+excision of a piece of the nerve, that I have ever seen, completely
+answered to this anticipation. In common fairness,
+however, I must admit that there is a large amount of evidence
+on the other side. Neuralgias of the trigeminus are
+pretty nearly the only cases in which the proposal of neurotomy<span class="pagenum"><a name="Page_169" id="Page_169">[169]</a></span>
+or neurectomy ought to be entertained; in mixed
+nerves the inconvenience of the muscular paralyses that would
+follow would be usually too serious to allow of our incurring
+them. But resection of painful branches of the trigeminus
+has been performed in a great number of instances, more
+especially by German surgeons, with results that merit our
+attention; the cases recorded by Nussbaum, Wagner, Bruns,
+and Podratzki, may be especially referred to. On the other
+hand, with the exception of simple division of the nerve,
+which can be subcutaneously performed, and is a trivial proceeding
+(but has very short-lived effects), these operations are
+by no means without danger, especially when they are pushed
+to such a length as the opening of bony canals, and the
+resection of considerable portions of bone in order to get sufficiently
+far toward the centre, and fatal results have in more
+than one case followed. Above all, we can never too seriously
+reflect on the most interesting case of Niemeyer's reported by
+Wiesner,<a name="FNanchor_40_40" id="FNanchor_40_40"></a><a href="#Footnote_40_40" class="fnanchor">[40]</a> in which the most formidable operations of this
+kind have been performed, in an apparently desperate case of
+epileptiform facial tic, and in which, after all, the application
+of the constant current painlessly effected an infinitely greater
+amount of good than had been done by all those severe and
+painful surgical manipulations. I think it is impossible, after
+this, not to conclude that neurectomy ought never to be even
+thought of except as a last resort, in cases of extreme severity,
+after other measures had been patiently tried and had
+decisively failed.</p>
+
+<p>(<i>c</i>) Of remedies that are intended to relieve local congestion,
+I must speak with very doubtful approbation. Leeches or
+scarifications are, I think, very seldom of value. The only
+remedy that has sometimes seemed to do good is local compression,
+and, after all, it is quite as likely that this acts by
+anęsthetizing the nerve as by reducing congestion.</p>
+
+<p>(<i>d</i>) Remedies that interfere mechanically with arterial pulsation
+are of considerable value where they can be effectively
+applied. I have already pointed out the specially aggravating
+effect of the momentarily-repeated shocks of arterial pulsation
+upon neuralgic pain. Where, then, it is possible, effectively
+to control an artery pretty near to the point where it divides
+into the branches that lie close to the painful part of the nerve,
+it is always worth while to try the experiment. But such a
+measure as the compression of the carotid in trigeminal neuralgia
+is of very doubtful propriety; I suspect the consequent
+anęmiation of the brain more than does away with any benefit
+that might be mechanically produced. And any attempt
+to interfere with the general arterial circulation by cardiac
+depressants is not to be permitted for an instant.</p>
+<p><span class="pagenum"><a name="Page_170" id="Page_170">[170]</a></span></p>
+<p>(<i>e</i>) We enter now upon a most important subject, the treatment
+of neuralgia by electricity. It is necessary to exercise
+much caution in speaking upon this topic, and, as I shall have
+to express somewhat decided opinions, I may be excused for
+referring to the circumstances under which I have arrived at
+my present stand-point upon this question. I can hardly be
+accused of having, with any very rash haste, espoused the
+cause of medical electricity in the therapeutics of pain, as any
+one will see who cares to turn to my article on Neuralgia<a name="FNanchor_41_41" id="FNanchor_41_41"></a><a href="#Footnote_41_41" class="fnanchor">[41]</a>
+written only three years ago. At that time I had already been
+studying the subject for a considerable period, but was so convinced
+of the multitude of opportunities for fallacy that beset
+the student of electro-therapeutics, that I was unwilling to
+state more than the minimum of what I hoped and believed
+might be affected by this mode of treatment. Since that time
+I have become more fully acquainted with the researches of
+foreign observers, and, with the help of their indications, have
+been able to apply myself more fruitfully to my personal
+inquiries into the matter. The result is, that I am now able to
+speak with far greater assurance of the positive value of electricity
+as a remedy for neuralgic pain. I shall make bold to
+say that nothing but the general ignorance of the facts can account
+for the extraordinary supineness of the mass of English
+practitioners with regard to this question.</p>
+
+<p>In the first place, I have arrived at a decided conviction that
+Faradic electricity is of little or no value in true neuralgias,
+and that the cases which are apparently much benefited by it
+will invariably be found, on more careful investigation, to
+belong to some other category.</p>
+
+<p>On the effect of frictional electricity I have had such very
+small experience that I cannot venture to speak with any confidence,
+and the accounts that I have heard from others whose
+experience is much larger have not led me to attribute
+much importance to this agent. If I am to judge at all, I
+should say it merely acts as a skin-stimulant, and is, in that
+capacity, inferior to many other simpler and more facile
+applications.</p>
+
+<p>Very different is the verdict of experience as regards the
+effects of the constant current; here the results which I have
+obtained have been so remarkable that even now I should distrust
+their accuracy, were it not that they are in accord with
+the general result which (among minor discrepancies) may be
+gathered, we may fairly say, from all the more important
+researches that have lately been carried out in Germany. The
+constant current, as I now estimate it, is a remedy for neuralgia
+unapproached in power by any other, save only blistering
+and hypodermic morphia, and even the latter is often surpassed
+<span class="pagenum"><a name="Page_171" id="Page_171">[171]</a></span>
+by it in permanence of affect; while it is also applicable
+in not a few cases where blistering would be useless or
+worse.</p>
+
+<p>The English medical profession has not as yet adequately
+appreciated the necessity for great care in the choice of apparatus
+and the mode of application of electricity. It is all-important,
+however, and especially in the case of applying
+galvanism for the relief of pain. The first quality that must
+be absolutely required in a battery, that is to be used for this
+purpose, is that it shall deliver its current with as little as possible
+variation of tension, in fact that it shall be constant,
+and not merely continuous; a vast majority of all the various
+galvanic apparatus that have been used have been merely the
+latter, and have consequently been almost valueless for the
+relief of pain. Such are Pulvermacher's chains, the voltaic
+piles made with elements of metallic gauze, Cruickshank's
+battery, and many others that have been used. A sufficiently
+constant current may be obtained from either of the following
+apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's.
+For hospital use, the Daniell battery (in Muirhead's modification,
+or with the form of cells introduced by Siemens-Halske)
+is perhaps the most desirable; but for private practice it is
+worth while to sacrifice something of the superior constancy
+which we gain in the Daniell battery for the sake of comparative
+portability. All purposes which we aim at in the electric
+treatment of neuralgia may be sufficiently obtained by the
+use either of the Bunsen battery (zinc-carbon, excited by
+dilute sulphuric acid), as modified by Stohrer, or by the Smee
+battery (zinc and platinized silver, excited by dilute sulphuric
+acid), as in the highly convenient apparatus devised by Mr.
+Foveaux, of Weiss &amp; Son's. It must be remarked that, for
+the purpose of treating neuralgia, we shall never need to
+employ more than fifteen, or at the utmost twenty, cells of
+either of these batteries. Both the Stohrer's Bunsen and the
+modified Smee of Weiss are made so that the elements are not
+immersed in the exciting fluid until the moment when the
+battery is going to be used; a simple mechanism at once
+throws the battery into or out of gear. In this way, destruction
+of the elements is minimized; and either of these two batteries
+may be used for from three to six months without any
+renewal, supposing the average work done to be one or two
+daily seances. If the battery is worked harder, it will require
+more frequent revivification. I strongly recommend London
+practitioners to deliver themselves from all care and trouble
+about the repair of their batteries, by making an agreement
+with the manufacturers to inspect and set them in order at
+stated intervals. The country practitioner, on the other hand,
+will do well to familiarize himself with the process of renewing
+the acid, of cleaning the plates, of amalgamating the<span class="pagenum"><a name="Page_172" id="Page_172">[172]</a></span>
+zinc, etc.; in fact, to make himself independent of the manufacturer
+in every thing short of an actual renewal of the elements,
+when that becomes necessary. For all further details
+respecting the above-named, and other batteries, I must refer
+the reader to systematic works on medical electricity.<a name="FNanchor_42_42" id="FNanchor_42_42"></a><a href="#Footnote_42_42" class="fnanchor">[42]</a> I must
+now pass on to the various modes of application, and the cautions
+to be observed.</p>
+
+<p>It is, in the first place, necessary to say, that all the best
+observers coincide in the statement that the use of a current
+intense enough to produce actual pain or severe discomfort is
+never to be thought of in the treatment of true neuralgias;
+such practice will infallibly do harm. Only such a current is
+to be employed as produces merely a slight tingling, and (on
+prolonged application) a slight burning sensation, with a little
+reddening of the skin at the negative electrode. This being
+the case, it is perhaps not unnatural for those who have not
+had practical experience, to suspect that an application which
+causes so little palpable perturbation is devoid of any positive
+influence at all. Such skepticism will certainly not survive
+any tolerably lengthened observation of the actual facts; but,
+as some persons may be deterred by this <i>prima-facie</i> view of
+the case from making any fair trial of the current, it may be
+worth while, here, to allude to the unmistakable physical
+effects which similarly painless constant currents are repeatedly
+observed to produce in cases of motor-paralysis attended
+with a wasted condition of muscles. Those who have had
+experience of the treatment of such cases know that it is a by
+no means infrequent thing to see both muscles and nerves
+aroused from a state of complete torpidity, and brought into a
+condition in which the Faradic current, quite powerless before,
+is again able to excite powerful contractions, while, at the
+same time, the bulk of the muscles has increased most sensibly.
+These, surely, are sufficient indications of a positive
+action of the painless constant current; and such facts have
+now been recorded, in multitudes, by most competent observers.</p>
+
+<p>The next maxim of first-rate importance is that the applications
+of the current should be made at regular intervals, and
+at least once daily; in most instances, this is enough, but occasionally
+it will be found useful to operate twice in the day.
+The matter of regularity is, I find, of great consequence, and
+it will not do to intermit the galvanism immediately on the
+occurrence of a break in the neuralgic attacks: it should be
+continued for some days longer.</p>
+
+<p>The length of sittings is a point as to which there is considerable
+difference of opinion between various authorities; but
+<span class="pagenum"><a name="Page_173" id="Page_173">[173]</a></span>
+my own experience coincides with that of Eulenburg, that
+from five to ten, or, at the utmost, fifteen minutes, is almost
+the range of time.</p>
+
+<p>Closely connected with the question of the length of sittings,
+is that of the continuity with which the current is to be
+applied. I have seen the best results, on the whole, from
+passing a weak current, without any breaks, for about five
+minutes. But, where there are several foci of intense pain,
+it will often be advisable to apply the current to each of these,
+successively, for three or four minutes.</p>
+
+<p>The places to which the electrodes should be applied vary
+much according to the nature of the case.</p>
+
+<p>Benedikt's rule, that the application of electricity, to be useful,
+must be made to the seat of the disease, is undoubtedly
+true; but it is capable of being applied in a somewhat different
+manner from that which he recommends in particular
+cases, the difference being due to the view of the pathology of
+neuralgia which is taken in this work. That view is, that the
+essential <i>locus morbi</i> is always in the posterior nerve-root (and
+usually in that portion of the root which is within the substance
+of the cord), and that the peripheral source of irritation,
+if any, is only of secondary&mdash;though sometimes of considerable&mdash;importance.
+Hence the main object, in electrization,
+would seem to be to direct the influence of the current
+upon the posterior nerve-root. This may, however, be done
+in different ways, according to the situations in which we
+place the electrodes, and the direction in which we send the
+current.</p>
+
+<p>There are, as yet, very considerable differences of opinion
+among electro-therapeutists as to the principles which should
+govern us, both in the localization of the effect and the direction
+of the current. Benedikt, for example, recommends that
+the current should be directed toward the supposed seat of the
+mischief. Thus, if we suppose a neuralgia to depend on morbid
+action within the spinal cord, then we may galvanize the
+spine, taking care to make the current come out through any
+vertebra over which we detect tenderness. If we suppose the
+seat of the disease to be in the nerve-root in the mere ordinary
+sense of the word, then we apply the positive pole to the
+vertebra opposite the highest nerve-origin that can be concerned,
+and we stroke the negative pole down by the side of
+the spinous processes, some forty times in succession. The
+proportion of cases of idiopathic neuralgia in which this
+treatment succeeds is, according to Benedikt, very large. In
+other cases, he sends the current from the cord to the apparent
+seat of pain.</p>
+
+<p>On the other hand, Althaus<a name="FNanchor_43_43" id="FNanchor_43_43"></a><a href="#Footnote_43_43" class="fnanchor">[43]</a> tells us that, whether the
+<span class="pagenum"><a name="Page_174" id="Page_174">[174]</a></span>
+application be central or peripheral, it is the positive pole,
+alone, which should be applied to the part which we intend to
+affect: and that the application of the negative pole in this
+situation is rather likely to do harm than good, as proving too
+exciting. Eulenburg, also, says that in general the positive pole
+should be applied to the seat of the disease, the negative on an
+indifferent spot, or on the peripheral distribution of the nerve.</p>
+
+<p>It is, however, very doubtful to me whether, in the majority
+of cases, the direction of the current makes any considerable
+difference in its effects, provided only that the stream is fairly
+directed so as to include the <i>locus morbi</i> in the circuit, and care
+is taken to apply it with sufficient persistence and with not too
+great intensity. Upon this point I am glad to be able to cite
+the authority of Dr. Reynolds, whose experience is very large.
+This author, while admitting that in theory the "direct" and
+the "inverse" currents would seem likely to have different
+effects, declares that in practice this does not prove to be the
+case, either in the instance of pain of nerve or of spasm
+of muscle. Dr. Buzzard, also, in relating a very striking
+case (which I had the advantage of personally observing)
+before the Clinical Society, particularly mentioned that the
+direct and the inverse currents had a precisely similar effect in
+relieving the pain. The patient suffered from severe and probably
+incurable cervico-brachial neuralgia; the poles were
+placed, respectively, on the nape of the neck and in the hand
+of the affected limb, and whether the positive was on the nape
+and the negative in the hand, or <i>vice versa</i>, the effect was the
+same. Very striking remission of the pain was always produced,
+and the immunity from suffering sometimes lasted for a
+considerable time, while no other plan of treatment seemed to
+have more than the most momentary effect.</p>
+
+<p>My own experience tells the same story very decidedly, for
+I have on very many occasions obtained great benefit, both by
+the direct and by the inverse currents, in the same patient. I
+shall here relate a few instances:</p>
+
+<p><span class="smcap">Case I.</span>&mdash;A married woman, aged forty-eight, whose menstrual
+periods had ceased quietly some six years previously.
+She was, on the whole, a healthy person, but had suffered from
+migraine in her youth, and came of a neurotic family. She
+was attacked with severe cervico-brachial neuralgia, which
+resisted all treatment for nearly three months, and, on her
+then trying a month's change of air and absence from medication,
+became worse than ever. The constant current was
+applied, from ten (and afterwards fifteen) cells of Weiss's battery,
+daily for twenty-four days, the pain vanished finally at
+the end of thirteen days, and the accompanying anęsthesia
+and partial paralysis disappeared before the treatment was concluded.
+In this case the negative pole was applied by the side
+of the three lower cervical vertebrę, and the positive was<span class="pagenum"><a name="Page_175" id="Page_175">[175]</a></span>
+applied, successively, to three or four different parts of the
+most intense peripheral pain.</p>
+
+<p><span class="smcap">Case II.</span>&mdash;A young lady, aged twenty-four, suffered from
+neuralgia in the leg. Galvanization (twenty cells Daniell),
+from the anterior tibial region to the spine was found invariably
+to cut short the pain. I now reversed the current; the
+effect was the same. After ten sittings I suspended the treatment,
+as there had been no attack for three days; but a week
+later the neuralgia returned in full fury. I resumed galvanization
+from periphery to spine; after twelve more sittings the
+attacks had become rare and slight. I continued treatment
+for eight days longer, during the whole of which time there
+was no pain. It had not recurred when I saw her fifteen
+months afterward.</p>
+
+<p><span class="smcap">Case III.</span>&mdash;H. G., a footman, aged twenty-three, applied to
+me at Westminster Hospital, with neuralgia of the first and
+second divisions of the right trigeminus, of six weeks' standing.
+The right eye was bloodshot and streaming with tears,
+the skin of the right side of the nose and right cheek was anęsthetic,
+the right levator palpebrę was partially paralyzed.
+Hypodermic injections of morphia proved only very temporarily
+beneficial. After a fortnight's treatment with this and
+with flying blisters to the nape of the neck and the mastoid
+process, I commenced the use of the constant current daily
+(ten cells, Weiss). The first application (positive on nape, negative
+on infra-orbital foramen) stopped the pain, and procured
+fourteen hours' immunity. On the next day I reversed the
+current; the pain stopped after three minutes' galvanization;
+it did not recur for four days, during which time, however, I
+continued the daily use of the direct current. On the sixth
+day of treatment the patient came to me with a somewhat
+severe paroxysm, almost limited to the ophthalmic division; it
+was accompanied by spasmodic twitchings of the eyelid, and
+copious effusion of altered Meibomian secretion, looking like
+pus. Galvanization from supra-orbital foramen to nape
+stopped the pain in five minutes. The next day the patient
+presented himself, quite free from pain, which had not
+returned; the conjunctiva was clear, and there was no visible
+Meibomian secretion. Inverse galvanization was continued for
+ten days; but no recurrence of the pain took place. The cure
+was permanent three months later.</p>
+
+<p>On the contrary, we sometimes see complete failure of the
+current to affect any good whatever; and in these cases the
+reversal of the current has not, so far, appeared to me to make
+any particular change in the result. Such was the case with a
+patient whose history I detailed (along with that of Case I.) to
+the Clinical Society. She was an ill-fed and overworked
+unmarried needle woman, aged thirty; the neuralgia was a
+most violent double occipital pain, with foci, on each side,<span class="pagenum"><a name="Page_176" id="Page_176">[176]</a></span>
+where the great occipital nerves become superficial. The current
+was passed daily, for some days, from one focus to another
+(necessarily passing through the nerve-roots and the spinal
+cord), and the positions of the conductors were occasionally
+reversed; this not succeeding, the current was applied altogether
+to the spine, the negative pole being placed on the
+highest cervical vertebrę, but no good effect was produced
+after a treatment, altogether, of sixteen days.</p>
+
+<p>Notwithstanding these, and a good many similar facts that
+could be adduced, I should hesitate to go so far as to say that
+there is never any importance in the direction of the current.
+In old-standing cases, where there are well-marked <i>points
+douloureux</i> that are exceedingly sensitive, I have found that
+the application of the positive pole, successively, on the most
+tender points, the negative being placed on the spine opposite
+the point of origin of the nerve, has had a more beneficial
+effect than any other mode of application.</p>
+
+<p>There are very considerable differences, both as to the best
+manner of galvanization, and also as to the chances of
+doing good with it, in the case of neuralgias of different
+nerves; and, on the whole, I find Eulenburg's conclusions
+on this matter very just. He indicates sciatica as the
+affection which is by far the most curable by the constant current;
+he says that many cases are cured in from three to five
+sittings, while others require as many weeks, or even months
+of treatment; and that a total absence of benefit is only seen
+in rare cases dependent on central causes, or on diseases which
+are irremovable (like malignant pelvic tumors). On the other
+hand, he reports that intercostal neuralgia has never been
+materially benefited by galvanization in his hands. With
+regard to ordinary trigeminal neuralgias, he speaks strongly
+of the current as a palliative, but very doubtfully of its power
+to cure, in genuine and severe cases. In cervico-brachial
+neuralgia he speaks of it as dividing with hypodermic morphia
+the whole field of useful treatment, in the majority of cases.
+In cervico-occipital neuralgia he says it rarely does much
+good. I shall return to Eulenburg's estimate of its utility in
+migraine, presently. Let me here say that I am inclined to
+indorse everything in the above-detailed statements, excepting
+that I should place a considerably higher estimate on the curative
+powers of the current in ordinary trigeminal neuralgias.
+The remedy, like every other, will doubtless fail in a considerable
+number of those very bad cases which occur in the degenerative
+period of life; but if anyone desires to see the proof of
+the power it sometimes exerts, even in extreme cases, he should
+study the two most remarkable cases treated by Prof. Niemeyer,
+of Tubingen, and reported by Dr. Wiesner.<a name="FNanchor_44_44" id="FNanchor_44_44"></a><a href="#Footnote_44_44" class="fnanchor">[44]</a> The patients
+<span class="pagenum"><a name="Page_177" id="Page_177">[177]</a></span>
+were respectively aged sixty-four and seventy-four, and the
+duration of the neuralgia had been respectively five and
+twenty-nine years; in both the pain was of the severest type,
+and in both the success was most striking. In one of them
+every possible variety of medication, and several distinct
+surgical operations for excision of portions of the affected
+nerve, had been quite vainly tried. The cases are altogether
+among the most interesting facts in therapeutics that have
+ever been recorded. Dr. Russell Reynolds has also told me of
+a case under his own care, in which a lady, who had been the
+victim, for twenty years, of an extremely severe neuralgia of
+the ophthalmic division of the fifth, which attacked her daily,
+and had caused great injury to her general health and nutrition,
+was not merely benefited, but the affection absolutely
+removed, at any rate for a long period, by a single application
+of the current. I have personally seen no such remarkable
+cases as these but I have had some extremely severe cases
+under my care in which the effect of the current was to arrest
+the pain in a few applications, and procure a remission for
+several days, or even weeks. And I have had several slighter
+cases which were as much cured, to all appearance, as any disease
+can be, by any remedy.</p>
+
+<p>As a general rule, neuralgia of the limbs requires to be
+treated with a more powerful current than neuralgia of the
+face (twenty cells instead of ten). In the latter case, indeed, it
+is necessary to be exceedingly cautious (commencing with five
+cells), since a current of high power has been known to produce
+most serious effects upon the deeper-seated organs; the
+retina has been permanently paralyzed, by too strong a current
+applied on the face, and still graver dangers attend the incautious
+use of galvanization of the brain or of the sympathetic,
+of which we have now to speak.</p>
+
+<p>Galvanization of the brain is a remedy chiefly employed in
+true migraine, and is certainly very effective in that disease.
+I have not found it useful to apply the current in the long
+axis of the cranium, but transmitted from one mastoid process
+to the other it has proved most useful; and I am glad to find
+that my experience on this point coincides with that of Eulenburg.
+But the use of this remedy is highly perilous in careless
+hands. In working with either Daniell's or Weiss's battery,
+it is necessary to use at first only three or four cells, and
+to increase the number only with the greatest caution. The
+sittings should never last more than half a minute; but the
+slightest giddiness should make us stop even sooner. On the
+other hand, the applications ought to be made daily, and
+usually twice a day. Ten cells (Daniell or Weiss) is the utmost
+that will ever be required, few patients will bear so much;
+and, apart from the possibility of more serious mischief, there
+is nothing which annoys and frightens patients more seriously<span class="pagenum"><a name="Page_178" id="Page_178">[178]</a></span>
+than the sudden and intense vertigo which over-galvanization
+of the brain may induce.</p>
+
+<p>Even more ticklish than the galvanization of the cerebral
+mass is galvanization of the sympathetic. I am not going to
+raise here the vexed question in physiological electricity as to
+the possibility of a galvanization the effects of which shall be
+accurately limited to the sympathetic. The fact is unquestionable,
+that very powerful and peculiar effects, utterly unprocurable
+in any other way, can be produced by placing one
+pole on the superior cervical ganglion (just behind and below
+the angle of the jaw) and the other on the manubrium sterni.
+This is a mode of galvanization which has been highly praised,
+more especially by Remak, and after him by Benedikt, but it
+has yielded rather disappointing results in neuralgia in my
+hands. Either I have not observed any distinct effect at all,
+or, if a current even a very little too strong were applied, I
+have repeatedly seen most uncomfortable, and sometimes very
+alarming, symptoms. I shall not easily forget a patient who
+applied at the Westminster Hospital, suffering from a severe
+form of facial neuralgia, and who was persuaded to come to
+my house and have his sympathetic galvanized. I used only
+twenty cells of Daniell, but the current had not been applied
+more than a few seconds when the patient fell on the floor,
+and remained in a state of half swoon for a considerable time.
+I allude to this and other less dangerous accidents that I have
+seen follow galvanization of the sympathetic, not with the
+view to prove that the method is useless in trigeminal neuralgia&mdash;I
+should certainly hesitate to say that, considering the
+large amount of respectable evidence in its favor&mdash;but I think
+that it is a procedure requiring the utmost caution, and meantime
+I have not personally found it nearly so useful as the
+methods already described.</p>
+
+<p>There are sundry special applications of galvanism to particular
+forms of neuralgia which require a few words of notice.
+Of electrical treatment in regular angina pectoris I have had
+no experience; and in the one case of intercostal neuralgia,
+complicated with quasi-anginal attacks, in which I applied the
+constant current to the spine and the cardiac region, in the
+direction of the affected intercostal nerve, no effect was produced.
+I shall, however, mention the experience of Eulenburg,
+as he is a sober and dispassionate writer on the effects of
+electric treatment in general. He says he believes that in the
+proper use of the constant current we shall discover the chief,
+possibly the only direct, remedy for angina; and he describes
+the apparently favorable results he has already obtained in
+three or four cases. The current was from thirty cells; the
+positive pole was placed on the sternum (broad electrode), the
+negative on the lower cervical vertebrę. The alternative
+method which Eulenburg suggests, but has not, so far, put in<span class="pagenum"><a name="Page_179" id="Page_179">[179]</a></span>
+practice, is direct galvanization of the sympathetic and vagus
+in the neck.</p>
+
+<p>The application of the constant current in neuralgic affections
+of the larynx and pharynx is of most indisputable service;
+the experience of Tobold<a name="FNanchor_45_45" id="FNanchor_45_45"></a><a href="#Footnote_45_45" class="fnanchor">[45]</a> upon this point is fully borne
+out by my own, as far as it goes. In many cases it will be
+sufficient to place the positive pole (from fifteen cells Weiss)
+on the pomum Adami, and the negative on the nape of the
+neck, and to keep up a continuous current for five or ten minutes
+daily; but in some cases the direct application of the current
+to the pharynx or larynx may be required; in such, a
+modification of Dr. Morell Kackenzie's laryngeal conductor
+will be found useful. [I shall have occasion, in Part II., to
+notice the superior action of Faradization in mere hysteric
+throat-pain, as distinguished from true neuralgia.]</p>
+
+<p>Neuralgia of the testicle can be best treated, if galvanism be
+thought necessary, by immersing the whole scrotum in a basin
+of salt and water, in which the positive pole is placed: the
+negative pole is to be placed on the upper lumbar vertebrę; the
+current should be from fifteen cells Weiss, and the application
+should last continuously for ten minutes. In neuralgia of the
+urethra, I should be inclined to adopt a plan, mentioned to me
+by Dr. Buzzard, of attaching one conductor to an ordinary
+silver catheter introduced into the urethra, and placing the
+other pole upon the perinęum.</p>
+
+<p>Neuralgia of the neck of the bladder I have found to be
+materially relieved by the constant current from twenty cells
+passed through from pubis to perinęum; the sittings being
+rather long. I have also, on one occasion, tried the introduction
+of a proper <i>porte-electricite</i>, insulated, except at the tip;
+but the result was not superior to that obtained in the other
+way.</p>
+
+<p>As a general rule, it may be said that electricity, like other
+local measures which tend to concentrate the patient's attention
+on the parts, is only to be applied to the genital organs as
+a last resort. This is, of course, especially true in the neuralgias
+of these organs in women.</p>
+
+<p>In concluding what will doubtless seem to some English
+readers an over-long and over-favorable estimate of the
+employment of galvanism in neuralgias, I must carefully guard
+myself against the supposition that I consider it a remedy to be
+applied in all cases, or likely to meet with uniform success,
+even in the forms of the disease to which it is most appropriate.
+It is a weapon which I seldom employ in the first instance, for
+many reasons; the principal of which is the costliness of the
+proceeding to the patient. Either the physician must personally
+administer the remedy, daily, often for a considerable
+<span class="pagenum"><a name="Page_180" id="Page_180">[180]</a></span>
+period, or he must make the patient provide himself with an
+expensive battery; and in the latter case there is, after all, the
+unsatisfactory consideration that the application (even after
+the most careful directions have been given) will perhaps be
+unskilfully and inefficiently made. On the other hand, it is
+not desirable to delay the employment of galvanism too long,
+if other remedies have been fairly tried; and the practitioner
+will do well to remember the distinctions above laid down as
+to the varieties of neuralgia in which it is specially likely to
+prove decidedly and quickly beneficial. More especially in
+sciatica it would really, with our present knowledge, be a
+decided neglect of duty were we to allow the disease to run any
+considerable length without giving the constant current a
+thorough trial. [I can only briefly refer, here, to the novel
+mode of galvanization introduced by Dr. Radcliffe, and based
+upon his ingenious theory, according to which the true effects
+of the voltaic current upon nerve are the result of the charge
+of free electricity which it sets up, and not of the current
+directly. The reader will find the whole argument elaborately
+worked out in Dr. Radcliffe's recent work on "The Dynamics
+of Nerve and Muscle," Macmillan &amp; Co., 1871. It will be
+enough to say, here, that the object to be attained, according
+to this view, is to replace the neuralgic nerve in its healthy
+physiological state, by charging it with free positive electricity.
+The manner in which this is done is as follows: In a
+case, <i>e.&nbsp;g.</i>, of cervico-brachial neuralgia, we place the positive
+pole as near as may be to the central origin of the affected
+nerve; the negative pole is held in the hand of the same side,
+which is immersed in a basin of warm salt and water. In this
+same basin is another electrode, the wire from which is put in
+communication with the earth&mdash;most conveniently by putting
+it in contact with a gas-pipe. The patient, and the battery,
+ought properly to be insulated. The result of this arrangement
+is, that the free negative electricity is carried off by the
+earth-wire, and the limb remains charged with free positive
+electricity. I have had no sufficient experience of this method
+to give any opinion of its merits, but the inventor thinks it
+decidedly superior to the ordinary modes of applying the constant
+current.]</p>
+
+<p>(<i>f</i>) The last kind of local remedies for neuralgia of which
+we have to speak are those by which we seek to mitigate the
+paroxysm by thoroughly excluding the air from the site of
+apparent pain. These are chiefly of value in those cases where
+a distinct inflammation (herpetic or erysipelatoid), or an
+unusual degree of sensitiveness on pressure, etc., has become
+developed around the superficial branches of the neuralgic nerve.
+Very much the best agent of this kind with which I am
+acquainted is the flexible collodion; in neuralgic herpes and
+erysipelas the effect of this application, conjoined with the<span class="pagenum"><a name="Page_181" id="Page_181">[181]</a></span>
+hypodermic injection of morphia (preferably in the immediate
+neighborhood), is of the greatest possible service in mitigating
+the pain. In herpes it has this further special advantage, that
+it prevents the occurrence of sores after the vesicles fall, an
+accident which otherwise will sometimes happen, and which
+very much increases the severity and intractability of the consecutive
+neuralgic pain.</p>
+
+<p>4. Lastly, we have to speak of prophylactic measures, which
+really ought never to be thought of as a separate matter, but
+always as an essential and most important part of the treatment
+of neuralgia. The prophylaxis of neuralgia is divisible
+into (<i>a</i>) measures for preventing the development of the
+neuralgic habit in those who may be supposed to have a predisposition
+to it; (<i>b</i>) measures between the paroxysms; (<i>c</i>) measures
+to be adopted after the attacks have ceased.</p>
+
+<p>(<i>a</i>) The measures that should be taken to avert neuralgia, in
+those who may be reasonably assumed to be predisposed to it,
+have scarcely received any consideration at the hands of systematic
+writers; yet this is a most important subject. The
+persons in question are children who belong to families known
+to be infected with tendencies to neurotic diseases, or persons
+whose daily occupations submit them to peculiarly strong predisposing
+influences of an external kind. The hostile influences
+that should be avoided, or at any rate compensated, are
+of several kinds: (1) Psychical; (2) defects of nutrition; (3) mismanagement
+of the muscular system; (4) sexual irregularities;
+(5) over-fatigue of the special senses, and insufficiency of sleep,
+especially the latter; (6) unhealthy atmosphere and climate.</p>
+
+<p>(1) The psychical influences which must be especially avoided,
+if we would avert the formation of the neuralgic habit, form
+a large and somewhat indefinite group, which it is doubtless
+difficult to deal with satisfactorily. The matter is, however,
+highly important, and the attempt must be made. And there
+are, at any rate, some leading principles that I feel justified in
+laying down with confidence.</p>
+
+<p>We shall best commence the inquiry by directing our attention
+once more to the fact, so often insisted upon in this work,
+that the large majority of neuralgic patients carry in them the
+seeds of their malady from their birth. It has been amply
+proved that every child born of a family that has shown strong
+tendencies to insanity, epilepsy, paralysis, etc., etc., ought to
+be looked on as a neurotic subject, and as a potential sufferer
+from neuralgia. It has been shown that such children will be
+exposed, even under favoring external circumstances, to the
+danger of neuralgia at certain important stages of their physiological
+history. The earliest of these critical periods is marked
+by the occurrence of puberty; and it is not till this time that
+psychical influences, as such, come to have any serious bearing
+on the formation of the neuralgic habit. Mischief may,<span class="pagenum"><a name="Page_182" id="Page_182">[182]</a></span>
+indeed, be done to the brain and the general nervous system,
+by injudicious mental training, at a far earlier period; but
+this mischief, serious or even fatal as it may be, usually takes
+some other form than that of neuralgia. It will be necessary,
+here, to reflect a little upon certain features of the childish
+mind, in order that we may rightly estimate the kind of influence
+which puberty exerts upon it.</p>
+
+<p>A very young child is selfish, in the purely animal sense; it
+is greedily acquisitive, and its selfishness is unchecked by any
+sense of shame. With later childhood there comes a sense of
+right and wrong, and a sensitiveness to shame, which
+check this tendency; still it is the exception rather than the
+rule to find any great capacity of self-abnegation in young
+school-boys. But a moderately healthy-minded child, up to
+the age of puberty, is only acquisitively selfish; he is not self-centered
+in the sense of dwelling upon his own mental state,
+and reflecting upon the nature of his motives and feelings. It
+is with the age of puberty that self-consciousness begins to be
+a feature in the mind of the young, and its appearance marks
+the entrance of a dangerous element into the character. It is
+an inevitable stage in mental growth, and, if wisely dealt with,
+is ultimately productive, not of evil, but of good; but it is
+more perilous to some children than to others, and it is especially
+fraught with danger to those whose nervous centres are,
+by inheritance, weak and unstable in whole or in parts. The
+mental antidote to its possible evil effects is to be found in a
+vigorous (but not excessive) training of the mind in studies
+which shall be as far as possible external, and the discouragement
+of all tendencies to introspection. I would venture to
+express the decided opinion that the common idea, that close
+study injures the young, is only true in a modified sense. It
+is, however, unquestionably the fact, that hasty and imperfect
+cram-work does very seriously impair the stability of the brain
+and the nervous system in young people; there is a spurious
+excitement about this kind of learning (especially when it is
+mainly competitive, and directed to the gaining of prizes and
+medals) which must be injurious. But I think it is quite
+ridiculous to suppose that, in this country, the actual amount
+of intellectual labor undergone by boys and girls at school is
+sufficient to do harm, were it only regular and systematic, and
+carried out in a conscientious manner; on the contrary, though
+I think that the total daily period occupied in study ought not
+to exceed some six or seven hours, I believe that the insisting
+on strenuous diligence during school hours, and the maintenance
+of a high standard as to the quality of the work
+exacted, is all on the side of nervous health. But, an
+even more serious and difficult matter than the regulation of
+the amount of intellectual work to be done is, the question
+how we are to deal with the unfolding emotional instincts of<span class="pagenum"><a name="Page_183" id="Page_183">[183]</a></span>
+the boy or girl who has reached the age of puberty. It is useless
+to ignore this side of the mental life; it will assert itself
+either for good or for evil. At the risk of seeming to meddle
+with matters that belong to the school-master rather than to
+the physician, I would urge very strongly that a portion of the
+training be deliberately directed to a serious study of one or
+other of the fine arts&mdash;to that one, whether poetry, painting,
+sculpture, or music, to which the boy or the girl instinctively
+leans. I am aware that there is a prejudice among parents
+that the study of the fine arts renders young people idle and
+indifferent to other branches of education and other duties of
+life. I believe that this only applies to the miserably inefficient
+way of teaching these subjects which prevails at present
+in all but a few English schools; and that, in truth, a thorough
+knowledge of the principles of either music or painting, and a
+real study of the best masters, would be sure to prevent the
+development of that lazy, conceited manner, and that neglect
+of other duties, which no doubt unfavorably distinguish a good
+many of the young ladies and gentlemen who dabble a little
+in music, or painting, or versification. We want the German
+rather than the English type of training, we want the acquirement
+of sound knowledge of the principles of music (at any
+rate) to be made so common that the accidental possession of
+two pennyworth of superficial accomplishment in that line
+shall not enable young ladies and gentlemen to give themselves
+airs in society. The truth is, that the young people who make
+music or painting an excuse for idleness respecting other matters
+are invariably imposters even in that which is their own
+supposed <i>forte</i>. On the other hand, the serious study of art,
+a certain definite portion of time being set apart for it, and
+thoroughness being insisted upon, is, I believe, an admirable
+vent for the emotional effervescence of commencing sexual
+life; and I no less firmly believe that the things that are usually
+substituted for it are intensely pernicious. I have already,
+in the chapter on Pathology, remarked on the mischief which
+is often done by the anxiety of religious parents to make their
+children (usually somewhere about this perilous time of
+puberty) experience the emotional struggle which is believed
+to end in a change of heart and principles. I need, therefore,
+only now repeat the expression of my intense conviction that
+the results of this process, as seen by the physician to occur
+within that mental region where the emotions and the organic
+nervous system come into closest relations, are simply disastrous.
+It is not my business to suggest the proper alternative
+to a mode of spiritual training which I think deleterious; I can
+only intimate, in the most general way, my belief that a calm
+and systematic training in the simplest principles of duty and
+religion is greatly more suitable to the immature mind and
+brain of youth than any strong emotional excitement on such<span class="pagenum"><a name="Page_184" id="Page_184">[184]</a></span>
+topics. But if ill-regulated spiritual emotion of a religious
+kind be a dangerous thing for young persons in the most serious
+crisis of bodily development, far more decidedly pernicious
+is the spurious excitement of feeling which is directed to
+lower and often most unworthy objects. The increasing precocity
+of boys and girls, in their familiarity with the most
+objectionable aspects of passion and intrigue, is steadily fed, in
+the present day, by a system that allows them, too often,
+unlimited access to light literature which (as is strikingly the
+case with many novels of our day) is at once devoid of true
+literary and artistic merit and at the same time replete with
+sensational incident of a vulgarly exciting kind. The same
+degrading tendency is very distinctly to be noted in the character
+of the dramatic and other public exhibitions which are
+most popular at the present day; the main characteristics being,
+bad art, and thinly-veiled sensuality, all the more pernicious
+for being veiled at all. It would be a hundred times better that
+a boy, or even a girl, should study the frank and outspoken
+descriptions to be found in Shakespeare or Fielding, with all
+their occasional coarseness, than that they should enervate
+their minds with the sickly trash that is most current and most
+popular at the present day, in theatre and circulating library.</p>
+
+<p>(2) The defects of nutrition that assist the development of
+the neuralgic tendency are often the consequence of a system
+which, it is to be hoped, is to a large extent becoming effete,
+but which, nevertheless, survives in sufficient vigor and
+extent to demand express reprobation. It was till lately the
+general, and it is still a too common practice, to keep children
+and young persons on a very insufficient allowance of the
+most important elements of food; the state of things in this
+respect, both in public and private schools, in the first half of
+the present century, is a lasting reproach to the medical practitioners
+of those days, who scarcely lifted a finger to amend
+it, even when they did not expressly approve it, under the
+influence of absurd theories about the dangers of excessive
+"grossness of blood." It is indeed amazing that, with the palpable
+fact staring them in the face, of the rapid and incessant
+additions to tissues which are being made by children and
+young people, medical men should have failed to perceive the
+necessity for supplies of food practically unlimited except by
+the capacity of digestion. Yet this seems hardly ever to have
+been thought of, and the unfortunate results seem scarcely to
+have been noticed, except when they led to emaciation or
+consumptive disease. But the effects were perhaps even more
+disastrous where, with a maintenance of a fair amount of
+muscular nutrition, there was only a little dyspepsia, and perhaps
+some slight tendency to nervousness, to show that anything
+was wrong. The children who were born of strong and
+healthy parents, may have suffered comparatively little from<span class="pagenum"><a name="Page_185" id="Page_185">[185]</a></span>
+this regimen as regards their nervous system, but those who
+were born of neurotic ancestors undoubtedly suffered extensively.
+The crisis of puberty was, in such ill-nourished children,
+too frequently the signal for an explosion of epilepsy,
+chorea, or neuralgia; and too often the mischief was yet further
+increased by a most injudicious medical treatment, including
+a deterioration rather than an improvement in the already
+insufficient dietary system. At the present day, however, we
+may fairly hope that common sense is prevailing, so as to put
+an end to this mischief as regards the children of the upper
+and middle classes. Unfortunately, with the poor a similar
+ill-nourishment of the young is too often inevitable, and the
+consequences are constantly to be traced in enfeeblement of the
+nervous system, of which neuralgia is a pretty common result.</p>
+
+<p>It cannot be too frequently repeated that for those children,
+more especially those who come of nervous families, any
+considerable error in this direction has a fatal tendency
+to awaken the disposition to nervous disease. At
+every step of the infancy, childhood, and youth of
+such persons, the most generous allowance of the more
+nutritive elements of food is of the first importance. At
+the same time I am entirely opposed to the practice of giving
+stimulants to any considerable extent, or indeed to any extent,
+save in exceptional instances. Good meat, bread, milk, butter,
+fruit, and vegetables, are really the efficacious means of fortifying
+the nervous system against the impending dangers.
+With hospital out-patients, for whom we cannot command
+such diet, our best course, whenever they show signs of deficient
+nutrition, will be the steady administration of cod-liver
+oil for a long period.</p>
+
+<p>(3) The true and proper training of the muscular system is
+among the most important means of antagonizing the tendency
+to the development of the neuralgic habit. It is a great mistake
+to suppose that over-training in athletics of any kind is
+of use; but the systematic employment of means which tend to
+make the muscular system hardy and efficient is of very great
+benefit. The parents of children who may be supposed by
+inheritance to possess a tendency to neuralgia would do well
+to study such a methodical series of directions as those which
+are given by Mr. Maclaren, in his excellent work on physical
+training. I suspect that the benefit of judicious gymnastics is
+wrought in two ways: first, by its improving circulation and
+general nutrition, including the nutrition of the nervous centres;
+and, secondly, that it gives the nervous centres an education,
+so to speak, by the variety of difficult co-ordinative movements
+over which it trains those centres to preside. But
+unquestionably the matter is a science, not a mere rude art,
+and requires to be studied as such.</p>
+
+<p>(4) Of unspeakable importance to the object of averting the<span class="pagenum"><a name="Page_186" id="Page_186">[186]</a></span>
+formation of the neuralgic habit is the prevention of sexual
+irregularities in the young. Under this heading is included a
+large and various group of influences; of these the first that requires
+notice is the prevention of precocious sexual stimulation,
+whether by talk or by acts, which may precipitate the occurrence
+of puberty at an unnaturally early age. I know very well how
+difficult it is to devise any scheme which really would effectively
+control and antagonize the worst mischief of schools; but
+it is at least a duty to say here, that no experienced physician
+can doubt that such a scheme must be found, if we are ever to
+hope for a healthier race of children and of young men and
+women, and if we are to break down one of the most potent of
+the influences that go to the production and maintenance of
+the neurotic disposition. I would be clearly understood not to
+suppose for a moment, either that this sort of cause is usually
+at work in the production of neuralgia in the young, or that of
+itself it is sufficient to produce the disease; but I would say,
+for certain, that on children of nervous families such influences
+act with disastrous energy; and, moreover, that where we see
+signs, in a neuralgic young person, of that general form of
+bad health which is connected with precocious puberty, we
+may be nearly certain that such influences have actually been
+at work. At all cost, and by all conceivable means, all children,
+but most especially the delicate and nervous ones, ought
+to be shielded from the risk of this occurring.</p>
+
+<p>Another form of sexual irregularity which can be counted
+as a contributor to the formation of the neuralgic habit is menstrual
+irregularity, especially at the commencement of sexual
+life. By far the most mischievous in this way is menorrhagia
+of the young. I have seen exceedingly severe and intractable
+neuralgia set up by it. As regards the influence of simple
+amenorrh&#339;a, I am by no means clear: it seems pretty nearly
+as likely that the deficient excretion (when not dependent on
+mechanical cause) is a mere sign of the general weakness
+which also predisposes to the neuralgia, as that the neuralgia is
+in any way the direct consequence of the amenorrh&#339;a.</p>
+
+<p>Leucorrh&#339;a, especially when profuse and long-continued, is
+a much more indisputable factor in many neuralgias. It is a
+point of real importance to put an end promptly to such a discharge,
+if it exists, and the usual remedies&mdash;cold bathing, mild
+astringent injections, etc.&mdash;should be at once prescribed.</p>
+
+<p>Dysmenorrh&#339;a, a painful menstruation, when not dependent
+on a purely mechanical cause, affords a strong example
+of neuralgia connected with sexual difficulty; but there is every
+reason to think that the neuralgia is the primary and not the
+secondary affection. The only effective prophylaxis, therefore,
+is the adoption of such general measures as will raise the
+whole tone of nervous health. It often happens that marriage
+completely cures the tendency to these attacks.<span class="pagenum"><a name="Page_187" id="Page_187">[187]</a></span></p>
+
+<p>(5) Insufficiency and irregularity as to the allowance of
+sleep are potent influences in developing neuralgia in those
+who are hereditarily predisposed. It is needless to say a single
+word to prove the imperative need of the young for periodical
+and prolonged repose from the conscious actions of the nervous
+system. Full ten hours of sleep in the twenty-four, for boys
+and girls who are at or near the period of puberty, is an absolute
+necessity if we would prevent any existing irritability of
+the nervous system from developing into the fully-formed neurotic
+temperament. Indeed, I believe that, for all young people
+(but especially girls) up to the age of twenty-five, this
+allowance is not the least beyond what is necessary: only the
+need is most pressing at, and just before, the development of
+the sexual organs. Of course a much larger allowance of
+sleep is necessary in actual infancy: from seven to twelve we
+may be content if we get nine hours clear sleep; but during
+the two or three years preceding puberty we should insist upon
+ten hours, at any rate for children who possess the nervous
+temperament.</p>
+
+<p>(6) Impurity of the atmosphere in which they habitually or
+daily reside must be carefully shunned for young children,
+especially for the nervous. The kind of dull and diffused
+headache which children often complain of, after study for
+some time in a close, ill-ventilated school-room, is very likely
+(if the bad influence be continued for a number of years) to
+develop itself, at puberty, into a regular migraine. Purity of
+air in the school-room must therefore be scrupulously provided
+for; and the same thing must be attended to as regards the
+sleeping rooms.</p>
+
+<p>Of the climatic influences we may speak in a few words.
+Besides the avoidance of distinctly malarial districts, and also
+of places where, although there is no distinct ague, there is a
+prevalence of neuralgic or even of so-called "rheumatic" complaints,
+it is necessary very carefully to shun damp soils, and
+places where there is a great deal of harsh and cold wind.
+Mere lowness of average temperature is not in itself a strong
+predisposer to neuralgia, at any rate if guarded against by
+abundant food and the use of such clothes as will prevent
+children from ever feeling chilly and depressed. But damp
+and harsh winds are actively bad; and when joined to habitual
+or frequent lowness of temperature, they constitute very
+unfavorable surroundings for the nervous systems of delicate
+children.</p>
+
+<p>(<i>b</i>) We come now to the prophylaxis which is to be adopted
+in the intervals of the paroxysms when neuralgia has been
+actually set up. This consists essentially in three things: (1)
+Physiological rest, as perfect as possible, of the affected parts;
+(2) protection from cold; (3) protection from sunlight; (4)
+avoidance of injurious mental emotions.<span class="pagenum"><a name="Page_188" id="Page_188">[188]</a></span></p>
+
+<p>(1) The maintenance of physiological rest, to the greatest
+extent that is possible, is an absolute necessity, if we would
+shield a nerve, which has lately been attacked with neuralgia,
+from fresh paroxysms. The most evident illustrations of this
+fact are afforded by those neuralgic affections in which it is
+most difficult to adopt this precaution. Thus the greatest
+embarrassment from this cause is met with in the case of
+sciatica; a mild case is often converted into one of great severity
+and intractability because the patient, in the early stages,
+either cannot or will not maintain the recumbent posture. So,
+too, though in less marked degree, the cure of cervico-brachial
+neuralgia is often greatly impeded by the difficulty of maintaining
+complete rest of the limb. Again, in neuralgia affecting the
+third division of the fifth, the movements of mastication and
+of speech are a terrible hinderance to the progress of recovery;
+and it often becomes necessary, in severe cases, to prescribe
+absolute silence, and even to feed the patient exclusively with
+such liquid or semi-liquid food as shall require no efforts of
+chewing.</p>
+
+<p>(2) Preservation from external cold is highly important.
+When a nerve of the arm, or leg, or trunk, is affected, warm
+flannel under-clothing ought immediately to be adopted. The
+patient who has been suffering from cervico-occipital neuralgia
+should for some time, in anything but quite summer
+weather, never go out without wearing a warm comforter
+round the neck. The sufferer from facial neuralgia should for
+some time after the cessation of actual attacks never face wind
+without wearing a thick veil.</p>
+
+<p>(3) Exposure to bright light must be scrupulously avoided by
+sufferers from ophthalmic neuralgia. The affection known as
+"snow-blindness" is really a neuralgia, with vaso-motor complications,
+produced by the glare of light reflected from snow; and
+one of the severest attacks of neuralgia which I personally
+ever experienced was provoked in this way. Even the comparatively
+slighter, but for an Englishman unusual, glare of
+sunlight which one meets with during the first days of a Continental
+holiday, in wandering about towns made up of clean
+white stone or whitewashed houses, is enough to provoke an
+attack, unless the eyes are carefully guarded with colored
+glasses.</p>
+
+<p>(4) It is scarcely necessary, after what has been already said,
+to insist upon the absolute necessity of mental quietude, as far
+as this can be obtained. This precaution is more or less important
+in all neuralgic affections; but in migraine and in
+other trigeminal neuralgias it is almost of more consequence
+than any other prophylactic measure; and in angina pectoris
+it is so essential that adoption or neglect of it may easily turn
+the scale between life and death. All forms of abdominal
+visceral neuralgia, also, are greatly affected by emotion, and<span class="pagenum"><a name="Page_189" id="Page_189">[189]</a></span>
+passion or strong excitement of any kind must be scrupulously
+shunned if the neuralgic habit is to be broken through. Unfortunately,
+it too often happens that the mental surroundings of
+the patient cannot be so changed as to enable us to carry out
+this kind of prophylaxis effectually; and neuralgic cases of
+this class are among the severest trials of the physician's tact
+and skill, and too frequently defy his efforts.</p>
+
+<p>(<i>c</i>) The precautionary measures which are to be adopted,
+after the neuralgic habit has apparently been fairly broken
+through, in order to prevent the patient from sliding again
+into the old vicious groove, can hardly be defined with exactness
+though their general character will be readily gathered from
+the picture of the clinical history and pathology of the disease
+which has been exhibited at large in this work. They mainly
+consist in the avoidance of severe, and especially of unequal,
+strains upon bodily or mental powers; and in redoubled carefulness
+in these respects at those natural crises in the life of
+the organism which have been shown to exercise so important
+an influence upon the neuralgic tendency. To a certain
+extent, also, but with much precaution, we may attempt to
+modify the peripheral sensibility by what is commonly
+called a hardening regimen. Thus, with great care, and proceeding
+in a very gradual manner, we may by degrees accustom
+the patient to a larger amount of exposure to free air, and
+even at last to rough weather, so that in the end he may
+become less sensitive to some of the commonest immediately
+exciting causes of neuralgia. If one were to construct an
+advancing scale of such measures, one might arrange them
+something like this: First, in-door gymnastics, and gentle
+horse-exercise for out-door work, in fine weather only; then
+horse-exercise alternated with pedestrianism, sea-bathing in
+warm weather; and, finally, we should try to reach a stage at
+which the patient can well endure a ten or fifteen miles' walk
+or ride every day, and be comparatively careless about the
+weather. In reaching this latter stage I have seen some
+patients helped, in an extraordinary degree, by the frequent
+use of the Turkish bath, followed by douche. Upon this latter
+subject I beg to offer some remarks, which are the result of
+pretty careful and extensive study of the effects of the Turkish
+bath in a variety of chronic nervous diseases. I believe it to
+be a very great mistake to suppose that, either in rheumatism
+or in true neuralgia, the process of the bath should be prolonged
+to such an extent as is commonly done. Instead of the
+usual slow heating process, gradually carried to a point at
+which excessive sweating occurs, I believe that the really
+scientific is the following: The patient should as quickly as
+possible get into the hottest atmosphere he intends to expose
+himself to, which should never be more than about 170° Fahr.
+He should stay in this place just long enough to get thoroughly<span class="pagenum"><a name="Page_190" id="Page_190">[190]</a></span>
+hot, and, with the assistance of a glass or so of water drunk,
+throw himself into a free but gentle perspiration. He should
+then be rapidly shampooed, exposed to the spinal douche for
+two or three minutes, and then pass to the cooling-room. Let
+him beware of too long dawdling in the latter place, and let
+him avoid smoking there. It is a positively dangerous thing
+to cool one's self quite down to the normal heat, still more so
+to induce the slightest chilliness; the body should be still in a
+universal glow when one issues into the street. Over and over
+again I have proved upon myself that it is the beneficial
+method, whereas the prolonged use of the bath, the production
+of very copious sweating, and above all a lengthened cooling
+process, most seriously exhaust the nervous energy.</p>
+
+<p>There are certain special considerations as to the habits of
+life that require a word or two. I need say nothing more to
+enforce the views already put forward as to the necessity of
+copious supplies of food. I need only refer to what I have
+already said about the decidedly mischievous tendency of anything
+like habitual excess in the use of alcohol, merely adding
+a special caution against such indulgence during, and particularly
+toward, the end of the period of sexual activity. There
+is one more topic upon which something must be said, namely,
+the extent to which sexual intercourse should be allowed.
+Speaking of neuralgia generally (excluding neuralgic affections
+of the sexual organs themselves), it may decidedly be
+said that the regular and moderate exercise of the function,
+during the natural period of sexual life, is beneficial; but that
+excess is always dangerous, and that the continuance of sexual
+intercourse, after the powers naturally begin to wane, is
+extremely pernicious in its tendency to revive latent tendencies
+to neuralgia. As regards neuralgias of the sexual organs,
+it is very difficult to speak positively; and yet I believe that
+(once the neuralgic habit broken through by other means) it is
+very desirable that the patient should live according to the
+laws of normal physiological life.</p>
+
+
+<div class="center">NOTE I.<br /><br /></div>
+
+<div class="center">ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC
+INHERITANCE.</div>
+
+<p>The following cases must be now added to those recorded in
+my list of private patients whose family history has been ascertained
+with reliable accuracy.</p>
+
+<p><span class="smcap">Case I.</span> is that of a gentleman, aged forty-seven, the subject
+of lumbo-abdominal neuralgia: no history of nervous disease
+in the family; his mother, however, was of a "nervous"
+temperament.</p>
+
+<p><span class="smcap">Case II.</span>&mdash;A gentleman, aged sixty-four, suffering from<span class="pagenum"><a name="Page_191" id="Page_191">[191]</a></span>
+angina. His family nervous history is fearful. On the father's
+side it is not possible to get a clear account. But on the
+maternal side there has been a strong tendency to insanity and
+suicide; and in the patient's own generation one brother committed
+suicide from insanity, and one sister is still alive, insane.
+An interesting fact is, that the mother's family have shown
+an extraordinary proclivity to erysipelas.</p>
+
+<p><span class="smcap">Case III.</span>&mdash;The young gentleman, whose single but
+extremely severe attack of angina is previously described,
+comes of a family in whom the tendency to neuralgia is
+undoubtedly very strongly inherited. His father is frequently
+and very severely <i>migraineux</i>, and in early life suffered cardiac
+symptoms not unlike his son's. A brother was also
+liable to attacks of true migraine between puberty and the
+age of twenty-one.</p>
+
+<p><span class="smcap">Case IV.</span>&mdash;On the other hand, a case of angina which I saw
+in the country, last year, occurred in a gentleman, aged fifty,
+whose family presented no traceable neurotic history. But
+the damage inflicted upon his nervous system by various
+external influences was quite extraordinary. In some way or
+other he got some attacks of migraine at the age of fifteen or
+sixteen; for these he was treated with bleeding, and with a
+most savage antiphlogisticism generally. From that time he
+never got free of the neuralgic tendency. He used to have not
+only facial, but intercostal neuralgia; for this last he was
+repeatedly bled, under the idea that it was pleurisy. Added to
+all this he habitually did an immense deal of brain-work in his
+study, and for years had performed clerical duties of the most
+exacting and exhausting character. It is not much wonder
+that these combined circumstances had sufficed to generate the
+neurotic temperament.</p>
+
+
+<div class="center">NOTE II.<br /><br /></div>
+
+<div class="center">THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD.</div>
+
+<p>In the present transitional state of opinion concerning the
+mode in which the phenomena are produced that are popularly
+known under the name of "reflex paralysis," I cannot pass
+without notice the doctrines of these two observers. The
+reader will have perceived that, as regards the secondary paralytic
+symptoms observed in neuralgias, I explain the phenomena
+mainly on the theory of a process which is central, and
+not peripheral, in origin. And, even where, as in some few
+instances, it seems possible that the starting-point was an
+organic affection of some viscus, we must always consider the
+possibility that the link between this and the neuralgia and
+paralyses was a neuritis migrans travelling inward to the sensory
+centre, and from that passing over to motor centres and<span class="pagenum"><a name="Page_192" id="Page_192">[192]</a></span>
+thus producing paralysis; or that, without the intervention of
+any truly inflammatory process, the continual impressions
+streaming in upon the cord from the original seat of organic
+disease may damage the nutrition of the sensory nerve-root,
+producing a partial atrophy, and that this process may extend
+to the motor root.</p>
+
+<p>It remains, however, to inquire whether the influence of
+powerful peripheral agencies may not, in a purely "functional"
+manner, disable the nerve-centres for a time, causing
+paralysis with or without neuralgia. The main supporters of
+such a doctrine are Dr. Handfield Jones<a name="FNanchor_46_46" id="FNanchor_46_46"></a><a href="#Footnote_46_46" class="fnanchor">[46]</a> and M. Jaccoud.<a name="FNanchor_47_47" id="FNanchor_47_47"></a><a href="#Footnote_47_47" class="fnanchor">[47]</a></p>
+
+<p>Dr. Handfield Jones expressly rejects the theory of Brown-Sequard,
+as to spasm of the vessels in the nerve-centres, and
+we need not repeat his arguments on that head, because it
+seems to be generally felt that the vascular spasm theory will
+not account for the facts. Jones believes that the state produced
+in the nerve-centre by the peripheral influence is one of
+paresis from shock-depression, and that from the sensory centre
+this state can communicate itself to motor and vaso-motor
+centres, though commissural fibres. He does not believe in the
+existence of a special inhibitory portion of the nervous system:
+he believes that an impression may prove stimulating when it
+is mild, or paralyzing when it is strong; and that any afferent
+nerve may convey either the one influence or the other to the
+centres and thus produce secondary stimulus or secondary
+paralyses in various efferent nerves. Jones has the distinguished
+merit of being one of the first authors distinctly to
+perceive that pain must rank on the same level with paralysis:
+hence he sees nothing unintelligible in the communication of
+paralysis to a motor centre from a sensory centre that was in
+the state which the mind interprets as pain.</p>
+
+<p>The <i>theorie d'epuisement</i> of Jaccoud (Erschopfungs-theoric)
+also denies the possibility of Brown-Sequard's idea of prolonged
+spasm of the vessels of the centres. It imagines that powerful
+peripheral excitements exhaust the irritability of the nerve,
+and through that of the centres, and induce a state of unimpressibility&mdash;analogous
+to that which exists in a nerve or
+nerve-centre, which is included in the circuit of a constant current.
+The nervous force is wasted, and, until an opportunity
+of repose is afforded to the centre, the faculty of impressibility
+cannot again revive.</p>
+
+<p>I must say that of these two theories I decidedly incline to
+that of Handfield Jones (though I imagine that in reality the
+cases are extremely rare, if there be any, in which the change
+in the centres is really only functional and non-organic), I
+<span class="pagenum"><a name="Page_193" id="Page_193">[193]</a></span>
+prefer the idea of paralyzing shock to that of exhaustion from
+over-excitement, from a consideration of the nature of that
+form of peripheral influence which has been specially mentioned
+by authors as competent to produce this sort of "reflex"
+affections, namely, intense and persistent cold. It seems to me
+a mere abuse of words to speak of this as an agent that could
+exhaust the nerve by over-stimulation; it must surely exhaust
+it in a much more direct manner than this, namely by the direct
+physical agency of withdrawing heat from the nerve, and spoiling
+its physical texture, <i>pro tanto</i>. If such an effect as that
+which must thus be produced on the nerve, and through it on
+the centre, is to be looked on as a case of over-stimulated
+function, then, it seems to me, there is no meaning in language,
+and no possibility of attaining to clear ideas on the
+subject of nervous influence.</p>
+
+
+<div class="center">NOTE III.<br /><br /></div>
+
+<div class="center">ARSENICAL TREATMENT OF VISCERALGIĘ.</div>
+
+<p>Since writing the above chapter on the Treatment of Neuralgia,
+I have had two fresh and very striking examples, in private
+practice, of the power of arsenic to break the morbid chain
+of nervous actions in angina pectoris.</p>
+
+<p>The first example was that of a medical man, aged seventy-five,
+in whom a neuralgia, originally malarial in origin, and
+of some years' duration, had fixed itself for some time in the
+fifth and sixth left intercostal spaces, and of late had become
+complicated with anginoid attacks of an unmistakable character,
+though not of the highest degree of severity. The case
+certainly seemed very unpromising, looking at the patient's
+age and the consequent high probability that there was much
+arterial degeneration. However, the use of Fowler's solution
+(five minims three times a day) was commenced and steadily
+pushed. The anginoid attacks rapidly diminished in frequency
+and at the end of ten days' time were entirely gone, and after
+one month of treatment he still had no return of them,
+although they had previously been of daily occurrence. It is
+a curious fact, whether a mere coincidence or not I cannot say,
+that, some few days after the anginoid attacks ceased, he began
+to experience somewhat severe pains, rheumatic in feeling, but
+unattended with heat or swelling, in the elbows, wrists, and
+fingers, symmetrically. This has nearly disappeared, but he
+is still free from angina. There is no discoverable heart-lesion
+in this patient.</p>
+
+<p>The other case was that of a fine old man of sixty-four, who,
+but for some few slight attacks of gout, a few small calculi, and
+a troublesome prostatic affection, had always enjoyed remarkably
+good health, until about five months ago, when he began<span class="pagenum"><a name="Page_194" id="Page_194">[194]</a></span>
+to notice tightness across the chest, etc., when he walked uphill.
+About a fortnight before he came to me, he was seized
+with very violent and alarming paroxysms of pain across
+the chest and running down both arms, extreme intermittence
+of pulse, and a sense of impending dissolution. The attack
+had recurred daily, at the same hour (6 <span class="smcap">p. m.</span>), ever since;
+besides which there was an abiding sense of uneasiness in the
+cardiac region, and a consciousness that the least excitement
+or exertion would bring on the paroxysm. I put the patient
+on five minims of Fowler, three times a day, with directions to
+take ether when the paroxysms came. At the end of the first
+week there was already much improvement, the paroxysms
+having been both less frequent and less severe. At the end of
+a fortnight's treatment he reported that there had been nothing
+like a paroxysm for the last eight days, although there was
+still a good deal of uneasiness from time to time. The hour at
+which the attack was expected passed by absolutely without a
+trace of angina. It remains to be seen how long this improvement
+will last, but the altered state of things, and particularly
+the suddenness of the change, cannot be overlooked, and has
+very much struck the patient himself. It is now six weeks
+since he had any paroxysm.</p>
+
+<p>It becomes more and more apparent that arsenic is generally
+applicable to neuroses of the vagus. In asthma, I have long
+held it to be the most powerful prophylactic tonic that we possess.
+It is also an excellent remedy in gastralgia; although I
+have rather dwelt (in the text of this work) on the action of
+strychnia in this disease, I would not omit my testimony to
+arsenic. Dr. Leared has related some exceedingly interesting
+cases bearing on this point. (See <i>British Medical Journal</i>,
+November 23 and 30, 1867.)</p>
+
+
+<div class="center">NOTE IV.<br /><br /></div>
+
+<div class="center">INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT.</div>
+
+<p>Dr. Reynolds pointed out to me the exceedingly curious
+fact, which I have several times verified, that the constant
+current, in relieving facial neuralgia, not unfrequently disperses,
+almost instantaneously, the brown skin-pigment that
+has collected in the painful region; <i>e.&nbsp;g.</i>, near the orbit.</p>
+
+
+<div class="center">NOTE V.<br /><br /></div>
+
+<div class="center">THE ACTUAL CAUTERY.</div>
+
+<p>A remedy for inveterate neuralgia which of late years I had
+almost discarded&mdash;the actual cautery&mdash;has quite recently
+yielded me very good palliative results in two cases. Its
+omission from the text of the chapter on Treatment was an
+accident due to the effect of habit in making one, half unconsciously,<span class="pagenum"><a name="Page_195" id="Page_195">[195]</a></span>
+reckon this remedy as a "counter-irritant." The
+longer I practise, however, the more decidedly I am convinced
+that the actual cautery, if properly applied, does not act as an
+irritant at all; and this fact was sufficiently in my mind, when
+writing of irritant remedies, to make me omit the cautery from
+that section. I should have inserted it under the heading of
+remedies that interrupt the conductivity of nerves, and thus
+give the centres temporary rest. The only useful way to apply
+it is, to make an iron white hot, and very lightly brush the
+skin over so as to make an eschar not followed by suppuration.
+The galvano-cautery (Stohrer's Bunsen) is the best for the purpose,
+but I have made the flat-iron cautery serve very well.</p>
+
+
+
+<hr style="width: 85%;" />
+<p><span class="pagenum"><a name="Page_196" id="Page_196">[196]</a></span></p>
+<h2><a name="myal" id="myal"></a>PART II.</h2>
+
+<h2>DISEASES THAT RESEMBLE
+NEURALGIA.</h2>
+<p><br /></p>
+<h2>CHAPTER I.</h2>
+
+<h3>MYALGIA.</h3>
+
+
+<p>Of all the diseases which superficially resemble neuralgia,
+none are so likely to be confounded with it, on a cursory glance,
+as myalgia. More careful inquiry, however, furnishes, in
+nearly all cases, ample means for distinguishing between the
+two affections.</p>
+
+<p>Myalgia is an exceedingly painful affection, and it is also
+much more common than was formerly supposed. It is to Dr.
+Inman that we undoubtedly owe the demonstration of the frequent
+occurrence of this malady, and the facility with which
+it may be mistaken for other, and sometimes much more
+serious, diseases, with very disastrous results. At the same
+time, I must express the opinion that this ingenious author has
+decidedly exaggerated the importance of this local disease at
+the expense of an unjust depreciation of the frequency and
+significance of other painful disorders which have their origin
+within the nervous system.</p>
+
+<p>Myalgia proper includes all those affections which are
+severally known as "muscular rheumatism" (for the muscles
+generally), and "lumbago," "pleurodynia," etc. (according to
+locality). It is essentially pain produced in a muscle obliged
+to work when its structure is imperfectly nourished or
+impaired by disease.</p>
+
+<p>The clinical history of the different varieties of myalgia
+absolutely requires this key for its interpretation; otherwise,
+the appearance of the sufferers from different kinds of myalgia
+is so widely dissimilar that we should be exceedingly likely to
+miss the important features of treatment, which must be
+applied to them all in common. Nothing, for instance, can
+be more strikingly unlike than the appearance of the pallid,
+stunted, under-nourishment cobbler who complains of epigastric
+myalgia, and that of the ruddy and muscular navvy who
+suffers from acute lumbago, or the similarly plethoric-looking
+country commercial traveller, who has been driving in his gig<span class="pagenum"><a name="Page_197" id="Page_197">[197]</a></span>
+against wind and rain, and complains of violent aching pains
+in one or both shoulders; yet one and all of these individuals
+are suffering from precisely the same cause of pain, viz., a
+temporarily crippled muscle or set of muscles which has been
+compelled to work against the grain. Why this state of things
+should invariably be interpreted as sensation in the form of
+acute pain never absent, but severely aggravated by every
+movement of the affected part, is a matter beyond our powers
+of explanation, we must accept it as an ultimate fact for the
+present.</p>
+
+<p>There is scarcely any need to describe the pain of myalgia,
+since almost every one has suffered either from lumbago, or from
+a stiff neck produced by cold. The pain is essentially the
+same in all cases; it is an aching actually felt either in or
+toward the tendinous insertions of the affected muscles, and
+sharply renewed by every attempted contraction of those muscles.
+The variations in the character and severity of the pains
+are really entirely due to the greater or the less opportunity
+for physiological rest which the muscle can obtain. Thus the
+most obstinate and the most severe, kind of myalgic pain is
+undoubtedly that of pleurodynia&mdash;pain in the intercostal muscles
+and their fibrous aponeuroses&mdash;a fact which depends on the
+incessant movements which these muscles are compelled to
+perform in the act of respiration. And next to this in severity
+and obstinacy are myalgias of the great muscles which are
+incessantly engaged in maintaining, by their accurately
+opposed contraction, the erect position of the spinal column
+and of the head. This rate of proportional frequency and
+severity, however, must be taken as strictly relative; <i>i.&nbsp;e.</i>, it is
+correct upon the supposition that the different sets of muscles
+were equally worked and that the state of nutrition was equal
+in the different parents. It is otherwise when the conditions
+are reversed. Thus, the unfortunate cobbler or tailor, who sits
+for long hours in one cramped and bent posture, is continuously
+exerting his recti abdominales (probably suffering from
+an under-nutrition common to all his tissues) to a degree perfectly
+abnormal, and out of all proportion to the functional
+work he is getting out of any other part of his muscular system.
+The consequence is, that he comes to us complaining of
+acute epigastric, and sometimes pubic, pain, rising to agony
+when he assumes his ordinary sitting posture, and only
+reduced to any thing moderate by the most complete extension
+of the whole trunk in the supine posture.</p>
+
+<p>There is no need to dilate at greater length upon the varieties
+in the symptoms of myalgia, according as it affects one or
+another part of the body. We must consider, briefly the different
+kinds of cause that produce it. The immediate source of
+the pain being, as we have seen, the sense of embarrassment in
+a muscle obliged to contract when unfit for the work, we have<span class="pagenum"><a name="Page_198" id="Page_198">[198]</a></span>
+to ask what are the remoter causes that can produce this special
+unfitness for the work of contraction. They are three: (<i>a</i>)
+Overlabor pure and simple (<i>i.&nbsp;e.</i>, in proportion to the existing
+bulk and quality of the muscle); (<i>b</i>) cold, and especially damp
+cold, producing a semi-paralyzing effect on the vaso-motor
+nerves, and causing congestion and sometimes a little effusion
+among the fibres or within the sheath of the muscle; (<i>c</i>) fatty
+degeneration of muscle which is exposed to inevitable and
+incessant work. Either of these conditions may so disable the
+muscle that its unavoidable contractions will set up the
+myalgic state.</p>
+
+<p>Undoubtedly however there is something further, in the
+shape of a natural predisposition not yet understood, which
+makes some patients so much more liable to suffer myalgic
+pain as a consequence of this sort of influences than other
+persons are. I am in no condition to decide what the nature
+of this predisposition is; I feel sure it is heightened by an
+inherited or acquired gouty taint, but I have seen it in people
+whom there is no reason to suspect of gouty tendencies. It
+appears to have no connection with true rheumatism.</p>
+
+<p>Still after all that can be said, myalgia remains a disease
+chiefly of local origin, and depending for nine-tenths of its
+causation upon a derangement between the balance of work
+and nutrition in the muscle.</p>
+
+<p>As regards the diagnosis of myalgia from neuralgia, which
+is a very important matter, the following are the main points
+that we should recollect:</p>
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="4" summary="neuralgia myalgia">
+<tr><td align="center" width="50%"><i>Neuralgia.</i></td><td align="center" width="50%"><i>Myalgia.</i></td></tr>
+<tr><td class="topleft">Follows the distribution of a recognizable nerve or nerves.</td><td class="topleft">Attacks a limited patch or patches that can be identified with the tendon or aponeurosis of a muscle which, on inquiry, will be found to have been hardly worked.</td></tr>
+<tr><td class="topleft">Goes along with an inherited or acquired nervous temperament, which is obvious.</td><td class="topleft">As often as not occurs in persons with no special neurotic tendency.</td></tr>
+<tr><td class="topleft">Is much less aggravated, usually, by movement than myalgia is.</td><td class="topleft">Is inevitably, and very severely, aggravated by every movement of the part.</td></tr>
+<tr><td class="topleft">Is at first accompanied by no local tenderness.</td><td class="topleft">Distinguished from the first, by localized tenderness on pressure as well as on movement.</td></tr>
+<tr><td class="topleft">Points douloureux, when established at a later stage, correspond to the to the emergence of nerves.</td><td class="topleft">Tender points correspond to tendinous origins and insertions of muscles.</td></tr>
+<tr><td class="topleft">Pain not materially relieved by any change of posture.</td><td class="topleft">Pain usually completely and always considerably relieved by full extension of the painful muscle or muscles.</td></tr>
+</table></div>
+<p><span class="pagenum"><a name="Page_199" id="Page_199">[199]</a></span></p>
+
+<p>The treatment of myalgia is not only satisfactory in itself,
+but often affords, in its results, a very desirable confirmation
+of diagnosis.</p>
+
+<p>For a very large number of cases, all that is required is (<i>a</i>)
+to put and keep the affected muscle in a position of full extension,
+which is only to be changed at somewhat rare intervals;
+(<i>b</i>) to cover the skin all over and round it with spongio-piline,
+so as to maintain a perpetual vapor-bath; (<i>c</i>) on the subsidence
+of the acutest pain and tenderness, to complete the treatment
+by one or two Turkish baths, to be taken in the manner that I
+have recommended by speaking of the prophylaxis of neuralgia.</p>
+
+<p>When treatment such as this cures a pain which was greatly
+aggravated by muscular movement, we may be sure that pain
+was myalgic and not neuralgic.</p>
+
+<p>The pain, however, is not unfrequently rebellious to such
+simple remedies as these, more especially when (as in pleurodynia)
+we are not able to enforce complete physiological rest of
+the part. When this is the case, we shall find the internal use
+of twenty and thirty grain doses of muriate of ammonia by far
+the most effective remedy. In the first very acute stage of a
+severe case it may be advisable to inject morphia hypodermically;
+but this is seldom necessary. The muriate-of-ammonia
+treatment may be usefully accompanied by prolonged gentle
+frictions, three or four times a day, with a weak chloroform
+liniment.</p>
+
+<p>When there is visibly a very great deficiency in the general
+nutrition, we shall often fail to obtain a cure until we have
+remedied this defect; and accordingly, in the majority of cases
+of half-starved and overworked needle-women, cobblers, tailors,
+and the like, who present themselves in the out-patient room,
+I accompany the above-named treatment with the steady
+administration of cod-liver oil for three or four weeks or more.</p>
+
+<p>There is one remedy for this pain which I have myself seen
+used in only a few cases, but which I believe promises exceedingly
+well for the treatment of obstinate myalgia; viz.,
+acupuncture. I have not even mentioned it as a remedy for
+neuralgia, for I believe it to be totally useless in true cases of
+that disease, whether applied in the simple form or in that of
+galvano-puncture. I think very differently of its use in
+myalgia; and I venture to believe that it is entirely to cases of
+this disease that the exceedingly interesting observations of
+Mr. T. P. Teale, in a recent number of the <i>Lancet</i>, apply.
+Where (after the usual remedies for myalgia have been applied)
+we are unable to get rid of a deep-seated and fixed muscular
+pain, I believe it to be excellent practice to plunge two or
+three long needles deeply into the muscle near its tendinous
+attachment.</p>
+
+
+
+<hr style="width: 65%;" />
+<p><span class="pagenum"><a name="Page_200" id="Page_200">[200]</a></span></p>
+<h2><a name="spin" id="spin"></a>CHAPTER II.</h2>
+
+<h3>SPINAL IRRITATION.</h3>
+
+
+<p>I retain this phrase, not because it is an absolutely good one,
+but because it has become so familiar that it is difficult to dispense
+with it. We have taken a useful step, however, in
+separating the true neuralgias from the somewhat indefinite
+group of diseases to which this title has been given. I think
+the reader who has carefully studied Part I. of this work will
+not deny that the latter disorders present a very clear and
+definite common outline which distinguishes them essentially
+from the vaguer affections to be described under the present
+heading.</p>
+
+<p>Spinal irritation, in my sense, includes all those conditions
+in which, without any special mental affection, and without
+any single nerve being definitely affected, there are sensations
+varying between mere cutaneous tenderness, often of a large
+and irregular surface, and acute pain approaching neuralgia in
+character, together with fixed tenderness of certain vertebrę
+on deep pressure. A very large majority of the phenomena
+are such as would be popularly included (now that they are
+known not to be of an inflammatory character) under the term
+"hysterical." That unhappy word crosses our path at every
+turn in a most embarrassing manner, and yet it can hardly at
+present be said that we could afford to do without it.</p>
+
+<p>The more typical cases of so-called "hysterical hyperęsthesia"
+present the following phenomena: Along with the
+general symptoms of the hysterical temperament (tendency to
+causeless depression, variable spirits, sensation of globus, semi-convulsive
+attacks terminated by the discharge of a great
+quantity of pale, limpid urine) there is commonly a marked
+superficial tenderness of the surface everywhere, and an exaggeration
+of reflex irritability. The general tenderness is so far
+merely cutaneous that deep pressure is ordinarily borne better
+than the lightest finger-touch. But besides this there are
+usually one or several spots in which the tenderness is more
+profound and genuine. There is almost sure to be some point
+in the spinal column where firm pressure not merely evokes a
+complaint of pain, but also induces secondary objective phenomena
+connected with distant organs, such as nausea and
+vomiting when the cervical vertebrę are tender, severe gastric
+pain when the dorsal vertebrę are tender, etc. In such cases
+there is not only spinal tenderness, but very usually also a
+well-marked tenderness in the epigastrium and the left
+hypochondrium, the <i>trepied hysterique</i> of Briquet. The reader
+must, however, be warned that the whole of these three tender
+points may be merely myalgic, and it is necessary very carefully<span class="pagenum"><a name="Page_201" id="Page_201">[201]</a></span>
+to observe whether local movements do or do not seriously
+aggravate the pain in them. And, on the other hand,
+the spinal tender point may be merely the "point apophysaire"
+of a true neuralgia which exhibits no other symptoms of the
+so-called hysteric constitution.</p>
+
+<p>The kind of hysteria that is joined with the existence of fixed
+tender spots in definite points of the vertebral column is not
+commonly distinguished by the occurrence of cutaneous
+anęsthesia; but those writers are certainly wrong in saying
+that such a combination never takes place. I have seen examples
+of the most marked union of the two classes of symptoms
+in the same person.</p>
+
+<p>These cases of so-called spinal irritation with general hysteric
+manifestations are very commonly attended with paroxysmal
+pains that approach true neuralgia in character. Nor
+is it to be denied that we sometimes meet with the combination
+of general hysteria, spinal tenderness in definite points (with
+secondary spasmodic or paralytic phenomena always following
+pressure exerted on the latter), and true neuralgia limited to
+one nerve. But the more typical spinal irritation cases are
+merely complicated with a tendency to vague pains which are
+shifting both in character and position, not with definite
+unilateral neuralgia always haunting the same nerve and
+exhibiting more or less of the same type. In fact, as far as one
+can judge in the absence of any precise information as to the
+condition of the nervous centres in such cases, it would seem
+likely that the ordinary cases of spinal irritation differ from
+the true neuralgias chiefly in this&mdash;that the injury, or
+inherited weakness of organization, or both, which is at the root
+of the malady, is at once slighter in degree, and spread over a
+larger tract of the nervous centres, than that which produces
+a true neuralgia. I believe that Dr. Radcliffe is right in supposing
+it to be probable that a blow or other injury to the back
+producing general spinal shock, is the original but unsuspected
+cause of a large proportion of these cases. One of the
+most perfect examples of spinal irritation that I have ever
+seen (and which also contrasts keenly with the commoner
+hysteric affections on the one hand, and the true neuralgię
+on the other) was that of a girl whom I examined together
+with Dr. Walshe, Dr. Reynolds, and Dr. Bridge. This young
+lady was a most intelligent person, and not in the slightest
+degree inclined to the apathy and idleness so often seen in
+hysterical people. She had received what was thought at
+the time to be a very slight contusion in a railway collision,
+in which, however, her sister, who was in the same carriage,
+had been severely injured. She nursed this sister assiduously,
+and it was not till three or four months later that her own
+health began to fail seriously; but she then became anęmic
+and extremely depressed. About six months after the accident<span class="pagenum"><a name="Page_202" id="Page_202">[202]</a></span>
+it was quite casually discovered that there was a spot over
+the lowest cervical vertebra, pressure on which gave her exquisite
+pain and a sensation of extreme nausea; and the very
+curious observation was made that such pressure instantaneously
+produced extinction of the right pulse, the left pulse
+remaining unaltered. In this case it cannot be doubted that
+a serious shock had been communicated to a lateral segment of
+the cord involving chiefly the vaso-motor nerve fibres, in which
+probably some decided material lesion had been gradually set
+up; and besides this there was probably slighter damage to
+the spinal cord generally, as there was great general feebleness
+of movement, though no actual paralysis of the limbs.</p>
+
+<p>Along with the phenomena of fixed spinal tenderness, without
+distinct neuralgia of any particular nerve, we not unfrequently
+observe the development of more or less decided tenderness
+of some of the internal surfaces of the body. I
+have recently had under my care a young woman in whom
+a very tender point was developed over the second cervical
+vertebra, and who suffered from such persistent tenderness of
+the whole posterior part of the pharynx, that I was for some
+time seriously apprehensive of the existence of spinal caries
+and post-pharyngeal abscess. The general character of her
+symptoms, however, induced me to hope that the case was one
+of spinal irritation merely, and the event proved that this was
+the case, for under the use of iron and small doses of strychnia
+she recovered completely in about three weeks. In another
+patient who came under my care about twelve months ago,
+there was extraordinary sensitiveness of the gastric mucous
+membrane, causing exquisite pain after she had eaten almost
+any thing: there was only occasional vomiting, however,
+and there had never been any hęmorrhage, so that the evidence
+for gastric ulcer, which I otherwise inclined to think
+existed, was insufficient. I discovered that pressure on the
+third or the fourth dorsal vertebra gave great pain, and produced
+a strong inclination to vomit; this made it probable
+that the affection was spinal, and accordingly all treatment
+addressed to the stomach was abandoned. Flying blisters to
+the neighborhood of the painful spinal points quickly relieved
+all the symptoms.</p>
+
+<p>Another distressing class of symptoms, which is very commonly
+observed in connection with these cases of spinal irritation,
+is that of abnormal arterial pulsations: I am not sure
+whether even severe neuralgia produces more distress than
+does this pulsation. I have repeatedly seen abnormal pulsation
+of the carotids in connection with fixed tender-points over
+the cervical or the upper dorsal vertebrę; and still more commonly
+pulsation of the abdominal aorta in connection with
+tenderness over one or two of the upper dorsal vertebrę.
+Spasmodic cough and spasmodic dyspn&#339;a frequently accompany<span class="pagenum"><a name="Page_203" id="Page_203">[203]</a></span>
+tenderness of points in the upper half of the spinal
+column; and in one instance I have seen pressure on the
+lowest cervical vertebrę produce a paroxysm which looked
+alarmingly like angina pectoris. A case of singularly prolonged
+and obstinate spasmodic hiccough which came under
+my notice was distinguished by the presence of a fixed tender
+spot over the third dorsal vertebra.</p>
+
+<p>Prolonged spastic contraction of voluntary muscles, going
+on, sometimes for weeks, and even months, is a phenomenon
+that has often been observed; it may attack the arm only, or
+may affect all the limbs, and the muscles of the trunk and of
+the neck: it is for the most part symmetrical, but is occasionally
+unilateral. It begins in the extremities, and is very commonly
+limited to them; it is much more gentle than tetanic
+spasm, and is also painless, or nearly so; but the contraction
+is often strong enough to resist very vigorous efforts at artificial
+extension.</p>
+
+<p>Paralyses, both of bowel and bladder, have been recorded
+among the occasional phenomena of spinal irritation with
+fixed tender points; but I cannot say that I have ever seen
+such an occurrence. On the whole, I must say that by far the
+most frequent phenomena of spinal irritation that I have seen
+have been somewhat diffuse cutaneous or mucous tenderness
+and irritability (without acute pain) and the presence of tormenting
+arterial throbbings; also a marked tendency to
+aggravation of some symptoms, especially the gastric, when
+firm pressure is made upon the tender spinal points. For a
+further and fuller account of the phenomena of spinal irritation
+I may refer the reader to the able article of Dr. Radcliffe,<a name="FNanchor_48_48" id="FNanchor_48_48"></a><a href="#Footnote_48_48" class="fnanchor">[48]</a>
+and the work of the brothers Griffin, already quoted; adding
+the suggestion, however, that both these authorities, and
+especially the Griffins, appear to me not to draw a sufficiently
+clear distinction between the class of cases that I have been
+attempting to describe and the true neuralgias.</p>
+
+<p>After what has been said, there is no need to draw out a
+formal list of the points of diagnosis between spinal irritation
+and neuralgia. It must be admitted, moreover, that the two
+forms of diseases have a strong connection in the fact that
+they are each of them most frequently developed in the
+descendants of neurotic families. It is by the more generalized
+character of the symptoms, and the absence of the tendency
+to perpetual recurrence of paroxysmal pain in one
+definite nerve, that spinal irritation is mainly distinguishable
+from true neuralgia. I may add that there is a marked distinction,
+also, in the results of treatment.</p>
+
+<p>The treatment of spinal irritation is, it must be confessed
+still in an unsatisfactory position; and I believe that a good
+<span class="pagenum"><a name="Page_204" id="Page_204">[204]</a></span>
+deal of unnecessary discouragement has been occasioned to
+physicians by their failures to cure supposed neuralgias which
+really belonged to the spinal irritation class. I would assuredly
+by no means assert that genuine neuralgia is not frequently
+intractable, or even incurable; but it is certainly much
+more curable than spinal irritation; and for this reason,
+mainly as I believe&mdash;that there is much more possibility of
+aiming our remedies at the actual seat of the disease. On
+the other hand, in spinal irritation we are confused and distracted
+with a variety of phenomena for which even the most
+subtle analysis will frequently fail to trace a common origin.
+It is true that the existence of definite tender spots in the spine
+apparently suggests a strictly local application of remedies;
+and it true also that medication based upon this fact is sometimes
+very effective; but this is, in my experience, only an
+occasional result, and the practitioner who trusts to local
+measures will frequently be disappointed. And, on the other
+hand, the general tonic treatment, and the use of special medicines,
+like quinine and arsenic, or the hypodermic injection of
+morphia oratropia, have nothing like the extensive utility in
+the treatment of spinal irritation that they possess in that of
+true neuralgia. Of internal remedies, by far the most useful
+in my hands have been sesquichloride of iron with small
+doses of strychnia, and the milder vegetable bitters, especially
+calumba.</p>
+
+<p>There is one special phase, however, of spinal irritation
+which is very amenable to the direct, treatment, viz., cutaneous
+and mucous tenderness. Whatever the "hyperęsthetic"
+part is within reach, so that we can apply Faradization,
+we can almost certainly eradicate the morbid sensibility very
+quickly. The secondary current of an electro-magnetic or
+volta-electric induction apparatus is to be employed; the conductors
+should be of dry metal and the negative one, which
+is to be applied to the painful surface, should be in the form of
+the wire brush. The positive pole is to be placed on some
+indifferent spot, and the negative is to be stroked briskly backward
+and forward over the sensitive skin, a pretty strong current
+being employed. The process is painful so much so that
+it will often be advisable, with delicate patients, either to
+administer chloroform or to inject morphia subcutaneously
+before the Faradization. A very few daily sittings of four or
+five minutes length will generally remove the morbid tenderness
+completely. Where the tender part is within one of the
+cavities, at the rectum, bladder, vagina, or pharynx, we must
+of course use a solid negative conductor of appropriate form,
+and must content ourselves with applying it steadily to one
+point after another of the sensitive surface.</p>
+
+<p>The fact that Faradization proves so remarkably useful, in
+these cases of spinal irritation with diffuse cutaneous or<span class="pagenum"><a name="Page_205" id="Page_205">[205]</a></span>
+mucous tenderness, is in itself a strong diagnostic between this
+sort of affection and the true neuralgię, which, as I have stated
+are seldom benefited, and are often made worse, by the interrupted
+current, though the constant current frequently mitigates
+or cures them.</p>
+
+<p>Sometimes where it is not possible to apply the remedy
+directly to the sensitive surface, we may nevertheless do great
+good by sending the interrupted current through it. Thus, in
+gastric sensitiveness connected with spinal tenderness in the
+upper dorsal region, I have seen very great relief afforded by
+sending a current from the positive pole, placed on the tender
+vertebrę, to a broad, negative conductor placed on the epigastrium.
+And similarly, I have seen an acutely sensitive condition
+of the neck of the bladder greatly soothed by the passage
+of a current from a painful lumbar vertebra to the perinęum
+immediately behind the scrotum.</p>
+
+<p>Undoubtedly, however, the more serious cases of spinal irritation
+will yield only (if they yield at all) to a prolonged
+treatment in which very skilful use is made of general hygienic
+measures, and especially of morbal influences. As the brothers
+Griffin long ago pointed out, although rest is useful in the
+early stages of this malady, if the disease does not quickly
+yield to this and to appropriate tonic medication, and perhaps
+local applications to the spine, it will not do to keep the
+patient recumbent and confined to the house; on the contrary
+at whatever cost of immediate discomfort, he (or she for these
+patients are by far the most frequently females) must be
+roused up, and persuaded or compelled to take out-door exercise,
+and if possible to travel, and divert the mind by complete
+change of scene. When such expensive remedies are out of
+the question, it seems better that patients, even seemingly
+very feeble, should take to their ordinary avocations in life
+again, and fight down the tendency to invalidism. But of
+course, the decision on such a point must rest with the tact and
+judgment of the practitioner in each individual case, for there
+are, doubtless, instances in which the attempt to carry out
+such a plan, even moderately, would break down the remaining
+strength, and make matters worse than they were before.</p>
+
+<p>In the worse case of spinal irritation that I ever saw, that of a
+young lady, aged twenty-eight, there were pronounced anęmia
+and general feebleness, the true hysteric <i>trepied</i> of tender
+points, painful irritability of the stomach, which baffled all
+medical advisers and resisted almost every possible form of tonic
+and nervine medicines, counter-irritation to the spine, and, in
+fact every thing that one dared attempt with so feeble-looking
+a patient, but at once cleared up and was quite cured after
+marriage. And there can be no question that a very large proportion
+of these cases in single women (who form by far the
+greater number of subjects of spinal irritation) are due to this<span class="pagenum"><a name="Page_206" id="Page_206">[206]</a></span>
+conscious or unconscious irritation kept up by an unsatisfied
+sexual want. In some patients there cannot be a doubt
+that this condition of things is indefinitely aggravated by the
+practice of self abuse; but it would be most unjust to think that
+this is a necessary element in the causation; on the contrary,
+it is certain that very many young persons (women more especially)
+are tormented by the irritability of the sexual organs
+without having the least consciousness of sensual desire, and
+present the sad spectacle of a <i>vie manquee</i> without ever knowing
+the true source of the misery which incapacitates them
+for all the active duties of life. It is a singular fact, that in
+occasional instances one may even see two sisters inheriting
+the same kind of nervous organization, both tormented with
+the symptoms of spinal irritation, and both probably suffering
+from repressed sexual function, but of whom one shall
+be pure-minded and entirely unconscious of the real source of
+her troubles, while the other is a victim to conscious and fruitless
+sexual irritation.</p>
+
+<p>I have already <ins title="Transcriber's Note: original reads 'causually'">causally</ins> alluded to the danger of mistaking
+mere myalgia for spinal irritation and must again enforce this
+consideration upon the reader. Myalgic tender points in the
+region of the spine are common enough; and it would be easy
+without careful attention, to mistake them for the deeper-seated
+vertebral tenderness which is truly characteristic of
+spinal irritation. Hence the utmost care must be taken to
+ascertain the true history of the commencement of the disorder
+whether it succeeded to great and long continued fatigue of particular
+sets of muscles, and whether it is specially aggravated by
+contractions of those muscles, and relieved by their full extension.
+The differences of treatment which depend on the diagnosis
+are too obvious to need dwelling upon.</p>
+
+<p>The question of administering remedies with the direct
+intention of procuring sleep, for patients suffering from
+spinal irritation, often becomes an important and a very difficult
+one. It is, for the most part, highly objectionable to commence
+the use of such remedies; and yet sleeplessness is a very
+distressing symptom with many patients, and is, of course in
+itself exhausting and deleterious. For as long as we possibly
+can, we should content ourselves with efforts to produce sleep
+by the timely administration of nourishment. The same general
+rule of a very generous (though not very stimulating) diet
+to be enforced as carefully as in the case of sufferers from neuralgia.
+But it is especially advisable in spinal irritation; that
+the patient should take some food shortly before bedtime; and it
+is well, also to place food within reach at the bedside, so that if
+he wakes up he may take some. If, however, we are absolutely
+driven to employ hypnotics, we must commence with
+the very mildest. The popular remedy of a pillow stuffed
+with hops will sometimes suffice; and a better way of administering<span class="pagenum"><a name="Page_207" id="Page_207">[207]</a></span>
+the volatile principle of hops is to scatter a few hops
+on hot water in an inhaler, and let the patient breathe the
+steam. Hot foot-baths, with mustard, are also very useful.
+If these fail, chloral, in moderate doses is probably the best
+and safest remedy, and, with care not to give too much, we may
+go on using the same dose without increase for a good many
+times.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="hypo" id="hypo"></a>CHAPTER III.</h2>
+
+<h3>THE PAINS OF HYPOCHONDRIASIS.</h3>
+
+
+<p>There is perhaps nothing, in the whole range of practical
+medicine, more difficult to seize with clear comprehension, and
+picture to the mind with accuracy, than the group of pseudo-neuralgię
+which belong to the domain of hypochondriasis.
+They are among the most indefinable, and at the same time
+the most intractable, of nervous affections.</p>
+
+<p>To understand what hypochondriac pains are, we must first
+be familiar with the general character of the hypochondriacal
+temperament, for the pains are only a subordinate and ever-varying
+phenomena of the general disease.</p>
+
+<p>Hypochondriasis is not insanity, if by insanity we mean
+intellectual perversion dependent mainly or entirely on the
+state of the higher nervous centres. But it is closely allied to
+insanity in its phenomena, only that these are, as it were,
+manifested in a scattered form, unequally distributed over the
+whole central nervous system, and especially affecting the
+spinal sensory centres. And its radical relationship to true
+insanity is strongly indicated by the fact that the sufferers
+from hypochondriasis are nearly, if not quite, always members
+of families in which distinct insanity has shown itself; indeed,
+more often than not, of families which have been strongly
+tainted in this way. In the majority of instances there are
+psychical peculiarities of a marked kind which accompany or
+precede the development of the abnormal sensations which
+form the especial torment of hypochondriacs. Without
+apparent cause, they begin to evince a heightened self-feeling
+and an anxious concentration of their thoughts upon the state
+of one or more of their bodily organs. Or it may be that,
+before any such definite bias is given to their thoughts, they
+simply become less sociable and more self-centred, and are subject
+to fits of indefinite and inexplicable depression, or at least
+to great variability of spirits. But before long they begin to
+experience definite morbid sensations, most commonly connected
+with the digestive organs, and very often accompanied
+by positive derangement of digestion of an objective character;<span class="pagenum"><a name="Page_208" id="Page_208">[208]</a></span>
+such as flatulence, sour eructation, spasmodic stomach-pain,
+etc. Along with these phenomena, or soon afterward (and not
+unfrequently before the patient has acquired that intensity of
+morbid conviction of his having some special disease which is
+afterward so marked a peculiarity of his mental state), he very
+often becomes the subject of the kind of pains which it is the
+special purpose of this chapter to describe.</p>
+
+<p>The pains of hypochondriasis, when they assume any more
+definite form than that of mere dyspeptic uneasiness, present
+many analogies with neuralgia. They are not, usually, periodic
+in any regular manner, but they have the same tendency to
+complete intermission, and they frequently haunt some one or
+more definite nerves for a considerable period of time. Of all
+nerves that are liable to this kind of affections the vagus is
+undoubtedly the most susceptible; hypochondriac patients
+very frequently complain of pseudo-anginoid and pseudo-gastralgic
+pains; next in frequency are nervous pain in the region
+of the liver, or in the rectum or bladder. The main distinctions
+by which they are separable from true neuralgia are two:
+in the first place, the character of the pain nearly always is
+more of the boring or burning kind than of the acutely darting
+sort which is most usual in true neuralgia; and, secondly, the
+influence of mental attention in aggravating the pain is far
+more pronounced than in the latter malady; indeed, it is often
+possible, by merely engaging the patient in conversation on
+other topics, to cause the pain to disappear altogether for the
+time. But in hypochondriasis it is not often that we are left,
+for any long time, to these means of diagnosis only; the special
+character of the disease is that the morbid sensations shift from
+one place to another, in a manner that is quite unlike that of
+the true neuralgias. The patient who to-day complains of the
+most severe gastralgia, or liver-pain, will to-morrow place all
+his sufferings in the cardiac region, or in the rectum, or will
+complain of a deep fixed pain within his head; and these
+changes are often most rapid and frequent. Frequently there
+are also peculiar skin sensations, which usually approach
+formication in type, and these, like the pains, are apt to shift
+with rapidity from one part of the body to another. Later on
+in the disease, especially in those worst cases which approach
+most closely to the type of true insanity, there are often
+hallucinations of a peculiar and characteristic nature, such as
+the conviction of the patient that he has some animal inside
+him gnawing his vitals, that he is made of glass and in constant
+danger of being broken, and a variety of similar absurdities.
+In short, it is not the fully-developed cases of hypochondriasis
+that need puzzle us, these are usually distinct
+enough; but the earlier and less characteristic stages in which
+pain may be nearly the only symptom that is particularly
+prominent.<span class="pagenum"><a name="Page_209" id="Page_209">[209]</a></span></p>
+
+<p>In hypochondriasis, as in hysteria, there is often great sensitiveness
+of the surface; and, as in hysteria, this sensitiveness
+is found to be very superficial, so that a light touch often
+hurts more than firm, deep pressure. As in hysteria, too, the
+tenderness is a phenomenon so greatly affected by the mind,
+that, if we can divert the patient's attention for a moment, he
+will let us touch him anywhere, without noticing it at all.</p>
+
+<p>It is a marked peculiarity of hypochondriasis that it is far
+more common in men than in women; a relation which is precisely
+the opposite to that which rules in neuralgia. Hypochondriasis
+is also pre-eminently a disease of adult middle life; it is
+scarcely ever seen in youth, except as the result of excessive
+masturbation acting on a temperament hereditarily predisposed
+to insanity.</p>
+
+<p>The results of treatment frequently assist our diagnosis in
+difficult cases. Almost any medicine will relieve the pains of
+the hypochondriac for a time, and it is generally far easier
+to do him good, temporarily, than it is to relieve a neuralgic
+patient; but, <i>en revanche</i>, every remedy is apt to lose its affect
+after a little while. The only chance of producing permanent
+benefit in hypochondriasis is by the judicious combination of
+remedies that remove symptoms (especially dyspepsia, flatulence,
+etc.), which mischievously engage the patient's mind,
+with general tonics, and, above all, which such alterations in
+the patient's habits of daily life as take him out of himself and
+compel him to interest himself in the affairs of the world
+around him. And, after all, our best efforts will frequently
+lead to nothing but disappointment.</p>
+
+<p>It is notoriously the fact that hypochondriasis especially
+affects the rich and idle classes; but it would be a great mistake
+to suppose that it never attacks the poor or the hard-worked:
+only, in the latter instances, it apparently needs, for it development,
+the existence of strong family tendencies to neurotic
+disease, and especially to insanity. Among the numerous
+debilitated persons who attend the out-patient rooms of our
+hospitals we every now and then encounter as typical a case of
+hypochondriasis as could be found even among the rich and
+gloomy old bachelors who haunt some of our London clubs.
+I have one such patient under my care now, who has been a
+repeated visitor at the Westminster Hospital during many
+years: he has had pseudo-neuralgic pains nearly everywhere
+at different times; but his most complaint has been of pain in the
+groin and scrotum of the right side. The existence of what
+seemed, at first, like the tender points of lumbo-abdominal
+neuralgia, at one time led me to believe it was a case of that
+affection; but I was soon undeceived by finding that the tenderness
+did not remain constant to the same points, but shifted
+about. This man has professed, by turns, to derive benefit
+from nearly all the drugs in the Pharmacop&#339;ia; but the only<span class="pagenum"><a name="Page_210" id="Page_210">[210]</a></span>
+remedies that have done him good, for more than a day or
+two at a time, have been valerian and assaf&#339;tida, with the
+prolonged use of cod-liver oil. He will never be really cured;
+and I suspect that the secret of his maladies is an inveterate
+habit of masturbation acting on a nervous system hereditarily
+predisposed to hypochondriasis.</p>
+
+<p>Sometimes it happens that the starting-point of hypochondriac
+pains, simulating neuralgia, is a blow, or other bodily
+injury acting on a predisposed nervous system. Another of
+my patients at the Westminster Hospital was a policeman,
+who had received a severe kick in the groin; he suffered pains
+which at first seemed to wear all the characters of true neuralgia
+in the pudic nerve, but afterward shifted to other places
+and exhibited all the intractability of hypochondriasis; the
+patient also developed the regular appearance and the characteristic
+hallucinations of the latter disease. On the last
+occasion when I saw him, he struck me as likely to become
+really insane, in the melancholic form; and the probability is
+that the casualty which he suffered was only accidentally the
+starting-point of a malady which was inherent in him since
+birth, and would have been developed, in any case, at some
+period of his life.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="loco" id="loco"></a>CHAPTER IV.</h2>
+
+<h3>THE PAINS OF LOCOMOTOR ATAXY.</h3>
+
+
+<p>Considering the vast amount that has been written about
+this disease during the last few years, it might be thought
+superfluous for me to give any description of its general features.
+But it unfortunately happens that there is still great
+divergence of opinion among authorities as to the true limitation
+of the group of cases that can properly be ranked under
+this title, and, indeed, as to the propriety of employing the title
+at all. The phrase ataxie locomotrice progressive, as every
+one knows, was applied by Duchenne de Boulogne to a class
+of cases which really only form a subdivision of the group
+known under the older title of <i>tabes dorsalis</i> and the most
+advanced German pathologists maintain that the old word
+was better, and that Duchenne was altogether wrong in making
+the one symptom, ataxy of locomotion, the bases of a new
+phraseology;<a name="FNanchor_49_49" id="FNanchor_49_49"></a><a href="#Footnote_49_49" class="fnanchor">[49]</a> more especially as his theory as to the seat of
+the morbid changes was undoubtedly erroneous.</p>
+<p><span class="pagenum"><a name="Page_211" id="Page_211">[211]</a></span></p>
+<p>In this country, however, there is as yet no disposition to
+give up the phrase locomotor ataxy, and it only remains to
+define with sufficient care the class of cases to which the word
+is here meant to apply. The disease is understood to depend
+upon a degeneration of the spinal cord, of which the following
+description is given by Lockhart Clarke:<a name="FNanchor_50_50" id="FNanchor_50_50"></a><a href="#Footnote_50_50" class="fnanchor">[50]</a> "In true
+locomotor ataxy, the spinal cord is invariably altered in structure.
+Its membranes, however, are sometimes apparently
+unaffected, or affected only in a slight degree; but generally
+they are much congested, and I have seen them thickened posteriorly
+by exudations, and adherent, not only to each other,
+but to the posterior surface of the cord. The posterior columns,
+including the posterior nerve-roots, are the parts of the
+cord which are chiefly altered in structure. This alteration is
+peculiar, and consists of atrophy and degeneration of the nerve
+fibres to a greater or less extent, with hypertrophy of the connective
+tissue, which give to the columns a grayish and more
+transparent aspect; in this tissue are embedded a multitude of
+corpora amylacea. Many of the blood vessels that travel the
+columns are loaded or surrounded to a variable depth by oil-globules
+of various sizes. For the production of ataxy, it seems
+to be necessary that the changes extend along a certain length,
+from one to two inches of the cord. The posterior nerve-roots,
+both within and without the cord, are frequently affected by
+the same kind of degeneration, which sometimes extends to the
+surface even of the lateral columns, and occasionally along
+the edges of the anterior. Not unfrequently the extremity of
+the posterior cornua, and even deeper parts of the gray substance,
+are more or less damaged by areas of disintegration.
+The morbid process appears to travel from centre to periphery,
+that is, from the spinal cord to the posterior roots. In the
+cerebral nerves, on the contrary, the morbid change seems to
+travel in the opposite direction, that is, from the periphery
+toward the centres. From the optic nerves it has been found
+to extend as far as the corpora geniculata, but seldom as far
+as the corpora quadrigemina. With the exception of the fifth,
+seventh, and eighth pair, all the cerebral nerves have occasionally
+been found more or less altered in structure."</p>
+
+<p>The symptoms which occur in cases in which the above are
+the morbid appearances found after death are (roughly speaking)
+as follows:<a name="FNanchor_51_51" id="FNanchor_51_51"></a><a href="#Footnote_51_51" class="fnanchor">[51]</a> "A peculiar gait, arising from want of
+co-ordinating power in the lower extremities, a gait precipitate
+and staggering, the legs starting hither and thither in a very
+disorderly manner, and the heels coming down with a stamp
+at each step."</p>
+
+<p><span class="pagenum"><a name="Page_212" id="Page_212">[212]</a></span></p><p>No true paralysis in the lower extremities or elsewhere.
+Characteristic neuralgic pains, erratic paroxysmal in the feet
+and legs chiefly&mdash;pains of a boring, throbbing, shooting character,
+like those caused by a sharp electric shock.</p>
+
+<p>More or less numbness, in the feet and legs chiefly, in all
+forms of sensibility, excepting that by which differences of
+temperature are recognized.</p>
+
+<p>Frequent impairment of sight or hearing, one or both.</p>
+
+<p>Frequent transitory or permanent strabismus or ptosis, one
+or both.</p>
+
+<p>No very obvious paralysis of the bladder or lower bowel.</p>
+
+<p>No necessary impairment of sexual power.</p>
+
+<p>No tingling or kindred phenomenon.</p>
+
+<p>No marked tremulous, convulsive, or spasmodic phenomena.</p>
+
+<p>No marked impairment of muscular nutrition and irritability.</p>
+
+<p>No impairment of the mental faculties.</p>
+
+<p>Occasional injection of the conjunctivę, with contraction of
+the pupils.</p>
+
+<p>The probable limitation of the distinctive phenomenon of
+locomotor ataxy (the want of co-ordinating motor power) to
+the lower extremities.</p>
+
+<p>The above description includes all the necessary facts for the
+recognition of the disease, except one, namely, that the use of
+the eyesight is always needed in order to prevent the patient
+from falling during progression; and is usually necessary even
+to enable him to stand upright without falling.</p>
+
+<p>The pains of locomotor ataxy are early phenomena in most
+cases, and they are usually present, more or less, throughout
+the course of the disease.</p>
+
+<p>They are often preceded by strabismus, with or without
+ptosis; the strabismus, is usually accompanied by amblyopia.
+It may happen, however, that neuralgic pains are, for a considerable
+time, the only noticeable phenomena; or they may
+be attended with a certain amount of anęsthesia.</p>
+
+<p>The most frequent type of the pains is lancinating or stabbing;
+they are like violent neuralgias occurring successively
+in various nerves; shifting about from one to another. Sometimes
+it will happen that the pain remains fixed to one particular
+nerve for hours together; but it never continues long
+without showing the characteristic tendency to move about.
+Most commonly our diagnosis is soon assisted by the occurrence
+of a greater or less degree of ataxy. But, even before
+the setting in of definite atactic symptoms, the shifting character
+of the pains, and the development of a very noticeable
+amount of anęsthesia, together with the absence of anything
+like positive motor paralysis, will have given us the necessary
+clew.</p>
+
+<p>The effect of treatment, or rather its want of effect, usually<span class="pagenum"><a name="Page_213" id="Page_213">[213]</a></span>
+affords powerful assistance in distinguishing the pains of locomotor
+ataxy from those of true neuralgia. Even where the
+pain has been fixed for some hours in a single nerve, and has
+been stopped by some powerful remedy (such as hypodermic
+morphia), it will be apt speedily to recur, and frequently in
+some quite distant nerve.</p>
+
+<p>Locomotor ataxy is a disease affecting chiefly the male sex,
+and occurring in the immense majority of cases between the
+thirty-fifth and the fiftieth year.</p>
+
+<p>Not merely is it strictly limited to individuals who belong to
+families with neurotic tendencies, but it is itself frequently
+seen to occur in several members of the same family, and
+sometimes of the same generation. When, therefore, we meet
+with neuralgic pains of the shifting type above described, it is
+very important at once to make careful inquiries whether any
+members of the family have suffered from symptoms of ataxy
+going on to a fatal result. Otherwise, we might be the more
+readily deceived into the idea that the pains were merely neuralgic,
+because the symptoms of the disease are not unfrequently
+provoked by such causes as fatigue and exposure to
+cold or wet, which are also very ordinary exciting causes of
+true neuralgia.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="cere" id="cere"></a>CHAPTER V.</h2>
+
+<h3>THE PAINS OF CEREBRAL ABSCESS.</h3>
+
+
+<p>Cerebral abscesses is, fortunately, a rare disease; but the
+very fact of its rarity makes the resemblance of the pain it
+causes to that of neuralgia the more likely to lead us into serious
+errors. We are apt to forget the possibility of suppuration
+of the brain on account of its infrequence.</p>
+
+<p>Pain in the head is present as an early symptom of abscess
+in the brain in a large proportion of cases in which there is
+pain at all. [Of seventy-five cases of cerebral abscess analyzed
+by Gull and Sutton (Reynolds's "System of Medicine,"
+vol. ii.), pain was a symptom in thirty-nine, and most frequently
+an early symptom.] Many cases are recorded in
+which it preceded every other morbid sign by a considerable
+period. It is usually more or less paroxysmal, often strikingly
+so; in the latter case, it bears a great similarity to neuralgia.
+On the other hand, it sometimes takes the shape
+of a fixed burning sensation, much less resembling neuralgia.
+The situation of the pain by no means always, nor
+even usually, corresponds to the situation of the cerebral<span class="pagenum"><a name="Page_214" id="Page_214">[214]</a></span>
+abscess; on the contrary, abscess in the cerebellum has often
+caused pain referred to the anterior part of the head, and so
+on. So long as the disease remains characterized only by
+pain, more or less, of a paroxysmal character, the diagnosis
+must be very uncertain; but in the great majority of cases
+certain more distinctive symptoms soon become superadded;
+either convulsions (sometimes hemiplegic), vertigo, coma,
+paralysis, vomiting, or a combination of some of these.</p>
+
+<p>In the stage in which there is as yet no conspicuous symptom
+but severe pain, the diagnosis of cerebral abscess from
+neuralgia must rest on the following points of contrast:</p>
+
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="4" summary="abscess neuralgia">
+<tr><td align="center" width="50%"><i>Cerebral Abscess.</i></td><td align="center" width="50%"><i>Neuralgia of Head.</i></td></tr>
+<tr><td class="topleft">Often occurs secondarily to caries of internal ear, and purulent discharge the result of scarlet fever, measles, etc., in childhood.</td><td class="topleft">Rarely appears before puberty.</td></tr>
+<tr><td class="topleft">Frequently follows a blow or injury.</td><td class="topleft">Comparatively seldom caused by blow, or other external injury or caries of bone.</td></tr>
+<tr><td class="topleft">No true "points douloureux."</td><td class="topleft">If severe, soon presents, in most cases, the "points douloureux."</td></tr>
+<tr><td class="topleft">Usually the pain does not completely intermit.</td><td class="topleft">Intermissions of pain complete, and of considerable length.</td></tr>
+<tr><td class="topleft">Pain often excruciating from a very early period.</td><td class="topleft">Pain usually not very violent at first.</td></tr>
+<tr><td class="topleft">Pain often limited in situation, seems deep-seated, though, as often as not, it has no relation to the site of the abscess.</td><td class="topleft">Pain superficial; follows distribution of recognizable nerve-branches belonging to the trigeminus or the great occipital.</td></tr>
+<tr><td class="topleft">No well localized vaso-motor or secretory complications.</td><td class="topleft">Usually there are lachrymation, congestion of conjunctiva, or other vaso-motor and secretory complications, such as are described in Chapter III.</td></tr>
+<tr><td class="topleft">Very rare in old age; then usually traumatic.</td><td class="topleft">Severe and intractable neuralgia is commonest in the degenerative period of life.</td></tr>
+<tr><td class="topleft">Relief from stimulant narcotics very transitory.</td><td class="topleft">Relief from opium, etc., is much more considerable and permanent.</td></tr>
+</table></div>
+
+<p>The only case of cerebral abscess that I have personally
+seen, in which the above points of distinction would have been
+insufficient, was that of a boy of sixteen, in whom the only discoverable
+symptom, for nearly three months, was pain, very
+strongly resembling ordinary migraine, recurring not oftener<span class="pagenum"><a name="Page_215" id="Page_215">[215]</a></span>
+than once in ten days or a fortnight, lasting for some hours at
+a time, and nearly always ending in vomiting, and disappearing
+after sleep. At the end of the three months, acute pain in
+the left ear set in, and this was followed, soon, by right hemiplegia,
+coma, and death. It was then discovered, although it
+had formerly been denied, that the boy had suffered from discharge
+from the left ear, following a febrile attack which had
+been marked by sore-throat, and followed by desquamation of
+the cuticle&mdash;evidently scarlet fever. In all cases of severe
+pain in the head, it is a golden rule to inquire most carefully
+as to the possible existence, present or past, of discharge from
+the ear, or other signs of caries of the temporal bone; and,
+even if no positive history of this kind be given, we should
+still regard with great suspicion any case in which there has
+been scarlet fever followed by deafness.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="alco" id="alco"></a>CHAPTER VI.</h2>
+
+<h3>PAINS OF ALCOHOLISM.</h3>
+
+
+<p>A very important class of pains, which are occasionally
+confounded with true neuralgias, are those which occur in certain
+forms of chronic alcoholism. The diagnosis of their true
+nature is a matter of the utmost consequence, and the failure
+to recognize them for what they are may have very disastrous
+results. It is a curious fact that this consequence of chronic
+alcoholic poisoning has been entirely overlooked by some of
+the best known writers on that affection; it has, however,
+been described by Mr. John Higginbottom, and also by M.
+Leudet.</p>
+
+<p>It must be clearly understood that the pains of which we are
+now to speak are not among the common consequences of
+chronic excess in drink. The affections of sensation which
+most usually occur in alcoholism take the shape either of
+anęsthesia, or of this combined with anomalous feelings partaking
+more or less of the character of formication. Chronic
+drinking has also a tendency, in its later stages, when the
+nutrition of the nervous centres has been considerably impaired
+by the habit, to set up true neuralgia, of a formidable type, in
+subjects who are hereditarily predisposed to neuroses. But
+the affection of which I now speak may occur at any stage
+except the very earliest, and, though often severely painful, is
+essentially different both in its seat and in its general characters,
+from neuralgia proper.</p>
+
+<p>The earliest symptoms from which the patient usually suffers<span class="pagenum"><a name="Page_216" id="Page_216">[216]</a></span>
+in these cases are insomnia, and intense depression of spirits,
+which, however, is not incompatible, indeed is frequently
+combined, with a morbid activity and restlessness of thought.
+There is generally marked loss of appetite, but often there is
+none of the morning nausea so characteristic of the common
+forms of alcoholism. Nor is there, ordinarily, any special
+unsteadiness of the muscular system. The pains are usually
+first felt in the shoulder and down the spine; but as the case
+progresses they especially attack the wrist and ankles; and it
+is in these latter situations that I have found them to be most
+decidedly complained of. Their similarity to neuralgia consists
+(<i>a</i>) in their somewhat paroxysmal character; (<i>b</i>) in their
+frequently recurring at about the same hour of the day, most
+commonly toward night; and (<i>c</i>) in their special aggravation
+by bodily and mental fatigue.</p>
+
+<p>Their differences from neuralgia are&mdash;(<i>a</i>) that they never
+follow the course of a recognizable single nerve; (<i>b</i>) that they
+are nearly always present in more than one limb, and usually
+in both halves of the body, at the same time; and (<i>c</i>)
+especially, that they are far less promptly and effectually
+relieved by hypodermic morphia than are the true neuralgias;
+indeed, opiates very frequently only slightly alleviate the pain,
+while they excite and agitate the patient and render sleep
+impossible. On the contrary, a large dose of wine or brandy
+will never fail to procure temporary comfort and induce sleep,
+at least until the patient reaches an advanced stage of the disorder,
+and is, in fact, on the verge of delirium tremens.</p>
+
+<p>I am not quite sure that I am right in believing that there is
+a special physiognomy for this form of chronic alcoholism, and
+yet I am much inclined to believe that there is. All the
+patients whom I have seen suffering with it have presented a
+peculiar brown sallowness of face, and a general harsh dryness
+of the skin, which has usually lost its natural clearness,
+not only in the face, but even more remarkably in the hands,
+which are so dark-colored as to appear as if they were dirty.
+There is usually considerable leanness of the limbs, and, though
+the abdomen may be somewhat prominent, this does not seem
+to depend much on the presence of fat, but rather on relaxation
+of the abdominal muscles, and sometimes flatulent distention
+of the stomach and intestines. The hands are usually
+hot, sometimes quite startlingly so.</p>
+
+<p>Some of the patients suffer, besides the pains in the limbs
+(which they often describe as resembling the feeling of a tight
+band pressing severely around the ankles or wrists), from frequent
+or occasional attacks of genuine hemicrania; such a
+combination is to me always a suspicious sign, and induces me
+immediately to direct my attention to the possibility of chronic
+alcoholic poisoning. Otherwise, the limb-pains are often
+spoken of as resembling rheumatism, but there is no swelling<span class="pagenum"><a name="Page_217" id="Page_217">[217]</a></span>
+of joints, and usually no decided tenderness of the painful
+parts. The patient has usually a particular worn and haggard
+appearance, complains of intense fatigue after the most
+moderate muscular exertion, and is usually utterly indisposed
+to physical exercise even though the mind, as already
+said, may display a feverish activity.</p>
+
+<p>So far as I have seen, the subjects of this affection are by far
+the most frequently women; and I am inclined to attribute
+this predisposition of the sex not to inherent peculiarities
+of female organization, but to the fact that a much
+larger proportion of intemperate women than of intemperate
+men indulge in secret excess. They never get drunk, probably,
+but they fly to the relief of alcohol upon every trivial occasion
+of bodily or mental distress; and this habit may have been
+going on for years before it comes to be suspected by their
+friends or their medical attendant. Meantime, they have been
+more or less looked upon, and have looked upon themselves as,
+"debilitated" and "neuralgic" subjects, and have come,
+either with or without mistaken medical advice, to consider
+free stimulation as the proper treatment for the very ailments
+which have been produced by their own unfortunate habits. I
+cannot avoid the expression of the misgiving, that imperfect
+diagnosis, and consequent erroneous prescription, have done
+great harm in many such cases. It has happened to me
+no less than three times within the last six months to be called
+to lady patients, all suffering from alcoholism induced by a
+habit of taking stimulants for the relief of so-called neuralgic
+pain; and in the most distressing of these the mischief had been
+greatly aggravated by a prescription of brandy, based on the
+erroneous idea that the pains were truly neuralgic. I have
+already protested against this kind of medication, even in cases
+that are truly neuralgic in character; but it is doubly mischievous
+where given for a state of things which actually
+depends on alcoholic excess.</p>
+
+<p>It is undoubtedly very difficult, sometimes, to elicit the truth,
+even in cases where we may entertain considerable suspicion
+that alcoholic excesses are the real cause of the pains which
+the patient calls neuralgic; more especially where the patient
+is aware that he or she is taking an amount of alcohol which
+is seriously damaging to health. And it is therefore necessary
+to look out for every possible additional help to our diagnosis.
+Besides the cardinal features of the disease&mdash;the insomnia, loss
+of appetite, foul breath, haggard countenance, and pains
+encircling the limbs near the joints rather than running
+longitudinally down the extremities there are certain moral
+characteristics of the patient that often tells a significant tale.
+The drinker, especially if a woman, is shifty, voluble, and full
+of plausible theories to account for this and the other phenomenon.
+It will be well to try the effects of a somewhat sudden<span class="pagenum"><a name="Page_218" id="Page_218">[218]</a></span>
+though not uncourteous remark, to the effect that the diet
+should be strictly unstimulating. If this be introduced with
+some abruptness, in the course of a conversation not apparently
+leading to it, the patient's manner will not unfrequently
+betray the truth; while, if our suspicions are groundless, we
+shall also probably perceive that, in the unconscious, or
+frankly surprised, expression of the countenance. We may
+sometimes derive crowning proof of the existence of alcoholic
+excess by cautious questions which at least reveal the fact that
+the patient suffers from spectral hallucinations; this is a far
+commoner occurrence in chronic alcoholism than is generally
+supposed; it needs to be inquired for with great tact, but,
+when established beyond doubt, and joined to insomnia and
+the peculiar foul breath, is of itself sufficient to establish a
+positive diagnosis of alcoholic poisoning.</p>
+
+<p>The results of treatment, in true neuralgia and in alcoholic
+pains, respectively, establish an important difference between
+these affections. In the former malady, for instance, the hypodermic
+injection of morphia always produces striking palliative,
+and very often curative effects. In alcoholic pains this
+remedy either affords only trifling relief, or more commonly
+aggravates the malady by increasing the general nervous
+excitement; and the only true treatment is at once to suspend
+all use of stimulants, to administer quinine, and to insist upon
+a copious nutrition. If any hypnotic must be employed, let it
+be chloral, or bromide of potassium with cannabis Indica. It
+will be well also to put the patient upon a somewhat lengthened
+course of cod-liver oil. There is one special symptom
+from which the chronic alcoholist often suffers acutely, namely
+a hypersensitiveness to cold; for this I found the use of
+Turkish bath two or three times a week, for three or four
+weeks, very useful in one case that was under my care. It
+will be important to insist that the patient shall take the bath
+only after that shorter method which I have described in speaking
+of the prophylaxis of true neuralgia.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="syph" id="syph"></a>CHAPTER VII.</h2>
+
+<h3>THE PAINS OF SYPHILIS.</h3>
+
+
+<p>Syphilis, as has already been shown in Part I. of this work,
+may excite true neuralgia in subjects already predisposed to
+the latter. The case of Matilda W., previously given, is an
+example. The pains, however, which are now to be described,
+are those which occur in the ordinary course of a constitutional
+syphilitic infection, and have nothing to do with neuralgia
+proper, from which they should be carefully distinguished.<span class="pagenum"><a name="Page_219" id="Page_219">[219]</a></span></p>
+
+<p>There are two varieties of syphilitic pains proper, which are
+quite distinct. The first kind is represented by the so-called
+<i>dolores osteocopi</i>, which occur in the early stages of the constitutional
+affection, coincidently with, or just before, the secondary
+skin-eruptions. The second kind are those which occur
+in the tertiary stage, and are the immediate precursors of the
+formation of periosteal nodes.</p>
+
+<p>It is the first of these varieties of syphilitic pains which is
+least commonly confounded with neuralgia. The pain is
+referred to the superficial bones, of which those most frequently
+attacked are the forehead, sternum, clavicle, ulna, and tibia,
+pretty much those selected for the growth of nodes at a later
+stage of the disease. Besides the bones, the shoulders, elbows,
+and nape of the neck are attacked sometimes simultaneously,
+sometimes successively. The pains are readily controlled by
+proper treatment; if untreated, their course is very uncertain.
+When they manifest themselves at the outset of the disease,
+they usually cease when the cutaneous eruption is fairly out.
+Commonly, there is no swelling or heat at the painful places;
+but, when the pains are very severe, nodes now and then form
+at this early period.<a name="FNanchor_52_52" id="FNanchor_52_52"></a><a href="#Footnote_52_52" class="fnanchor">[52]</a></p>
+
+<p>These early syphilitic pains, in their violent aching character,
+and their intermittence, occasionally resemble true neuralgia
+very closely; but they are usually distinguished from it by
+their symmetrical disposition and by their attacking several
+bones at once. Moreover, they nearly always show the peculiarity
+of being distinctly aggravated by the warmth and
+repose of bed even if they be not altogether absent (as is not
+unfrequently the case) when the patient is up and moving
+about. A typical case of this kind is not so likely to be confounded
+with neuralgia as with rheumatism; but we occasionally
+meet with cases in which the pains are localized in a manner
+much more resembling the former. Thus I have met with
+several instances in which a patient, entirely unconscious (or
+professing to be unconscious) of having been syphilized, complained
+of violent pain in one tibia, recurring every night at a
+certain hour, and at first undistinguishable from that variety of
+sciatica in which the pain is principally felt in this situation,
+especially as it was relieved by firm pressure, just as neuralgia
+is in the early stages. And in one remarkable case, which came
+under my care at Westminster Hospital, the resemblance to
+clavus was most misleading:</p>
+
+<p>H. A., aged nineteen, worker in a laundry, presented herself
+on account of a violent pain in the right parietal region, recurring
+three times daily with great regularity. The first two
+attacks occurred in the day-time, the third, which was always
+the severest, woke her out of sleep about midnight; the pain
+<span class="pagenum"><a name="Page_220" id="Page_220">[220]</a></span>
+of this last was so agonizing that on more than one occasion
+she had become delirious. The girl (whose respectable appearance
+was against the notion of syphilis) was very anęmic;
+not, however, with the tint either of anęmic from hęmorrhage,
+or with that of chlorosis, exactly. It was rather a dirty
+sallowness of skin; but the gums and the conjunctivę
+were exceedingly bloodless, and she complained of almost constant
+noises in the head. Menses scanty but regular. There was a
+soft anęmic bruit with the first sound at the base of the heart.
+Having failed to make any impression on the pains with iron
+and with muriate of ammonia in large doses, I was led to
+observe the fact that there was no diffuse soreness of the scalp,
+such as very commonly occurs in clavus, in the intervals of
+the pains, and the mere fact that there was this unusual circumstance
+in the case led me to reconsider the diagnosis
+thoroughly. In order to be sure of not omitting a point, I
+inquired, though without any expectation of an affirmative
+answer, as to the possibility of syphilitic disease; the girl at
+once confessed to having had sores, and examination detected
+a papular rash about the shoulders and back and on both
+thighs. Small doses of mercury greatly relieved the pain
+within a week, and cured it in less than three weeks; and it
+was very remarkable that the anęmia, which had obstinately
+refused to yield to iron, improved at once as the mercury
+began to relieve the pains. The eruption disappeared simultaneously.</p>
+
+<p>It is the later pains of syphilis, however, that are most frequently
+confounded with neuralgia, and occasionally with very
+disastrous results. These pains, which are the precursors of
+the formation of true nodes, frequent the same localities as
+those affected by the earlier pains; they may exist in considerable
+severity for days, or even for many weeks, before any
+node-formation can be detected. The situation in which, of
+all others, they are likely to be mistaken for neuralgia is the
+scalp or face, especially when a single spot is affected on one
+side, and in the situation of one of the usual foci of trigeminal
+or occipital neuralgia. I have personally known the mistake
+to be made with syphilitic affections causing pain, respectively,
+in the superciliary region, in the malar bone, the jaw near the
+mental foramen, and the parietal eminence.</p>
+
+<p>The possibility of mistaking tertiary syphilitic pain for neuralgia
+is fraught with such grave dangers, that we ought to be
+constantly and most vigilantly on the watch against it. But
+most especially is this the case when the pain is situated in
+some part of the cranium, as the parietal or temporal eminences,
+the mastoid process, or the prominences of the occipital
+bone. For it must be remembered that the same process,
+which forms syphilitic nodes upon the external surface of
+bones, or within bony canals, can produce them on the lining<span class="pagenum"><a name="Page_221" id="Page_221">[221]</a></span>
+membrane of the skull, with most serious consequences,
+should the symptoms be neglected or misunderstood.</p>
+
+<p>The pains produced by nodes upon the internal surface of
+the cranium are usually of a very intense character, and are
+mostly continuous, though aggravated from time to time,
+especially at night. Where syphilitic inflammation is diffused
+over a considerable portion of the meninges, it is certain very
+quickly to produce symptoms which can hardly fail to apprise
+us of the gravity of the affection; there will be decided and
+rapidly increasing impairment of memory, and general cloudiness
+of intellect, tending toward complete imbecility, the special
+senses will be greatly interfered with or lost, and muscular
+paralysis will be developed. But in the case of a more
+limited syphilitic affection of the dura mater, pain, of the kind
+already described, may be for some days the only very noticeable
+symptom. The following is an instance:</p>
+
+<p>J. E., aged forty-seven, a street and tavern singer, applied
+to me (November 14, 1861), on account of severe pain in the
+right temporal region, which had on the whole the character
+of neuralgia, though rather more continuous than such pain
+usually is. He said that it commenced on the 10th, without
+any particular provocation that he knew of, and that it had
+hardly left him at all from that moment. It kept him awake
+at night, and that circumstance seemed to account sufficiently
+for a very worn and depressed look which he presented; he
+was otherwise a robust-looking man, and at first denied having
+suffered from any previous illness. The pain always came to
+a climax about one o'clock, <span class="smcap">a.&nbsp;m.</span>, waking him out of his first
+sleep in agony, and allowing him little rest for the remainder
+of the night; toward morning he would drop to sleep for an
+hour or so. There was no particular tender point, corresponding
+to any recognized neuralgic focus, yet the pain was limited most
+strictly to a spot that might be covered with two finger-points.
+There was no lachrymation nor conjunctival congestion, and
+nothing to remark in any way about either eye. The patient
+was ordered quinine in large doses, in the belief that the pain
+was neuralgic. On the following day he reported himself a
+trifle better, though still suffering greatly; and on the afternoon
+of that day there was an almost complete intermission of
+the pain for several hours; but it returned severely at the
+usual nocturnal period. On the 16th, at 10 <span class="smcap">a.&nbsp;m.</span>, he came to
+my house looking exceedingly ill, but the only additional
+symptom that I could detect was a small droop of the right
+eyelid. He was subcutaneously injected with one-fourth of a
+grain of morphia and sent home, where he immediately fell
+into a heavy sleep that lasted till bedtime. He awoke, undressed
+himself without feeling much pain, and got to bed;
+after an hour or so of dozing he was awakened by the pain,
+which was exceedingly severe. On the 17th he called on me<span class="pagenum"><a name="Page_222" id="Page_222">[222]</a></span>
+in the morning, and I at once perceived that the ptosis of the
+right eyelid was much greater, and the right pupil was much
+dilated and insensitive, and the external rectus was paralyzed;
+the man also wore a look of stupidity, and answered questions
+with an apparent mental effort. I now cross-questioned him
+more closely; and also explored the tibię and other superficial
+bones: on the sternum a distinct though not very advanced
+node was found. Upon this he was induced to confess that he
+had suffered from chancre three years and a half previously,
+and subsequently had "blotches" on the skin, which had
+quickly disappeared under treatment, of which all that could
+be learned was, that it was fluid medicine and did not make
+his mouth sore. He was immediately ordered to take two
+grains of calomel in pill, with a little opium, every four hours.
+He had only taken one dose when I was sent for to him, and
+found him in an epileptiform convulsion, in which the left
+side of the body was almost exclusively affected; the convulsions
+recurred several times during the next twenty-four hours,
+and in the intervals he remained almost completely unconscious.
+The mercurial treatment was pushed, in the form of
+calomel-powders placed on the tongue. On the evening of the
+18th he began to recover consciousness, and then had a little
+natural sleep; the next morning, at 10 <span class="smcap">a.&nbsp;m.</span>, he was found to
+be fully conscious, had had no return of convulsions, but the
+left arm and leg, especially the latter, were almost entirely
+powerless; the parietal headache had vanished; the gums were
+slightly tender; the third and sixth nerves of right side were
+completely paralyzed. Mercurial treatment was very gently
+continued, so as to keep the patient on the borders of ptyalism
+for the next three or four days; and he was then put on full
+doses of iodide of potassium. The pain never recurred; the
+left extremities recovered power rapidly; but it was six weeks
+before the ocular paralyses were completely well.</p>
+
+<p>Late in the autumn of 1865 I was sent for hastily one evening
+to see this same man, and found him totally unconscious
+and apparently again hemiplegic, but now on the right side.
+He was miserably wasted, and covered with a rupious eruption;
+I was informed that he had been leading a most debauched
+and drunken life for some time past, and that, after looking
+extremely ill, and apparently half imbecile for a week or two
+past, he had suddenly fallen down unconscious in the street a
+few hours before I saw him. He remained deeply comatose,
+and died the next morning; no <i>post mortem</i> could be
+obtained.</p>
+
+<p>The true neuralgias in which syphilis only plays the part of
+secondary factor, and which have been referred to in Part I.
+of this work, may depend for their exciting cause on local
+syphilitic processes, affecting either the peripheral distribution,
+the main trunk or the central origin of a sensory nerve; but I<span class="pagenum"><a name="Page_223" id="Page_223">[223]</a></span>
+have pointed out the fact that, whatever the reason may be,
+syphilis does but rarely attack the central portions of individual
+sensory nerves, in comparison, with the frequency with
+which it attacks individual motor (cranial) nerves. But without
+any neuralgic predisposition at all, and without any limitation
+of the syphilitic process to a particular sensory nerve,
+the latter may become neuralgic in consequence of being involved
+in extensive intracranial or intra-spinal syphilitic mischief.
+The trigeminus is liable to suffer in this way from
+spreading syphilitic processes about the base of the brain; and
+my own impression is, that the cause of the neuralgic pain in
+some such cases is the extension of the mischief to the vertebral
+artery of the affected side, leading to interfering with the
+nutrition of the trigeminal nucleus in the medulla. A very
+interesting case is reported by Dr. Hughlings Jackson (who has
+done so much to acquaint us with syphilitic affections of cerebral
+arteries) in vol. iv. of the "London Hospital Reports," pp.
+318-321. The patient was a woman, aged twenty-seven, and
+the initial symptoms of the malady which destroyed her life
+were violent trigeminal neuralgic pains on the right side: subsequently
+she had complete paralysis of the fifth, and of the
+sixth, seventh, and eighth nerves of the right side. After
+death the right vertebral artery was found engaged in the
+mass of syphilitic deposit; it must be added, however, that the
+(superficial) origin of the fifth nerve was itself softened, opposite
+the pons. Another mode in which syphilitic disease very
+probably causes neuralgia of the fifth, in a certain number of
+cases, is by injuring the Gasserian ganglion, upon the integrity
+of which (according to Waller's general law concerning
+the ganglia of posterior nerve-roots) the nutrition of the sensory
+root of the trigeminus materially depends. I have seen
+an example (as I cannot but suppose) of this sequence of morbid
+events; the evidence appears sufficiently complete, although
+I was unable to obtain a <i>post mortem</i> examination:</p>
+
+<p>W. M., a house painter, of extremely dissipated habits, but
+who had never suffered either from distinct symptoms of alcoholism,
+nor from any affection traceable to lead-poisoning. In
+March, 1867, he applied to me on account of neuralgic pain,
+affecting chiefly the right eyeball, but also darting along the
+course of the frontal nerve of that side; after a short time it
+extended also into the infra-orbital nerves. He bore several
+scars of tertiary ulcers about the nose and forehead, and made
+no secret of having suffered from chancre six or seven years
+before, and from subsequent secondary and tertiary symptoms.
+I was consequently not at all surprised at his developing severe
+iritis (right) after he had been a fortnight under my care,
+although I had from the first given large doses of iodide of
+potassium; but I was not prepared for the extensive processes
+of destruction which followed, notwithstanding that I immediately<span class="pagenum"><a name="Page_224" id="Page_224">[224]</a></span>
+commenced mercurial treatment, and applied atropine.
+I remarked that while the inflammation of the iris proceeded
+with great violence, the cornea was also much more severely
+affected than is usually the case in syphilitic iritis; in fact, the
+changes closely resembled those which have been noted after
+section of the fifth at the Gasserian ganglion, and at the date
+of the patient's death (seventeen days from the commencement
+of the iritis) a corneal ulcer was on the point of perforating.
+For the first three or four days after the iritis set in, the neuralgic
+pains went on augmenting in intensity, and extended
+into all three divisions of the fifth; there was a copious discharge
+from the right nostril. Almost suddenly, on the
+fourth day, the pains abated and then ceased, and it was now
+evident that the whole surface of the right half of the face was
+completely anęsthetic. Two days later a dark-red patch appeared
+on the cheek, and in the course of the next two days
+this ulcerated, the ulcer presenting a somewhat livid appearance,
+and exuding a sanious discharge; at the same time,
+superficial ulcers appeared on the right side of the tongue, and
+coalesced to form one large sore. The sores both on cheek and
+tongue assumed more and more a gangrenous appearance, and
+on the sixteenth day from the commencement of iritis there
+was considerable loss of substance in both these situations. On
+the evening of this day (the patient having become extremely
+depressed and much emaciated) general epileptiform convulsions
+set in, and followed each other rapidly; in a few hours
+coma supervened, and the patient sank the next day. No <i>post
+mortem</i> could be obtained; but it seems extremely probable,
+from the above history, that the Gasserian ganglion was early
+involved in the syphilitic inflammation, and that the neuralgia
+and subsequent anęsthesia, the iritis, and the other trophic
+lesions, were due to the injury inflicted upon it.</p>
+
+<p>The treatment of syphilitic pains will, in doubtful cases,
+often give us valuable assurance of the correctness of our
+diagnosis. Where the disease is extensively diffused, we may
+fail to do any good; but, in cases where the syphilitic mischief
+is limited to a small portion of the meninges, we may often
+arrest it. In all merely suspicious cases, where the pain is thus
+limited, it will be well to use iodide of potassium tentatively&mdash;forty
+to sixty grains daily. But, where the pains are very
+severe and continuous, and there is danger to the integrity of
+the eye, or threatenings of a paralytic attack are observed, it is
+better not to trust to anything short of mercury, used in such
+a manner as just to stop short of absolute ptyalism. In very
+bad cases, like the last one narrated, we may fail to produce
+any good effect, but, where the specific treatment is commenced
+in good time, we may not unfrequently succeed in
+arresting the symptoms with a rapidity that assures us of the
+correctness of the diagnosis of syphilis.</p>
+
+
+<hr style="width: 65%;" />
+<p><span class="pagenum"><a name="Page_225" id="Page_225">[225]</a></span></p>
+
+<h2><a name="suba" id="suba"></a>CHAPTER VIII.</h2>
+
+<h3>PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.</h3>
+
+
+<p>So firmly is the idea of an essential connection between
+rheumatism and neuralgia implanted in the popular mind,
+and, indeed, in the minds of a certain portion of the medical
+profession, that the two complaints are continually confounded.
+In the great majority of instances, the mistake made is that of
+calling neuralgia a "rheumatism." But the opposite error
+occasionally occurs, and a patient is styled "neuralgic" who
+is really suffering from chronic rheumatism.</p>
+
+<p>As true neuralgia is an essentially localized disease, there
+can be no excuse for mistaking for it the more typical cases of
+chronic rheumatism, in which a number of different joints,
+muscles, or tendons, are affected, more especially in the
+advanced stages, when the characteristic fixed contractions of
+the limbs and extremities have occurred. But there are a few
+cases in which, either with or without a previous history of
+acute rheumatism, one, or perhaps two, joints begin to suffer
+vague pains, which after a little time begin to shoot down the
+course of the limb, and are aggravated from time to time in a
+manner which superficially much resembles neuralgia; and
+when the malady has reached a certain intensity the pains may
+be so much more severely felt in the longitudinal axis of the
+limb than in the immediate neighborhood of a joint, that the
+patient forgets that in reality they commenced either within a
+joint (as the elbow or hip), or in the fibrous structures immediately
+outside it. Certain localities are much more frequently
+the seat of this kind of affection than other parts of the body;
+thus it occurs, perhaps in nine-tenths of the cases, in the neighborhood
+either of the shoulder (especially involving the insertions
+of the deltoid and triceps muscles), of the elbow (particularly
+affecting the tendinous insertions of the muscles on the
+internal aspect of the forearm), or the hip (extending to the
+aponeuroses on the outer and back part of the thigh): in all
+these cases there is a considerable superficial resemblance to
+true neuralgic pains. Nevertheless, the diagnosis need not
+present any serious difficulties after the earliest stages; for
+there soon arises a very diffuse and acute tenderness of the
+parts, and usually an amount of generalized swelling, which,
+though it may not be readily detectable by the eye, is sensible
+enough to the touch. Movement of the parts is also very painful;
+but usually not with the acute and agonizing pain which
+occurs in myalgia.</p>
+
+<p>It is, however, upon signs which are of a more general character
+that we ought chiefly to rely for diagnosis. The fact
+that the patient has previously experienced a genuine attack of<span class="pagenum"><a name="Page_226" id="Page_226">[226]</a></span>
+acute rheumatism, though of some value, is by no means to be
+taken as a conclusive argument that the present attack is of a
+rheumatic nature. The really important matter is, that
+whether the patient has or has not suffered acute rheumatism
+before the occurrence of the subacute or chronic form,
+the latter will always be attended by more or less of the specific
+constitutional disturbance of rheumatism. I would carefully
+abstain from the assumption that rheumatism is originally
+dependent on a blood-poisoning, a theory which I believe
+to be most doubtful and very probably false; but there is,
+nevertheless, a truly specific character about the general phenomena
+in acute rheumatism, and I maintain that similar
+though less-marked phenomena are always to be seen even in
+the mildest and least acute forms of rheumatism. Thus there
+will be, invariably, more or less of the peculiar sallow anęmia,
+together with red flushing of the cheeks when the pain is
+at the worst; and there will be a certain amount of the oily
+perspiration which makes the faces of rheumatic patients look
+shiny and greasy. No doubt these characteristics will sometimes
+be very slightly developed, but I believe that attentive
+observation will always discover them in any case which is
+genuinely rheumatic. One case, in particular, which has been
+under my care, very strongly impresses me with the value of
+these diagnostic signs, where otherwise the symptoms are
+obscure:</p>
+
+<p>L. P., aged thirty-one, single, a printer by trade, applied to
+me, January, 1863, suffering from what I at first decidedly
+thought was cervico-brachial neuralgia, the pain having followed
+exposure to cold and wet, situated in the lower part of
+the neck, the shoulder, elbow and inner side of the right arm,
+and existing nowhere else. The character of the pain was
+described as at least remittent, if not distinctly intermittent.
+The pulse was not more than 78; the tongue was thickly coated
+with white fur, but the man did not complain of thirst, and
+there were no evident signs of fever. As the pains had only
+existed for about a fortnight, it appeared an excellent case for
+cure by the hypodermic injection of morphia; and, accordingly
+this was used in quarter-grain doses twice a day. After
+about ten days an attempt was made to do without the morphia,
+but the pains returned, worse than before, and meantime
+the tongue had remained uniformly coated, and was now very
+yellow; the appetite was bad, and there was some increase in
+frequency of pulse. It now struck me, for the first time, that
+the man presented, in a slight degree, the sallow and red tint
+and oily features of a rheumatic patient; it was now found
+that sweat and urine were distinctly acid. Acting on this idea,
+I administered five grains of iodide of potassium, and thirty
+grains of bicarbonate of potassium, four times every twenty-four
+hours, after giving a moderate saline aperient. The result<span class="pagenum"><a name="Page_227" id="Page_227">[227]</a></span>
+was manifest improvement within twenty-four hours, and
+almost complete relief of the pain within three or four days
+(the urine never becoming distinctly alkaline, however.) As
+the attack subsided, the oily appearance of the skin disappeared,
+and the rheumatic tint was replaced by mere ordinary
+pallor, which the patient lost after taking a short course of
+steel.</p>
+
+<p>At the time this case occurred to me, I was not aware of the
+importance, in doubtful instances, of looking to the temperature;
+but subsequent experience has convinced me that in every
+truly rheumatic case, however limited in extent, there is a real,
+though it may be a small, rise of temperature. The thermometer
+will be found to mark from 99-1/4° to 100° Fahr., and this,
+joined with the appearances above mentioned, and a strong
+acidity of urine, will be sufficient to distinguish the complaint
+as rheumatic; and the striking effect of such remedies as iodide
+with bicarbonate of potash, followed up with sesquichloride of
+iron, in full doses, helps still further to distinguish the cases
+from true neuralgias. Since the introduction of the full doses
+of the iron-tincture in the treatment of acute rheumatism, I
+have had the opportunity of treating two of these cases of
+subacute rheumatism in the same manner, viz., with the iron
+from the first, and the results have been most satisfactory in
+every way. These cases were independent of a much larger
+number, treated in the same way, in which the symptoms of
+rheumatism were more generalized and more severe.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="late" id="late"></a>CHAPTER IX.</h2>
+
+<h3>PAINS OF LATENT GOUT.</h3>
+
+
+<p>Pains which are connected with a chronic and more or less
+latent form of gout not unfrequently receive the designation
+"neuralgic," and are treated upon that erroneous theory of
+their pathology. I have already endeavored to show that there
+is by no means that intimate causal relation between gout and
+neuralgia which is very commonly assumed to exist: true neuralgia
+is, I believe, only caused in an indirect and secondary
+manner by the gouty condition setting up changes of the blood-vessels,
+which precipitate the occurrence of the neuralgic
+malady, to which the patient was otherwise predisposed from
+birth. But the common idea, both without and within the
+profession, seems to be that neuralgia is only one expression,
+and that a quite common one, of the gouty habit. Nevertheless,
+with strange inconsistence, the kind of truly gouty pains<span class="pagenum"><a name="Page_228" id="Page_228">[228]</a></span>
+of which I am now speaking are constantly treated upon a
+special plan, upon the supposition that they are neuralgic.</p>
+
+<p>There are six situations in which gouty pains are apt to be
+developed in a way to lead to the false diagnosis of neuralgia:
+(1) In the eye; (2) more indefinitely within the cranium; (3)
+in the stomach, simulating gastralgia; (4) in the chest, simulating
+angina pectoris; (5) in the dorsum of the foot, simulating
+neuralgia of the anterior tibial nerve; (6) in a somewhat
+diffuse manner about the hip and back of thigh, simulating
+sciatica.</p>
+
+<p>It is not really a common thing to find such cases very difficult
+of diagnosis, provided that the possibility of their occurrence
+has been carefully noted; for the gouty habit has a
+number of slight manifestations which are usually enough to
+discover it even when its more decided symptoms are entirely
+wanting.</p>
+
+<p>Thus, in the first place, it will be almost invariably found,
+on inquiry, that the patient has always been intolerant of
+beer and of sweet wines. Also, he has been liable (either after
+a single large excess in eating or a prolonged course of a diet
+too highly animalized in proportion to the amount of exercise
+taken) to attacks of general malaise, with or without uneasiness,
+just short of decided pain, about the metacarpo-phalangeal
+joint of the great-toe, and ending after a few hours or
+days with a free discharge of uric acid. Less frequently, but
+still very often, it will be found that he has some deposit of
+lithate of soda (chalk-stone) in some situation where its presence
+does not necessarily arrest attention; Dr. Garrod has
+shown how often these little tophi are found in the cartilage of
+the ear. Careful examination will sometimes detect their
+presence in the sclerotic of the eye. But in doubtful cases it
+would be always well to make a cautious trial of colchicum,
+which, if the case be gouty, will nearly always produce an
+amount of relief sufficient to confirm the diagnosis of gout.
+At least, this rule holds goods for the external forms; but in
+the case of the supposed gouty pseudo-angina it is far best to
+trust to opium, as colchicum may prove too depressing to a
+heart which may quite possibly be already the subject of
+organic disease. My own impression is, that it was these cases
+of gouty heart-pain, which are not true angina at all, that procured
+for opium its high reputation for relieving the latter disease,
+a reputation which is by no means confirmed by my own
+experience, since I have found that drug enormously inferior
+to stimulants like ether in its power to relieve genuine angina.</p>
+
+<p>Lastly, if there be no other possibility of making ourselves
+certain whether there is or is not a gouty taint at the bottom
+of the quasi-neuralgic pains, we may adopt Dr. Garrod's test of
+subjecting the serum of the blood to a search for uric acid
+(thread-test).</p>
+
+
+
+<hr style="width: 65%;" />
+<p><span class="pagenum"><a name="Page_229" id="Page_229">[229]</a></span></p>
+<h2><a name="coli" id="coli"></a>CHAPTER X.</h2>
+
+<h3>COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.</h3>
+
+
+<p>Colic, or painful half spasm, half paralysis of the large
+intestines, is the best example of a kind of spasmodic pains to
+which some authors accord the name of neuralgia, as it seems
+to me without good reason. They appear to be quite independent
+of the operation of the neurotic temperament, and to
+be caused entirely by the operation of some local irritant, or
+narcotic irritant, upon the muscular fibres of the viscus. In
+the case of colic this influence is most frequently and most
+powerfully exerted by lead, which undoubtedly becomes
+locally deposited in chronic poisoning with that metal; at
+other times it is produced by the irritation of indigestible food
+passing along the alimentary canal.</p>
+
+<p>That there may be such a thing as enteralgia, of really neuralgic
+character, I do not deny; on the contrary, so far as
+regards the rectum, I have myself seen such a case. But true
+neuralgia of the large bowel is exceedingly uncommon; what
+goes by the name is usually either colic from local irritation
+of the viscus; or a mere hysterical hyperęsthesia of the lining
+membrane, which is one of the occasional phenomena of spinal
+irritation; or else it is a case of neuralgia of the abdominal
+wall, such as is included in the description of "lumbo-abdominal
+neuralgia," in Part I. of this work.</p>
+
+<p>There is no occasion to describe minutely the symptoms of
+so familiar a disease as lead-colic, or as colic from irritation by
+indigestible food, when they occur in their typical forms. In
+the former case the marked constipation which ushers in the
+attack of pain, and the peculiar greenish-yellow sallowness
+nearly always seen in the countenance, ought to be sufficient
+to direct examination to the gums (for the blue line) and
+inquiry as to any possible impregnation of the system with
+lead, owing either to the nature of the patient's occupation, or
+to some accidental entry of the poison into the drinking-water,
+or its inhalation from the walls of newly-painted rooms, etc.
+In the latter case, the fact that the attack of colic was shortly
+preceded by a meal, either of obviously indigestible food, or
+too copious in quantity and heterogeneous in kind, or too
+hastily eaten without sufficient mastication, supplies a clew.</p>
+
+<p>But there are a few cases representing minor degrees of
+either of these kinds of colic, that are much less easy to diagnose
+distinctly.</p>
+
+<p>Lead-poison sometimes enters the system continuously, for a
+long period, but in proportions too minute to produce the
+effects which we identify as an attack of lead-colic. I believe
+that for the production of the latter complaint it is necessary<span class="pagenum"><a name="Page_230" id="Page_230">[230]</a></span>
+that the poisoning shall be sufficiently intense completely to
+paralyze a considerable piece of bowel, thus altogether hindering
+peristalsis, or, rather, making the peristaltic acts of the
+non-paralyzed portions above worse than fruitless. But there
+is a minor degree in which it may happen that the local affection
+(owing, I believe, to a less extensive deposit of lead in the
+bowel) does not reach the decidedly paralytic stage; the state
+then is one of irregular and painful spasm of individual fibres
+(quite possibly intermingled with paralysis of a few others),
+and the practical result is irregularity of evacuation&mdash;now
+diarrh&#339;a, and again constipation&mdash;and the frequent recurrence
+of twinges of pain that are easily mistaken for abdominal
+neuralgia. Such symptoms as these are nearly always found
+to have occurred, if proper inquiry be made, in those examples
+of chronic lead-poisoning in which the toxic process goes
+on to the development of epilepsy, or marked symmetrical
+paralysis of the wrist-extensors, without the patient having
+ever suffered an attack of ordinary colic. In these slow and
+insidious cases the constitutional affection may not have
+reached the height at which the complexion and general aspect
+of the patient suggests metallic poisoning: and the case may
+present very neuralgia-like features. The absence of the
+<i>points douloureux</i> is not, as we have seen, conclusive against
+neuralgia in its early stages. It is therefore an excellent rule,
+in all cases of chronic recurrent spasmodic pain in the abdomen,
+especially in men, to investigate the possibilities of lead-poisoning;
+and, if the slightest suspicious appearance of the
+gums be found, this track of inquiry must be followed up
+exhaustively before we abandon the idea. The absence of all
+special neurotic history in a patient's family should increase
+our suspicions respecting pains of this character that continue
+with an obstinacy which makes it unlikely they are due to
+improper food.</p>
+
+<p>Pains of abdominal irritation are, however, without doubt
+produced in some cases by unsuspected faults of diet, and may
+even recur in such a quasi-periodic manner as to strongly suggest
+the idea of neuralgia in the lumbo-abdominal nerve. One
+special variety of this happens, I believe, much more often
+than is thought. A patient will habitually take considerable
+quantities of some article of food which he does not readily
+digest, but which is not at all acutely irritant: under these
+circumstances a simple accumulation is apt to take place in
+the colon, especially at the top of the ascending colon, the top
+of the descending colon, or just above the sigmoid flexure, or
+else in the cęcum. The result of accumulation in the last of
+these places is not unfrequently typhlitis and perityphlitis,
+this part of the bowel having (for some reason) a special tendency
+to inflammation. Deposits in the other localities named
+are rarely the cause of inflammation, but they very frequently<span class="pagenum"><a name="Page_231" id="Page_231">[231]</a></span>
+give rise to violent pain, which is exceedingly apt to be taken
+for the pain either of gall-stone, of renal calculus, or else of
+some abdominal neuralgia. In cases, therefore, where there
+is any possibility that accumulation is the cause of pain, it is
+highly desirable to commence with a dose of castor-oil and
+laudanum, followed up, if needful, by the administration of a
+large warm-water enema, given through an O'Beirne's tube.
+The most violent and recurrent attacks of pain in the renal
+region, the flank, the abdomen, or the groin, will sometimes
+be instantly cured by such means, sufficiently proving the
+non-neuralgic character of the complaint.</p>
+
+<p>I have elsewhere explained that the impaction of a renal or
+an hepatic calculus, in the ureter or the ductus choledochus,
+may set up a true neuralgia in persons with the requisite congenital
+predisposition. The passage of renal or hepatic calculi
+may give rise to symptoms falsely suggesting neuralgia, which
+require just to be mentioned here. But there is no need to
+dwell much upon the diagnosis, for the passage of renal or
+hepatic calculi has always attendant symptoms and features of
+constitutional history, which ought to preserve the physician
+from mistake. The sensation of constriction, of nausea and
+vomiting, the faintness approaching to collapse, the persistent
+and constantly increasing severity of the pain up to the
+moment at which mechanical relief occurs, to say nothing of
+other phenomena, are distinctive to the skilled observer, and,
+when taken in conjunction with the history of past attacks, if
+any, will always prevent mistakes. In the few cases which
+might still be doubtful it will be well to try the effect of a
+relaxing dose of chloroform, which, in the case of calculus,
+will often put an end to the paroxysm at once and finally.</p>
+
+
+
+<hr style="width: 65%;" />
+<h2><a name="dysp" id="dysp"></a>CHAPTER XI.</h2>
+
+<h3>DYSPEPTIC HEADACHE.</h3>
+
+
+<p>A final word or two must be given to the distinction between
+neuralgia of the head and an affection so utterly different that
+it is surprising that they should be so frequently confounded.
+One constantly hears medical men speak of "sick headache"
+(migraine) as if it were the same thing as headache from indigestion;
+and, unfortunately, they often treat migraine upon
+this confused and erroneous notion, doing no little mischief
+thereby.</p>
+
+<p>But, although migraine, already amply described, is entirely
+independent of the state of digestion, and its stomach-phenomena<span class="pagenum"><a name="Page_232" id="Page_232">[232]</a></span>
+are purely secondary to the affection of the fifth
+nerve, there is a kind of headache really dependent on imperfect
+digestion. The sufferers from these headaches are dyspeptics
+whose stomach troubles are the result of chronic gastric
+catarrhal inflammation. (In the acute form of gastric
+catarrh there are even more severe headaches; but the general
+symptoms of the disorder are too marked to allow us to mistake
+the case for neuralgia complicated with secondary stomach
+disturbance.) The patients in question have frequently passed
+so gradually into the dyspeptic condition as to have become
+accustomed to it, and inclined to forget that the stomach was
+the organ which first gave them annoyance. The headaches,
+which occur from time to time, are either frontal or (more frequently)
+occipital in position, and they are usually quite evenly
+bilateral; still, there is not enough uniformity of difference
+between them and true migraine, in this respect, to enable us
+to establish a decided diagnosis upon it. This much may be
+said, however: that the pain is rarely or never seated in one
+parietal region, as is frequently the case with migraine and
+with clavus. The patient suffers very strikingly, in almost
+every case, from languor and a feeling of inability to exert
+himself; and has also much aching pain in the limbs, and
+usually a pain (sometimes very severe) in the scapular region.
+The tongue may vary a good deal in appearance, especially as
+regards the degree of general redness; but it always has
+enlarged papillę, most prominent toward the tip, and more or
+less thick furring at the back, and reaching forward, in some
+cases, nearly to the tip, to which the "strawberry" aspect is
+then confined. The headache is frequently joined with nausea,
+but never with absolute vomiting, unless the stomach has
+been provoked with a meal that gives it more trouble than
+usual. The desponding frame of mind which this kind of
+dyspeptics always exhibit distinguishes them, in most cases,
+quite sufficiently (together with the unwholesome complexion,
+the appearance of the tongue, and the great complaints of general
+malaise and aching and feebleness of the limbs) from the
+victims of migraine, who are often persons of bright spirits
+and lively intelligence in the intervals of their attacks; but,
+above all, there is nothing of the regular and characteristic
+sequence of events which distinguishes the attacks of migraine.
+The attacks are not periodic, but nearly always depend on
+some chance dietary indiscretion, or other imprudence, which
+has visibly aggravated the stomach irritation. And, when the
+pain does come on, it has no uniform tendency to go on intensifying
+for some hours and culminate in vomiting, followed by
+sleep, after which the patient is free. On the contrary, the
+digestive disturbance is the provocation, and the pain itself is
+of a heavy character, with a sense of tension or fulness, and it
+does not go on intensifying in a regular manner, up to a climax,<span class="pagenum"><a name="Page_233" id="Page_233">[233]</a></span>
+but hangs about in a dull, tormenting way, and frequently
+is just as bad after sleep as it was before. The diagnosis
+of these headaches from neuralgic headache is not really
+difficult; it only requires the use of a fair amount of caution
+in observation. It would, however, be exceedingly advantageous
+that the word "sick-headache" should be dropped altogether,
+and that migraine should always be called by that
+name (or "megrim," if you will), and that headaches really
+proceeding from chronic catarrhal disease of the stomach
+should be called "dyspeptic" headaches. The present state of
+nomenclature does much to perpetuate a confusion of ideas
+which ought not to exist any longer, and which leads to much
+practical mischief.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> See, on this subject, some remarks, in my work on "Stimulants
+and Narcotics" on Sir W. Hamilton's "Theory of the Relations of
+Perception and Common Sensation."
+</p><p>
+A very distinct and careful statement of the distinction between
+pain and hyperęsthesia will be found in a prize essay "On Neuralgia"
+by M. C. Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> "Senses and Intellect."</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> "Gunshot Wounds and other Injuries to Nerves." Philadelphia:
+Lippincott &amp; Co., 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> <i>Med. Times and Gazette</i>, March 26, 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> "London Hosp. Reports," 1866.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> "Stimulants and Narcotics," Macmillan, 1854, p. 86.</p></div>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes
+du Nevralgies," Journ de Med. de Bruxelles, tome xl.</p></div>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> Amer. Jour. Med. Science. Jan. 1850.</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> "Diseases of the Heart and Great Vessels." Third edition, 1862.</p></div>
+
+<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> <i>Gaz. des Hop.</i>, 114, 117, 120. 1862.</p></div>
+
+<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> <i>Wien Med. Presse</i>, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66,
+p. 120.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p.
+120.</p></div>
+
+<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> See Wahn, <i>Journ. de Med. et Chir. Prat.</i> 1854. Also several
+original and quoted cases in Dr. Handfield Jones's "Functional
+Nervous Disorders," second edition, 1870.</p></div>
+
+<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> <i>Journ. de Med. et <ins title="Transcriber's Note: original reads 'Chim.'">Chir.</ins> Prat.</i>, July, 1862.</p></div>
+
+<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.</p></div>
+
+<div class="footnote"><p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a> Eulenburg, to whose excellent work ("Lehrbuch der functionellen
+Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion
+to refer, has partly misunderstood the drift and scope of my
+argument, a misfortune which I owe to the impossibility of giving, in
+the "System of Medicine," more than the briefest and most superficial
+sketch, both of my ideas and of the facts on which they rest.</p></div>
+
+<div class="footnote"><p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a> <i>Op. cit.</i>, p. 60.</p></div>
+
+<div class="footnote"><p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">[18]</span></a> This opinion is somewhat stronger than that expressed in my article
+in the "System of Medicine." I can only say it is the result of
+much increased experience.</p></div>
+
+<div class="footnote"><p><a name="Footnote_19_19" id="Footnote_19_19"></a><a href="#FNanchor_19_19"><span class="label">[19]</span></a> <i>Journal de la Physiologie, v.</i></p></div>
+
+<div class="footnote"><p><a name="Footnote_20_20" id="Footnote_20_20"></a><a href="#FNanchor_20_20"><span class="label">[20]</span></a> "Ernährungsstörungen der Augen bei Anęsthesie des Trigeminus."
+Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen.
+Archiv f. Ophthalm. Band. xiii.</p></div>
+
+<div class="footnote"><p><a name="Footnote_21_21" id="Footnote_21_21"></a><a href="#FNanchor_21_21"><span class="label">[21]</span></a> Zeitsch. f. rat. Med., 1867. There is corroborative evidence,
+from independent sources, of the truth of Meissner's views. His own
+observation only proved half the case; but he quotes an observation
+of Buttman's in which the exact converse of his own experience happened,
+the external fibres being affected without the inner band, and
+anęsthesia without trophic changes being the result. Moreover,
+Schiff (Gaz. hebdom., 1867) obtained experimental results (in operating
+on cats and rabbits) which coincide with Meissner's.</p></div>
+
+<div class="footnote"><p><a name="Footnote_22_22" id="Footnote_22_22"></a><a href="#FNanchor_22_22"><span class="label">[22]</span></a> London Hospital Reports, vol. iii., p. 305.</p></div>
+
+<div class="footnote"><p><a name="Footnote_23_23" id="Footnote_23_23"></a><a href="#FNanchor_23_23"><span class="label">[23]</span></a> Wegner, loc. cit.</p></div>
+
+<div class="footnote"><p><a name="Footnote_24_24" id="Footnote_24_24"></a><a href="#FNanchor_24_24"><span class="label">[24]</span></a> Archiv f. Ophthalm., xv., 1.</p></div>
+
+<div class="footnote"><p><a name="Footnote_25_25" id="Footnote_25_25"></a><a href="#FNanchor_25_25"><span class="label">[25]</span></a> "Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware
+whether Piotrowski has at all altered his opinions since the (subsequent)
+observations of Ludwig and Cyon upon the "depressor" nerve.</p></div>
+
+<div class="footnote"><p><a name="Footnote_26_26" id="Footnote_26_26"></a><a href="#FNanchor_26_26"><span class="label">[26]</span></a> "Functional Nervous Disorders." Churchill, 2d edit., 1870.</p></div>
+
+<div class="footnote"><p><a name="Footnote_27_27" id="Footnote_27_27"></a><a href="#FNanchor_27_27"><span class="label">[27]</span></a> "Prize Essay of the New York Academy of Medicine." New
+York: Wood &amp; Co., 1869.</p></div>
+
+<div class="footnote"><p><a name="Footnote_28_28" id="Footnote_28_28"></a><a href="#FNanchor_28_28"><span class="label">[28]</span></a> Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber
+Reflex Lahmungen," von E. Leyden. Leipzig, 1870.</p></div>
+
+<div class="footnote"><p><a name="Footnote_29_29" id="Footnote_29_29"></a><a href="#FNanchor_29_29"><span class="label">[29]</span></a> "Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.</p></div>
+
+<div class="footnote"><p><a name="Footnote_30_30" id="Footnote_30_30"></a><a href="#FNanchor_30_30"><span class="label">[30]</span></a> Wurzburg. Med. Zeitsch., iv., 56-64.</p></div>
+
+<div class="footnote"><p><a name="Footnote_31_31" id="Footnote_31_31"></a><a href="#FNanchor_31_31"><span class="label">[31]</span></a> Med. Cent. Ztg. 21, 1860.</p></div>
+
+<div class="footnote"><p><a name="Footnote_32_32" id="Footnote_32_32"></a><a href="#FNanchor_32_32"><span class="label">[32]</span></a> <i>Op. cit.</i>, pp. 65, 66.</p></div>
+
+<div class="footnote"><p><a name="Footnote_33_33" id="Footnote_33_33"></a><a href="#FNanchor_33_33"><span class="label">[33]</span></a> Idem, p. 8.</p></div>
+
+<div class="footnote"><p><a name="Footnote_34_34" id="Footnote_34_34"></a><a href="#FNanchor_34_34"><span class="label">[34]</span></a> "Elektrotherapie." Wien, 1868.</p></div>
+
+<div class="footnote"><p><a name="Footnote_35_35" id="Footnote_35_35"></a><a href="#FNanchor_35_35"><span class="label">[35]</span></a> Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)</p></div>
+
+<div class="footnote"><p><a name="Footnote_36_36" id="Footnote_36_36"></a><a href="#FNanchor_36_36"><span class="label">[36]</span></a> Practitioner, vol. iv., 1870.</p></div>
+
+<div class="footnote"><p><a name="Footnote_37_37" id="Footnote_37_37"></a><a href="#FNanchor_37_37"><span class="label">[37]</span></a> Berlin. klin. Wochensch., 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_38_38" id="Footnote_38_38"></a><a href="#FNanchor_38_38"><span class="label">[38]</span></a> In a paper on the "Hypodermic Use of Remedies," in the
+<i>Practitioner</i> of July, 1868, I gave the reasons for this opinion in full;
+and I see no reason to alter any thing I then said.</p></div>
+
+<div class="footnote"><p><a name="Footnote_39_39" id="Footnote_39_39"></a><a href="#FNanchor_39_39"><span class="label">[39]</span></a> Practitioner, vol. iv.</p></div>
+
+<div class="footnote"><p><a name="Footnote_40_40" id="Footnote_40_40"></a><a href="#FNanchor_40_40"><span class="label">[40]</span></a> Berlin. klin. Wochensch., 17, 1868.</p></div>
+
+<div class="footnote"><p><a name="Footnote_41_41" id="Footnote_41_41"></a><a href="#FNanchor_41_41"><span class="label">[41]</span></a> "System of Medicine," vol. ii.</p></div>
+
+<div class="footnote"><p><a name="Footnote_42_42" id="Footnote_42_42"></a><a href="#FNanchor_42_42"><span class="label">[42]</span></a> The English reader may consult Althaus ("A Treatise on Medical
+Electricity," second edition, Longmans), or Meyer ("Medical
+Electricity," translated by Hammond: Trubner &amp; Co.)</p></div>
+
+<div class="footnote"><p><a name="Footnote_43_43" id="Footnote_43_43"></a><a href="#FNanchor_43_43"><span class="label">[43]</span></a> "A Treatise on Medical Electricity," second edition, Longmans.</p></div>
+
+<div class="footnote"><p><a name="Footnote_44_44" id="Footnote_44_44"></a><a href="#FNanchor_44_44"><span class="label">[44]</span></a> <i>Op. cit.</i></p></div>
+
+<div class="footnote"><p><a name="Footnote_45_45" id="Footnote_45_45"></a><a href="#FNanchor_45_45"><span class="label">[45]</span></a> Berlin. klin. Wochensch., 22, 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_46_46" id="Footnote_46_46"></a><a href="#FNanchor_46_46"><span class="label">[46]</span></a> <i>Op. cit.</i></p></div>
+
+<div class="footnote"><p><a name="Footnote_47_47" id="Footnote_47_47"></a><a href="#FNanchor_47_47"><span class="label">[47]</span></a> "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud.
+Paris, 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_48_48" id="Footnote_48_48"></a><a href="#FNanchor_48_48"><span class="label">[48]</span></a> Reynolds's "System of Medicine," vol. ii., Art. "Spinal Irritation."</p></div>
+
+<div class="footnote"><p><a name="Footnote_49_49" id="Footnote_49_49"></a><a href="#FNanchor_49_49"><span class="label">[49]</span></a> The most complete and careful work of the German school, on
+this subject, is the "Lehre von der Tabes dorsualis," of E. Cyon.
+(Berlin, 1867.)</p></div>
+
+<div class="footnote"><p><a name="Footnote_50_50" id="Footnote_50_50"></a><a href="#FNanchor_50_50"><span class="label">[50]</span></a> <i>Lancet</i>, June 10, 1865. (Comment on a case of Dr. J. Hughlings
+Jackson's.)</p></div>
+
+<div class="footnote"><p><a name="Footnote_51_51" id="Footnote_51_51"></a><a href="#FNanchor_51_51"><span class="label">[51]</span></a> Radcliffe, in "Reynolds's System of Medicine," vol. ii.</p></div>
+
+<div class="footnote"><p><a name="Footnote_52_52" id="Footnote_52_52"></a><a href="#FNanchor_52_52"><span class="label">[52]</span></a> Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.</p></div>
+</div>
+<hr style="width: 85%;" />
+
+<p>Transcriber's Notes:</p>
+
+<p>Punctuation and spelling errors fixed. Variant spellings and hyphenations
+changed when there is a clear majority. Other unusual spellings retained.</p>
+
+<p>Hover notes were added in the text to show original
+versions of changed texts for the following notes:</p>
+
+<p>Discrepancies in headings and outline labels repaired. In some cases, this
+required adding headings implied but not present in the original, to agree with
+headings that were present.</p>
+
+<p>Table of Contents, Part 1, Chapter IV: original reads "Diagnosis and
+Progress of Neuralgia." "Progress" has been corrected to "Prognosis" as
+shown in the Chapter heading.</p>
+
+<p>P. 51, "but her mensural troubles" changed to "but her menstrual
+troubles".</p>
+
+<p>P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat."
+"Chim." is typo for "Chir." as in footnote just above.</p>
+
+<p>P. 96, "investigation of neralgi" changed to "investigation of
+neuralgia".</p>
+
+<p>P. 105, "genealogical connection between migraine and epilepsy": in all
+reviewed copies of this 1882 edition, original shows "aological" with
+4 or 5 spaces in front of it, an apparent printer error. However, in the
+1872 edition, the entire sentence reads as presented here.</p>
+
+<p>P. 206, "I have already causually" changed to "I have already causally".</p>
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Neuralgia and the Diseases that
+Resemble it, by Francis E. Anstie
+
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+The Project Gutenberg EBook of Neuralgia and the Diseases that Resemble it, by
+Francis E. Anstie
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Neuralgia and the Diseases that Resemble it
+
+Author: Francis E. Anstie
+
+Release Date: October 1, 2011 [EBook #37592]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT ***
+
+
+
+
+Produced by Bryan Ness, JoAnn Greenwood and the Online
+Distributed Proofreading Team at https://www.pgdp.net (This
+file was produced from images generously made available
+by The Internet Archive/Canadian Libraries)
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+
+
+
+
+
+
+                 NEURALGIA
+                    AND
+       THE DISEASES THAT RESEMBLE IT.
+
+                    BY
+
+      FRANCIS E. ANSTIE, M.D., LONDON,
+
+FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S
+COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER HOSPITAL;
+LECTURER ON MEDICINE IN WESTMINSTER HOSPITAL SCHOOL; PHYSICIAN TO THE
+BELGRAVE HOSPITAL FOR CHILDREN.
+
+              [Illustration]
+
+                NEW YORK:
+      BERMINGHAM & CO., UNION SQUARE.
+                  1882.
+
+           W. L. MERSHON & CO.,
+   _Printers, Electrotypers and Binders_,
+              RAHWAY, N. J.
+
+
+
+
+PREFACE.
+
+
+I believe it will not be disputed that there was considerable need for
+an English treatise dealing rather fully with the subject of Neuralgia,
+and therefore I hope that the profession will be willing to give me a
+hearing. The present work, moreover, does not profess to be a mere
+compilation of standard authorities corrected down to the present time,
+but puts forward a substantially new view of the subject--at least, a
+view that has been only briefly sketched by me in an article that
+appeared, three years ago, in Reynolds's "System of Medicine." My
+principal object, in writing this volume, was to vindicate for Neuralgia
+that distinct and independent position which I have long been convinced
+it really holds, and to prove that it is not a mere offshoot of the
+Gouty or Rheumatic diatheses, still less a mere chance symptom of a
+score of different and incongruous diseases. In order to set the
+diagnosis of true Neuralgia from its counterfeits in the clearest light,
+it seemed advisable to draw separate pictures of each of the latter (at
+least of as many as are of real importance) and present them separately,
+as a kind of gallery of spurious neuralgias, and this I have done in the
+second part of the volume. No one who had not tried to do it would
+imagine how difficult this latter kind of work is. It was necessary for
+the sketches to be very brief (unless my book was to become unmanageably
+large), and yet to be as truthfully characteristic as possible; and it
+was necessary also that only those diseases which so much resemble
+Neuralgia as practically to lead medical men astray in diagnosis, should
+be dealt with. The selection of the subjects, and the execution of this
+part, took a long time, though it only covers about fifty pages. Then,
+as regards Neuralgia itself, it became necessary to completely recast
+the chapters on "Pathology" and on "Complications," on account of some
+of the polite criticisms which Dr. Eulenburg directed (in his recent
+"Lehrbuch der Nervenkrankheiten") to my argument in the article above
+referred to, since it was obvious that a too brief statement of my views
+had caused them to be partially misunderstood by the German physician.
+These chapters (Part I., Chapters II. and III.) are certainly the most
+important portion of my book, and I would particularly direct attention
+to them, in order that their contents may be affirmed or corrected: the
+reader will at any time find that they contain a kind of investigation
+never before systematically carried out with regard to Neuralgia. The
+causes above mentioned, together with others over which I had no
+control, have kept back the appearance of this work so long beyond the
+date for which it was originally announced, that I feel I ought to
+apologize for an amount of delay that would seem hardly justified by the
+moderate size of the volume.
+
+16 WIMPOLE STREET, LONDON, _October_ 1, 1871.
+
+
+
+
+CONTENTS.
+
+
+    INTRODUCTION--ON PAIN IN GENERAL                7
+
+
+                 PART I.
+
+             _ON NEURALGIA._
+
+    CHAP.                                        PAGE
+
+       I.--CLINICAL HISTORY                        12
+
+      II.--COMPLICATIONS OF NEURALGIA              79
+
+     III.--PATHOLOGY AND ETIOLOGY OF NEURALGIA     96
+
+      IV.--DIAGNOSIS AND PROGNOSIS OF NEURALGIA   142
+
+       V.--TREATMENT OF NEURALGIA                 149
+
+
+                 PART II.
+
+     _DISEASES THAT RESEMBLE NEURALGIA._
+
+    CHAP.
+
+       I.--MYALGIA                                196
+
+      II.--SPINAL IRRITATION                      200
+
+     III.--THE PAINS OF HYPOCHONDRIASIS           207
+
+      IV.--THE PAINS OF LOCOMOTOR ATAXY           210
+
+       V.--THE PAINS OF CEREBRAL ABSCESS          213
+
+      VI.--THE PAINS OF ALCOHOLISM                215
+
+     VII.--THE PAINS OF SYPHILIS                  218
+
+    VIII.--THE PAINS OF SUBACUTE AND CHRONIC
+              RHEUMATISM                          225
+
+      IX.--THE PAINS OF LATENT GOUT               227
+
+       X.--COLIC, AND OTHER PAINS OF PERIPHERAL
+              IRRITATION                          229
+
+      XI.--DYSPEPTIC HEADACHE                     231
+
+
+
+
+INTRODUCTION.
+
+ON PAIN IN GENERAL.
+
+
+Although it is, in a general way, unadvisable to introduce abstract
+discussions into a treatise which should be strictly practical, it is
+almost impossible to avoid some few general reflections on the
+physiological import of Pain, as a preliminary to the discussion of the
+maladies which form the subject of this volume. This whole group of
+disorders is linked together by the fact that pain is their most
+prominent feature; and, with regard to most of them, the relief of the
+pain is the one thing required of the physician. It seems, therefore,
+very important that we should ascertain, at least approximately, in what
+the immediate state consists, which consciousness interprets as pain. It
+is not necessary to enter at this stage into any inquiry as to the
+pathological causes of the phenomenon; what we know of these, and it is
+unfortunately too little, will be discussed in detail under the headings
+of the several affections which I shall have to describe.
+
+The question before us now is this: What is that functional state of the
+nerves which consciousness interprets as pain? Is it, or is it not, an
+exaltation of the ordinary function of sensation?
+
+The latter question is generally answered affirmatively, without much
+thought, by those to whom it casually occurs; but indeed there is plenty
+of prescriptive authority for so dealing with it. Pain has been
+described by some of the most distinguished writers on nervous diseases
+as a hyperaesthesia. Yet there is really little difficulty in convincing
+ourselves, if we institute a thorough inquiry into the matter, that pain
+is certainly not a hyperaesthesia, or excess of ordinary sensory
+function, but something which, if not the exact opposite of this, is
+very nearly so.
+
+The leading fallacy in the common view is the confusion which is
+perpetually being made between function and action. Now, the function of
+individual nerves is very nearly a constant quantity, at least, it
+varies only within narrow limits; while the action of the same nerves
+may be almost any thing. The function of the nerve is that kind of work
+for which it is fit when its molecular structure is healthy; it is the
+series of dynamic reactions which are necessarily produced in
+nerve-tissue by the external influences which surround and impinge upon
+it in the conditions of ordinary existence. The action of nerves, under
+the pressure of extraordinary influences, may include all manner of
+vagaries which really have nothing in common with the effects of
+ordinary functional stimulation; which are, in fact, nothing but
+perturbation. No one can suppose, for instance, that the explosive
+disturbances of nerve-force which give rise to the convulsions of
+tetanus are any mere exaggerated degree of the orderly and symmetrical
+action by which the healthy nerve responds to the stimulus of volition
+ordering a given set of muscles to contract; they are something quite
+different in kind. And so it is with the sensory nerves. The functions
+of these conductors, in health, is to convey to the perceptive centres
+the sensations, varying only within a most limited range, which
+correspond to a state of well-being of the organs, and which excite only
+those reflex actions that are necessary to life. Thus the large surface
+of sensitive nerve terminals which is represented by the collective
+peripheral branches of the fifth cranial conveys to the medulla
+oblongata an impression, derived from the temperature and movement of
+the surrounding air, when the latter is neither too hot nor too cold,
+which imparts to the brain a perception of comfortable sensations, and
+excites in return the reflex action of breathing, which is necessary to
+life. But the impression produced on this same peripheral expanse of
+nerve-branches by prolonged exposure to cold wind may, and often does,
+convey to the centres sensations which are quite different and provokes
+reflex movements which are altogether abnormal. Pain is the product in
+one direction; sneezing, perhaps, in the other. It seems absurd to say
+that sneezing is any part of the function of those motor nerves whose
+action regulates the performance of expiration. And it appears to me not
+less absurd to say that pain is the function of the sensitive fibres of
+the trigeminus. But the best way, perhaps, to illustrate the looseness
+and incorrectness of applying the term "hyperaesthesia" (implying exalted
+function) to the state of sensitive nerves when suffering pain, is to
+examine the condition of distinctive perception in the very same parts
+to which the painful nerves are distributed. It will invariably be
+found, as we shall have occasion to see more fully proved hereafter,
+that, in parts which are acutely painful, a marked bluntness of the
+tactile perceptions can be detected. The tactile perceptions are, no
+doubt, conveyed by an independent set of fibres from those which convey
+the sense of pain.[1] Yet it is surely impossible to believe the effect
+of the same influence, in functional power can be different--much more
+than it can be exactly opposite--in the two cases.
+
+If pain be not a heightening of ordinary sensation, then we seem to be
+shut up to the idea that it is a perversion owing to a molecular change
+of some part of the machinery of sensation which frustrates function.
+For it is to be observed that, while the sensations conveyed by the
+healthy nerve are correct in the indications which they afford to the
+percipient brain, the indications given by pain are vague and
+untrustworthy, and often seriously misleading. Not to speak of the
+nerves of special sense, or of the fibres which convey the sensations of
+muscular movement, even the nerves of common sensation do carry to the
+internal perception, in health, a distinct impression of the well-being
+of the organs to which they are distributed. Mr. Bain[2] has well
+pointed out the positive character of this feeling, which is so often
+incorrectly referred to as if it were a mere negation of feeling. It is
+a sensation of equable and diffused comfort, if I may be allowed to use
+the expression, which streams in from all parts of the organism; and
+there is no possibility of comparing it, in any scale of less or more,
+with the sensation of pain; for the latter commonly conveys no correct
+information as to the organ from which it proceeds, or appears to
+proceed. Especially is this the case in the neuralgias, for more
+commonly than not the apparent seat of the pain is widely removed from
+the actual seat of the mischief which causes it.
+
+If we inquire a little further into the circumstances under which
+various kinds of pain occur, we gain some fresh suggestions. Among the
+neuralgias, those are the most acutely agonizing which occur under
+circumstances of impaired nutrition incident to the period of bodily
+decay, and strong reasons will be hereafter adduced for the belief that
+there is especial impairment of the nutrition of the central end of the
+painful nerves. To find a parallel to the severity of this kind of pains
+we must turn to the case of organic tumors, which, from their position,
+structure, and mode of growth, necessarily exercise continuous and
+severe pressure on the branches or the trunk of a nerve; or to the class
+of pains which attend severe cramp, or tonic contraction of muscles.
+Now, it can scarcely be doubted that in the latter instance there is an
+abnormally rapid and violent destruction of tissue going on; at the very
+least there is an extraordinarily violent and irregular manifestation of
+motor force. In any case the patent fact here is dynamic perturbation
+of a severe kind; and, in the instance of organic tumors exercising
+steady and continuously increasing pressure on nerves, one can scarcely
+doubt that a similar perturbation, less intense but more enduring, is
+necessarily set up. That which can be done in the way of producing
+severe pain by these severe affections of the peripheral portions of
+nerves, or of tissues lying outside them, we might _a priori_ expect
+would be effected by slighter but continuous changes in the nutrition of
+the more important portion of the nerve itself--its central gray
+nucleus. One would say that a pathological process which continuously
+and progressively lowered the standard of nutrition here must interfere
+from hour to hour, certainly from day to day, with that regular and
+equable distribution of force which is the essence of unimpeded
+function.
+
+Take, again, the case of the very severe pain which frequently attends
+inflammation of the pleura and of the peritoneum. Whatever theory of the
+causation of these pains we may adopt, it is certain that one most
+important element in their production and maintenance is the continual
+movement and friction of the affected parts. But there is little doubt
+that the moving muscles are involved in the inflammatory process, as Dr.
+Inman has correctly observed. It would seem plain that under these
+circumstances--an inflamed muscular structure forced to perform its
+ordinary contractions as well as it can--there must be powerful dynamic
+perturbation going on.
+
+If perturbation of nerve-function--a disturbance quite different from
+mere exaltation of the normal development of nerve-force--be the essence
+of pain, how comes it that pains of the severest type may be produced by
+changes in structures which are usually described, for practical
+purposes, as lying outside the nervous system? We must, in the first
+place, remark that the externality of any bodily tissue to the nervous
+system is more apparent than real. Microscopic researches are constantly
+revealing nerve-fibres, in ever-increasing profusion, which penetrate to
+parts seemingly the least vitalized in the organism. But, in any case,
+the nerves are certainly the ultimate channel of communication between
+the suffering part and the sentient centre. It seems, therefore, the
+inevitable conclusion that a dynamic perturbation going on in the
+non-nervous tissue is continued along the nerves themselves: and that
+the severity of the pain perceived by the conscious centres is
+proportionate to the tumultuousness, the want of coordination, and the
+waste with which force is being evolved in the cramped muscle, or
+whatever structure it may be, in which the pain takes its source.
+
+Not to pursue these topics further, we may sum up the considerations
+which have now been adduced, in the following general propositions,
+which will tend to simplify the examination of the various painful
+disorders which we are about to discuss:
+
+1. Pain is not a true hyperaesthesia; on the contrary, it involves a
+lowering of true function.
+
+2. Pain is due to a perturbation of nerve-force, originating in dynamic
+disturbance either within or without the nervous system.
+
+3. The susceptibility to this perturbation is great in proportion to the
+physical imperfection of the nervous tissue, until this imperfection
+reaches to the extent of cutting off nervous communications
+(paralysis).
+
+FOOTNOTES:
+
+[1] See, on this subject, some remarks, in my work on "Stimulants and
+Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception
+and Common Sensation."
+
+A very distinct and careful statement of the distinction between pain
+and hyperaesthesia will be found in a prize essay "On Neuralgia" by M. C.
+Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.
+
+[2] "Senses and Intellect."
+
+
+
+
+PART I.
+
+ON NEURALGIA.
+
+
+
+
+CHAPTER I.
+
+CLINICAL HISTORY.
+
+
+Neuralgia may be defined as a disease of the nervous system, manifesting
+itself by pains which, in the great majority of cases, are unilateral,
+and which appear to follow accurately the course of particular nerves,
+and ramify, sometimes into a few, sometimes into all, the terminal
+branches of those nerves. These pains are usually sudden in their onset,
+and of a darting, stabbing, boring, or burning character; they are at
+first unattended with any local change, or any general febrile
+excitement. They are always markedly intermittent, at any rate at first;
+the intermissions are sometimes regular, and sometimes irregular; the
+attacks commonly go on increasing in severity on each successive
+occasion. The intermissions are distinguished by complete, or almost
+complete, freedom from suffering, and in recent cases the patient
+appears to be quite well at these times; except that, for some short
+time after the attack, the parts through which the painful nerves ramify
+remain sore, and tender to the touch. In old-standing cases, however,
+persistent tenderness, and other signs of local mischief, are apt to be
+developed in the tissues around the peripheral twigs. Severe neuralgias
+are usually complicated with secondary affections of other nerves which
+are intimately connected with those that are the original seat of pain;
+and in this way congestions of blood vessels, hypersecretion or arrested
+secretion from glands, inflammation and ulceration of tissues, etc., are
+sometimes brought about.
+
+The above is a general description of neuralgia which will identify the
+disease sufficiently for the purpose of introducing it the attention of
+the reader. We must now proceed to give a more accurate account of its
+
+_Clinical History and Symptoms._--These vary so greatly in different
+kinds of neuralgia that it will be necessary to discuss the greater part
+of this subject under the headings of the special varieties of the
+disease. There are certain common features, however, in all true
+neuralgias.
+
+I. In the first place, it is universally the case that the condition of
+the patient, at the time of the first attack, is one of debility, either
+general or special. I make this assertion with confidence,
+notwithstanding that Valleix, and some other very able observers, have
+made a contrary statement. In the first place, it is certainly the case
+that the larger half of the total number of cases of neuralgia which
+come under my care are either decidedly anaemic, or else have recently
+undergone some exhausting illness or fatigue; and if other writers have
+failed to see so many neuralgic patients in whom these conditions were
+present, it must certainly be because they have limited the application
+of the term "neuralgia" within bounds which are too narrow to be
+justified by any logical argument; as will, indeed, be shown at a later
+stage. On the other hand, although a considerable number of neuralgic
+patients have an externally healthy appearance, as indicated by a ruddy
+complexion and a fair amount of muscular development, it cannot be
+admitted that these appearances exclude the possibility of debility,
+either structional or functional, of the nervous system. The commonest
+experience might teach us that, so far from the nervous system being
+invariably developed with a corresponding completeness and maintained
+with a corresponding vigor to those which distinguish the muscular
+system and the organs of vegetative life, there is often a very striking
+contrast between these in the same individual. What physician is there
+who has not seen epileptic patients, in whom mental habitude, a low
+cranial development, imperfect cutaneous sensibility, and other obvious
+marks of deficient innervation, were marked and striking features at, or
+even before, the first occurrence of convulsive symptoms, while the body
+was robust, the face well colored, and the muscular power up to or
+beyond the average? Now, it will invariably be found, on carefully
+sifting the history of apparently robust neuralgic patients, that they,
+too, have given previous indications of weakness of the nervous system:
+thus, women, who, after a severe confinement attended with great loss of
+blood, are attached with _clavus hystericus_ or with _migraine_; will
+inform us that whenever, in earlier life, they suffered from headache,
+the pain was on the same side as that now affected, and chiefly or
+altogether confined to the site of the present neuralgia. In a
+considerable number of cases, also, in which I have been able to observe
+accurately the events which preceded an attack of neuralgia, it has been
+found that the skin supplied by the nerves about to become painful was
+anaesthesic to a remarkable degree; and it is very often the case that a
+more moderate amount of blunted sensation was perceptible in these parts
+during the intervals between attacks of pain. A somewhat delusive
+appearance of general nervous vigor is often conveyed to the observer of
+neuralgic patients, by reason of the intellectual and emotional
+characteristics of the latter. Both ideation and emotion are, indeed,
+very often quick and active in the victims of neuralgia, who in this
+respect differ strikingly from the majority of epileptics. But this
+mobility of the higher centres of the nervous system is itself no sign
+of general nervous strength; which last can never be possessed except by
+those in whom a certain balance of the various nervous functions is
+maintained. Much more will be said on this topic when we come to discuss
+the etiology of neuralgia. Meantime I may content myself with repeating
+the fact which is indubitably taught by careful observation--that
+neuralgics are invariably marked by some original weakness of the
+nervous system; though in some cases this defect is confined strictly to
+that part of the sensory system which ultimately becomes the seat of
+neuralgic pain.
+
+Another circumstance is common to all neuralgias of superficial nerves;
+and, as a large majority of all neuralgias are superficial in situation,
+this is, for practical purposes, a general characteristic of the
+disease. I refer to the gradual formation of tender spots at various
+points where the affected nerves pass from a deeper to a more
+superficial level, and particularly where they emerge from bony canals,
+or pierce fibrous fasciae. So general is this characteristic of
+inveterate neuralgias, that Valleix founded his diagnosis of the genuine
+neuralgias on the presence of these painful points. Herein he appears to
+me to be decidedly in error. I have watched a great many cases (of all
+sorts of varieties as to the situation of the pain), and I have
+uniformly observed that in the early stages firm pressure may be made on
+the painful nerve without any aggravation of the pain; indeed, very
+often with the effect of assuaging it. The formation of tender spots is
+a subsequent affair: they develop in those situations which have been
+the foci, or severest points, of the neuralgic pain. There is however, a
+point which, though not always, nor often, the seat of spontaneous pain,
+is nevertheless very generally tender. Trousseau, who criticises
+unfavorably the statement of Valleix as to the situation of the points
+douloureux, insists that this tender spot, which is over the spinous
+processes of the vertebrae corresponding to the origin of the painful
+nerve, and which he calls the points apophysaire, is more universally
+present than any of those pointed out by Valleix. I shall hereafter
+endeavor to show that these spinal points are by no means characteristic
+of neuralgia; they are present in a variety of affections which were
+ably described, under the heading of "Spinal Irritation," many years
+ago, by the brothers Griffin. ["Observations on the Functional
+Affections of the Spinal Cord," by William and Daniel Griffin. London,
+1834] and they are also present with misleading frequency in cases of
+mere myalgia, such as I shall have to describe at a later stage.
+
+Another characteristic of neuralgic patients in general is, I believe,
+a certain mobility of the vaso-motor nervous system and of the cardiac
+motor nerves; but I insist less on this than on the above-named
+features, because a more extended experience is necessary to establish
+the fact with certainty. Within my own experience it has always seemed
+to be the case that persons who are liable to neuralgia are specially
+prone to sudden changes of vascular tension, under emotional and other
+influences which operate strongly on the nervous system. The observation
+of this fact has been made accidentally, without any previous bias on my
+part, in the course of a large number of experiments made upon
+individuals free from manifest disease at the time, with Marey's
+sphygmograph.
+
+Neuralgic attacks are always intermittent, or at the least remittent, in
+every stage of the disease.
+
+The manner in which neuralgic pain commences is characteristic and
+important. There is always a degree of suddenness in its outset. When
+produced by a violent shock, it may, and often does, spring into full
+development and severity at once, of which, perhaps, the most striking
+example is the sudden and violent neuralgic pain of the eyebrow which
+some persons experience from swallowing a lump of undissolved ice.
+Usually, however, the first warning is a sudden, not very severe, and
+altogether transient dart of pain. The patient has probably been
+suffering from some degree of general fatigue and malaise, and the skin
+of the affected part has been somewhat numb, when a sudden slight stitch
+of pain darts into the nerve at some point which corresponds to one of
+the foci hereafter to be particularized. It ceases immediately, but in a
+few seconds or minutes returns; and these darts of pain recur more and
+more frequently, till at last they blend themselves together in such a
+manner that the patient suffers continuous and violent pain for a minute
+or so, then experiences a short intermission, and then the pain returns
+again, and so on. These intermittent spasms of pain go on recurring for
+one or several hours; then the intermissions become longer, the pain
+slighter, and at last the attack wears itself out. Such is generally the
+history of first attacks, especially in subjects who are not past the
+middle age, nor particularly debilitated from any special cause.
+
+A point of interest in connection with the natural history of the
+neuralgic access is the condition of the circulation. The commencement
+of pain is generally preceded by paleness of skin and sensations of
+chilliness. At the commencement of the painful paroxysm, sphygmographic
+observation shows that the arterial tension is much increased, owing, in
+all probability, to spasm of the small vessels. This condition is
+gradually replaced by an opposite state, the pulse becoming large, soft,
+and bounding, though very unresisting, and giving a sphygmographic trace
+which exhibits marked dicrotism. Simultaneously with this the skin
+becomes warmer, sometimes even uncomfortably warm, and there is
+frequently considerable flushing of the face.
+
+The final characteristic common to all neuralgias is that fatigue, and
+every other depressing influence, directly predispose to an attack, and
+aggravate it when already existing.
+
+_Varieties._--It is possible to classify neuralgias upon either of two
+systems: first (_a_), according to the constitutional state of the
+patient; and, secondly (_b_), according to the situation of the affected
+nerves. It will be necessary to follow both these lines of
+classification, avoiding all needless repetition.
+
+(_a_) In considering the influence of constitutional states upon the
+typical development of neuralgia, it will be convenient to commence with
+the group of cases in which the general condition of the organism
+produces the least effect. This is the case when the pain is the result
+of direct injury to a nerve-trunk, whether by external violence, by the
+mechanical pressure of a tumor, or by the involvement of a nerve in
+inflammatory or ulcerative processes originating in a neighboring part.
+As regards the development of symptoms, the important matters are, that
+the pain in these cases commences comparatively gradually, that the
+intermissions are usually more or less complete, and that the pain is
+far less amenable to relief from remedies, than in other forms of
+neuralgia. The little that can be said about the form which is dependent
+upon progressively increasing pressure, or involvement of a nerve in
+malignant ulcerations, caries of bones or teeth, etc., falls under the
+heads of Diagnosis and Treatment, and need not detain us here. The
+clinical history of neuralgia from external violence, however, requires
+separate discussion:
+
+1. Neuralgia from external shock may be produced by a physical cause (as
+by a fall, a railway collision, etc.), which gives a jar to the central
+nervous system; or by severe mental emotion, operating upon the same
+part of the organism. Under either of these circumstances the
+development of the affection may occur at once, but by far the most
+frequently it ensues after a variable interval, during which the patient
+shows signs of general depression, with loss of appetite and strength.
+Sometimes vomiting, and in other instances paralysis, of a partial and
+temporary kind, occur. When once developed, the neuralgic attacks do not
+differ from those which proceed from causes internal to the organism. In
+the greater number of instances, so far as my experience goes, it is the
+fifth cranial nerve which becomes neuralgic from the effects of central
+shock. Illustrative cases will be given in the section on Local
+Classification. Meantime the important facts to note, in relation to the
+influence of constitutional states, are these: In the first place, the
+tendency of such accidents to excite neuralgia varies directly with the
+hereditary predisposition evinced by the liability of the sufferer's
+family to neuralgic affections and to the more serious neuroses.
+Secondly, the likelihood of a neuralgic attack is indefinitely increased
+if he has already had neuralgia. Thirdly, although debility from
+temporary and special causes can rarely be sufficient to insure a true
+neuralgic access after a severe shock, it probably heightens,
+indefinitely, the tendency in a person otherwise predisposed. Delicate
+women are many times more liable to experience such consequences, from a
+physical or mental shock, than men of tolerably robust constitution.
+
+2. Neuralgia from direct violence to superficial nerves is produced by
+cutting or, more rarely, by bruising wounds. Cutting wounds may divide a
+nerve-trunk (_a_) partially, or (_b_) completely.
+
+(_a_) When a nerve-trunk is partially cut through, neuralgic pain
+occurs, if at all, immediately, or almost immediately, on the receipt of
+the injury. One such instance only has come under my own care, but many
+others are recorded. In my case the ulnar nerve was partly cut through,
+with a tolerably sharp bread-knife, not far above the wrist; partial
+anaesthesia of the little and ring fingers was induced, but at the same
+time violent neuralgic pains in the little finger came on, in fits
+recurring several times a day, and lasting about half a minute.
+Treatment was of little apparent effect in promoting a cure; though
+opiates and the local use of chloroform afforded temporary relief. The
+attacks recurred for more than a month, long after the original wound
+had healed soundly; and, for a long time after this, pressure on the
+cicatrix would reproduce the attacks. A slight amount of anaesthesia
+still remained, when I saw the patient more than a year after the
+injury.
+
+(_b_) Complete severance of a nerve-trunk is a sufficiently common
+accident, far more common then is neuralgia produced by such a cause;
+indeed, so marked is this disproportion between the injury and the
+special result, that I have been led to infer that a necessary factor in
+the chain of morbid events must be the existence of some antecedent
+peculiarity in the central origin of the injured nerve. This opinion is
+rendered the more probable because the consecutive neuralgia is in some
+cases situated, not in the injured nerve itself, but in some other nerve
+with which it has central connections. Two such cases are recorded in my
+Lettsomian Lectures, [_Lancet_, 1866], in which the ulnar nerve, and one
+in which the cervico-occipital, were completely divided; in all three
+the resulting neuralgia was developed in the branches of the fifth
+cranial. Here we may suppose that the weak point existed in the central
+nucleus of the fifth; and that the irritation, or rather depression,
+communicated to the whole spinal centres by the wound of a distant
+nerve, first found, on reaching this weak point, the necessary
+conditions for the development of the neuralgic form of pain, which
+therefore would be represented to the mental perception as present in
+the peripheral branches of the fifth nerve. In all the cases which have
+come under my notice, the neuralgia set in at a particular period,
+namely, after complete cicatrization of the wound, and while the
+functions of the branches on the peripheral side of the wound were
+partly, but not completely, restored. The same obstinacy and
+rebelliousness to treatment are observed as in other instances of
+neuralgia from injury.
+
+One of the cases above referred to may here be briefly detailed, as it
+shows very completely the clinical history of such affections. C. B.,
+aged twenty-four, an agricultural laborer, applied for relief in the
+out-patient room of Westminster Hospital, suffering from severe
+neuralgic pains of the forehead and face of the left side. Then pains
+were felt in the course of the supra-orbital, ocular, nasal, and
+supra-trochlear branches, and also in the cheek, appearing, there, to
+radiate from the infra-orbital foramen. They had commenced about three
+weeks previously to the patient's first visit to the hospital, and about
+six weeks after the accident which appeared to have started the whole
+train of symptoms. This was a cutting wound, evidently of considerable
+depth as well as external size, toward the back of the neck, and so
+situated that it must have divided the great occipital nerve of the left
+side: and, from the man's account of the numbness of the parts supplied
+by the nerve which immediately followed the wound, there could be no
+doubt that this had occurred. There was no acute nerve-pain, either
+during the healing of the wound, which was rapid, or subsequently, until
+more than three weeks from the date of the injury; at this time there
+was still a considerable sense of numbness in the skin of the occipital
+and upper cervical region; but there now commenced a series of short
+paroxysms of pain in the forehead of the same side. These at first
+occurred only about twice daily, at regular intervals; the pain was not
+very sharp, and only lasted a minute or two. The attacks rapidly
+increased in frequency and duration, however, and extended their area.
+At the time when I first saw the case the pain was very formidable, it
+recurred with great frequency during the day, but would sometimes leave
+the patient free for several hours together. The site of the wound was
+occupied by a firm cicatrix of about a line in breadth and an inch and a
+quarter in length; pressure on this excited only a vague and slightly
+painful tingling in the part itself, but severely aggravated the
+trigeminal pains, or reproduced them if they happened to be absent. The
+regions supplied by the great occipital nerve were still very
+imperfectly sensitive. This patient gave me a great deal of trouble. He
+continued for many weeks under my care, and I can scarcely flatter
+myself that any of the numerous remedies which I administered
+internally, or applied locally, had any serious effect in checking the
+disorder. The subcutaneous injection of morphia gave some relief, as it
+always does, but this seemed to be perfectly transitory; and, although
+when the patient ceased to attend the hospital he was decidedly better,
+I cannot imagine that there was anything in it except the slow wearing
+out of the neuralgic tendency, very much without reference to the
+administration of any remedies.
+
+The description of neuralgia from injury would be incomplete without
+some special words on a variety of this affection which has only very
+recently been described with that fulness which it deserves. I refer to
+the pains which are produced by gunshot injuries of nerves, received in
+battle, of which no sufficient account had been given until the
+publication of the experience of Messrs. Mitchell, Moorehouse, and Keen,
+in the late American civil war.[3]
+
+From the interesting treatise of the above-named writers it appears that
+not merely is neuralgia of an ordinary type a frequent after-consequence
+of wounds, but that certain special pains are not unfrequently produced.
+In the more ordinary instances, pain is of the darting, or of the aching
+kind; and all writers on military surgery, who have recorded their
+experience of the results of wounds received in battle, have spoken of
+affections of this kind, for the most part singularly severe and
+obstinate, and in not a few recorded instances clinging to the patient
+during the remainder of his life. These pains may at times leave the
+sufferer, but they infallibly recur when from any cause his health is
+depressed, and it is an especially common thing for them to be evoked in
+full severity under the influence of exposure to cold, and particularly
+to damp cold.
+
+But the American writers introduce us to another and more terrible
+neuralgia which is a, fortunately, less frequent result of serious
+injuries to nerves. They speak of it as a burning pain of intense and
+often intolerable severity; they believe that it seldom if ever
+originates at the moment of the injury, but rather at some time during
+the healing process; and it is especially noteworthy that it is
+sometimes felt not in the nerve actually wounded, but in some other
+nerve with which it has connections. After it has lasted a certain time,
+an exquisite tenderness of the skin is developed, and a peculiar
+physical change of skin-tissue occurs; it becomes thin, smooth, and
+glossy. It is a remarkable fact that these burning pains which are so
+definitely linked with a nutrition-change of skin are never felt in the
+trunk, and rarely in the arm or thigh, not often in the forearm or leg,
+but commonly in the foot or hand; and the nutrition changes of the skin
+are generally observed on the palm of the hand, the palmar surface of
+the fingers, or the dorsum of the foot; rarely on the sole of the foot
+or the back of the hand. It is very interesting to remark that these
+skin-lesions correspond very nearly, not only to those observed in the
+cases of nerve-injury reported by Mr. Paget,[4] in which actual
+neuralgia was present (though the kind of pain is not exactly
+specified), but also very nearly with the nutritive changes observed by
+Mr. Jonathan Hutchinson in a number of cases of surgical injuries of
+nerves.[5] The tendency of neuralgic pain accompanied by nutritive
+lesions of the skin and nails to seat itself in the hands and feet will
+be hereafter noted in connection with the subject of the pains of
+locomotor ataxy and of those produced by profound mercurial poisoning.
+And it will be seen in the section on Pathology, that very important
+conclusions are suggested by the coincidence.
+
+Joined with the burning pains, and the altered skin-nutrition, in the
+cases of gunshot injury of nerves which we are considering, there is
+nearly always a marked alteration in the temperature of the parts,
+either in one direction or the other. In the great majority of instances
+of ordinary neuralgia after wounds, this alteration is a very
+considerable reduction of the temperature of the parts supplied by the
+painful nerves; a change which corresponds with what appears in the vast
+majority of all cases of division of sensitive nerves, whether pain be
+set up or not. But, in all examples of the burning pain after injury,
+Messrs. Mitchell, Moorehouse, and Keen found the temperature of the
+painful parts notably elevated.
+
+It would appear that there is no form of neuralgia more dreadful, and
+scarcely any so hopeless, as this burning pain coming on as a sequel to
+severe nerve injuries. It exercises a profoundly depressing effect upon
+the whole nervous tone; the most robust men become timid and broken
+down, and their condition is compared by the American writers to that of
+hysterical women.
+
+There is another peculiar nutritive affection, first recognized as an
+occasional consequence of nerve injuries by Messrs. Mitchell,
+Moorehouse, and Keen, namely, an inflammation of joints, and, although
+we have no concern here with this symptom, it will be referred to
+hereafter as throwing interesting light on certain questions of
+pathology. Certain lesions of secretion will also be specially referred
+to under the heading of Diagnosis.
+
+II. NEURALGIAS OF INTRA-NERVOUS ORIGIN.--As regards the constitutional
+conditions with which the several varieties of neuralgia that arise
+independently of external violence, or disease of extra-nervous tissues,
+are respectively allied, the following preliminary subdivisions may be
+made:
+
+    1. Neuralgias of malarious origin.
+    2. Neuralgias of the period of bodily development.
+    3. Neuralgias of the middle period of life.
+    4. Neuralgias of the period of bodily decay.
+    5. Neuralgias associated with anaemia and mal-nutrition.
+
+1. _Neuralgias of malarious origin_ were formerly far more prevalent
+than they are at present, within the sphere of the English practitioner
+of medicine; with the general decline of malarial fevers, consequent on
+improved drainage and cultivation of lands, they have become constantly
+more scarce. The districts in which they still are found to prevail with
+any frequency are carefully specified in the interesting report of Dr.
+Whitley to the Medical Officer of the Privy Council, in the Blue-Book
+for 1863.
+
+Of course, however, there are a considerable number of persons
+continually returning to England from countries where malarious diseases
+are common; and these often bear about with them the effects of paludal
+poisoning which occasionally exhibits itself in the form of neuralgia.
+Till very lately, however, I had not happened to come across such cases,
+although at one time and another I have seen and treated a good many
+persons returned from India and Africa, whence I judge that neuralgia
+with this special history is less common than many seem to think. In
+former times, on the contrary, malarioid neuralgias were so common that
+they forced themselves on the notice of every practitioner. The term
+"brow-ague," to this day applied by many medical men to every variety of
+supra-orbital neuralgia, is a relic of the older experience on this
+point, as is also the very common mistake of expecting all neuralgic
+affections to present a distinctly rhythmic recurrence of symptoms.
+
+In the year 1864 I published the statement[6] that, "in a fair
+sprinkling" of the cases of neuralgia which present themselves in
+hospital out-patient rooms, ague-poisoning may be suspected; but I was
+then speaking rather from hearsay than from my own experience, which, in
+fact, had yielded no clear cases of this sort of neuralgia, and was till
+just recently unable to reckon up more than two undoubted and one
+doubtful case of the affection, in all of which the fifth cranial nerve
+was unattacked. The periodicity in one of the genuine cases was regular
+tertian, in the other regular quotidian. A semi-algide condition always
+ushered in the attacks; but this was gradually exchanged, as the pain
+continued, for a condition in which the pulse was rapid and locomotive,
+but compressible, and the strength was further depressed. In both these
+cases there was unilateral flushing of the face, and congestion of the
+conjunctiva, to a slight degree, during the attack of pain. The pain
+became duller and more diffused contemporaneously with the lowering of
+arterial pressure; and, after the disappearance of active pain, moderate
+tenderness over a considerable tract round the course of the painful
+nerves remain for some time. There was no distinct development of
+painful points in the situations described by Valleix; but it should be
+remarked that the cases were rapidly cured with quinine, which very
+probably accounts for this circumstance.
+
+Till lately I had not witnessed neuralgia as an after-consequence of
+tropical malaria-poisoning, although I have had many cases of other
+diseases, the relics of hot climates, under my care; but within the last
+year I have seen a case of extremely severe intercostal neuralgia of a
+perfectly periodic type occurring in a patient whose constitution had
+been thoroughly saturated with tropical marsh poison, and in whom the
+spleen was still much enlarged. The neuralgia was so terrible, and
+accompanied by such severe algide phenomena at the beginning of the
+attacks, and such a sense of throbbing as the pain developed, as to lead
+to serious suspicions of hepatic abscess, for the moment; but the course
+of events soon corrected this idea.
+
+2. _Neuralgias of the Period of Bodily Development._--By the "period of
+bodily development" is here understood the whole time from birth up to
+the twenty-fifth year, or there-abouts. This is the period during which
+the organs of vegetative and of the lower animal life are growing and
+consolidating. The central nervous system is more slow in reaching its
+fullest development, and the brain especially is many years later in
+acquiring its maximum of organic consistency and functional power.
+
+That portion of the period of development which precedes puberty is
+comparatively free from neuralgic affections. At any rate, it is rare to
+meet in young children with well-defined unilateral neuralgia, except
+from some very special cause, such as the pressure of tumors, etc. Such
+neuralgias as do occur are commonly bilateral, and are connected either
+with the fifth cranial or the occipital nerves.
+
+I must here mention an affection which was quite unknown to my
+experience, but was brought under my notice by the late Dr. Hillier, who
+kindly called my attention to the notes of two cases which were
+published in his interesting work on "Diseases of Children." The cases
+are those of two female children, aged nine and eleven respectively, in
+whom the principal symptom was violent and paroxysmal neuralgic
+headache. In both of these children the existence of cerebral tubercle
+was suspected, but this proved to be a mistake. In both there were
+intolerance of light, vomiting, tonic contraction of the muscles of the
+neck, and occasional double vision; but no impairment of intelligence,
+no amaurosis, and no paralysis or rigidity of the limbs. Each of these
+children died rather suddenly, after a violent paroxysm of pain. The
+main, indeed almost the only characteristic post-mortem change was a
+marked loss of consistence of tissue, in one case in the pons varolii,
+in the other in the pons, the medulla oblongata, and the cerebellum.
+These cases are of the highest possible interest, as are also several
+other instances of headache in children recorded by Dr. Hillier; notably
+one in which severe paroxysmal pains were attended with general
+impairment of brain-power, and, on the occurrence of death from
+exhaustion, the autopsy revealed an amount of degeneration in the
+cerebral arteries (as also in the general arterial system) which was
+astonishing, considering that the child was only ten and a half years
+old. This case, the full significance and interest of which will be
+better seen when we come to discuss the subject of pathology, is an
+example of physical changes in the nervous system, which are usually
+delayed to an advanced period of life, occurring altogether prematurely,
+and bringing with them a kind of neuralgic pain which is far more common
+in the decline than in morning of life. It will be seen presently that
+functional derangements may be in like manner precociously induced, with
+the parallel effect of inducing such pains as are ordinarily the product
+of a later epoch.
+
+From the moment that puberty arrives all is changed in the status of the
+nervous system. In the stir and tumult which pervade the organism, and
+especially in the enormous diversion of its nutritive and formative
+energy to the evolution of the generative organs and the correlative
+sexual instincts, the delicate apparatus of the nervous system is apt to
+be overwhelmed, or left behind, in the race of development. Under these
+circumstances, the tendency to neuralgic affections rapidly increases.
+It will, however, be seen later that there is a great preponderance of
+particular varieties of the disease during this time. This period is
+above all things fruitful in trigeminal neuralgias, especially migraine.
+
+There remains to be noticed the fact that sexual precocity sometimes
+very much anticipates the peculiar characteristics of the period after
+puberty. It is well known that in too many instances children are led,
+by the almost irresistible influence of bad example, to indulge in
+thoughts and practices which are thoroughly unchildish, and which
+exercise a powerfully disturbing influence upon the nervous system. A
+child before the age of puberty ought to be distinguished (if moderately
+healthy in other respects) by the absence of any tendency to dwell upon
+his own bodily health. Under the influence of precocious sexual
+irritation he becomes hypochondriacal and self-centred, and often
+suffers, not merely from fanciful fears and fanciful pains, but from
+actual neuralgia, which is sometimes severe. The attacks of migraine
+which are a frequent affection of delicate children whose puberty
+occurs at the normal time, are a much earlier torment with children who
+have early become addicted to bad practices. It is an anticipatory
+effect upon the constitution, strictly analogous to the production of
+the so-called "hysteria" in little girls under similar circumstances;
+and I suppose there is no physician who has not once or twice, at least,
+met with cases of the latter kind. The existence of any severe neuralgic
+affection in a young child, if it cannot be traced to tuburcle or other
+recognizable or organic brain-disease is _prima-facie_ ground for
+suspicion of precocious sexual irritation; though, as Dr. Hillier's
+cases show, it is occasionally produced otherwise. Usually, there are
+other features which assist in the discovery of precocious sexualism,
+when it exists; there is a morbid tendency to solitary moping, and a
+moral change in which untruthfulness is conspicuous.
+
+3. _Neuralgias of the Middle Period of Life._--By this period is meant
+the time included between the twenty-fifth and about the fortieth or
+forty-fifth year. It is the time of life during which the individual is
+subjected to the most serious pressure from external influences. The
+men, if poor, are engaged in the absorbing struggle for existence, and
+for the maintenance of their families; or, if rich and idle, are
+immersed in dissipation, or haunted by the mental disgust which is
+generated by _ennui_. The women are going through the exhausting process
+of child-bearing, and supporting the numerous cares of a poor household,
+in some cases; or are devoured with anxiety for a certain position in
+fashionable society for themselves and their children; or again, they
+are idle and heart-weary, or condemned to an unnatural celibacy. Very
+often they are both idle and anxious.
+
+It must not be supposed that there is a sharp line of demarcation
+between this period and the last; nevertheless, there are certain
+well-marked differences, both in their general tendencies, and as
+regards the local varieties which are commonest in each. We shall
+discuss the latter point farther on. At present, it is interesting to
+remark on the general freedom of the busy middle period of life from
+first attacks of neuralgia. A person who has had neuralgia previously
+may, and very likely will, during this epoch, be subject to recurrence
+of the old affection under stress of exhaustion of any kind. But it is
+very rare, in my experience, for busy house-mothers or fathers of
+families to get first attacks of neuralgia during this period of life.
+It is not the way in which a still vigorous man's nervous system breaks
+down, if it breaks down at all. Men frequently do break down, of course,
+at an age when their tissues generally are sound enough, and there is no
+reason, except on the side of their nervous system, why they should not
+remain in vigorous health for years. But it is greatly more common for
+the nervous collapse to take the form of insanity, or hypochondriasis,
+or paralysis, then that of neuralgia. If a man has escaped the latter
+disease during the period when the growth of his tissues was active, it
+is not very often that he falls a victim to it till he begins,
+physiologically speaking, to grow old.
+
+4. _Neuralgias of Declining Bodily Vigor._--The period here referred to
+is that which commences with the first indications of general physical
+decay, of which the earliest which we can recognize (in persons who are
+not cut off by special diseases) is perhaps the tendency to atheromatous
+change in the arteries. The first development of this change varies very
+considerably in date; but whenever it occurs it is a plain warning that
+a new set of vital conditions has arisen, and especially notable is its
+connection with the characters of the neuralgic affections which take
+their rise after its commencement. The period of declining life is
+pre-eminently the time for severe and intractable neuralgias.
+Comparatively few patients are ever permanently cured who are first
+attacked with neuralgia after they have entered upon what may be termed
+the "degenerative" period of existence. I mentioned the existence of
+commencing arterial degeneration as the special and most trustworthy
+sign of the initiation of bodily decay; but it is needless to say that
+this change is often not to be detected in its earliest stage. Something
+has been done of late years, however, to render its diagnosis more easy.
+Not to dwell upon the phenomenon of the arcus senilis, which though of a
+certain value is confessedly only very partially reliable, we may
+mention the sphygmographic character of the pulse as possessing a real
+value in deciding the physiological status of the arterial system. There
+is a well-known form of pulse-curve, square-headed, with marked
+lengthening of the first or systolic portion of the wave, and with an
+almost total absence of dicrotism, even when the circulation is rapid,
+which will often seem to assure us that atheromatous change of the
+arterial system has commenced, even when the physical characters of
+inelastic artery are not to be recognized with the finger in any of the
+superficial vessels by the touch of the finger. Indeed, the latter test
+is in all cases far less reliable than the sphygmographic trace, except
+when the arterial change has proceeded to a very marked degree of
+development.
+
+To a certain extent, the presence or absence of gray hair is of value in
+deciding whether physiological degeneration has begun. Like the arcus
+senilis, however, this is only reliable when joined with other
+indications, for it may be a purely local and separate change, having
+nothing to do with the general vital status of the body.
+
+5. _Neuralgias which are immediately excited by Anaemia or
+Mal-nutrition._--Of the neuralgic affections which can be reckoned in
+this class, the sole characteristic worthy of note is the circumstances
+in which they arise. It would seem that anaemia and mal-nutrition simply
+aggravate the tendency of existing weak portions of the nervous system
+to be affected with pain; just as they notoriously do aggravate lurking
+tendencies to convulsion and spasm. It is very common, for instance, for
+women to suffer severely from migraine, and other forms of neuralgia,
+after a confinement in which they have lost much blood. According to my
+own experience, however, those patients are generally, if not
+invariably, found to have previously suffered more or less severe
+neuralgic pain, at some time or other in their history, in the same
+nerves which now, under the depressing influence of haemorrhage, have
+become neuralgic. One of the very worst cases of clavus which I ever saw
+happened after haemorrhage in labor; the pain was so severe and
+prostrating that it appeared likely the patient would become insane. I
+discovered, on inquiry, that this woman had been liable for many years
+to headache affecting precisely the same region, on the occasion of any
+unusual fatigue or excitement.
+
+There is, however, one variety of neuralgia from mal-nutrition which
+deserves special consideration, viz., that which is occasionally
+produced as an after-effect of mercurial salivation. I have only seen
+one instance of this affection, but several are recorded. [Such, at
+least, is my impression, but I have not been able to find the reports of
+them.] My patient was a woman of somewhat advanced years when she first
+came under my notice, but her malady had (though with long
+intermissions) existed ever since she was a young girl in service. At
+that early date she was severely salivated by some energetic but
+misguided practitioner, for an affection which was called pleurisy, but
+(according to her description) might well have been only pleurodynia, to
+which servant girls are so very subject. At any rate, the consequences
+of the medication were most disastrous. Not only did she then and there
+lose every tooth in her head and suffer extensive exfoliations from the
+maxillae, but after this process was over she began to suffer frightfully
+from neuralgic pains in both arms and in both legs. Tonic medicines and
+a change to sea-air brought about a tardy and temporary cure; but from
+that moment her nervous system never recovered itself. Whenever she took
+cold, or was over-fatigued, or depressed from any bodily or mental
+cause, she was certain to experience a recurrence of the pains. At the
+time of her application to me she was suffering from an attack of more
+than ordinary severity, and which had lasted a long time without showing
+any signs of yielding. She apparently could not find words to express
+the acuteness of her sufferings. All along the course of the sciatic
+nerve in the thigh, all down the course of the middle cutaneous and long
+saphenous branches of the anterior crural, in the musculo-spiral,
+radial, and the course of the ulnar nerves, and also, in a more
+generalized way, in the gastrocnemii, in the soles of the feet, and in
+the palms of the hands, the pains were of a tearing character, which she
+described as resembling "iron teeth" tearing the flesh. The pains
+recurred many times daily; her life was a perfect burden to her, and
+always had been during these attacks. This patient was under my
+observation, on various occasions, during several years, and I
+established the fact that cod-liver oil always did very great good. But
+it was evident that nothing would remove the tendency to the recurrence
+of the pains. I should mention, as additional proof of the extent to
+which the mercurial poison had shattered the nervous system of this
+woman, that she had violent muscular tremors at the time of her first
+attack, and on several subsequent occasions. A more completely ruined
+life was never seen; the poor woman had been on the highway to promotion
+in the service of a nobleman when she was mercurialized, but her whole
+prospects were blighted by the serious danger to her health which was
+caused by the preposterous antiphlogisticism of her medical attendant.
+
+I do not know that the poisonous action of any other metallic poison
+than mercury has been distinctly shown to produce neuralgic pains of
+superficial nerves. The action of lead is well known to produce colic, a
+disease which will be specially dwelt on elsewhere. And undoubtedly a
+certain amount of aching pain sometimes attends certain stages of
+lead-palsy of the extensor muscles of the forearm. But I know of no
+facts pointing to a true saturnine neuralgia. And the chronic poisonous
+effects of arsenic on the nervous system seem to produce sensory
+paralysis, rather than pain.
+
+We come now to the consideration of the local varieties of neuralgia.
+The primary subdivision of them may be made as follows:
+
+I. Superficial Neuralgias. II. Visceral Neuralgias.
+
+I. SUPERFICIAL NEURALGIAS.
+
+Of superficial neuralgias a further classification may be made:
+
+    (_a_) Neuralgia of the fifth (trigeminal, or trifacial).
+    (_b_) Cervico-occipital neuralgia.
+    (_c_) Cervico-brachial neuralgia.
+    (_d_) Intercostal neuralgia.
+    (_e_) Lumbo-abdominal neuralgia.
+    (_f_) Crural neuralgia.
+    (_g_) Sciatic neuralgia.
+
+This arrangement is that of Valleix, and appears to me substantially
+correct.
+
+(_a_) _Neuralgia of the Fifth._--The most important group of neuralgias
+are those of the fifth cranial nerve.
+
+Neuralgia of the fifth nerve always exhibits itself in the especial
+violence in certain foci, which Valleix was the first to define with
+accuracy. These foci are always in points where the nerve becomes more
+superficial, either in turning out of a bony canal, or in penetrating
+fasciae. In the ophthalmic division of the nerve the following possible
+foci are noticeable: (1) The supra-orbital, at the notch of that name,
+or a little higher, in the course of the frontal nerve; (2) the
+palpebral, in the upper eyelid; (3) the nasal, at the point of emergence
+of the long nasal branch, at the junction of the nasal bone with the
+cartilage; (4) the ocular, a somewhat indefinite focus within the globe
+of the eye; (5) the trochlear, at the inner angle of the orbit.
+
+In the superior maxillary division the following foci may be found: (1)
+The infra-orbital, corresponding to the emergence of the nerve of that
+name from its bony canal; (2) the malar, on the most prominent portion
+of the malar bone; (3) a vague and indeterminate focus, somewhere on the
+line of the gums of the upper jaw; (4) the superior labial, a vague and
+not often important focus; (5) the palatine point, rarely observed, but
+occasionally the seat of intolerable pain.
+
+In the inferior maxillary division the foci are: (1) The temporal, a
+point on the auriculo-temporal branch, a little in front of the ear; (2)
+the inferior dental point, opposite the emergence of the nerve of that
+name; (3) the lingual point, not a common one, on the side of the
+tongue; (4) the inferior labial point, only rarely met with.
+
+Besides these foci in relation with distinct branches of the trigeminus,
+there is one of especial frequency which corresponds to the inosculation
+of various branches. This is the parietal point, situated a little above
+the parietal eminence. It is small in size--the point of the little
+finger would cover it. It is the commonest focus of all.
+
+Neuralgia may attack any one, or all, of the three divisions of the
+nerve; the latter event is comparatively rare. Valleix, indeed, holds a
+different opinion; but this seems to me to arise from the fact that his
+definition of neuralgia was too narrow to include a large number of the
+milder cases of neuralgia, which are, nevertheless I believe, decidedly
+of the same essential character with the severer affections. The most
+frequent occurrence is the limitation of the pain to the ophthalmic
+division, and incomparably the most frequent foci of pain are the
+supra-orbital and the parietal.
+
+The most common variety of trigeminal neuralgia is migraine, or
+sick-headache, as it is often called. This is an affection which is
+entirely independent of digestive disturbances, in its primary origin,
+though it may be aggravated by their occurrence. It almost always first
+attacks individuals at some time during the period of bodily
+development. Under the influences proper to this vital epoch, and often
+of a further debility produced by a premature straining of the mental
+powers, the patient begins to suffer headache after any unusual fatigue
+or excitement, sometimes without any distinct cause of this kind. The
+unilateral character of this pain is not always detected at first; but,
+as the attacks increase in frequency and severity, it becomes obvious
+that the pain is limited to the supra-orbital and its twigs, with
+sometimes also the ocular branches. In rare cases, as in all forms of
+neuralgia, the nerves of both sides may be affected; I have already
+observed that this seems to be relatively more common in young children.
+If the pain lasts for any considerable length of time, nausea, and at
+length vomiting, are induced. This is followed at the moment by an
+increase in the severity of the pain, apparently from the shock of the
+mechanical effect; but from this point the violence of the affection
+begins to subside, and the patient usually falls asleep. The history of
+the attacks negatives the idea that the vomiting is ordinarily remedial.
+This symptom merely indicates the lowest point of nervous depression;
+but it may happen that a quantity of food which has been injudiciously
+taken, lying as it does undigested in the stomach, may of itself greatly
+aggravate the neuralgia, by irritation transmitted to the medulla
+oblongata. In such a case vomiting may directly relieve the nerve-pain.
+When the patient awakes from sleep, the active pain is gone. But it is a
+common occurrence--indeed it always happens when the neuralgia has
+lasted a long time--that a tender condition of the superficial parts
+remains for some hours, perhaps for a day or two. This tenderness is
+usually somewhat diffused, and not limited with accuracy to the foci of
+greatest pain during the attacks.
+
+Sick headache is not uncommonly ushered in by sighings, yawning, and
+shuddering--symptoms which remind us of the prodromata of certain graver
+neuroses, to which, as we shall hereafter see, it is probably related by
+hereditary descent. In its severer forms, migraine is a terrible
+infliction; the pain gradually spreads to every twig of the ophthalmic
+division; the eye of the affected side is deeply bloodshot, and streams
+with tears; the eyelid droops, or jerks convulsively; the sight is
+clouded, or even fails almost altogether for the time, and the darts of
+agony which shoot up to the vertex seem as if the head were being split
+down with an axe. The patient cannot bear the least glimmer of light,
+nor the least motion, but lies quite helpless, intensely chilly and
+depressed, the pulse at first slow, small and wiry, afterward more rapid
+and larger, but very compressible. The feet are generally actually, as
+well as subjectively, cold. Very often, toward the end of the attack,
+there is a large excretion of pale, limpid urine.
+
+Another variety of trigeminal neuralgia which infests the period of
+bodily development is that known as clavus hystericus: clavus, from the
+fact that the pain is at once severe, and limited to one or two small
+definite points, as if a nail or nails were being driven into the skull.
+These points correspond either to the supra-orbital or the parietal, or,
+as often happens, to both at once. But for the greater limitation of the
+area of pain in clavus, that affection would have little to distinguish
+it from migraine, for the former is also accompanied with nausea and
+vomiting when the pain continues long enough; and in both instances it
+is obvious that there is a reflex irritation propagated from the painful
+nerve. The adjective hystericus is an improper and inadequate definition
+of the circumstances under which clavus arises. The truth is, that the
+subjects of it are chiefly females who are passing through the trying
+period of bodily development; but there is no evidence to show that
+uterine disorders give any special bias toward this complaint. Both
+migraine and clavus are often met with in persons who have long passed
+their youth; but their first attacks have nearly always occurred during
+the period of development.
+
+One circumstance in connection with well-marked clavus appears worth
+noting, as somewhat differentiating it from migraine. It is, I think,
+decidedly more frequently the immediate consequence of anaemia than they;
+but it does not appear, from my experience, that the chlorotic form of
+anaemia is any more provocative of it than is anaemia from any other
+cause. Some of the worst cases of clavus, probably, that have ever been
+seen were developed in the old days of phlebotomy. It was then very
+common for a delicate girl, on complaint of some stitch of neuralgia or
+muscular pain in the side, to be immediately bled to a large extent,
+with the idea of checking an imaginary commencing pleurisy. The
+treatment, so far from curing the pain and the dyspepsia (which it
+produced), often aggravated them; whereupon the signs of inflammation
+were thought to be still more manifest, and more blood was taken. Under
+such circumstances the most complete anaemia was developed, and very
+often the patient became a martyr to clavus in its severest forms. One
+does not now very frequently meet with the victims of such mistaken
+practice; but I have seen one [since writing this I have seen another
+case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus
+produced by loss of blood (in a subject who was doubtless predisposed to
+neuralgic affections, to judge from his family history). The case was
+that of a boy who accidentally divided his radial.
+
+The middle period of life is not, according to my experience, fruitful
+in first attacks of trigeminal neuralgia. But, when the neuralgic
+tendency has once declared itself, there are many circumstances of
+middle adult life which tend to recall it. Over-exertion of the mind is
+one of the most frequent causes, especially when this is accompanied by
+anxiety and worry; indeed, the latter has a worse influence than the
+former. In women, the exhaustion of haemorrhageal parturition, or of
+menorrhagia, and also the depression produced by over-suckling, are
+frequent causes of the recurrence of a migraine or clavus to which the
+patient had been subject when young. The middle period of life is very
+obnoxious to severe mental shocks, which are more injurious than in
+youth, because of the diminished elasticity of mind which now exists;
+and the same may be said of the influence of severe bodily accident of a
+kind to inflict damage on the central nervous system. Special mention
+ought to be made, in the case of women, of the disturbing influence of
+the series of changes which close the middle portion of their life,
+viz., the involution of the sexual organs. It would seem as if every
+evil impression which has ever been made on the nervous system hastens
+to revive, with all its disastrous effects, at this crisis. Latent
+tendencies to facial neuralgia are particularly apt to reassert their
+existence, and they are usually accompanied and aggravated by a tendency
+to vaso-motor disturbance, which not unfrequently seems to be the most
+distressing part of the malady. I have several times been consulted by
+women undergoing the "change," whose chief complaint was of disagreeable
+flushings and chills, especially of the face; and, on inquiring further,
+one has found that they were suffering from severe facial neuralgia,
+which, however, alarmed and distressed them less than did the vaso-motor
+disturbance, and the giddiness, etc., which were an evident consequence
+of it.
+
+It is, however, the final or degenerative period of life which produces
+the most formidable varieties of facial neuralgia. Neuralgia of the
+fifth, which have previously attacked an individual, may recur at this
+time of life without any special character, except a certain increase of
+severity and obstinacy. But trigeminal neuralgias, which now appear for
+the first time, are usually intensely severe, and nearly or quite
+incurable. These cases correspond with the affection named by Trousseau
+tic epileptiforme, and it is of them, doubtless, that Romberg is
+speaking, when he says that the true neuralgias of the fifth rarely
+occur before the fortieth year of life. These neuralgias are
+distinguished by the intense severity of the pain, the lightning-like
+suddenness of its onset, and the almost total impossibility of effecting
+more than a temporary palliation of the symptoms. But they are also
+distinguished by another circumstance which too often escapes attention,
+namely, they are almost invariably connected with a strong family taint
+of insanity, and very often with strong melancholy and suicidal
+tendencies in the patient himself, which do not depend on, and are not
+commensurate with, the severity of the pain which he suffers. It may
+seem a strong view to take, but I must say that I regard a
+well-developed and typical neuralgia, of the type we are now speaking
+of, as an affection in which the mental centres are almost as deeply
+involved as in the fifth nerve itself; though, whether this is an
+original part of the disease, or a mere reflex effect of the affection
+of the trigeminal nerve, I am not prepared to say. Other reflex
+affections are common enough in this kind of facial neuralgia, and
+especially spasmodic contractions of the facial muscles, which, indeed,
+often form one of the most striking features of the malady, the attacks
+of pain being accompanied by hideous involuntary grimaces. Even in the
+earlier stages of the disease there is usually some degree of the same
+thing, as, for instance, spasmodic winking. In the great majority of
+cases, after a little time, exquisitely tender points are formed in the
+chief foci of pain; in the intervals between the spasms the least
+pressure on these points is sufficient to cause agony, and a mere breath
+of wind impinging on them will often reproduce the spasm. Yet, in the
+height of the acute paroxysm itself, the patient will often frantically
+rub these very parts in the vain attempt to produce ease; and it has
+often been noticed that such friction has completely rubbed off the hair
+or whisker on the affected side: this happens the more easily, because
+the neuralgic affection itself impairs the nutrition of the hair and
+makes it more brittle, as we shall have occasion to show more fully
+hereafter. The general appearance of a confirmed neuralgic of the type
+now described is very distressing, and the history of his case fully
+corresponds to it. He is moody and depressed, he dreads the least
+movement, and the least current of air; he hardly dares masticate food
+at all, more especially if the inferior maxillary division of the nerve
+be implicated (as is generally the case sooner or later), for this
+movement re-excites the pain with great violence. Nutrition is very
+commonly kept up by slops, and is thus very insufficiently maintained:
+this failure of nutrition is itself a decidedly powerful influence in
+aggravating the disease. And there is a still further calamity which is
+not unlikely to occur. The patient may fly to the stupefaction of drink
+as a relief to his sufferings, and, if he has once experienced the
+temporary comfort of drunken anaesthesia, is excessively likely to repeat
+the experiment. But this is another and one of the most fatally certain
+methods of hastening degeneration of nerve-centres, and the ultimate
+effect, therefore, is disastrous in every way.
+
+Although the neuralgias of the degenerative period are thus fatally
+progressive, on the whole, there are some curious occasional anomalies.
+Many cases are recorded, and I have myself seen such, in which the
+attacks of pain, after reaching a very considerable degree of intensity,
+have ceased for many months, whether under the influence of remedies or
+not it is difficult to say with certainty, but probably far more from
+independent causes. Whatever may be the reason of these sudden arrests,
+however, certain it is that they are very seldom permanent, the pain
+returning sooner or later, like an inexorable fate.
+
+(_b_) _Cervico-occipital Neuralgia._--As Valleix has remarked, there are
+several nerves (in fact, the posterior branches of all the first four
+spinal pairs) which are more or less frequently the seat of this
+affection. But among them all there is none comparable to the great
+occipital, which arises from the second spinal pair, for the frequency
+and importance of its neuralgic affections. This nerve sends branches to
+the whole occipital and the posterior parietal region. On the other
+hand, the second and third spinal nerves help to make up the superficial
+cervical branch of the cervical plexus which is distributed to the
+triangle between the jaw, the median line of the neck, and the edge of
+the sterno-mastoid, and those to the lower part of the cheek. Then there
+is the auricular branch, which starts from the same two pairs, and
+supplies the face, the parotid region, and the back of the external ear.
+Then the small occipital, distributed to the ear and to the occiput.
+And, finally, superficial descending branches of the plexus. These,
+altogether, are the nerves which at various points, where they become
+more superficial, form the foci of cervico-occipital neuralgia.
+
+The most typical example of this form of neuralgia which has fallen
+under my notice occurred (after exposure to cold wind) in a lady about
+sixty years of age, who had all her life been subject to neuralgic
+headache approaching the type of migraine, and who came of a family in
+which insanity, apoplexy, and other grave neuroses, had been frequent.
+The pain centred very decidedly in a focus corresponding to the
+occipital triangle of the neck; it recurred at irregular intervals, and
+in very severe paroxysms, lasting about a minute. It was interesting to
+follow the history of this case in one respect. It afforded a clear
+illustration of the manner in which local tenderness is developed; for
+during the first three or four days the patient, so far from complaining
+that the painful part was tender on pressure, experienced decided relief
+from pressure, although she experienced none from mere rest, however
+carefully the neck might be supported. But in the course of a few days
+an intensely painful spot developed itself in the occipital triangle,
+and the back of the ear became excessively tender. All manner of
+remedies had been tried in this case, without the slightest success and
+especially there was a large amount of speculative medication, on the
+theory of the probably "rheumatic" or "gouty" nature of the affection.
+Nothing was doing the least good to the pain, and meantime the old
+lady's digestion and general health and spirits were suffering very
+severely. Blistering was now suggested, and the affection yielded at
+once. The relief afforded must have been very complete, to judge by the
+warm gratitude which the patient expressed. The subsequent history of
+this patient illustrates several points which will engage our attention
+under the section of Pathology. It may be just mentioned here, that she
+suffered, twelve months later, from a hemiplegic attack of paralysis.
+
+The tendency of cervico-occipital neuralgias is to spread toward the
+lower portions of the face, as observed by Valleix; in this case they
+become, sometimes, undistinguishable from neuralgias of the third
+division of the trigeminus. In the early stages of the disease, if the
+physician had been lucky enough to witness them, the true place of the
+origin of the pain would have been easily recognizable; at a later date
+it sometimes needs great care, and a very strict interrogation of the
+patient, to discover the true history of the disease. Sometimes, even, a
+cervico-occipital neuralgia which spreads in this way causes great
+irritation and swelling of the submaxillary and cervical glands; and I
+have known a case of this kind mistaken for commencing glandular
+abscess. The pain and tension were so great in this case, and the
+constitutional disturbance was so considerable, that the presence of
+deep-seated pus was strongly suspected, and the propriety of an incision
+(which would have been a hazardous proceeding) was seriously canvassed.
+
+Experience is too limited, to judge by what I have personally seen, and
+the recorded cases with which I am acquainted, to enable us to say
+anything with confidence of the conditions, as to age and general
+nutrition of the body, which specially favor the occurrence of
+cervico-occipital neuralgia. Apparently, however, there is much reason
+for thinking that the immediately exciting cause of it is most
+frequently external cold. I have known it produced several times in the
+same person, by sitting in a draught which blew strongly on the back of
+the neck. And I am inclined to think that it is seldom the first form of
+neuralgia which attacks a patient, but usually occurs in those who have
+previously suffered from neuralgic pains either of the trigeminus or of
+some other superficial nerve. I have known it once to occur in a person,
+thus predisposed to neuralgic affections, in consequence of reflex
+irritation from a carious tooth, as was proved by its cessation on the
+extraction of the latter, although there was no facial pain.
+
+(_c_) _Cervico-brachial Neuralgia._--This group includes all the
+neuralgias which occur in nerves originating from the brachial plexus,
+or from the posterior branches of the four lower cervical nerves. The
+most important characteristic of the neuralgias of the upper extremity
+is the frequency, indeed almost constancy, with which they invade,
+simultaneously or successively, several of the nerves which are derived
+from the lower cervical pairs. The neuralgic affections of the small
+posterior branches (distributed to the skin of the lower and back part
+of the neck) are comparatively of small importance. But the
+"solidarite," which Valleix so well remarked, between the various
+branches of the brachial plexus, causes the neuralgias of the shoulder,
+arm, forearm, and hand to be extremely troublesome and severe, owing to
+the numerous foci of pain which usually exist. Perhaps Valleix's
+description of these foci is somewhat over-fanciful and minute; but the
+following among them which he mentions I have repeatedly identified; (1)
+An axillary point, corresponding to the brachial plexus itself; (2) a
+scapular point, corresponding to the angle of the scapula. (It is
+difficult to identify the peccant nerve here; the one to which it
+apparently corresponds, and to which Valleix refers it, is the
+subscapular; but we are accustomed to think of this as a motor nerve.
+Still, it is certain that pressure on a painful point existing here will
+often cause acute pain in the nerves of the arm and forearm.); (3) A
+shoulder point, which corresponds to the emergence, through the deltoid
+muscle, of the cutaneous filets of the circumflex; (4) a median-cephalic
+point, at the bend of the elbow, where a branch of the musculo-cutaneous
+nerve lies immediately behind the median-cephalic vein; (5) an external
+humeral point, about three inches above the elbow, on the outer side,
+corresponding to the emergence of the cutaneous branches which the
+musculo-spiral nerve gives off as it lies in the groove of the humerus;
+(6) a superior ulnar point, corresponding to the course of the ulnar
+nerve between the olecranon and the epitrochlea; (7) an inferior ulnar
+point, where the ulnar nerve passes in front of the annular ligament of
+the wrist; (8) a radial point, marking the place where the radial nerve
+becomes superficial, at the lower and external aspect of the forearm.
+Besides these foci, there are sometimes, but more rarely, painful points
+developed by the side of the lower cervical vertebrae, corresponding to
+the posterior branches of the lower cervical pairs.
+
+The most common seat of cervico-brachial neuralgia has been, in my
+experience, the ulnar nerve, the superior and inferior points above
+mentioned being the foci of greatest intensity; an axillary point has
+also been developed in one or two cases which I have seen. Rarely,
+however, does the neuralgia remain limited to the ulnar nerve; in the
+majority of cases it soon spreads to other nerves which emanate from the
+brachial plexus. A very common seat of neuralgia is also the shoulder,
+the affected nerves being the cutaneous branches of the circumflex. I am
+inclined to think, also, that affections of the musculo-spiral, and of
+the radial near the wrist, are rather common, and have found them very
+obstinate and difficult to deal with. One case has recently been under
+my care in which the foci of greatest intensity of the pain were an
+external humeral and a radial point; but besides these there was an
+exquisitely painful scapular point. In another case the pain commenced
+in an external humeral and a radial point, but subsequently the shoulder
+branches of the circumflex became involved. A most plentiful crop of
+herpes was an intercurrent phenomenon in this case, or rather, was
+plainly dependent on the same cause which produced the neuralgia.
+
+Median cephalic neuralgia is an affection which used to be comparatively
+common in the days when phlebotomy was in fashion, the nerves being
+occasionally wounded in the operation. I have only seen it in connection
+with this cause, that is to say, as an independent affection. One such
+case has been under my care. But a slight degree of it is not uncommon,
+as a secondary symptom, in neuralgia affecting other nerves. The
+traumatic form is excessively obstinate and intractable.
+
+In the neuralgias of the arm we begin to recognize the etiological
+characteristic which distinguishes most of the neuralgic affections of
+the limbs, namely, the frequency with which they are aggravated, and
+especially with which they are kept up and revived when apparently dying
+out, the muscular movements. In the case above referred to, of neuralgia
+of the subscapular, musculo-spiral (cutaneous branches), and radial, the
+act of playing on the piano for half an hour immediately revived the
+pains, in their fullest force, when convalescence had apparently been
+almost established.
+
+There is a special cause of cervico-brachial neuralgias which is of more
+importance than, till quite lately, has ever been recognized, namely,
+reflex irritation from diseased teeth. The subject of these reflex
+affections from carious teeth has been specially brought forward by Mr.
+James Salter, in a very able and interesting paper in the "Guy's
+Hospital Reports" for 1867; and Mr. Salter informs me that he has been
+surprised by the number of cases of reflex affections, both paralytic
+and neuralgic, of the cervico-brachial nerves, produced by this kind of
+irritation, and that he agrees with me in thinking that a peculiar
+organization or disposition of the spinal centres of these nerves must
+be assumed in order to account for the fact.
+
+The liability of particular nerves in the upper extremity to neuralgia
+from external injuries requires a few words. The nerve which is probably
+most exposed to this is the ulnar. Blows on what is vulgarly called the
+funny-bone are not uncommon exciting causes of neuralgia in predisposed
+persons, and cutting wounds of the ulnar a little above the wrist are
+rather frequent causes. The deltoid branches of the circumflex and the
+humeral cutaneous branches of the musculo-spiral are much exposed to
+bruises and to cutting wounds. So far as I know, it is only when a nerve
+trunk of some size has been wounded that neuralgia is a probable result.
+Wounds of the small nervous branches in the fingers, for instance, are
+very seldom followed by neuralgia. I have no statistics to guide me as
+to the effect of long-continued irritation applied to one of these small
+peripheral branches, but it is probable that that might be more capable
+of inducing neuralgia. As far as my own experience goes, however, it
+would appear that a more common result is convulsion of some kind, from
+reflex irritation of the cord.
+
+(_d_) _Dorso-intercostal Neuralgia._--This is one of the commonest
+varieties of neuralgia, and yet it is very likely to be confounded with
+other affections not neuralgic in their nature. The disorder with which
+it is especially liable to be confounded is myalgia, which will be fully
+described in another chapter, and which, when developed in the region of
+the body to which we are now referring, is commonly spoken of as
+pleurodynia, or lumbago (according as it affects the muscles of the back
+or of the side), or muscular rheumatism. It must be owned that the
+severer forms of this affection can scarcely be distinguished from true
+intercostal neuralgia by anything in the character or situation of the
+pains. It will be seen, hereafter, however, that myalgia has its own
+specific history, which is very characteristic; at present, it is
+sufficient to remember that it is often extremely like neuralgia when
+situated in the dorso-intercostal region.
+
+Dorso-intercostal neuralgia is an affection of certain of the dorsal
+nerves. These nerves divide, immediately after their emergence from the
+intervertebral foramina, into an interior and a posterior branch. The
+latter sends filaments which pierce the muscles to be distributed to the
+skin of the back; the former, which are the intercostal nerves, follow
+the intercostal spaces. Immediately after their commencement they
+communicate with the corresponding ganglia of the sympathetic.
+Proceeding outward, they at first lie between two layers of intercostal
+muscles, and, after giving off branches to the latter, give off their
+large superficial branch. In the case of the seventh, eighth and ninth
+intercostal nerves, which are those most liable to intercostal
+neuralgia, the superficial branch is given off about midway between the
+spine and the sternum. The final point of division, at which superficial
+filets come off, in all the eight lower intercostal nerves, is nearer to
+the sternum; and is progressively nearer to the latter in each
+successive space downward. There are thus, as Valleix observes, three
+points of division: (1) At the intervertebral foramen; (2) midway in the
+intercostal space; (3) near to the sternum. And there are three sets of
+branches (reckoning the posterior division) which respectively make
+their way to the surface near to these points.
+
+In one of its forms, intercostal neuralgia is one of the commonest of
+all neuralgic affections. I refer to the pain beneath the left mamma,
+which women with neuralgic tendencies so often experience, chiefly in
+consequence of over-suckling, but also from exhaustion caused by
+menorrhagia or leucorrhoea, and especially from the concurrence of one
+of the latter affections with excessive lactation. It is especially
+necessary, however, to guard against mistaking for this affection a mere
+myalgic state of the intercostal or pectoral muscles, which often
+arises in similar circumstances with the addition of excessive or too
+long continued exertions of these muscles. "Hysteric" tenderness also
+sometimes bears a considerable resemblance, superficially, to true
+intercostal neuralgia, in cases where the genuine disease does not
+exist.
+
+A less common but very remarkable variety of intercostal neuralgia than
+that just mentioned, is the kind of pain which attends a good many cases
+of herpes zoster, or shingles. It is only of recent years that any
+essential connection between zoster and neuralgia has been suspected.
+The occurrence of neuralgia as a sequel to zoster had indeed been
+mentioned by Rayer, Recamier, and Piorry, but the essential nature of
+the connection between the two diseases was evidently not suspected by
+Lecadre, when, as late as 1855, he published his valuable essay on
+intercostal neuralgia. M. Notta was one of the first to present
+connected observations on the subject. But it was much more fully
+discussed in a paper published by M. Barensprung, in 1861. [_Ann. der
+Charite-Krakenhauser zer Berlin, ix._, 2, p. 40. _Brit. and For. Med.
+Rev._, January, 1862.] This author showed the absolute universality with
+which unilateral herpes, wherever developed, closely followed the course
+of some superficial sensory nerve, and gave reasons, which will be
+discussed hereafter, for supposing that the disease originates in the
+ganglia of the posterior roots, and that the irritation spreads thence
+to the posterior roots in the cord, causing reflex neuralgia. We shall
+have more to say on this matter. Meantime, it seems to be established,
+by multiplied researches, that, though unilateral herpes may and often
+does occur without neuralgia, and neuralgia without herpes, the
+concurrence of the two is due to a mere extension of the original
+disease, which is a nervous one.
+
+In young persons, zoster is not attended with severe neuralgia, but a
+curious half-paretic condition of the skin, in which numbness is mixed
+with formication, or with a sensation as of boiling water under the
+skin, precedes the outbreak of the eruption by some hours, or by a day
+or two. Painless herpes is commonest in youth. I remember, for instance,
+that, in an attack of shingles which I suffered about the age of eleven,
+there was at no stage any acute pain; only, in the pre-eruptive period,
+for a short time, I had the curious sensations referred to above: and
+the same thing has occurred in all the patients below puberty that I
+have seen, if they complained at all. From the age of puberty to the end
+of life, the tendency of herpes to be complicated with neuralgia becomes
+progressively stronger. The course of events varies much in different
+cases, however. In adult and later life the symptoms usually commence
+with a more or less violent attack of neuralgic pain, which is
+succeeded, and generally, though not always, displaced by the herpetic
+eruption. The latter runs its course, and after its disappearance the
+neuralgia may return, or not. In old people it almost always does
+return, and often with distressing severity and pertinacity. Six weeks
+or two months is a very common period for it to last, and in some aged
+persons it has been known to fix itself permanently, and cease only with
+life. In these subjects a further complication sometimes occurs. The
+herpetic vesicles leave obstinate and painful ulcers behind them, which
+refuse to heal, and which worry the patient frightfully, the merest
+breath of air upon them sufficing to produce agonizing darts of
+neuralgic pain. I have known one patient, a woman over seventy years of
+age, absolutely killed by the exhaustion produced by protracted
+suffering of this kind.
+
+The foci of pain in intercostal neuralgia are always found in one or
+more of the points, already enumerated, at which sensory nerves become
+superficial. In long-standing cases acutely tender points are developed
+in one or more of these situations; not unfrequently the most decided of
+these spots is where it gets overlooked, namely, opposite the
+intervertebral foramen. H. G., a young woman aged twenty-six, who
+applied to me at Westminster Hospital, had suffered for twelve months
+from an irregularly intermitting but very severe neuralgia at the level
+of the seventh intercostal space of the left side. The violence of the
+pain was sometimes excessive, and when the paroxysm lasted longer than
+usual it generally produced faintness and vomiting. This patient had no
+sign of tenderness anywhere in the anterior or lateral regions, though
+the pain seemed to gird round the left half of the chest as with an iron
+chain, but an exquisitely tender spot, as large as a shilling, was found
+close to the spine; pressure on this always induced a strong feeling of
+nausea.
+
+As an illustration of the herpetic variety of dorso-intercostal
+neuralgia, running a severe but not protracted course, I may relate the
+case of a medical man whom I formerly attended. This gentleman was about
+thirty-two years of age, and a highly neurotic subject: inter alia, he
+had already suffered from a severe and protracted sciatica; and, very
+shortly before the herpetic attack, had been jaundiced from purely
+nervous causes. His nervous maladies were undoubtedly caused by
+over-brain-work. In this case the neuralgia developed itself during the
+latter half of the eruptive period, which was rather unusually
+lengthened. It occupied the seventh, eighth, and ninth intercostal
+spaces of the side affected with herpes, and was very violent and acute,
+so that the patient expressed himself as almost "cut in two" with it.
+The pain ceased even before the vesicles had perfectly healed; a rather
+unusual occurrence in my experience. I shall refer to this case
+hereafter, as an example of what I believe to be the effect of a
+particular method of treatment in lessening the tendency to
+after-neuralgia. The result of my experience is certainly this--that if
+a case of herpes in an adult, or still more in an aged person, be left
+to itself, the amount of after-neuralgia will very closely correspond
+with the severity of the eruptive symptoms.
+
+There is a variety of intercostal neuralgia which is of more importance
+than the commoner kinds. Occurring mostly in persons who have passed the
+middle age, it possesses the characters of obstinacy and severity which
+belong to the neuralgias of the period of bodily decay. It is at first
+unattended with any special cardiac disturbance. By-and-by, however, it
+begins to attract more careful attention from the fact that the severer
+paroxysms extend into the nerves of the brachial plexus of the affected
+side, so that pain is felt down the arm. In the midst of a paroxysm of
+intercostal and brachial pain, it may happen that the patient is
+suddenly seized with an inexpressible and deadly feeling of cardiac
+oppression, and, in fact, the symptoms of angina pectoris, such as they
+will be described in a future chapter, become developed. A case of this
+kind is at present under my care at the Westminster Hospital. The
+patient is a man only fifty-six years of age, but whose extreme
+intemperance has produced an amount of general degeneration of his
+tissues such as is rarely seen except in the very aged; he has the most
+rigid radial arteries, and the largest arcus senilis, I think, that I
+ever saw. This man has long been subject to attacks of violent
+intercostal neuralgia, and a recent access assumed the type of
+unmistakable angina. It is very probable that his coronary arteries have
+now become involved in the degenerative process. In this case, before
+the development of any marked anginal symptoms, the paroxysmal pain,
+from being merely intercostal, had come to extend itself into the left
+shoulder and arm.
+
+Intercostal neuralgia not unfrequently accompanies, and is sometimes a
+valuable indication of, phthisis. I do not mean to say that the vague
+pains in the chest-walls, which are so very common in phthisis, are to
+be indiscriminately accounted neuralgia; on the contrary, they are, in
+the large majority of instances, merely myalgic, and arise from the
+participation of the pectorals, or intercostals, or both, in the
+mal-nutrition which prevails in the organism generally. But it happens,
+sometimes that a distinctly intermitting neuralgia occurs as an early
+symptom of phthisis; in fact, where there is a predisposition to
+neurotic affections, I believe that this is not very uncommon. The
+subjects are generally women; they are mostly of that class of
+phthisical patients who have a quick intelligence, fine soft hair, and a
+sanguine temperament. I have had one male patient under my care: this
+was a young gentleman aged eighteen, in whom a neuralgic access came on
+with so much severity, and caused so much constitutional disturbance,
+that the idea of pleurisy was strongly suggested. The paroxysms returned
+at irregular intervals for a considerable period: they were quite
+unlike myalgic pains, not only in their character, but more especially
+with respect to the circumstances which were found to provoke their
+recurrence. They were the first symptoms which lead to any careful
+examination of the chest; it was then found that there were prolonged
+expiration and slight dulness, at one apex. At this period, wasting had
+not seriously commenced; but, on the other hand, there was an
+extraordinary degree of debility for so early a stage of phthisis. I am
+inclined to think that self-abuse was the principal cause both of the
+phthisis and the neuralgia, acting doubtless on a predisposed organism,
+for his family was rather specially beset with tendencies to
+consumption. I may add here, that it has appeared to me that young
+persons with phthisical tendencies are specially liable to neuralgic
+affections as a consequence of self-abuse.
+
+A special variety of intercostal neuralgia is that which attacks the
+female breast. The nerves of the mammae are the anterior and middle
+cutaneous branches of the intercostals; and they are not unfrequently
+affected with neuralgia, which is sometimes very severe and intractable.
+Dr. Inman has very properly pointed out that a large number of the cases
+of so-called "hysterical breast" are really myalgic, and are directly
+traceable to the specific causes of myalgia; but there is no question in
+my mind that true neuralgia of the breast does occur, and indeed is
+frequent, relatively to the frequency of neuralgias generally. There are
+several kinds of circumstances under which it is apt to occur. In
+highly-neurotic patients it may come on with the first development of
+the breasts at puberty; and it may be added that this is especially apt
+to occur where puberty has been previously induced by the unfortunate
+and mischievous influences to which we had occasion to refer in speaking
+of certain other neuralgiae. A neuralgia of the left breast occurred in a
+patient of mine, who attended the Westminster Hospital. She was only
+twelve years of age, and small of stature, but the mammae were
+considerably developed. The face was haggard, there was an almost
+choreic fidgetiness about the child, and a very unprepossessing
+expression of countenance; the result of inquiries left no doubt that
+the patient was much addicted to self-abuse; and it seemed probable that
+to this was due the fact that menstruation had come on, and was actually
+menorrhagic in amount.
+
+A very painful kind of mammary neuralgia is experienced by some women
+during pregnancy; but more commonly the mammary pains felt at this
+period are mere throbbings, not markedly intermittent in character, and
+plainly dependent on mechanical distention of the breast: such
+affections are not to be reckoned among true neuralgiae. A true neuralgia
+of a very severe character is sometimes provoked by the irritation of
+cracked nipples. I have seen a delicate lady, of highly-neurotic
+temperament, and liable to facial neuralgia, most violently affected in
+this way. Vain attempts had been made for several consecutive days to
+suckle the infant from the chapped breast; when suddenly the most severe
+dorso-intercostal neuralgia set in. The attacks lasted only a few
+seconds each, but they recurred almost regularly every hour, and were
+attended with intense prostration, and sometimes with vomiting.
+Discontinuance of suckling was found necessary, for even the application
+of the child to the sound breast now sufficed to arouse a paroxysm of
+pain. Complete rest, protection of the breast from air and friction, and
+the hypodermic injection of morphia, rapidly relieved the sufferer.
+
+(_e_) _Dorso-lumbar Neuralgia._--The superficial branches of the spinal
+nerves emanating from the lumbar plexus are considerably less liable to
+be affected with severe and well-marked neuralgia than are the
+dorso-intercostal nerves. Pains in the abdominal walls, which are a good
+deal like neuralgia, are not uncommon; but the majority of them will be
+found, on careful observation, to be myalgia. At least, this has been
+the case in my own experience.
+
+When true neuralgia of the superficial branches of the lumbo-abdominal
+nerves occurs, it develops itself in one or more of the following foci:
+(1) Vertebral points, corresponding to the posterior branches of the
+respective nerves; (2) an iliac point, about the middle of the crista
+ilii; (3) an abdominal point, in the hypogastric region; (4) an inguinal
+point, in the groin, near the issue of the spermatic cord, whence the
+pain radiates along the latter; (5) a scrotal or labial point, situated
+in the scrotum or in the labium majus.
+
+Such is the description given by Valleix; for my own part, I cannot say
+that I have seen enough cases to test its accuracy. I believe it to be
+generally correct, yet it may fairly be doubted whether the author might
+not have revised his description had the natural history of myalgic
+affections been as carefully investigated as it has since been. The
+hypogastric foci of pain of which he speaks are at least open to
+considerable suspicion, as it will be shown, in the chapter on Myalgia,
+that an extremely common variety of the latter affection is situated in
+this region, and the severity of the pain which it often produces might
+well cause it to be mistaken for a genuine neuralgia.
+
+I have, however, seen three or four cases in which the very complete
+intermittence of the paroxysms, without any perceptible relation to the
+question of muscular fatigue, left no doubt in my mind of the really
+neuralgic character of the malady. In one of these instances, oddly
+enough, the exciting cause appeared to be fright; and this was as severe
+a case as one often sees. The patient was a woman of middle age, and
+much depressed by the long continuance of a profuse leucorrhoea. As
+she was walking along the street, a herd of cattle, in a somewhat
+irritable and disorderly condition, came suddenly toward her; she
+immediately began to suffer pain just above the crest of the ilium, and
+at the lumber region, and, most acutely, in the labium majus of one
+side; and then pain returned daily, about 10 A. M., lasting for half an
+hour with great severity. This woman's family history was remarkable:
+her mother had been paraplegic, her sister was a confirmed epileptic,
+and two of her children had suffered from chorea.
+
+In two other cases of lumbo-abdominal neuralgia which were under my
+care, there were also very painful points in the spermatic cord and in
+the testicle. One of these cases will be referred to under the head of
+Visceral Neuralgia. Another case, in which severe quasi-neuralgic pain
+was referred to the groin, will be described in the chapter on the Pains
+of Hypochondriasis.
+
+(_f_) _Crural Neuralgia._--This appears to be rare as an independent
+affection occurring primarily in the crural nerve. Valleix had only seen
+it twice in all his large experience, and I have never seen it myself.
+Neuralgic pain of the crural nerve is almost always a secondary
+affection arising in the course of a neuralgia, which first shows itself
+in the external pudic branch of the sacral plexus; or else occurring as
+a complication of sciatica. A remarkably severe example of the latter
+occurrence was observed in an old man who still occasionally attends the
+Westminster Hospital. He has been a martyr to the most inveterate
+bilateral sciatica for between two and three years; and, within the last
+three months, it has extended itself into the cutaneous branches of the
+curval nerves of both thighs. So great an aggravation of the pain is
+produced by any muscular movement, that the patient can only walk at the
+slowest possible pace, moving each foot forward only a few inches at a
+time. The bilateral distribution of the pain is remarkable in this case;
+but there can be no doubt of its really neuralgic character, from the
+truly intermittent way in which it recurs, and the absence of any
+history whatever to point in the direction of rheumatism, gout, or
+syphilis.
+
+The nervous supply to the skin of the anterior and external portion of
+the thigh includes: (1) The middle cutaneous, (2) the internal
+cutaneous, and (3) the long saphenous branch of the anterior crural
+nerve; (4) the cutaneous branch of the obturator; and (5) the external
+cutaneous nerve, derived from the loop formed between the second and
+third lumbar nerve. The sensitive twigs derived from the two latter
+sources, equally with the branches of the anterior crural, are liable to
+be secondarily affected by neuralgia, which commences in the
+lumbo-abdominal nerves; but it must be a rare event for them to be the
+seat of a primary neuralgia. The only occasion on which I have seen
+anything which looked like the latter was in the case of a porter, who,
+in straining to lift a very heavy load, ruptured some part of the
+attachment of the tensor vaginae femoris. But the susceptibility of all
+the nerves of the front of the thigh to secondary or reflex neuralgia
+receives numerous illustrations. The extremely severe pain at the
+internal aspect of the knee-joint, which is such a common symptom in
+morbus coxae, is evidently a reflex neuralgia of the long saphenous
+nerve, the ultimate irritation being situated in the branches of the
+obturator nerve which supply the hip-joints. For some reason
+unexplained, it happens that this saphenous nerve is specially liable to
+be affected in a reflex manner: for instance, this happens in a
+considerable number of cases of sciatica. I have a lady now under my
+observation, in whom the secondary neuralgia of the saphenous nerve has
+become even more intolerable than the pain in the sciatic, which was the
+nerve primarily affected. The pain in these cases very frequently runs
+down the inner and anterior surface of the leg to the internal ankle.
+Sometimes the branches of the anterior crural become the seat of
+intensely painful points in the course of a long-persisting sciatica. A
+patient at present under my care has a spot, about the size of a
+shilling, just at the emergence of the middle cutaneous branch from the
+fascia lata, which is intensely and persistently tender to the touch,
+and the skin here is so exquisitely sensitive to the continuous galvanic
+current that the application of moistened sponge-conductors, with a
+current of only fifteen Daniell's cells, causes intolerable burning
+pain; whereas at every other part of the limb the current from
+twenty-five cells can be borne without much inconvenience.
+
+(_g_) _Femoro-popliteal Neuralgia, or Sciatica._--This is one of the
+most numerous and important groups of neuralgia; but, notwithstanding
+that there are plenty of opportunities for studying it, I venture to
+think it is very commonly mistaken for different and non-neuralgic
+diseases, and they for it. The rules of diagnosis which will be laid
+down for all the neuralgiae would nevertheless prevent these errors, if
+carefully attended to.
+
+Sciatica is a disease from which youth is comparatively exempt. Valleix
+had collected one hundred and twenty-four cases, and in not one was the
+patient below the age of seventeen, only four were below twenty. In the
+next decade there were twenty-two; in the next, thirty; and the largest
+number of cases, thirty-five, occurred between the ages of forty and
+fifty. This completely tallies with my own experience, and appears to
+afford some support to a suspicion I have formed, that the chief
+exciting cause of sciatica is the pressure exercised on the nerve in
+locomotion, and that this cause exercises its maximum influence when the
+period of bodily degeneration commences. It is further remarkable that,
+in elderly persons (whose habits of locomotion are of course more
+limited), the proportion of fresh cases rapidly diminishes; and also
+that above the age of thirty the number of male patients greatly exceeds
+that of female patients attacked. All this seems to point in the same
+direction.
+
+According to my observation, there are three distinct varieties of
+sciatica. The first of these is obscure in its origin, but may be said,
+in general terms, to be connected with a nervous temperament of the
+highly impressible kind, which is more or less like what we call
+"hysteric," not only in the female, but also in male patients. The
+subjects of this kind of sciatica are mostly young persons, and hardly
+ever more than middle-aged; they are generally found to be liable to
+other forms of neuralgia; and the actual attack of sciatica is produced
+by some fatigue or mental distress, which at other times might have
+brought on sick headache, or intracostal neuralgia, etc. Very many of
+these patients are anaemic; and chlorotic anaemia seems specially to favor
+the occurrence of the affection. The greater number of the victims are
+females, and in very many, whether as cause or effect, there is impeded,
+or at least imperfect, menstruation. This kind of sciatic pain is not
+usually of the highest degree of intensity, but it generally spreads
+into a great many branches, both in a direct and a reflex manner. It is
+probable that this variety of the disease is, at least very often,
+dependent upon, or much aggravated by, an excited condition of the
+sexual organs; certainly, I have observed it with special frequency in
+women who have remained single long after the marriageable age, and in
+several male patients there has been either the certainty or a strong
+suspicion of venereal excess. Sciatica of this kind also occurred in the
+case of a single woman aged about thirty, who to my knowledge was
+excessively addicted to self-abuse.
+
+The second variety of sciatica occurs for the most part in middle-aged
+or old persons who have long been subject to excessive muscular
+exertion, or have been much exposed to damp and cold, or who have been
+subject to the combined influence of both these kinds of evil influence.
+One must also include, I think, in this group a considerable number of
+cases where the age is not so advanced, but the patient has been
+obliged, by the nature of his business, to maintain the sitting posture
+daily, for hours together, exercising pressure on the nerve; this is
+especially liable to happen in these persons.
+
+The sufferers from this variety of sciatica are mostly, as already said,
+of middle age or more; but this statement must be understood to be made
+in the comparative sense, which refers rather to the vital status of the
+individual than to the mere lapse of years. Many of these people have
+hair which is prematurely gray, and in some the existence of rigid
+arteries, together with arcus senilis, completes the picture of organic
+involution, or senile degeneration. In particular cases, where
+depressing influences have been at work for a long time, or unusually
+active, these appearances rectify the false impression we should
+otherwise derive from learning the mere nominal age of the person; this
+is especially often the case with regard to patients who have for a long
+time drunk to excess. The prematurely and permanently gray hair (it will
+be seen hereafter that permanency of grayness is an important point),
+together with well-marked inelasticity of arteries, very often tells a
+tale which is most useful in informing us, not only of the vital status
+of the patient, but of the kind of sciatica under which he labors; and
+also influences our prognosis seriously. There is otherwise a somewhat
+deceptive air about the appearance of many of these degenerative cases;
+for instance, a ruddy complexion is not uncommon, nor the retention of
+considerable, or even great, muscular strength. It is probable that
+these appearances deceived Valleix and many others, or they could hardly
+have failed, as they have, to observe the frequency of the degenerative
+type among the most numerous group of sciatic patients, namely, those
+between thirty and fifty years of age. These persons are not truly
+"robust," although at a hasty glance they might at first seem to be so.
+It would be a serious mistake to omit the search for the important vital
+evidences which have been referred to, since these therapeutic and
+prognostic indications are of the highest value.
+
+A prominent feature in this kind of sciatica is its great obstinacy and
+intractability. Another, equally marked, is the tendency to the
+development of spots around the foci of severest pain which are
+intensely and permanently tender, and the slightest pressure on which is
+sufficient to set up acute pain. This is a symptom much less developed,
+if developed at all, in the variety of sciatica which we first
+discussed. The places which are especially apt to present this
+phenomenon of tenderness are as follows: (1) A series, or line of
+points, representing the cutaneous emergence of the posterior branches,
+which reaches from the lower end of the sacrum up to the crista ilii;
+(2) a point opposite the emergence of the great and small sciatic nerves
+from the pelvis; (3) a point opposite the cutaneous emergence of the
+ascending branches of the small sciatic, which run up toward the crista
+ilii; (4) several points at the posterior aspect of the thigh,
+corresponding to the cutaneous emergence of the filets of the crural
+branch; (5) a fibular point, at the head of the fibula, corresponding to
+the division of the external popliteal; (6) an external malleolar,
+behind the outer ankle; (7) an internal malleolar.
+
+I have already mentioned that in sciatica the pain frequently spreads in
+a reflex manner to nerves which are connected, by their origin from the
+plexus, with the sciatic. It will be remembered, also, that I related
+cases in which the formation of tender points, in the course of the
+nerves thus secondarily affected, was even more distinct and remarkable
+than anywhere in the branches of the sciatic itself.
+
+Another circumstance which distinguishes the form of sciatica which we
+are now describing is, the degree in which (above all other forms of
+neuralgia) it involves paralysis of motion. [The subject of the
+complication of neuralgia will be treated in a general manner farther
+on; but it seems necessary to note here the special liability of sciatic
+patients to this and to the most material complications]. By far the
+largest part of the motor nervous supply for the whole lower limb passes
+through the trunk of the great sciatic; it might therefore be naturally
+expected that a strong affection of the sensory portion of the nerve
+would produce, in a reflex manner, some powerful effect upon the motor
+element. This effect is most frequently in the direction of paralysis.
+Complete palsy is rare, but in a large proportion of cases which have
+lasted some time there will be found, independently of any wasting of
+muscles, a positive and considerable loss of motor power. It is of
+course necessary to avoid the fallacy which might be produced by
+neglecting to observe whether movement was restricted merely in
+consequence of its painfulness. Not long since, I had occasion to test
+the electric sensibility in a case of sciatica, in which there was
+extremely severe pain, affecting chiefly the peroneal region of the leg,
+and great weakness of the leg, amounting to inability for walking. The
+gastrocnemius could hardly be got to contract at all, when the most
+powerful Faradic current was directed upon the nerve in the popliteal
+space of the affected limb, though the muscle of the sound side reacted
+with great vigor.
+
+_Anaesthesia_ is also a common complication of sciatica, far commoner, I
+venture to think, than it has been represented either by Valleix, or
+Notta. It is necessary, however, to be explicit on this point. In the
+early stages, both of this form of sciatica, and of the milder variety
+previously described, there is almost always partial numbness of the
+skin previous to the first outbreak of the neuralgic pain, and during
+the intervals between the attacks. By degrees this is exchanged, in the
+milder form, for a generally diffused tenderness around the foci of
+neuralgic pain, while other portions of the limb remain more or less
+anaesthetic. In the severer forms it sometimes happens that, besides an
+intense tenderness of the skin over the painful foci, there is diffused
+tenderness over the greater part or the whole of the surface of the
+limb. But it is important to remark that both in the anaesthetic and the
+hyperaesthetic conditions (so called) the tactile sensibility is very
+much diminished. I have made a great many examinations of painful limbs,
+in sciatica, and have never failed to find (with the compass points)
+that the power of distinctive perception was decidedly lowered.
+
+_Convulsive movements of muscles_ are met with in a moderate proportion
+of cases of sciatica in middle and advanced life, in which affection
+they are entirely involuntary. They differ from certain spasmodic
+movements not unfrequently observed in the milder form (and especially
+in hysteric women), for these are more connected with morbid volition,
+and are in truth, not perfectly involuntary. In several cases of
+inveterate sciatica I have seen violent spasmodic flexures of the leg
+upon the thigh. Cramps of particular muscles are occasionally met with.
+I have seen the flexors of the toes of the affected limb violently
+cramped, and in one case there was agonizing cramp of the gastrocnemius.
+It is chiefly at night, and especially when the patient is falling
+asleep, that this kind of affection is apt to occur.
+
+A third variety of sciatica is the rather uncommon one so far as my
+experience goes, in which inflammation of the tissues around the nerve
+is the primary affection, and the neuralgia is mere secondary effect,
+from mechanical pressure on the nerve, which, however, is not apparently
+itself inflamed. I believe that these cases are sometimes caused by
+syphilis, and sometimes by rheumatism. One of the most violent attacks
+of sciatic pain which ever came under my notice was in a syphilized
+subject, a discharged soldier, who had been the victim of severe
+tertiary affections, and had been mercilessly salivated into the
+bargain. This unfortunate man suffered dreadful agony, which was
+aggravated every night, but was never totally absent. The pain started
+from a point not far behind the great trochanter: pressure here caused
+intolerable darts of pain, which ramified into every offshoot of the
+sciatic nerve, as it seemed, and made the man quite faint and sick.
+Large doses of iodide of potassium, together with the prolonged use of
+cod-liver oil, completely removed the pain and tenderness. It need
+hardly be said that cases of this kind are essentially different, and
+require perfectly different principles of treatment from neuralgias in
+which the disturbance originates within the nervous tissues themselves.
+
+The chronic rheumatism does also, occasionally, affect the sheath of the
+nerve in such a manner as to produce a deposit which sets up neuralgic
+pain, must also be admitted, although I believe the number of such cases
+to be preposterously over-estimated by careless observers. It has
+several times happened that a patient has come under my care with
+so-called "rheumatic affection of the nerves" of the thigh and leg, and
+that on examination one has found all the symptoms and clinical history
+of a neurosis, but not the slightest valid argument for a diagnosis of
+the rheumatic diathesis. Indeed, upon this point, I think it is time
+that a decided opinion should be expressed. I firmly believe that a
+large number of sciatic patients have their health ruined by treatment
+directed to a supposed rheumatic taint which is purely imaginary. The
+state of medical reasoning, suggested by the way in which too many
+practitioners decide that such and such pains are rheumatic in their
+origin, is a melancholy subject for reflection. Nearly always it will be
+found, on cross-examination, that the state of the urine has been made
+the basis of a confident diagnosis; the practitioner will tell you that
+the urine was loaded, _i. e._, with lithtaes. He ignores the fact that
+nothing is more common, in neurotic patients who are perfectly guiltless
+of rheumatic propensities, than a fluctuation between lithiasis and
+oxaluria, neither of which phenomena, under the circumstances, indicates
+any more than a temporary defect of secondary assimilation of food,
+produced by nervous commotion. I may perhaps find room, on a future
+page, for a few further remarks on the subject; at present I only put in
+a caution against too ready an acceptance of the rheumatic hypothesis.
+
+II. VISCERAL NEURALGIAS.
+
+_Uterine and Ovarian Neuralgia._--This is an important group of
+neuralgic affections, and one which I cannot help thinking is strangely
+misappreciated, very often, in a therapeutic point of view. In one
+aspect these affections possess a special interest, namely this, that
+they are more frequently dependent on peripheral irritation for their
+immediate causation than any other group of neuralgias. If we consider
+the great copiousness of the nervous supply to the uterus and ovaries,
+and the powerfully disturbing character of the functional processes
+which are periodically occurring in these organs, we shall be at no loss
+to understand how this may be. The amount force of the peripheral
+influence and which are brought to bear upon the central nervous system
+by the functions of the uterus and ovaries are greater than any that
+emanate from the diseases and functional disturbances of any other organ
+in the body.
+
+The most common variety of peri-uterine neuralgia is that which attends
+certain kinds of difficult menstruation. It would be hardly correct to
+give the name of neuralgia to the pain existing in these very numerous
+cases of dysmenorrhoea in which the suffering is apparently altogether
+dependent on the mere retention or difficult escape of the menstrual
+fluid, although the character of the pain often resembles the neuralgic
+type. There is another group of dysmenorrhoeal affections however, in
+which the pain may fairly be called neuralgic, since it is apparently
+independent of the circumstances of the discharge of menstrual fluid,
+and simply attends the process, seemingly on account of a
+naturally-exaggerated irritability of the organs concerned. There is a
+large class of young women in whom, and more especially before marriage,
+the time of menstruation is always marked by the occurrence of more or
+less severe pain. Formerly I used to believe that this pain was relieved
+on the occurrence of the discharge, but I have seen too many cases of a
+contrary nature to retain this opinion. I now believe that the subjects
+of the kind of menstrual pain to which I am referring are naturally
+endowed with a very irritable nervous apparatus of the pelvic organs,
+and that there is a certain character at once of immaturity and
+excitability in their sexual organs, especially in the virgin condition.
+So far from these females being disposed to sterility, as is too often
+the case with those dysmenorrhoeal subjects whose troubles depend upon
+occlusion, distortion, or narrowing of the outlets, they are often
+extremely apt to the generative function; and, what is more, the full
+and natural exercise of the sexual function appears necessary to the
+health of their organs, as is shown by the fact that these menstrual
+pains lose their abnormal character, completely or in great part, after
+marriage, and especially after child-bearing. The contrast between the
+two types of dysmenorrhoeal patients is sharply brought out by the two
+following cases:
+
+CASE I.--S. M., a housemaid, aged twenty-three when first under my
+notice, was the picture of physical health and strength, very
+intelligent, and a girl of excellent character and most industrious
+habits. At every menstrual period, however, she suffered, for some hours
+previously to the occurrence of the flow, from severe pain in the
+uterine region, which was tumefied and tender. Hot hip-baths gave some
+relief, apparently by hastening the discharge; as soon as the latter was
+established, the pain rapidly subsided. This young woman married a
+healthy and vigorous young man, but has never had any children, and at
+the date of my last inquiries still suffered periodically from her old
+troubles.
+
+CASE II.--Mrs. B. was married at the age of twenty-six. Up to the date
+of her marriage she used to suffer the most severe pain at every
+menstrual period; the pain, however, bore no relation to the freedom of
+the discharge, but always lasted about the same length of time, under
+any circumstances, or was only less or more according as the general
+bodily vigor was greater or less at the moment. From the date of
+marriage these troubles steadily declined; a child was born at the end
+of twelve months, and the menstrual troubles have never resumed a
+serious shape up to the present time, a period of nearly nine years.
+This lady is herself a neuralgic subject, liable to migraine in
+circumstances of fatigue, and suffering horribly from it during her
+pregnancies; and she comes of a family in whom the nervous temperament
+is strongly developed.
+
+It must not always be concluded, because the menstrual pain is very
+severe before the discharge and is relieved at or soon after its
+appearance, that the case is one of occlusion, and not of neuralgia.
+There is a class of cases in which the affection appears to be a very
+severe ovarian neuralgia, attended with a vaso-motor paralysis which
+causes great engorgement of the ovary and consequent difficulty of
+"ovulation." I have seen several instances which I could not explain in
+any other way.
+
+CASE III.--One patient I particularly remember, from the fact that she
+was always attacked with dreadful pain, which was sometimes seated in
+one groin and sometimes in the other, but was regularly attended with
+large and palpable tumefaction of the ovary, which began to subside when
+the discharge commenced. This woman married rather late, but her
+menstrual troubles immediately became less, and she became pregnant and
+was happily delivered, nearly as soon as was possible. She, too, was a
+decidedly neuralgic subject, independently of her tendency to
+dysmenorrhoeal ovarian pain.
+
+In some women who remain single long after the marriageable age, ovarian
+or uterine neuralgia becomes a constantly-recurring torment, not only at
+the menstrual period, but at various other times when they are depressed
+or fatigued in body or mind. As might be expected, this tendency is
+greatly aggravated in the rarer cases where the patient's mind dwells in
+a conscious manner on sexual matters, especially if by an evil chance
+she becomes addicted to self-abuse. Among the many reproaches that have
+been thrown upon the indiscriminate use of the speculum in examining
+unmarried women, it has often been urged that it tends to excite sexual
+feelings. I do not for a moment doubt that this is the case, or that the
+indiscriminate use of the instrument is altogether indefensible. But I
+expect that neuralgic pain of the uterus or ovaries, in unmarried women,
+connected with an already irritable condition of the sexual organs, has
+often been the reason why such women have applied for advice and have
+consequently been examined with the speculum; and that the same thing
+has frequently happened in the case of women who have been left widows
+at a time of life when the sexual powers were still in full vigor. These
+patients deserve great pity.
+
+The peripheral irritation which gives rise to peri-uterine neuralgia is
+not always originally seated in the organs of generation. The following
+are various sources of external irritation which I have known to produce
+the affection:
+
+1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman,
+aged thirty-four, single, was under my care in King's College Hospital
+many years ago, under suspicions of ulcerated cervix. On examination, no
+lesion could be detected. It was discovered that the rectum was infested
+with ascarides, and, after the use of appropriate vermifuges and tonics,
+the patient entirely lost the uterine pains and also a tormenting
+pruritus vaginae, from which she suffered. This woman had at various
+times suffered from neuralgic headache a good deal.
+
+2. Profuse and intractable leucorrhoea, whether associated or not with
+ulceration of the cervix, may produce peri-uterine neuralgia, even of
+great severity, when there are strongly-marked neurotic tendencies. It
+must be noted, however, that many cases of pain in leucorrhoeal
+subjects, which superficially bear the aspect of neuralgia, turn out on
+closer investigation to be merely examples of myalgia of the abdominal
+muscles or aponeuroses.
+
+3. Calculus in the kidney, or in the ureter, sometimes causes
+intolerable ovarian neuralgia. In the case of a woman who was under my
+care at the Chelsea Dispensary, some years ago, this was the unsuspected
+origin of severe neuralgic pains in the left ovary, which recurred
+several times a day, and which certainly contributed to the patient's
+death by the exhaustion which they produced. A calculus was found
+tightly impacted in the ureter, near the kidney.
+
+4. Prolapsus uteri sometimes gives rise to severe peri-uterine
+neuralgia, or what appears to be such; though it is difficult here to
+draw the line between neuralgia and myalgia. The commonest kind of pains
+from prolapsus uteri are not neuralgic in their nature at all, but are
+of a "bearing down" character, and probably depend upon actual
+contractile movement of the walls of the uterus.
+
+5. The presence of tumors, either cancerous or fibroid, in the uterus or
+its appendages, gives rise, frequently, to severe and indeed almost
+intolerable pains of a distinctly intermittent character. In the early
+stages of cancerous diseases these pains are usually felt at the lower
+part of the back; in the later stages they are felt also in the
+hypogastric region, and are then much more severe.
+
+6. Ulcer of the cervix, of a non-malignant kind, probably sometimes
+gives rise to neuralgic pain of the uterus, though this is not so severe
+as in cancer.
+
+7. Large masses of scybalous faeces, impacted in the rectum, will
+occasionally, by the pressure which they exert on nerves, set up violent
+neuralgia of uterus or ovaries, the true nature of which is accidentally
+discovered by the use of aperients which unload the intestine and put an
+end to the suffering. No doubt it is chiefly in persons with neuralgic
+predisposition that this effect is produced; for, common as is the
+occurrence of extreme constipation in women, it is comparatively very
+rare for us to hear of distinctly neuralgic pain being caused by it.
+
+8. The condition known as "irritable uterus," ever since Gooch's
+classical description of it, is always attended with uterine pain, which
+is continuous, but is liable to periodical exacerbations of great
+severity. In this disorder there is no recognizable physical disease of
+the pelvic organs, and the patient will generally be found to have
+suffered neuralgia in other parts of the body on previous occasions.
+[There is some difference of opinion about this affection: some authors
+(_e. g._, Hanfield Jones) considering it as distinct from the true
+neuralgias.]
+
+9. Reflex irritation, the source of which is in some quite distant part
+of the body, has in many recorded instances occasioned uterine
+neuralgia, in highly-predisposed persons. I have seen one case in which
+severe pain of this kind was clearly proved to have been excited by the
+presence of a carious tooth which was itself little, if at all, painful,
+but the removal of which at once cured the pelvic pain.
+
+Neuralgia of the urethra is an affection which is occasionally seen,
+both in males and females. I have observed it three times; all these
+cases were apparently traceable to the effects of excessive self-abuse.
+The male subject was an unmarried man, aged forty-two, of cadaverous
+appearance, much emaciated, with clammy, perspiring skin, and habitual
+coldness of the extremities; he suffered much from dyspepsia and
+palpitation of the heart. The pain ran along the under side of the
+penis, which was very large, with an elongated prepuce. The paroxysms
+were severe, and came on chiefly in the morning, soon after he awoke. No
+remedies did this man any permanent good, and he passed out of my sight,
+being at that time in a condition of wretched feebleness, and with
+symptoms of threatened dementia. Of the female subjects, one was a
+married woman, who accused her husband of impotence, and from her
+account it would certainly appear that effective connection had never
+taken place; the hymen was completely destroyed, however. The neuralgic
+pains recurred nightly in several paroxysms, and were especially severe
+about the time of the monthly periods. In this case the patient was, she
+stated, induced to give up her malpractices; at any rate, the pain
+subsided in a manner which could not be well accounted for by any direct
+influence of the medicinal treatment. The other female patient was a
+widow in whom the morbid habit was suspected from her general
+appearance, and from the existence of enlarged clitoris and other signs
+of irritation about the external parts: she became rather rapidly
+phthisical, and suffered severely from neuralgic headaches.
+
+Neuralgia of the bladder has been specially described by various
+writers; the pain is usually spoken of as seated at the neck of the
+bladder, and as accompanied by frequent desire to micturate. I have seen
+two cases, both in women: the first was eventually discovered to be an
+instance of malignant disease of the fundus of the bladder; the other
+was apparently the result of a long-continued menorrhoeal flux, which
+had greatly impaired the health, and produced extreme anaemia. In neither
+of these instances was the pain referred to the external meatus, as in
+the female patients above mentioned who were suffering from urethral
+neuralgia. I have never seen the extreme examples of vesical neuralgia
+described by some writers, in which actual paralysis of the coats of the
+bladder was secondarily produced; but the reflex influence of the
+neuralgic affection in both the examples just mentioned appeared to
+produce great weakening of the muscular power of the rectum, occasioning
+most obstinate and troublesome constipation.
+
+It would appear, from recorded cases, that both the bladder and the
+uterus are liable to be affected with neuralgia from malarious
+influences; but I have never chanced to see any such cases.
+
+Neuralgia of the kidney is spoken of by several writers, and I suppose
+there is no doubt that it may exist as a special neurotic disease with
+obvious organic cause. For my own part, I cannot say that I have ever
+seen it except in instances where there was either the certainty, or a
+very strong suspicion, that the cause was the mechanical pressure and
+irritation of a calculus within the kidney. The diagnosis of the simple
+functional disorder must be excessively perplexing; for in the first
+place there is the greatest difficulty in making sure that the pain is
+not external, and seated either in the muscles of the back, or in the
+superficial dorsal or lumbar nerves, and certainly I am strongly
+inclined to suspect that this has been really the case in many examples
+of so-called renal neuralgia. That neuralgia of the kidney may arise
+secondarily, as a reflex extension of pelvic neuralgia, does, however,
+appear probable enough; for it is almost certain that in the latter
+affection at least, the vaso-motor nerves of the kidneys must be
+strongly influenced in a reflex manner; since the crisis or acme of a
+paroxysm of pelvic pain is not unfrequently attended with a copious
+secretion of pale urine.
+
+Neuralgia of the rectum has been carefully described by Mr. Ashton, but
+is probably not often seen except by practitioners who possess special
+opportunities of observing rectal diseases. In the one pure case which
+has fallen under my notice the patient complained of acute paroxysmal
+cutting pains extending about one inch within the anus, and, as these
+were greatly increased by defecation I suspected the existence of
+fissure. Nothing of the kind, however, was found on examination; and the
+pain ultimately yielded to repeated subcutaneous injections of atropine.
+This patient had got wet through, and had sat in his damp clothes,
+getting thoroughly chilled; the pain came on with great suddenness and
+severity, and the tenderness which has been mentioned was developed very
+quickly. Probably the influence of cold and wet is among the commonest
+causes of the complaint. Mr. Ashton also reckons as causes, reflex
+irritation from other parts of the alimentary canal, and the influence
+of malaria. He observes that the subjects of the affection are most
+frequently anaemic, and of a generally excitable and deranged
+susceptibility, and that females, who, from menorrhagia, or frequent
+child-bearing with much haemorrhage, have lost a great deal of blood, are
+specially predisposed.
+
+Neuralgia of the testis (as an independent affection and not a mere
+extension of lumbo-abdominal neuralgia) is fortunately a much less
+common malady than the corresponding affection of the ovary; as might
+indeed be expected, from the much less degree of functional perturbation
+to which, in ordinary physiological circumstances, the former organ is
+exposed than the latter. Except from actual growths within the testis,
+of which it was a mere symptom, I have never seen neuralgia of the
+testis save from one of three causes. In one remarkable example it was
+produced as a reflex effect of severe herpes preputialis. Secondly, it is
+sometimes observed as a symptom of calculus descending the ureter. And,
+thirdly, I have seen it several times undoubtedly produced by excessive
+self abuse.
+
+The occurrence of testicular neuralgia, in one case of epilepsy, as to
+the cause of which I had been previously much puzzled, led to the
+discovery of the real origin of the fits. I should observe here that I
+do not believe that self-abuse is ever more than an immediately exciting
+cause of epilepsy, a predisposition to the disease having previously
+existed in all cases. In the patient just referred to, there was a
+family history of epilepsy, but it was difficult to explain the exciting
+cause until this was suggested by the occurrence of neuralgic pain in
+the testicle. The patient relinquished his habit, and both the pain and
+the epilepsy ceased, and, for some twelve months during which I had him
+under observation, had not recurred at all. A medical friend has
+informed me of an instance in which the same habit had produced a
+neuralgia of the testis so severe as to strongly tempt the patient to
+castrate himself, and he would probably have done so but that he was too
+much of a coward with regard to physical pain. The attacks of pain were
+so severe as frequently to produce vomiting and the greatest
+prostration.
+
+_Hepatic Neuralgia._--It must be allowed that the evidence even for the
+existence of neuralgia of the liver is at present in an unsatisfactory
+state. At the same time, there are carefully-recorded cases, by
+Trousseau and other[7] writers of unquestionable authority, which leave
+no doubt in my mind, corroborated as they are by a certain amount of
+experience of my own, that such a form of neuralgia really exists. I
+must, of course, be understood to refer to something altogether
+different from the spasmodic pain which is produced by the difficult
+passage of a gall-stone toward the bowel. I have now seen several cases
+in which, as it appeared to me, there was sufficient evidence of
+neuralgic pain seated in the liver itself, and not dependent either on
+gall-stone or any so-called organic diseases of the viscus.
+
+The subjects of hepatalgia are probably never troubled only by pain in
+the liver; they are persons of a nervous temperament, in whom a slight
+shock to, or fatigue of, the nervous system, habitually provokes
+neuralgic attacks; the pain localizing itself sometimes in the branches
+of the trigeminal, sometimes in those of the sciatic, sometimes in the
+intercostal nerves, etc. In one instance which has been under my
+observation, the attacks of hepatalgia alternated with cardiac neuralgia
+assuming the type of a rather severe angina pectoris. In another case
+the patient, a man aged sixty-seven, was very liable to attacks of
+intermittent abdominal agony, in which one could hardly doubt that the
+pain was located in the colon, and was attended with paralytic
+distention of the bowel; the peculiar feature of the case being the
+sudden way in which the symptoms would appear and depart, independently
+of any recognizable provocation or the use of any remedies. On two
+separate occasions this patient was attacked with pain of a precisely
+similar kind, but limited to the right hypochondrium, attended with
+great depression of spirits, and followed by a well-pronounced jaundice.
+So remarkable was the conjunction of symptoms in these two attacks that
+a strong suspicion of biliary calculus was raised, but not the slightest
+confirmation of this idea could be obtained; and indeed one
+symptom--vomiting--which nearly always attends the painful passage of a
+biliary calculus, was altogether absent.
+
+Putting aside a considerable number of cases in which "pain in the
+liver" was vaguely complained of by patients who were plainly
+hypochondriacal, and whose account of their own sufferings could not be
+relied on, I have altogether seen five instances of what I regard as
+genuine hepatalgia. The first of these was very remarkable in its
+history and in all its features. The patient was a respectable girl of
+eighteen, subject to migraine, who had reason to fear that she had
+become pregnant, though this proved, ultimately, not to be the case.
+Under these circumstances she was attacked with intermittent pains, in
+the right hypochondrium, of intolerable severity; resembling, in fact,
+the pain of biliary calculus, but without the sense of abdominal
+constriction, and without any vomiting. These recurred daily at about
+the same hour in the morning, for about ten days; when rather
+suddenly, a jaundiced tint appeared upon the face, and very shortly the
+whole skin was colored bright yellow; there was intense mental apathy;
+the urine was loaded with bile-pigment, and the faeces clay-colored. This
+state of things lasted only about a week and then very rapidly
+disappeared; but as the jaundice subsided there was a partial recurrence
+of the neuralgic pains, which, for a day or two, were as severe as they
+had ever been; The other four cases of hepatalgia which I have seen,
+including that of the man above mentioned, have all been in persons in
+advanced life; but, except the latter, neither of them displayed any
+symptoms of disordered biliary secretion; and the diagnosis (as to
+situation, for the character of the attacks was manifestly neuralgic)
+rested mainly on the fact that the pain radiated to the shoulder.
+
+There remains to be noticed one clinical feature of the disease, which,
+I believe, is characteristic; namely, the peculiar mental depression
+which attended all the cases I have seen, but was most marked in the two
+in which jaundice occurred. In the girl above referred to, the apathy,
+during the period when there was jaundice but no pain, was even
+alarming; it reminded one of the mental state in commencing catalepsy;
+during the painful stages it was more like the gloom of suicidal
+melancholia. Of course, the acute mental anxiety which this patient had
+suffered would account for a good deal of this; but the symptom was as
+distinct, though less severe, in the case of an elderly lady, whom I
+have attended on another occasion for migraine; here there was no
+recognizable source of anxiety; and, on the other hand, there was no
+reason to suspect the retention of bile-elements in the blood. It seems,
+therefore, as if an essentially depressing influence on the mind was
+excited by hepatic neuralgia; or else, that emotional causes are the
+chief source of the malady.
+
+_Neuralgia of the Heart._--If there be any hesitation in treating this
+disease as exactly conterminous with angina pectoris, it can, I think,
+be only reasonably justified on two grounds: In the first place, it may
+be urged that acute pain of the neuralgic type is not always present in
+angina pectoris; and, secondly, it may be urged that many cases of
+painful neurosis of the heart have been observed, in which the
+recurrence of pain with some amount of cardiac embarrassment has gone on
+for years, whereas the popular conception of true angina almost
+necessarily involves rapid fatality.
+
+There is doubtless some force in these objections, especially in the
+second, for it does seem rather inconvenient to call by the same name so
+deadly a disorder as the worst form of angina, and so comparatively
+harmless a malady as some of those instances of chronic tendency to
+spasmodic pain of the heart which are not very uncommon, and in which
+the patient survives, perhaps, to an old age. Yet, after all, there is
+the greatest difficulty in drawing any rational line of distinction; for
+the basis of the affection seems the same in every case, whether pain or
+spasm be the predominant feature, and whether the course of the disease
+be long or short. All that appears to be necessary for its production is
+a certain originally neurotic temperament (with possibly some congenital
+weakness or some post-natal disease of that part of the spinal-cord
+centres which Von Bezold has described as furnishing three-fourths of
+the propulsive power of the heart) and the presence of almost any kind
+of difficulty or embarrassment of the action of the heart. The most
+common source of this embarrassment is perhaps failure of nutrition in
+the muscular walls of the heart, from disease of the coronary arteries.
+Indeed, it is not known that any organic change of the heart or great
+vessels, even of the slightest kind, is necessary to the production of
+angina; on the contrary, there is every reason to think that mere
+fatigue and depression may bring on the attacks in persons of a strongly
+nervous temperament. For my own part, I am inclined to believe, however
+that there really always is disease somewhere in the cardiac centre of
+the spinal cord, though that disease may consist in no more than a
+disposition to minute interstitial atrophy. But we shall say more about
+this presently.
+
+It is at any rate certain that cardiac neuralgia is always a most grave
+complaint, from the almost total uncertainty whether succeeding attacks
+will not involve a fatal amount of spasm. As for the expression angina
+pectoris, it is just one of those mischievous terms which, arising out
+of the mystified ignorance in which the elder physicians found
+themselves as to the pathology of internal diseases, have since been
+attached in turn to various definite organic changes, with none of which
+they had any essential connection; and it is therefore much to be wished
+that it could be altogether done away with. At the same time, there is
+so much that is peculiar in the case of cardiac neuralgia, owing to the
+importance of the organ affected, that it will be necessary here to
+treat not merely its symptoms, but also its diagnosis, prognosis,
+etiology, pathology, and treatment, in a separate and continuous manner.
+
+_Clinical History and Symptoms._--Cardiac neuralgia usually shows itself
+for the first time with considerable abruptness. The patient may or may
+not have been consciously ill before the actual seizure, but it rarely
+happens, even when the heart has notoriously been the subject of some
+organic disease, that there has been any thing to lead him to expect the
+kind of attack from which he now suffers. In the midst of some little
+unusual effort, or even without this kind of provocation, suddenly the
+patient is attacked with severe pain, usually at the lower part of the
+sternum; this pain darts through to the back and left shoulder, and
+nearly always runs down the left arm. Sometimes, indeed, it is felt
+acutely over a large area of the chest, and runs down both arms; this is
+the case in a patient now under my care, in whom the affection is more
+obviously a neurosis, and less attended with coarse organic changes,
+than is usually the case. Along with the pain, which is always very
+distressing, but varies greatly in severity in different cases, there is
+a variable amount of another sensation which can be compared to nothing
+but cramp, or rather compression; the patient usually describes it as
+feeling as if some one were grasping the heart in his hands, and, when
+this sensation is at all prominent, the idea of impending death is most
+strongly impressed on the sufferer's mind. His outward appearance seems
+to confirm the idea. In cases where the sense of compression is great,
+the face is of an ashen gray; the lips white, with a faint livid tinge;
+the pulse small, feeble, and unrhythmical, or imperceptible, at the
+wrist; cold perspiration breaks out upon the face; in short, all the
+signs of approaching dissolution are present. In cases where the
+suffering is chiefly or entirely confined to severe pain, of a darting
+or burning character, the state of the circulation is often different.
+The heart bounds against the ribs, in rapid and painful palpitation, the
+face is flushed deep crimson, the pulse at the wrist is large, bounding,
+but very compressible; in fact, the outward appearance of the patient is
+so different from that of one who suffers from the more depressing kind
+of angina, that it is difficult to consider the two affections as
+essentially similar. But there can be no question, if we carefully
+examine the matter, that they are mere varieties of the same disorder,
+especially as they both may successively occur in the same person.
+
+The course of cardiac neuralgia varies extremely. Supposing the malady
+to be purely neurotic, and not complicated with organic disease, which
+forms a constant source of cardiac embarrassment, then the patient may
+only experience one or two attacks, under some special circumstances of
+exhaustion, which may never recur; or, on the other hand, he may develop
+a strong tendency to cardiac neuralgia which may beset him during almost
+any number of years. In the latter case, it is an even chance whether
+the patient will at last sink from the anginal affection; for, even
+supposing him to escape any fatal intercurrent disease of an independent
+nature, the fatal event may be at last produced by cerebral softening,
+or by apoplexy, or other central nervous disease. In fact, the frequency
+with which the latter kind of termination occurs is very significant of
+the essential nature of the disease.
+
+The manner in which cardiac neuralgia commences varies very greatly. In
+the celebrated case of Dr. Arnold, the first attack did not occur till
+he was forty-seven years of age; it at once assumed full intensity, and
+proved fatal in two hours and a half. There is also reason to believe
+that Dr. Arnold's father died in a first attack of angina. I have myself
+known a first attack prove fatal in the course of an hour; there was
+very considerable ossification of the coronary arteries and fatty
+degeneration of the heart-walls. Again, there are many cases which
+commence gradually, and with great mildness, and with little appearance
+of danger to life in the first attacks; but the subsequent attacks are
+progressively more severe and dangerous up to a fatal result, after
+weeks, months, or years. On the other hand, I have known three instances
+in which the first attacks of spasmodic heart-pain very nearly proved
+fatal, but the subsequent fits were milder (in one there was no second
+attack): all those patients are living, six, eight, and three years
+respectively, after their first attacks.
+
+It can hardly be doubted that neuralgic spasm is the true cause of
+sudden death in some cases of stenosis of the aortic orifice, which, but
+for some accidental circumstances, would not have died suddenly at all,
+but would have gone through a long and gradual course of deterioration.
+I particularly remember an instance in which extreme and calcareous
+constriction of the aortic orifice, in a boy not yet come to puberty,
+was entirely unsuspected, until one day, in running fast, he screamed
+out and fell down, and was almost instantaneously dead. I remember
+another case very similar, in which extreme mitral constriction produced
+almost as sudden death, apparently from painful spasm, under the same
+kind of exertion. On the other hand, sudden death, when produced by the
+form of heart-disease which (as Dr. Walshe points out) is most likely to
+cause such a catastrophe, viz., aortic regurgitation pure, without
+hypertrophy, does not seem to be due to painful spasm, but to simple and
+complete failure of the muscular power, and is perhaps partly of the
+nature of paralysis from a syncopal condition of the brain, the
+unhypertrophied heart having become for the moment unable to supply
+blood enough to the brain to carry on nervous function at all.
+
+A good instance of the form which angina takes, when the element of
+organic cardiac change is well pronounced, was afforded by the case of a
+young gentleman recently under my care. He was twenty-one years of age,
+and from early boyhood had been accustomed to a great deal of muscular
+exercise; in fact, it is probable that he had undermined his health by
+the frequent and extraordinarily long walks which he took, for his frame
+was particularly small and slight, and the muscles small and soft. He
+came of a family in whom the tendency to neurotic disorders is obviously
+very strong; both his father and his brother are subject to bad attacks
+of migraine, and he had himself repeatedly suffered from the same thing.
+The family disposition, altogether, is highly nervous and excitable. The
+remarkable circumstance in this young gentleman's case is, that although
+he had taken for years an extraordinary amount of pedestrian exercise
+(including mountain-climbing), and latterly had exchanged this for the
+even more trying exertion of rowing, he had never suffered from any
+noticeable symptom of cardiac distress up to the very day of his anginal
+attack. For some months, however, he had been growing thin and pale, and
+I had given him certain cautions, and had made him take cod-liver oil
+and steel, as I entertained some fears of his becoming phthisical. On
+the day of the attack there was nothing particular in his appearance,
+but he complained of a slight cold, and had no appetite for his six
+o'clock dinner. He retired to rest at eleven o'clock, having taken a
+small dose of laudanum and chloric ether for his cold. In less than half
+an hour he awoke out of his sleep in fearful agony; so severe and
+prostrating was the anginoid pain that he had the greatest difficulty in
+crawling out of bed to unlock his door. I found him bathed in cold
+sweat, pale as a sheet, and with livid lips. He groaned with pain, which
+he described as "cutting him across" from the sternal notch to the
+nipple, and going down the left arm; and there was so marked a catching
+of the breath as to make it almost certain that there was diaphragmatic
+spasm; in fact, it was this which alarmed him, and made him say that he
+was certainly dying. The heart, however, appeared to be pushed up
+somewhat, and it was thought that this might be partly due to stomachic
+distention, but a mustard emetic produced little effect. The
+heart-sounds were so weak that the presence or absence of bruit could
+not be safely predicated; meantime, the pulsations intermitted in a most
+alarming manner. Large doses of brandy and sulphuric ether at length
+(after several relapses) seemed to subdue the pain and spasm, and in an
+hour and a half from the commencement of the attack the patient, though
+utterly worn out, sank into a tolerably quiet sleep. The spasms did not
+recur, but for the next three or four days he was in a state of great
+exhaustion. When his tranquillity of mind had been somewhat restored, a
+careful physical examination was made, and it was discovered that there
+was a moderately loud and somewhat thrilling systolic bruit at the site
+of the aortic valves, and extending some distance into the vessels. The
+pulse still remained strikingly intermittent, and, though of fair
+volume, was very compressible. Percussion indicated considerable
+enlargement of the heart, and the physical signs pointed, on the whole,
+to dilatation without hypertrophy. Some doubtful signs of consolidation
+were observed at both apices of the lungs.
+
+It is remarkable that, notwithstanding the serious degree of cardiac
+mischief indicated by the above signs, the patient, a very few days
+later, took a walk of some ten miles, and, though much exhausted,
+suffered no recurrence of his formidable spasmodic symptoms in
+consequence of this imprudence. He was sent to the mild climate of
+Mentone, and subsequently to Nice; the angina never recurred, but the
+patient remained weak, and liable to more or less dyspnoea for fifteen
+or sixteen months; now he lives an ordinary life, doing his duty as a
+Swiss citizen and officer. The cure of some haemorrhoids, about twelve
+months after the anginal attack, seemed greatly to benefit him. What the
+future of this case may be it is impossible to say, but of course there
+is no security against the angina recurring on extraordinary excitement
+or over-exertion.
+
+Of the purely neurotic variety of angina it is impossible to determine
+the frequency; but it seems certain that the affection is common, and I
+suspect that it occurs more often than is supposed, as a sequel to
+asthma. The probable relationship between the two affections was long
+ago indicated by Kneeland.[8] I have certainly seen several cases of
+asthma in which spasmodic pain of the heart has occurred on various
+occasions after or during a very severe asthmatic paroxysm. One case was
+that of a gentleman, of a highly delicate and neurotic temperament, who
+had suffered for fifteen or sixteen years from well-marked spasmodic
+asthma: this case is remarkable as an illustration of several points
+which will be dwelt upon in other parts of this volume. For some time
+before the outbreak of cardiac neuralgia, he had suffered repeatedly
+from severe facial neuralgia, and these attacks on more than one
+occasion culminated in facial erysipelas, or what was entirely
+indistinguishable from that affection. He then began to suffer from
+cardiac pain and spasm after his asthmatic paroxysms, and these new
+symptoms speedily assumed the form of a very severe intermittent angina:
+in several of the attacks he appeared about to die. The pain in these
+attacks is very severe; it occupies a large area in the centre of the
+chest, and runs down both arms; and, what is strange, the arms become
+remarkably swollen and hot after an unusually long bout of pain, I
+presume from vaso-motor paralysis. At present (nearly five years from
+the commencement of the cardiac neuralgia) the cardiac attacks, though
+of frequent occurrence, are decidedly more tolerable than they were at
+first, and the sense of squeezing or pressure, though never quite
+absent, does not amount to the dreadful sort of feeling which used to
+convince the patient that he was at the point of death. In this case,
+the heart has been repeatedly explored without any positive result, and
+the pulse has been frequently tested by the sphygmograph. The latter
+instrument is the only mode of examining by which I have been able to
+elicit even suspicious evidence that there is any organic change of the
+heart; by means of it I have lately obtained some grounds for suspecting
+that there is slight dilatation of the heart, but it is uncertain
+whether anything of the kind existed at the commencement of the anginal
+symptoms. In this case I am inclined, on the whole, to doubt whether the
+angina will ever prove fatal, unless the bronchitis, with which the
+patient's asthma has for some time past been liable to be complicated,
+should occur in a severe form; in that case it is likely that the
+additional embarrassment of the heart's action may bring on fatal
+spasms.
+
+One of the best examples I ever saw of cardiac neuralgia (ultimately
+proving fatal) was one of which the origin was entirely nervous. It
+occurred in a gentleman in the prime of life, and naturally of a
+powerful physique, whose very active and capacious mind had been greatly
+overwrought. The whole weight of responsibility for an undertaking of
+national importance, and which involved great difficulties and much
+anxiety, for a long time rested on his shoulders. Under these influences
+he broke down, and never effectually recovered himself. At first, the
+symptoms were those of mere ordinary nervous exhaustion, but after a
+time he became subject to frequently recurring attacks of agonizing
+spasmodic heart-pain, with a sense of impending dissolution; from these
+he was invariably relieved by the inhalation of a small amount of
+chloroform. Not the slightest organic heart mischief could be detected,
+either during life or after death.
+
+_Pathology._--Angina stands in so peculiar a position that I deem it
+well to discuss it as a whole, and not merely its clinical history, in
+this place. As I have already said, there is nothing in the morbid
+appearances found after death which is characteristic of fatal angina,
+and in the milder kinds of cardiac neuralgia we are driven back upon the
+general probabilities which we deal with in reasoning as to the origin
+of neuralgias in general. As to morbid changes, it is impossible to say
+any thing more exhaustive of the facts known than the following words of
+Dr. Walshe:[9] "First, there are few, if any, structural diseases either
+of the heart, its orifices, and its nutrient arteries, or of the aorta,
+found recorded in the narratives of the post-mortem examination of
+different victims of angina pectoris. Secondly, there is no conceivable
+disease of these structures and parts which has not in various
+individuals reached the highest point of development, without anginal
+paroxysms, even of a slight kind, having occurred during life; to this
+proposition extensive calcification of the coronary arteries perhaps
+furnishes a solitary exception. Thirdly, the organic changes most
+frequently met with have been fatty atrophy and flabby dilatation of the
+heart; obstructive disease of the coronary arteries by atheroma and
+calcification of the orifice and arch of the aorta. Fourthly, the rarest
+have been hypertrophy and hypertrophy with dilatation. In truth, it may
+be doubted whether these conditions in their genuine form, without any
+combination of fatty atrophy, have ever been the sole morbid states
+present." From all this Dr. Walshe concludes that the fundamental
+mischief of angina is neurotic; and, while he believes that some
+textural change in the heart is necessary as an irritant to generate
+this neurotic susceptibility to dynamic disturbance from slight causes,
+he recognizes only one common quality in these various cardiac lesions,
+viz., that they indicate mal-nutrition and weakened power. Dr. Walshe
+does not appear to believe the neurotic disturbance can arise without
+the kind of irritation which is kept up by such cardiac changes. In
+spite, however of the great authority of this author, it certainly seems
+very probable that organic cardiac change is by no means necessary to
+the occurrence of angina, and this for two reasons: In the first place,
+though full reliance may be placed on the details of the post-mortem
+examinations made by Dr. Walshe himself, they are very few (twelve or
+fourteen) in number; and other observers who have recorded cases are as
+little trustworthy, considering their evident tendency to find some
+disease where none exists, as the older narratives which Dr. Walshe
+naturally distrusts were unreliable when they declared that no morbid
+change was present. And, secondly, his view hardly takes it into account
+that there are still two other alternatives, even supposing that one or
+other of the above changes is always present: (_a_) it is possible that
+the neurotic disturbance and the cardiac lesions might both be the
+result of a common cause; and (_b_) it is even possible that the
+alterations of tissue in the heart and vessels are due to a morbid
+influence proceeding from a diseased nervous centre, either spinal or
+sympathetic.
+
+As for the state of the muscular fibre which immediately causes death,
+Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and
+he urges in favor of this view the fact that in his large experience he
+has never known the pulse to intermit during the attack--it was always
+regular, however feeble. In this respect he is in opposition to some
+distinguished authors, however, and, as he allows that he has not seen
+original attacks in their height, but only when they were subsiding, it
+would be possible that the spasm stage had subsided. However Dr. Walshe
+admits that there may be exceptional cases in which spasm, or cramp (_i.
+e._, spasm with rupture or dislocation of fibre), really occurs, and
+suggests that this is very probable in the rare cases where death is
+attended by general tetanic spasm of the muscles. As far as my own
+opinion is worth anything, I could insist that at least Dr. Walshe must
+be right as against Dr. Latham and Dr. Inman, in affirming that cardiac
+cramp, if it occurs, is the consequence and not the cause of the
+neuralgic pain.
+
+_Causes._--In some respects it is impossible to deal with the etiology
+of angina apart from the pathology, just as we remarked with regard to
+neuralgias in general. But there are certain special features in the
+causation of angina pectoris which require separate notice, just as
+there are special features in its pathology.
+
+Of predisposing causes, the majority are the same as those of which we
+have spoken in our general remarks on the etiology of neuralgia. A
+family history of a tendency to the graver neuroses is I believe
+universal, and, indeed, direct inheritance of angina from father to
+son, as in Arnold's case, has happened in many recorded instances. A
+very remarkable fact is the time of life at which the disease originally
+appears: Walshe says it is rare before the age of fifty, but excessively
+rare before forty. This is very interesting, as placing angina in the
+same category with the severe and intractable forms of facial and other
+neuralgias which are so highly characteristic of the period of bodily
+degeneration. One may even gather a suspicion, though it goes but a
+short way toward proof, that the essence of angina is an atrophy either
+of the cardiac plexus or of the nucleus of the vagus, or of that part of
+the spinal cord, already mentioned, which seems to be the centre of the
+major part of the propulsive force of the heart.
+
+On the other hand, there is a fact, even more remarkable than the
+influence of age, which tells somewhat in a contrary direction. There is
+a most extraordinary preponderance of males among the victims of angina.
+Sir John Forbes found eighty males among eighty-eight patients suffering
+from this disease. On the first blush it would seem natural, indeed
+almost necessary, to explain this by supposing that, as men take a much
+larger amount of strong physical exercise than women, they will furnish
+a much larger proportion of subjects in whom an ill-nourished heart will
+break down under its work and be seized either with paralysis or cramp
+(for the two states are, after all, not opposed to each other, but only
+varying shades of debility.) Upon this theory one would have to believe
+that the origin of angina was far more peripheral than central, if we
+are to suppose that spasm is the ordinary condition of the heart during
+the anginal paroxysm. But we do not know that this is the case; indeed,
+there are many arguments against it; and at any rate we must suppose
+that in a considerable number of cases the muscular state is one of
+relaxation from want of power. And certainly it is infinitely more
+probable that paralysis or spasm of a muscular viscus should occur as a
+reflex consequence of neuralgia occurring in a nerve whose central
+nucleus was closely connected with the motor centre of the organ, than
+that mere paralysis of the viscus should convey a reflex impression to
+sensitive nerves which should express itself in the form of acute pain.
+It must be confessed that the matter hangs in doubt; but the evidence
+is, on the whole, very strong for the belief that central nervous
+mischief is the most important element in angina.
+
+Another very important class of predisposing causes of angina is the
+mental emotions. It is notorious that the disease is one not common in
+humble life; it chiefly assails the more cultivated class, and
+especially men who are much engaged in affairs in which great mental
+anxiety or emotion is mingled with severe toil of intellect. Thus the
+professional class has always shown a sad predominance in tendency to
+this disease; a large number of the victims have been found among
+overworked clergymen, lawyers, doctors, engineers, etc. The various
+forms of heart-lesion which have been already mentioned must doubtless
+be considered highly predisposing, when there is already a neurotic
+susceptibility, more especially those which, like fatty degeneration of
+the muscular structure, greatly enfeeble the heart's action. I do not
+believe that these diseases will cause angina in a person who is free
+from the peculiar nervous susceptibility.
+
+The immediately exciting causes are very various. The most common of all
+is doubtless some exertion of body, or distress of mind, which at once
+agitates and embarrasses the heart's action; and, where the tendency to
+cardiac neuralgia has once declared itself by an actual attack, very
+slight excesses of this kind will usually suffice to re-excite the
+paroxysm. Sexual excitement is particularly provocative of the attacks,
+in the predisposed. But much slighter causes suffice, in those cases
+where the irritability of the cardiac nerves has become very intense:
+thus a mere puff of cold air upon the face, and other similar slight
+peripheral impressions, by acting in a reflex manner, have frequently
+produced the paroxysm. I have seen an extremely severe anginal attack
+brought on by the slight shock of the sudden slamming of a door. And it
+would even appear that some peripheral excitements of a powerful kind
+may operate with such force as to generate angina in persons who are
+merely in weak health, but who cannot be supposed to be specially
+predisposed to angina; it is in this way, I presume, that we must
+explain the extraordinary occurrence, reported by Guelineau,[10] of an
+epidemic outbreak of angina, in which numbers of men, belonging to a
+ship's crew, were simultaneously affected. The men had been badly fed,
+and their quarters were very unhealthy; but the powerful exciting cause
+seemed to be the rapid change from a very hot to a very cold climate.
+Not only were there many cases of severe angina, but other forms of
+neuralgia, and severe colics, were observed in others of the crew. Among
+the sources of peripheral irritation which ought to be particularly
+considered, in relation to angina, are the diseases and injuries which
+produce powerful irritation of the branches of the trigeminus. Lederer's
+cases[11] of violent vomiting and cardiac pain, from the operation of
+pivoting teeth, and Remak's instances[12] of violent palpitation and
+cardiac distress, produced by disease of the last molar tooth, seem to
+show that, both through the vagus and the sympathetic, the most
+powerful reflex action may be produced in the heart and stomach by
+irritation of the fifth cranial.
+
+Another occasional excitant of angina is an interesting link in the
+chain of proof that angina is _au fond_ a neuralgia, namely, the
+malarial poison, which has in a good many well-observed cases distinctly
+induced the disease.[13] Finally, the occasional influence of excessive
+tobacco-smoking in producing anginal attacks, in persons not affected
+with any discoverable organic heart-disease, affords the strongest
+corroborative evidence of the essentially neurotic character of angina
+pectoris. M. Beau[14] has recorded many serious, and some fatal, cases
+from this cause. Probably in both the malarial cases and those induced
+by tobacco-poisoning the special neurotic tendency existed already.
+
+_Diagnosis._--The diagnosis of angina pectoris, in those severe forms
+with which the popular idea of the disease is chiefly connected, can
+hardly be a matter of much difficulty. When we see an elderly man lying
+in a state of deathly collapse, which has suddenly come on, with cold
+sweats and nearly extinguished pulse, gasping for breath, and
+complaining of intolerable pain in the chest and arm, and a sense of
+oppression more dreadful, even, than the pain, we can hardly doubt that
+the case is angina in its worst form. On the other hand, when a young
+person, especially a young female, complains even of very severe pain in
+the cardiac region, together with breathlessness, especially if the
+heart be palpitating and the face flushed, the diagnosis, though not
+immediately certain, already very strongly indicates the probability
+that the case is not one of primary cardiac neuralgia at all. These are
+extreme instances, however. In more doubtful cases, the following are
+the principal materials for decision:
+
+        _Affirmative Signs._                  _Negative Signs._
+
+  1. Age over forty.                  1. Age under forty.
+
+  2. Male sex.                        2. Female sex.
+
+  3. Nervous temperament (personal    3. Temperament either not nervous
+      and family) without marked          at all, or markedly hysterical
+      hysteria or hypochondriasis.        or hypochondriacal.
+
+
+  4. Existence of arterial            4. No signs of arterial
+      degeneration.                       degeneration.
+
+  5. Existence of valvular disease    5. No discernible valvular
+      of the heart.                       disease.
+
+  6. Extension of the pain to         6. Heart sounds clear and strong.
+      one or both arms.
+
+  7. Vivid sense of approaching       7. Pain fixed to one spot and
+      dissolution.                        increased or relieved by
+                                          muscular movements of the
+                                          painful parts.
+
+                                      8. Pain running round one side,
+                                          but not extending to shoulder
+                                          or arm.
+
+It is scarcely necessary to say that no single one of the above signs is
+individually of positive worth for the decision, which must be made
+after a careful review of the comparative arguments, _pro_ and _con_.
+The disorders with which angina is most likely to be confused are (1)
+Myalgia of the intercostal or pectoral muscles; (2) intercostal
+neuralgia; (3) acute commencing pleurisy. Either of these may very
+perfectly simulate the more formidable disease, as regards the two
+elements of acute pain and catching of the breath; but the condition of
+the circulation, taken together with the consideration of the above
+named points, will generally decide the question. Especially important
+is the deep persuasion of impending dissolution, when present, as a
+positively affirmative symptom.
+
+It should be born in mind that, if we are summoned to a patient's
+assistance, and have no previous history to guide us, our diagnosis, to
+be useful, must be rapid; and it is always better to err on the side of
+angina than in other directions, and to employ remedies boldly in that
+sense, if there be any reasonable ground for believing the case to be of
+that nature. A more mature and careful diagnosis may be made when the
+patient has recovered from the severe symptoms of the paroxysm.
+
+_Prognosis._--The prognosis of cardiac neuralgia is at best doubtful,
+and, in many cases, positively bad in the highest degree. If the attacks
+occur for the first time in a patient who has passed middle life, and is
+physiologically old for his age, _i. e._, shows tendency to degenerative
+changes of vessels, arcus senilis, gray hair etc., they are of very
+gloomy import; more especially if any signs exist which make a fatty
+change in the ventricle probable, or if there be serious valvular
+lesions. The probability here is greatly in favor of a speedy fatal
+termination; if the first attack does not kill, a second or third very
+probably will; at any rate, the patient is not likely to survive any
+considerable number. If the attack occurs in a younger person, in whom
+there is not much likelihood that arterial degeneration has seriously
+commenced, or the heart-muscles become fatty, more especially if the
+attacks have been brought on by such an accidental circumstance as a
+very exhausting bout of mental or physical toil, then there is
+considerable reason to hope that the disease may soon wear itself out.
+Even patients who have serious valvular lesions may, with young and
+undegenerated tissues in their favor, quiet down again into a regular
+habit of semi-health, in which they may live for a long time without
+any recurrence of cardiac neuralgia. The more purely neurotic form,
+again, especially when it develops gradually out of some pre-existing
+chronic neurosis, such as asthma, is usually slow in its progress; and
+it may well happen, in such cases, that the danger to life is more on
+the side of serious nervous lesions than from the anginal attacks
+themselves. At the same time, it must be remembered that, even in the
+milder cases, any very unusual excitement, bringing on an unwontedly
+severe attack, may produce fatal results at any period of the disease.
+
+There is some reason to believe that cardiac neuralgia is occasionally
+produced in a reflex manner in consequence of a severe existing
+intercostal neuralgia. I cannot say that I have witnessed any thing
+which can be considered as completely proving this; but it certainly
+seems likely that, in some of the few cases of excessively painful
+herpes zoster which have proved fatal (of which I have given one
+example), cardiac spasm or paralysis may have been secondarily induced,
+and may have occasioned the catastrophe. It is likely enough that, if
+this was the case, the reflex irritation operated upon motor centres
+which themselves were predisposed to take on the morbid action; but this
+again is a fresh illustration of the uncertainties to which prognosis is
+liable in a disease like angina, the very fundamental character of which
+is that, upon increase of the irritation, the gravity of the resulting
+functional affection is liable to be indefinitely and most rapidly
+increased.
+
+_Treatment._--The treatment of cardiac neuralgia is (1) prophylactic,
+and (2) palliative of the attacks.
+
+As regards the prophylactic treatment, it is unnecessary to repeat the
+remarks which we have made elsewhere upon the general principles of
+tonic and nutritive medication in neuralgias of every kind. One especial
+prophylaxis, in the case of this formidable variety of neuralgia, is
+concerned with the preservation of the heart from certain disturbing
+influences which would render the occurrence of the fit more probable.
+All violent emotions and all strong physical exercise (but especially
+such forms of it as, like boating, are well known to "pump" the heart
+severely) are to be carefully avoided. Even indigestion and flatulence
+are to be carefully guarded against since these are quite capable of
+embarrassing the action of the heart to a degree which, though it might
+be trivial in the case of ordinary health, may prove fatal by exciting a
+flabby ventricle to irregular and embarrassing contraction. It is even
+possible that the strong irritation set up by some varieties of
+indigestible food might propagate an irritation to the spinal cord which
+would produce an interbitory paralysis at once.
+
+But besides these obvious precautions against interference with the
+regular and tranquil action of the heart, there are some special
+medicinal remedies which deserve particular notice. Whether we really
+possess any means of so influencing the nutrition of the muscular tissue
+of the heart as to prevent its lapsing into a fatty degeneration, it is
+impossible to say; but this may be affirmed with some confidence, that,
+in cases where awkward threatenings of cardiac neuralgia have occurred,
+and simultaneously it has been noticed that the heart-sounds become weak
+and the circulation languid, a most marked improvement has been produced
+in all respects by the administration of iron and strychnia. I usually
+give tincture of sesquichloride of iron, ten minims, and strychnia,
+one-fortieth of a grain, three times a day. Still better, where it can
+be borne, is the syrup of the triple phosphate of quinine, iron, and
+strychnia, which undoubtedly has an extraordinary influence upon tissue
+nutrition, as exemplified in its remarkable effects in many cases of
+phthisis. It must be observed, however, that it is not every neuralgic
+patient who will bear the combination of quinine with iron; it has
+occurred to me to meet with several in whom the union of these two
+remedies proved violently disturbing to the nervous system, causing
+distressing headache and palpitation of the heart, which could not be
+attributed to any want of care in the apportioning of the dose, or in
+the mode of administration. Iron is more especially indicated, of
+course, in cases where there is anaemia; but there are some cases in
+which strychnia given alone seems to produce a very beneficial
+influence. (_vide_ Chapter V., on "Treatment.")
+
+By far the most important prophylactic tonic against cardiac neuralgia,
+however, is arsenic. That this drug should prove useful in cardiac
+neuroses might readily be anticipated from its very great utility in
+many cases of asthma, a disease which, as already remarked, has a close
+relationship to the former. Dr. Philipp has recently recorded a case
+which is perhaps an extreme instance of this beneficial influence of
+arsenic, but is none the less encouraging, especially as it only
+corroborates what has been advanced by other observers. Given in doses
+of from three to five minims of Fowler's solution, twice or thrice
+daily, arsenic is an invaluable remedy in cardiac neuralgia; the one
+objection to it being that some neurotic patients possess such an
+irritable intestinal canal that the remedy cannot be borne, as it
+produces diarrhoea. Even here we may sometimes succeed by combining it
+with very small doses of opium. It is more especially with regard to
+those cases in which the neurotic character of the disease is very
+prominent--_i. e._, in which the nervous temperament of the patient
+betrays itself in other ways besides the tendency to spasmodic
+embarrassment of the heart's action, that arsenic holds such a very high
+place as a remedy. And it should be carefully remarked that the
+prophylaxis of angina extends itself, in such cases, beyond the limits
+of actually-declared and well-defined angina, which is, of course, an
+uncommon disease. This remedy is important, and may be most usefully
+employed in the far larger group of cases in which a marked tendency to
+spasmodic pain in the chest, on the occurrence of some comparatively
+trifling excitement, is observed in patients who either have some
+organic heart-disease, or who are liable to severe attacks of asthma. It
+cannot be too often repeated that there is no intelligible separation,
+except one of degree, between these cases and the malignant forms of
+angina. It may be added that, in my experience, I have found the whole
+group of cases to be bound together in a singular way by the tolerance
+of arsenic which, with certain exceptions already referred to, they
+display. Commencing with the small doses above mentioned, I have found
+it possible, in many cases, to advance to the administration of twice or
+thrice the quantity, and to continue this medication for months
+together, not only with no evil effect, but with the best results.
+
+Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but
+little. Truth to say, it is a nervine tonic of occasional great value,
+but which, on the whole, I have found so unreliable that I am somewhat
+prejudiced against it; and perhaps have not given it a fair trial in
+those milder cases of cardiac pain to which it might be suited. It does
+appear, however, to have some preferential action on the vagus, and
+might therefore be possibly more useful than I am at present inclined to
+think it.
+
+The treatment of the acute neuralgic stage itself is a matter in which
+we are sadly limited by the exigencies of the case. Relief must be
+excessively rapid if we are to save life in the most threatening cases,
+or to deliver the patient from a most prostrating agony, which might
+have lasted for hours, in other instances.
+
+The remedy which the highest authority, Dr. Walshe, seems to put first
+in efficacy is opium; and he directs the dose to be measured by the
+intensity of the pain, as much as forty to sixty drops of laudanum being
+given in a severe case. He says, however, that it should be given with
+an antispasmodic, such as brandy, or ether, or sal-volatile; and I
+confess that I believe the antispasmodic treatment to be by far the most
+important. Indeed, so marked is the success which I have found to attend
+the use of ether in the paroxysm, that till lately I scarcely cared to
+make further experiments, with drugs, for the relief of the patient at
+this stage. One teaspoonful of ether in two ounces of thickish mucilage
+should be given at once, and repeated in a short time if the patient
+does not rally.
+
+In a few instances, angina seems to be provoked by the irritation of
+indigestible food, and when there is good reason to suspect this an
+emetic should be given. I strongly recommend that mustard should be
+used for this purpose, for the effect of a mustard-emetic is by no means
+merely to empty the stomach, it has a powerfully rousing influence on
+the heart.
+
+Upon the subject of the inhalation of chloroform for cardiac neuralgia,
+I have only to say that, though I have seen it usefully employed, I
+should not, with my present experience, ever think of employing it
+myself. Every possible advantage which it could give is obtained by the
+internal use of ether, and many serious dangers are avoided, which would
+attend the use of chloroform. For it must be remembered that the only
+kind of chloroform inhalation which would be useful would be that in
+which a carefully measured small dose of a weakly impregnated atmosphere
+should be inhaled, and, without large experience in the administration
+of chloroform, the practitioner will be unable to secure this effect
+with certainty. And the effect of a powerfully-charged atmosphere,
+breathed only once or twice even, would be instantaneously fatal.
+
+Hot epithems to the epigastrium are probably of some use, and besides
+this the temperature of the body should be carefully kept up by hot
+bottles to the feet, hot tins to the epigastrium, etc. Brandy should be
+freely administered during the attack, if we cannot immediately obtain
+either ether or a remedy now to be mentioned. I refer to the nitrite of
+amyl, which, at the time when the first part of this chapter was
+written, I had not had the opportunity of testing.
+
+Nitrite of amyl is a highly-vaporizable fluid, which possesses the
+following remarkable physiological action: the inhalation even of a very
+small quantity is followed, after a minute or so, by a sudden
+acceleration of the heart's action, accompanied by intense crimson
+congestion of the vessels of the face and conjunctiva, and a sense of
+enormous fulness in the head; these phenomena are extremely fugitive,
+passing away completely in two or three minutes, unless the inhalation
+is renewed. These characteristic effects had for some years been
+experimentally exhibited by Dr. Fraser and others, but the practical
+application of amyl to the treatment of angina was first suggested, I
+believe, by Dr. Brunton, in the case of a patient under the treatment of
+Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The
+angina was in this case symptomatic, there being advanced valvular
+disease of the heart. Comparative examinations with the sphygmograph,
+during the intervals and during the paroxysms, made strikingly manifest
+the fact that, during the attacks, there was an increase of arterial
+tension which was directly proportionate to the severity of the pain and
+cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that
+nitrite of amyl, by relaxing the systemic arteries, might remove the
+unnatural tension, and give relief to the pain; and the result confirmed
+this hope. Doses of five and ten drops were inhaled from a towel, with
+the uniform result of at once quieting the pain; it might return in a
+few minutes, but a second dose usually removed it entirely for many
+hours. Various other cases have since been reported, in which similar
+relief was obtained, and I had occasion to employ it myself in one
+instance. The gentleman whose case has been related above (see page
+101), as an example of the relief obtainable by the use of ether began
+to suffer rather more severely from his attacks than had been the case
+for some time, toward the end of the year 1869. I now determined to try
+the amyl, and accordingly left a small bottle containing half an ounce
+of it in his possession, with exact instructions to the following
+effect: On the first symptoms of a paroxysm of angina, he was to get the
+bottle open, and as soon as their character was fully declared he was to
+put the bottle to one nostril (closing the other with the finger, and
+keeping the mouth shut) and take one long, powerful inspiration. The
+result of his first experiment was very remarkable: the first sniff
+produced, after an interval of a few seconds, the characteristic
+flushing of the face and sense of fulness of the head; the heart gave
+one strong beat, and then at once he passed from the state of agony to
+one of perfect repose and peace, and at his usual bedtime slept
+naturally. This experience was repeated on several occasions, and for a
+considerable time the patient retained such full confidence in the
+remedy that he discarded all use of ether, and greatly reduced his
+allowance of stimulants, with very marked benefit to his appetite and
+general health. The new remedy did not lose any of its power by
+repetition, but unfortunately the patient at last conceived a horror of
+it, which caused him to abandon its use. So distressing and alarming to
+him was the sense of fulness in the head produced by the amyl, that,
+notwithstanding his certain knowledge that he could at once cut short a
+paroxysm, he could not persuade himself to continue its use, and for
+some time past he has returned to the use of the ether and (though in
+less quantities than previously) of the brandy, for this purpose. And
+here it must be remarked that this objection, although probably needless
+in the case of this particular patient, may have real importance in
+certain circumstances. The admirable physiological researches of Dr.
+Brunton leave no doubt that the effect of inhalation of amyl is to
+relax, very suddenly, the tonic contraction of the systemic arteries,
+and in the case of the brain it would appear that a serious strain must
+be suddenly thrown upon the capillary net-work. This being the case, it
+appears likely that, where the atheromatous change has considerably
+invaded these delicate vessels, they might prove too brittle to stand
+the sudden distention, and a rupture and consequent cerebral haemorrhage
+might ensue. This suspicion, then, that such pathological changes exist,
+ought to seriously affect our judgment as to the administration of
+amyl; and this suspicion ought to be always entertained, _prima facie_,
+in the case of patients who have much passed the age of fifty, more
+especially if they have gray hair and an arcus senilis, or if the
+sphygmograph yields a pulse-trace of the decidedly square-headed type,
+or if they have been long addicted to alcoholic intemperance. In such
+patients I should be disinclined to allow the use of amyl.
+
+[Although I have thought fit here to give an outline of angina pectoris
+as a connected whole, I shall have occasion to recur to the subject
+again under the heads of Pathology and Treatment of Neuralgias in
+General.]
+
+_Gastralgia._--Neuralgia seated in the stomach itself is not to be
+distinguished with accuracy from neuralgic pains occupying one or other
+of the neighboring nervous plexuses. It must be remembered that not
+merely is the stomach itself copiously supplied by the pneumogastric
+nerves with afferent fibres, but the great solar plexus is close behind
+it, the coeliac plexus springs from the fore part of the latter, and
+these, with the coronary and superior mesenteric plexus, may all be said
+to be well within the region in which "gastralgic" pain is felt. It is
+not particularly important, however, in my opinion, to make any very
+exact diagnosis here, as to the site of the pain, since all these
+neuralgias must be considered to belong to the pneumogastric nerve, the
+branches supplied from which are probably the sole means by which these
+plexuses become the seat of neuralgia.
+
+Abdominal pneumogastric neuralgia is an extremely distressing and
+occasionally a very intractable disorder. The subjects of it are almost
+invariably in a state of marked and evident debility, and inquiry
+generally elicits the fact that they have suffered at other times from
+neuralgia elsewhere than in its present seat. By far the most common
+history of previous affections of this kind is that of trigeminal
+neuralgia, especially of the supra-orbital branch; and it has several
+times occurred to me to observe the direct sequence of a gastralgia upon
+a unilateral browache. Anaemia is a specially frequent attendant of
+gastralgia, more so than of other neuralgias. Women are, by the general
+consent of authors, more liable to gastralgia than men.
+
+The special mark of true neuralgic pain in the abdominal pneumogastric,
+as distinguished from other deep-seated pains in the epigastrium, is the
+remarkably direct relation of its severity to the patient's exhaustion,
+particularly in regard to the weakness induced by want of food. While
+the great majority of dyspeptic pains are increased by filling the
+stomach, gastralgia, on the contrary, is invariably relieved by food,
+often most strikingly and completely. Pressure from without, also, while
+it aggravates most pains dependent on local organic mischief, nearly
+always more or less relieves gastralgia. Equally striking is the comfort
+given by stimulants, especially by hot brandy-and-water; in this respect
+gastralgia resembles colic. There is something special in the degree of
+mental depression which attends gastralgic pain. In this it resembles
+the pains of hypochondriasis, but there is a resilience of the spirits
+when the pain has been relieved which is not seen in the latter
+affection. A very frequent complication of gastralgia is severe
+palpitation of the heart, but during the paroxysm itself the pulse,
+whether rapid or not, is commonly small, at first tense, and afterward
+soft, but not acquiring any considerable volume till the pain has
+ceased.
+
+So severe is the pain, and so complete the mental and physical
+prostration in bad attacks of gastralgia, that the first aspect of the
+patient might suggest--indeed often has suggested--the occurrence of
+gastric or duodenal perforation; but, as soon as the paroxysm is over
+all the alarming appearances vanish, leaving only a certain amount of
+tenderness on deep pressure. In the more typical cases there are no
+signs of dyspepsia whatever, no fulness nor excessive redness of the
+tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the
+neuralgic affection is complicated with more or less gastric catarrh;
+but this is a much rarer occurrence, in my experience, than some writers
+would lead one to believe; and, moreover, where a certain amount of
+organic disorder of the stomach is observed, it is usually a mere
+secondary result of the neuralgia. The most severe example of gastralgia
+which I ever saw was entirely unaccompanied by dyspepsia; this patient
+absolutely attempted suicide to escape from his agonizing pains, which
+recurred with the greatest frequency and obstinacy, but were at last
+entirely removed by strychnia. In another patient whose very interesting
+case will be again alluded to under the head of Complications of
+Neuralgia, violent abdominal pneumogastric pain was succeeded by a
+severe attack of trigeminal neuralgia, accompanied by inflammation of
+the eye, which inflicted irreparable damage; here, too, the gastralgia
+was entirely uncomplicated by any other stomach-symptoms.
+
+_Cerebral Neuralgia._--We enter, here, on an extremely obscure and
+doubtful subject: Can there be pain in the central masses of the
+encephalon? There are undoubtedly a not inconsiderable number of cases
+of pain, neuralgic in type on the whole, in which the suffering cannot
+be referred to any recognizable superficial nerve. It seems deeply
+situated within the cranium. I have also quoted cases of Dr. Hillier's
+in which not merely was there deep-seated headache in children, but
+there was something like a characteristic general change observed in the
+brain-tissues after death, viz., a great moisture and softness of
+texture. Notwithstanding all this, I am not convinced, nor indeed much
+disposed to believe, that pain is ever felt in the structure of the
+brain; I rather believe that, in the cases where this seems to occur,
+the pain is either in the intracranial portion of the nerve trunks, or,
+far more probably, in the twigs of nerves that are distributed to the
+cerebral membranes. In that case they are, strictly speaking, only
+varieties of neuralgia of the fifth nerve, and might have been properly
+discussed under that heading; but it is more convenient to speak of them
+apart, since their phenomena present considerable differences from those
+of the external neuralgias of the head and face.
+
+I have now seen several of these cases of intracranial neuralgias, and
+very perplexing and (at first sight) alarming they certainly are. The
+first of these cases came under my care in 1868. The patient was a
+single lady who had greatly over-tasked an intellect that was not,
+perhaps, originally very strong, by trying to do hack literature on
+conscientious principles; insisting, for instance, on knowing something
+about every subject she wrote upon. Her age was thirty-eight when she
+applied to me; menstruation was scanty but regular; and, on the whole,
+she could not be said to have passed an unhealthy life, although
+"nervous-headaches" and "sick-headaches" had occasionally beset her.
+This time the trouble seemed to be more serious. Ten days before
+applying to me, she had awaked in the morning with a feeling that
+something was very wrong in her head; there was not so much pain as a
+dull, brooding sort of weight, felt deeply within the cranium, and
+rather anteriorly. This had not lasted many hours when she was seized
+with a sensation of intense cold, amounting almost to rigors, and then
+before long was suddenly attacked with acute splitting pain in the same
+situation as the feeling of weight already mentioned had occupied. This
+pain, which came and went, or rather intensified and remitted, without
+ever completely ceasing, lasted about two hours, and then rather
+suddenly disappeared, leaving the patient with a deep "bruised and sore
+feeling in her brains." The pain recurred about the middle of the next
+day, lasting for several hours, and again leaving behind it the sore
+feeling. Day by day the paroxysms returned, and, on the day before her
+visit to me, the patient had, she told me, been driven frantic by her
+sufferings and had become actually delirious. Her appearance, when I
+first saw her, was wretched; the face haggard, both eyes sunken and
+surrounded with deep rings of dusky pigment, both conjunctivae bloodshot,
+the whole face almost earthy in its pallor. At that hour (11 A. M.) the
+pain had not positively recommenced, but she was in momentary dread of
+its recurrence. She complained of giddiness, muscae volitantes, and great
+feebleness of vision, and dreaded attempting to read, as the mere effort
+of fixing her eyes on anything intently caused flashes of fire before
+them. It was difficult at first to believe that there was not some
+serious organic brain-mischief; but on the whole I concluded that there
+was an absence of any genuine symptoms of such disease. At the same
+time, the pain was decidedly not referred to any cutaneous sensory
+nerve; and on the whole it appeared probable that the affection was
+intracranial. There remained the diagnosis of meningeal neuralgia, and
+to this I provisionally made up my mind. The opinion that the pain did
+not depend on any fixed organic disease was decisively justified by the
+results of treatment. One-sixth of a grain of morphia was injected on
+the occasion of the first visit, and this was repeated every day, and
+sometimes twice a day, for a fortnight; by this sole means, with rest,
+quietude, and light nourishing food, the patient was brought to
+comparative convalescence. The injections were then gradually
+discontinued, and she got quite well.
+
+In a second case, which presented itself in the out-patient room at
+Westminster Hospital, a young man of markedly-nervous temperament, who
+had been somewhat given to drink, complained of similarly deep-seated
+intermittent pain, which he referred, however, to a point nearer the
+back of the head. He suffered, also, from vertigo, especially after
+unusually long paroxysms. Blisters to the nape of the neck, and a few
+subcutaneous injections of morphia, removed the pain and the vertigo
+completely.
+
+A third example was that of a gentleman, aged thirty-four, who was sent
+over from the neighborhood of Sydney, Australia, to see me. Here, also,
+there was deep-seated intracranial neuralgic pain of the most severe
+kind, which greatly alarmed his local medical attendants; and it was
+only after a great many remedies had been tried that one medical man
+gave the opinion that the disease was "neuralgia of the membranes of the
+brain," and employed the hypodermic injection of morphia. This treatment
+at once gave great relief, though the pain had been so severe as to
+cause delirium on several occasions. In order to get thoroughly
+re-established, he was sent to England, and desired to consult me. As
+was expected, the voyage proved of the greatest service, as he hardly
+suffered at all while on the water. On arriving in England he was at
+first well, but in a week or two began to feel somewhat below par, and
+one morning, feeling an attack of pain coming on, he came to me. He was
+a tall and strongly-built man, with nothing peculiar in his appearance
+except a certain languor and heaviness of the eyes. He appeared to have
+lived somewhat freely and to have smoked decidedly to excess. His
+description of the attacks left no doubt of their neuralgic character,
+and in other respects they seemed quite analogous to the other cases
+mentioned above, except in one thing, that there seemed a good deal of
+evidence tending to show a bad local influence in the air of that part
+of Australia where he usually resided. Almost any change from that had
+always done him good, though nothing had done anything like so much as
+the voyage to England. On the occasion of his first visit to me I
+injected him with one-sixth grain acetate of morphia, thereby stopping
+the pain. I prescribed muriate of iron and minute doses of strychnia,
+which he took for some little time, but the pain never recurred during
+his stay in England and on the Continent. Unfortunately, as he was
+anxious to return to Australia, I permitted him to do so, after a stay
+in the Old World of only three or four months; but, very shortly indeed
+after his return to Sydney, his old complaint attacked him. This time,
+unhappily, the hypodermic morphia has proved merely palliative, and I
+have latterly heard very bad accounts from him; still, there has been
+nothing to throw doubt on the neuralgic character of the disease.
+
+In reflecting upon the anatomy of the nervous branches to the dura
+mater, I have formed the opinion that there are two situations, one
+anterior and the other posterior, in which intracranial neuralgia may
+occur; the former at the giving off of Arnold's recurrent branch from
+the ophthalmic division, near the sella turcica, the other in the
+peripheral twigs of this same branch, distributed to the tentorium
+cerebelli.
+
+_Pharyngeal Neuralgia._--A rather common and extremely troublesome form
+of neuralgia is that which attacks the pharynx. It is very much more
+common in women than in men, and especially in hysterical persons. The
+pain commonly commences in a not very acute manner; it may be felt for
+some days, or even weeks, as a dull aching, coming and going pretty much
+in accordance with the patient's state of fatigue, or of reinvigoration
+after meals, etc. Some trivial circumstance, such as a slightly extra
+degree of exhaustion, or the influence of some depressing emotion, will
+then change the type to that of decided neuralgia, which may become
+extremely severe. Nothing is more annoying, and even distressing, than
+the suffering itself, besides which there are abnormal sensations in the
+throat which almost irresistibly compel the patient to believe that
+there are severe inflammation and ulceration, and that the throat is in
+danger of being closed up. Although the pain is usually one-sided, it
+sometimes affects both sides, and is felt also at the back of the
+pharynx. The act of swallowing being painful, there is the greater
+suspicion of inflammation or ulceration, but careful observation shows
+that a large bolus of food is swallowed with as little, if not less,
+pain than a small mouthful of solids or even liquids.
+
+Pharyngeal neuralgia must, I think, be considered mainly an affection of
+the glosso-pharyngeal nerve; the evidence for this is found in the
+distribution of the pain. A slight degree of the neuralgia will only
+involve some one or two points in or behind the tonsil; but, when the
+pain is strongly developed, it will be found to radiate into the tongue,
+in one direction, and into the neck (following the course of the
+carotid) in another, besides spreading well into the region occupied by
+the pharyngeal plexus. One disagreeable reflex effect of severe
+pharyngeal neuralgia consists in involuntary movements of the muscles of
+deglutition, another is seen in the copious outpouring of thick mucus
+similar to that which collects in the pharynx and oesophagus when a
+foreign substance has become impacted.
+
+_Laryngeal neuralgia_ concentrates itself mainly in the twigs of the
+superior laryngeal branch of the pneumogastric which are distributed to
+the arytaeno-epiglottidean folds, the epiglottis, and the chordae vocales;
+more rarely a neuralgia is developed lower down, within the cavity of
+the larynx, apparently in one or more of the scanty twigs to the mucous
+membrane supplied by the recurrent laryngeal.
+
+Pure neuralgias of the larynx, like those of the pharynx, are more
+common in women, and especially in weakly hysterical women, than in men.
+They are easily excited and greatly aggravated by movements of the
+parts, and thus it happens that, among men, by far the most numerous
+subjects of laryngeal neuralgia are found among clergymen, professional
+singers, and others whose occupation compels them to strenuous and
+fatiguing employment of the laryngeal muscles. It is rather a singular
+and striking fact, however, that the so-called "clergyman's
+sore-throat," which is characterized by most unpleasant sensations, and
+by a more or less complete loss of voice, is not, in the majority of
+cases, attended with any distinct laryngeal neuralgia. It seems that a
+predisposition to neuralgia is a necessary element in the latter
+affection.
+
+FOOTNOTES:
+
+[3] "Gunshot Wounds and other Injuries to Nerves." Philadelphia:
+Lippincott & Co., 1864.
+
+[4] _Med. Times and Gazette_, March 26, 1864.
+
+[5] "London Hosp. Reports," 1866.
+
+[6] "Stimulants and Narcotics," Macmillan, 1854, p. 86.
+
+[7] Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du
+Nevralgies," Journ de Med. de Bruxelles, tome xl.
+
+[8] Amer. Jour. Med. Science. Jan. 1850.
+
+[9] "Diseases of the Heart and Great Vessels." Third edition, 1862.
+
+[10] _Gaz. des Hop._, 114, 117, 120. 1862.
+
+[11] _Wien Med. Presse_, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p.
+120.
+
+[12] Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120.
+
+[13] See Wahn, _Journ. de Med. et Chir. Prat._ 1854. Also several
+original and quoted cases in Dr. Handfield Jones's "Functional Nervous
+Disorders," second edition, 1870.
+
+[14] _Journ. de Med. et Chir. Prat._, July, 1862.
+
+
+
+
+CHAPTER II.
+
+COMPLICATIONS OF NEURALGIA.
+
+
+The secondary affections which may arise as complications of neuralgia
+form a deeply interesting chapter in nervous pathology, and one which
+has only been explored in quite recent years. The excellent treatises of
+Valleix and Romberg, written only thirty years ago, make but most
+cursory and superficial mention of these complications, and do not
+attempt to group them in a scientific manner. The reflex convulsive
+movement of the facial muscles in severe tic-douloureux had of course
+been long observed; and Valleix added the correct observation that
+gastric disturbance was often secondarily provoked in facial neuralgia,
+thus improving greatly on the old view, which supposed that, where
+trigeminal neuralgia and stomach disorder coexisted, the latter must
+have been the antecedent and the cause of the former. Still, he did not
+explain the pathological connection. And as regards certain other most
+interesting results of neuralgia, which he could not avoid meeting with
+from time to time, _e. g._, lachrymation, flux from the nostril,
+salivation, altered nutrition of the hair, he only speaks of these as
+occasional phenomena, and in no way classifies them, or explains their
+relation to the neuralgia itself.
+
+There did exist, however, one too little known work of some years
+earlier date, which, though not dealing specifically with neuralgia, and
+though based upon the necessarily very imperfect knowledge of the
+functions of the nervous system prevalent in its day, had nevertheless
+done much to lay the foundation of a comprehensive view of the
+complications of neuralgia; we refer to the work of the brothers
+Griffin, on "Functional Affections of the Spinal Cord and Ganglionic
+System," published in 1834. In this most interesting treatise, the
+record of acute and extensive observations made in a quiet and
+unpretending way by two Irish practitioners, numerous examples are cited
+in which neuralgic affections were seen to be inseparably united with
+secondary affections of the most various organs, with which the
+neuralgic nerves could have no connection except through the centres, by
+reflex action. The authors, while firmly grasping the fact of the common
+connection of the nerve-pain and the other phenomena (convulsions,
+paralysis, altered special sensation, changes in secretion, changes even
+in the nutrition of particular tissues) with the central nerve system,
+were doubtless in error in thinking that they could detect the precise
+seat of the original malady, by discovering certain points of tenderness
+over the spinal column. But their facts were observed with the greatest
+care, and can now be interpreted more intelligently than was possible at
+the time. Here, for example, is a case which forestalls one of the most
+interesting pieces of information which more recent research has made
+generally known:
+
+"CASE XXIV.--Kitty Hanley, aged fourteen years, catamenia never
+appeared; about six months ago was attacked with pain in the right eye
+and brow, occurring only at night, and then so violently as to make her
+scream out and disturb every one in the house; it afterward occurred in
+the infra-orbital nerve, and along the lower jaw in the teeth, and there
+was inflammation of the cornea, with superficial ulceration and slight
+muddiness. Tenderness was found at the upper cervical vertebrae, pressure
+on any of them exciting severe pain in the vertex and brow; but none in
+the eye or jaws, where it is never felt except at night."
+
+The above is a well-marked example of neuralgia of the trigeminus
+causing secondary inflammation and ulceration of the eye of a precisely
+similar kind to that which had been experimentally produced by Magendie
+by section of the fifth, at or posterior to its Gasserian ganglion. We
+shall see, hereafter, how extremely important are this and similar
+facts, not only in regard to the clinical history, but also to the
+pathology of neuralgia in general.
+
+The first regular attempt, I believe, to classify the complications of
+neuralgia, was made by M. Notta, in a series of elaborate papers in the
+"Archives Generales de Medecine" for 1854. We may specially mention his
+analysis of a hundred and twenty-eight cases of trigeminal neuralgia,
+which is well fitted to impress on the mind the frequency, though, as we
+shall presently see, it does not adequately represent the seriousness,
+of these secondary disorders. As regards special senses, Notta says that
+the retina was completely or almost completely paralyzed in ten cases,
+and in nine others vision was interfered with, partly, probably, from
+impaired function of the retina, but partly, also, from dilatation of
+the pupil or other functional derangement independent of the optic
+nerve. The sense of hearing was impaired in four cases. The sense of
+taste was perverted in one case, and abolished in another. As regards
+secretion, lachrymation was observed in sixty-one cases, or nearly half
+the total number. Nasal secretion was repressed in one case, in ten
+others it was increased on the affected side. Unilateral sweating is
+spoken of more doubtfully, but is said to have been probably present in
+a considerable number of cases. In eight instances there was decided
+unilateral redness of the face, and five times this was attended with
+noticeable tumefaction. In one case the unilateral tumefaction and
+redness persisted, and were, in fact, accompanied by a general
+hypertrophy of the tissues. Dilatation of the conjunctival vessels was
+observed in thirty-four cases. Nutrition was affected as follows: In
+four cases there was unilateral hypertrophy of the tissues; in two, the
+hair was hypertrophied at the ends, and in several others it was
+observed to fall out or to turn gray. The tongue was greatly tumefied in
+one case. Muscular contractions, on the affected side, were noted in
+fifty-two cases. Permanent tonic spasm, not due to photophobia, was
+observed in the eyelid in four cases, in the muscles of mastication four
+times, in the muscles of the external ear once. Paralysis affected the
+motor oculi, causing prolapse of the upper eyelid, in six cases; in half
+of these there was also outward squint. In two instances the facial
+muscles were paralyzed in a purely reflex manner. The pupil was dilated
+in three cases, and contracted in two others, without any impairment of
+sight; in three others it was dilated, with considerable diminution of
+the visual power. Finally, with regard to common sensibility, M. Notta
+reports three cases in which anaesthesia was observed. Hyperaesthesia of
+the surface only occurred in the latter stages of the disease.
+
+To Notta's list of complications of trigeminal neuralgia must be added
+the following, all of which have been witnessed, and several of them in
+a large number of instances: Iritis, glaucoma, corneal clouding, and
+even ulceration; periostitis, unilateral furring of the tongue, herpes
+unilateralis, etc. In writing on this subject three or four years ago, I
+mentioned that all these secondary affections had been seen by myself,
+except glaucoma. That is now no longer an exception; indeed, my
+attention has been so forcibly called to the connection between glaucoma
+and facial neuralgia, that I shall presently examine it at some length.
+
+The trigeminus is, of all nerves in the body, that one whose affections
+are likely to cause secondary disturbances of wide extent and various
+nature, owing to its large peripheral expanse, the complex nature of its
+functions, and its extensive and close connections with other nerves.
+Moreover, its relations to so important and noticeable an organ as the
+eye tends to call our attention strongly to the phenomena that attend
+its perturbations. But there is every reason to think that all secondary
+complications which may attend trigeminal neuralgia are represented by
+analogous secondary affections in neuralgias in all kinds of situations;
+and we may classify them in the principal groups which correspond to
+disturbance of large sets of functions:
+
+1. First, and on the whole, probably, the most common of all secondary
+affections, we may rank some degree of vaso-motor paralysis. It may be
+doubted if neuralgia ever reaches more than a very slight degree without
+involving more or less of this; for so-called points douloureux are
+themselves pretty certainly, for the most part, a phenomenon of
+vaso-motor palsy; and the more widely-diffused soreness, such as remains
+in the scalp, for instance, after attacks of pain, even at an earlier
+stage of trigeminal neuralgia than that in which permanently tender
+points are formed, is probably entirely due to a temporary
+skin-congestion. The phenomenon presents itself in a much more striking
+way in the condition of the conjunctiva seen in intense attacks of
+neuralgia affecting the ocular and peri-ocular branches of the fifth;
+one sometimes finds the whole conjunctiva deeply crimson; and, in one
+remarkable instance that I observed, the same shade of intense red
+colored the mucous membrane of the nostril of the same side. In several
+instances, I have seen a more than usually violent attack of sciatic
+pain followed by the development of a pale, rosy blush over the thinner
+parts of the skin of the leg, especially of the calf, which were then
+extremely tender, in a diffuse manner, for some time after spontaneous
+pain had ceased.
+
+2. Not merely the circulation, however, but the nutrition of tissues,
+becomes positively affected, in a considerable number of cases. It is
+difficult to judge, with any exactness, in what proportion of neuralgic
+cases this occurs, but its slighter degrees must be very common. It has
+very frequently happened to me, quite accidentally, in examining with
+some care the fixed painful points, which are so important in diagnosis,
+to be struck with the decided evidence to the finger of solid
+thickening, evidently dependent on hypertrophic development of
+tissue-elements; in severe and long-standing cases, I believe this
+condition will always be found. Probably the change is, more usually
+than not, sub-inflammatory; but it is certain, on the other hand, that
+there are great variations in the kind of tissue-changes complicating
+neuralgia, and that inflammation is no necessary element in them. This
+subject has greatly engaged my attention, and I find myself able to give
+what is probably a fuller account of the matter than any yet published
+connectedly.
+
+The following tissues have been seen by myself to become altered under
+the influence of neuralgia in nerves distributed to them, or to the
+parts in their immediate neighborhood.
+
+(_a_) The hair has changed in color in many cases. Of twenty-seven
+patients suffering from neuralgia of the ophthalmic division of the
+fifth, eleven had more or less decided localized grayness of hair on
+that side. The amount of this varied greatly, from mere patches of gray
+near the roots of the hair to decided grayness of the majority of the
+hairs over the larger part of half the head, nearly to the vertex; but
+in each case it was a change of color that did not exist on the other
+side of the head. In four of these cases there was also grayness of part
+of the eyebrow on the affected side. A very remarkable phenomenon, which
+I have sometimes identified, is fluctuation of the color, the grayness
+notably increasing during, and for some time after, an acute attack of
+pain, and the same hairs returning afterward more or less to their
+original color. My attention was first called to this curious occurrence
+in my own case. I have so often related this case [see, for instance, my
+article on Neuralgia in "Reynolds's System of Medicine," vol. ii.] that
+I shall merely recall the fact that, when pain attacks me severely, the
+hair of the eyebrow on the affected side displays a very distinct patch
+of gray (on some occasions it has been quite white) opposite the tissue
+of the supra-orbital nerve, and that the same hairs (which can be easily
+identified) return almost to the natural color when I am free from
+neuralgia. I must, however, add the very curious fact, which I observed
+accidentally in experimenting (as regards urinary elimination) on the
+effects of large doses of alcohol, that a dose sufficiently large to
+produce uncomfortably narcotic effects invariably caused the same
+temporary change of color in the hair of the same eyebrow, even when no
+decided pain was produced, but only general malaise. The subject will
+be again referred to under the heading of Pathology.
+
+Change in the size and texture of the hairs, in neuralgia, has been
+noted by Romberg and Notta, and has been several times observed by
+myself. Occasionally the individual hairs near the distribution of the
+painful nerve become coarsely hypertrophied; at times the number of
+hairs appears to multiply, but I imagine this is only a case of more
+rapid and exuberant development of hairs that would be otherwise weak
+and small. In one very remarkable instance of sciatica this came under
+my observation; the whole front of the painful leg, from the knee nearly
+to the ankle, became clothed, in the course of about six months, with a
+dense fell of hair, which strongly reminded me of similar abnormal
+hair-growths that have been occasionally seen in connection with
+traumatic injuries to the spinal cord. More commonly, the effect of
+neuralgia upon hair is to make it brittle, and to cause it to fall out
+in considerable quantities; one young lady, who consulted me for a
+severe migraine, was seriously afraid of having a good head of hair
+completely ruined in this way, but the hair gradually grew again after
+the neuralgia had disappeared.
+
+(_b_) The periosteum of bone and the fibrous fasciae in the neighborhood
+of the painful points of neuralgic nerves not unfrequently take on a
+condition of subacute inflammation, with marked thickening and
+tenderness on pressure. The most striking instance of this that I have
+seen was in a lady suffering from severe cervico-brachial neuralgia. In
+the neighborhood of the emergence of the musculo-spiral nerve at the
+outer side of the arm, there was developed what looked for all the world
+like a large syphilitic node, except that the skin was brightly reddened
+over it; this disappeared altogether some little time after the
+neuralgia had been relieved by ordinary treatment. I must say that, but
+for the peculiar circumstances of the case, putting syphilis out of the
+question, I could not have avoided the suspicion, at first, that the
+swelling was specific. But I have several times seen similar, though
+less developed, swellings in neuralgia, and in one case I noticed the
+occurrence of such a swelling on the malar bone, in an old woman in whom
+the neuralgic pain was limited to the auriculo-temporal and the
+supra-orbital branches of the fifth.
+
+A very important point is to be noted in connection with these
+sub-inflammatory swellings in connection with neuralgia. Pressure on
+them will, frequently, not merely excite the neuralgic pains in the
+branches of the affected nerve, but send a powerful reflex influence
+through the cord to distant organs, causing vomiting, for instance, or
+affecting the action of the heart in a very perceptible manner. I shall
+show, when I come to speak of the phenomena of so-called spinal
+irritation, that this circumstance has led to erroneous influences in
+many cases. These exquisitely tender points are often found where
+Trousseau places his neuralgic _point apophysaire_, namely, over, or
+very near, the spinous processes of the vertebrae. The tenderness is
+quite unlike that which is known as hysterical hyperaesthesia; it is much
+severer, and is limited to one, two, or three points, corresponding, in
+fact, to the superficial part of the posterior branches of as many
+spinal nerves.
+
+(_c_) The nutrition of the skin over neuralgic nerves is sometimes
+notably affected even when the process does not reach the truly
+inflammatory stage, which will be more particularly mentioned presently.
+A certain coarseness of texture of the skin has struck me much, in
+several cases of long-standing facial neuralgia. And there is a most
+curious phenomenon (which will be especially considered hereafter in
+regard to the singular influence of the constant galvanic current upon
+it), the distribution of a greater or less amount of dark pigment to the
+skin near the painful part. This phenomenon is much more marked during
+the paroxysms, and in the slighter cases entirely disappears in the
+intervals, but in old-standing severe cases it becomes more or less
+permanent.
+
+(_d_) The mucous membranes, in situations where we can observe them, not
+unfrequently show interesting changes, the nutrition of the epithelium
+of parts covering the painful nerve being exaggerated. It has been noted
+by various observers, in neuralgia affecting the second and third
+divisions of the trigeminus, that the half of the tongue corresponding
+to the painful nerve was covered with a dense fur. This is by no means
+universally the case, but I have seen it occur several times. In my own
+case, in which the neuralgia is limited for the most part to the
+ophthalmic division, and only rarely spreads even to the second division
+of the nerve, this does not usually occur, but I have noticed it on one
+or two occasions. And I once made the still more singular observation
+that a large narcotic dose of alcohol, which was sufficient to cause
+comparatively free elimination of unchanged alcohol in the urine, caused
+furring of the tongue, which was decidedly thicker on the side of the
+affected nerve than on the other half of the tongue.
+
+(_e_) We come now to a group of complications of neuralgia which are
+exceedingly important, and by no means adequately appreciated as yet,
+viz., the acute inflammations which directly result from neuralgic
+affections in a certain percentage of cases, probably much larger than
+has been at all generally suspected.
+
+The most familiar of the inflammatory complications of neuralgia is
+herpes zoster, the favorite seat of which is the skin which covers one
+or more of the intercostal spaces: the eruption, as occurring in this
+situation, is so well known that it would be waste of time to describe
+it. In young subjects zoster is commonly painless, at least the
+sensations are those of heat, pricking, and irritation, rather than of
+acute pain; but from puberty onward there is an increasing tendency,
+especially in those otherwise predisposed to neuralgia, for zoster to be
+preceded, accompanied, or followed by neuralgia of the intercostal
+nerves corresponding to the distribution of the eruption. Most commonly,
+the eruptive period is, in my experience, nearly or quite free from
+neuralgia, but it often recurs, or breaks out for the first time, when
+the vesicles are drying up, but more especially if, as is sometimes the
+case, especially in elderly people, the scabs fall off and leave
+superficial ulcers. Neuralgia may last, after herpes zoster, for any
+time from a few days to many weeks, and I have known it so agonizingly
+severe and so persistent as actually to kill an aged woman from sheer
+exhaustion. In spite of sundry objections that have been raised to the
+theory of the nervous origin of zoster, it appears to me that the
+evidence in favor of it is overwhelming, more especially now that it is
+proved that the disease, with all the same characteristics presented by
+it when seen on the chest or abdomen, may occur on the face (following
+the branches of the trigeminus), or on the forearm (following the course
+of nerves from the brachial plexus). Two of the severest cases of
+neuralgia attending herpes that I have ever seen were in private
+patients (whose family history, unfortunately, I had no means of
+ascertaining) who were affected, respectively, in the facial and in the
+brachial nerve-territories.
+
+A far more formidable occasional complication of neuralgia is
+inflammation affecting the eye. Mr. Jonathan Hutchinson records several
+cases in which neuralgic herpes zoster of the face was attended with
+iritis, with serious or even irremediable damage to the organ. For my
+own part, I have witnessed several instances in which neuralgia of the
+first and second divisions of the fifth has been attended with
+skin-inflammation, but only in one of these (just alluded to) did the
+inflammation present the characteristic appearances of herpes: in all
+the rest it far more closely resembled erysipelas. The skin was
+excessively reddened in an almost or quite continuous patch over the
+whole territory through which ran the painful nerves; by no means only
+linearly in the course of the nerves, though accurately limited to the
+district of the first or first and second divisions of the fifth. In the
+first case I saw (a woman, aged thirty-two), nothing could be more
+startling than the rapidity with which an irregular patch of the skin,
+including half of one cheek, the side of the nose, and a large part of
+the forehead and scalp on the same side, became converted into the
+dense, fiery-red, brawny tissue, with minute vesicles scattered over its
+surface, which looks so characteristic of erysipelas; this commenced
+immediately on the subsidence of severe neuralgic pain. During the
+erysipelatoid inflammation, though there was no spontaneous pain, the
+neuralgia could be instantly lighted up for a moment by pressure on the
+infra-orbital foramen, on the supra-orbital notch, or upon the malar
+bone, about its centre. Since that time I have seen several cases of a
+similar character; two of these, which were reported in the _Lancet_ for
+1866, I shall here reproduce: [Extensive inquiries convinced me that the
+tendency to erysipelatous complication of facial neuralgia is
+exceedingly common. Eulenburg expressly confirms my original statement
+to this effect, and extends it to all neuralgias.]
+
+CASE I.--A woman, aged sixty-three, presented herself in the out-patient
+room at Westminster Hospital, suffering from neuralgia of ten days'
+standing (which for the present, however, seemed to have abated
+considerably), but asking advice chiefly for an erysipelatoid
+inflammation which had come on a day or two before, and occupied the
+area of the painful nerve-district. The neuralgia had affected the
+supra-orbital nerve, running up toward the vortex, and the
+auriculo-temporal branch of the third division of the fifth; although
+there was no very acute pain present at this time, pressure over the
+supra-orbital notch, or at a point just in front of the ear, would at
+once cause a brief paroxysm of pain. It was curious to find that there
+was a thickened and tender spot over the malar bone (and corresponding
+to the exit of some nerve filaments from the bone) which had never been
+the seat of spontaneous neuralgia, but pressure here sent a dart of pain
+into the auriculo-temporal and supra-orbital nerves. The inflammation
+was markedly limited to the general area of distribution of the twigs of
+the auriculo-temporal and of the ophthalmic division; it was of a
+continuous deep-red color, and attended with much thickening of the
+skin. The conjunctiva was intensely congested, and there were
+lachrymation and very marked photophobia, but there were no signs of
+iritis, and no corneal clouding.
+
+CASE II.--M. W., a woman, aged forty-two, well-nourished and
+healthy-looking, married and had one child; had never suffered any
+serious ailment except once, about five years previously. She then had a
+decided attack of "erysipelas," very accurately limited to the right
+half of the face. Five months before coming to me she sustained a severe
+shock from being thrown out of a chaise, without suffering any external
+or visible damage. An hysterical tendency, which she had always
+possessed, became more marked; it revealed itself by palpitations,
+occasional dysphagia, and a disposition to weep causelessly. The menses
+were flowing at the time of the accident; they ceased abruptly soon
+after (they had been scanty for some time previously), and did not recur
+till four months later. The hysteric disturbance progressively increased
+during a fortnight, and then the patient was attacked with violent
+intermittent neuralgia, commencing in the eyeball and spreading over
+the district supplied by the branches of the first and second divisions
+of the trigeminus. The pain was accompanied by intense conjunctival
+congestion and photophobia [Dr. Handfield Jones remarks that
+photophobia, in his experience, is only a rare accompaniment of facial
+neuralgia. I have latterly come to the same opinion. Redness of the eye
+and lachrymation are very common; true photophobia uncommon. Notta's
+experience would seem to have been similar]. It lasted on the first day
+fourteen hours, and returned daily for the next fifteen or sixteen days.
+An attack of erysipelas, strictly limited to the district of the painful
+nervous branches, then set in. From that moment the neuralgic attacks
+became less frequent and severe. A second similar onset of erysipelas
+occurred some three or four weeks after the first. Finally, the
+neuralgia disappeared about four months after its first occurrence, and
+the menses reappeared in tolerable abundance about the same time. About
+a fortnight before this the patient had discovered that her right eye
+was dim; as the photophobia had previously disabled her from opening the
+eye, she could not be sure how long this dimness had existed. At the
+time of her visit to me the cornea was blurred with a large patch of
+interstitial lymph, with the remains of a superficial ulcer in the
+centre; the iris was turbid and discolored, showing the traces of recent
+but past iritis; the pupil was regular in form and active to light; the
+conjunctiva was slightly congested. Ophthalmoscopic observation was
+attempted by a skilled observer, but could not be satisfactorily carried
+out, from the turbid state of the media. The conjunctiva was slightly
+congested. In place of the lachrymation that had prevailed during the
+neuralgic period, there was a remarkable insensibility of the lachrymal
+apparatus, for the patient had noticed that the smell of onions, which
+would make the other eye weep profusely, had no influence on the
+affected one.
+
+The family history of this patient is a most remarkable one. All the
+members of her mother's family, for two generations back, had died at
+middle age, either from apoplexy or some disease involving hemiplegia.
+This case has, by a mistake, not been added to the list of twenty-two
+private cases in which the family history was carefully investigated,
+that will be found in the chapter on Pathology; this arose from the fact
+that the patient was not properly under my care, but was sent to me as a
+medical curiosity; the notes of her case were therefore taken in a
+different book from the others. The case certainly ought to be taken as
+a counterpoise to such a one as No. XVI. in the list, which is that of a
+gentleman who suffered from the most complicated neurotic maladies
+(asthma, angina pectoris, facial neuralgia, more than once attended with
+erysipelas), but whose family history, so far as it was known, presented
+no traces of tendency to neurotic disease.
+
+To these two cases of inflammation, secondary to neuralgia, I shall add
+a third, which is even more interesting, and which came under my notice
+not long since.
+
+CASE III.--H. T., watchmaker's assistant, aged forty-two, suffered for
+about three weeks with very severe remittent abdominal pain, entirely
+unconnected with dyspepsia, constipation, or diarrhoea. It was
+intermittent in character, but observation soon showed that the times at
+which it came on were simply those at which the stomach had gone longest
+without food, especially the early morning, and that nourishment never
+failed to relieve it. The suffering was great, and the man failed
+considerably in general health, notwithstanding that his appetite and
+digestion were unimpaired. He had only been under my care about ten days
+when he presented himself one day at the hospital, and stated that the
+pains in the stomach had entirely left him, but that he suffered the
+most frightful pains in and around the right eye. I found a well-marked
+conjunctival congestion and lachrymation, but there were as yet no
+tender points; the neuralgia was felt most severely in the globe of the
+eye and in one tolerably straight line, darting up toward the vertex
+from the brow. The iris seemed clear and free, and the cornea was not
+cloudy. I gave the man a subcutaneous injection of one-sixth grain
+acetate of morphia, for present ease, and ordered him muriate of iron
+and small doses of strychnia three times a day. When he next appeared,
+four days later, I was alarmed to perceive that unmistakable iritis had
+fully developed itself, the iris was already turbid and discolored and
+the pupil irregular, from a serious amount of adhesions. By this time
+there were fully-developed tender points, supra-orbital and parietal;
+besides this, pressure on the globe caused paroxysms of pain, in all the
+branches of the ophthalmic division, but there was not much spontaneous
+pain. I dropped atropine in the eye, applied blistering fluid to the
+back of the neck, [the nape of the neck is the point most suitable for
+blistering which is intended to affect the eye, and the ophthalmic
+division of the fifth, generally,] and desired the man to come to see me
+at my own house next day, intending to take him to an ophthalmic
+surgeon. Unfortunately he failed to do this, and three days later, when
+he came to see me at the hospital, the cornea was studded with
+opacities, the pupil was almost closed with effused lymph, there was
+violent ocular pain, and a great and increasing sense of tension. I
+begged him to go without loss of time to the Eye Hospital, as my own
+ophthalmic colleague was not at Westminster that day; and I have never
+heard any more of the patient.
+
+Glaucoma is a still more serious disease of the eye, which I think there
+is now sufficient evidence to show is sometimes entirely, and very often
+in considerable part, neuralgic in its origin. Since my attention was
+directed, some six years ago, to the frequent connection between the
+so-called rheumatic iritis and neuralgia, I have taken much interest in
+the subject of acute eye-affections; and the occurrence of one or two
+cases of glaucoma in personal friends of my own has made this interest
+even painfully strong. I am necessarily without the means of personally
+observing glaucoma on the large scale, but I have now seen two cases in
+which, if I possess any faculty of clinical observation whatever, the
+whole genesis of the disease was a neuralgic disorder of the trigeminus;
+and it was to me a melancholy reflection that nothing better than
+iridectomy in one case, and excision of the eyeball in the other, could
+be done in the present state of ophthalmic science. There are now a good
+many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell
+Carter, of St. George's, and the South London Ophthalmic Hospital,
+recently assured me that nervous aspect of some form of glaucoma
+presents itself the strongly to his mind, though he does not commit
+himself to any theory. Two cases were reported by Mr. Hutchinson, in
+Ophthalmic Hospital Reports IV. and V.; but the most complete and
+interesting cases that I have met with are recorded by Dr. Wegner;[15]
+they are two out of four that occurred within a very short time in the
+clinic of Prof. Horner at Zurich, and they form the basis of some
+researches by Wegner into the nature of the influence of the trigeminus
+upon ocular tension, which will be referred to, along with others, in
+the chapter on Pathology. The second of these cases is so important that
+I shall reproduce it in full.
+
+A. Hediger, aged twenty-four, a moderately strongly-built young woman,
+seen first in August, 1860. From her own and her mother's account, it
+seemed she had long suffered from convulsive attacks that did not appear
+to have been truly epileptic. Some days previously her left eye became
+very painful, and the sight failed, without any inflammatory symptoms.
+On inspection the pupil was somewhat dilated, the eye somewhat
+hypermetropic, fundus normal; No. 5, Jager's type, was read with
+difficulty. Wegner could not explain the condition. At the end of
+October the eye was much worse; after severe paroxysms of pain, No. 16
+type was the smallest legible, the field of vision was decidedly limited
+in all directions, but especially on the inner and upper portions. An
+unusually long hysteric attack was now observed. The patient was for
+twenty-four hours in a half-sleep, the extremities, meantime, were much
+jerked, the speech sometimes coherent and sometimes incoherent; she
+cried out to her friends, etc., but had no severe convulsion-fit with
+spasm of glottis. She was removed to the hospital, where she stayed six
+weeks. The hysteria improved under treatment with valerian and morphia
+(Prof. Greisinger had confirmed the opinion that there was no true
+lesion of the centres), but the neuralgia of the globe was
+extraordinarily severe, both day and night. From January to June, 1861,
+Wegner saw her occasionally. The visual power of the left eye fluctuated
+between 15 and 19 Jager. Field of vision very limited. Pupil very
+dilated and insensitive, the globe painful to the touch, and injected.
+The right eye weakly hypermetropic; normal field of vision, normal
+pupil, no pain. The scene suddenly changed on the 29th of June. She was
+attacked with fearful pain, and an enormous mydriasis with extreme
+amblyopia of the right eye; the fingers could hardly be counted when
+placed quite close. The optic disc appeared somewhat cloudy, with very
+evident venous pulsation. The mydriasis, amblyopia, and neuralgia lasted
+some time, while simultaneously the left eye could only read 19-17 type,
+but was painless. The pathology seemed quite obscure, and the surgeon
+remained almost passive till August, when he performed paracentesis on
+the left eye. The patient could distinguish fingers at that time at a
+foot's distance with the right eye; with the left read No. 11, but
+suffered fearful pains. These diminished after the puncture; the eye
+could read No. 20 next day, and improved after that to 19; the pains
+recurred in the next day, but for the first time ceased to disturb
+sleep. The scene again changed in the most surprising manner on the 27th
+of August. The most frightful pain again attacked the left eye. The
+pupil was dilated to the maximum (far beyond what occurs in oculo-motor
+paralysis); the globe was extremely painful on touch, visual power
+fallen to 19 Jager. On the other hand, the right eye had a normal pupil,
+was painless, and could read No. 12. Paracentesis of the left eye
+improved its vision and diminished pain, but only temporarily, so that
+it had to be repeated at short intervals. The condition was so far
+stationary toward the end of October that the right eye continually
+gained visual power, but the left stood still and fluctuated from worse
+to better, with the greater or less severity of the neuralgic paroxysms.
+Pupils always in extreme dilatation. In the end of October and beginning
+of November (the patient had worn a large seton for a month) remarkable
+changes occurred; the neuralgia of the left globe diminished steadily,
+the pupil got smaller, the visual power increased, the neuralgia now was
+only on the lower lid, which was slightly red and painful to the touch,
+and had continual spontaneous pain. Visual power of right eye No. 3, of
+left eye No. 5. Visual field intact; with full illumination by weak
+light there is a peripheral torpor, but only in a narrow zone. The
+hyperaemia now extended more and more over the lower lid and the upper
+part of the cheek; this was apparent during the paroxysms, which were
+very severe, and destroyed sleep; it did not allow the skin to be
+touched; the color was deep (with high temperature) and extended to the
+angle of the mouth. This phenomenon lasted till the beginning of
+December, when neuralgia again attacked the left globe, with strong
+mydriasis and diminution of visual power (15 to 20 Jager), till at last
+the movements of the hand could hardly be distinguished, and this state
+of things continued with fluctuations up to the end of the month. The
+seton had been taken off just before the new outbreak; it was put in
+again on December 31st. In January the pains continued severe in the
+eye, with only one remission (from the 17th to the 20th), when the
+hyperaemia recurred in the cheek. On the 26th the pupil was very dilated,
+and fingers could not be seen at half a foot's distance. Visual field
+very limited, globe hard. A large upper iridectomy was made. After this
+the pupil was contracted, the pains diminished, visual power 10 Jager,
+field seven inches. In the middle of February the hysterical attacks
+recurred with great force; the patient was unconscious half the day; she
+was clear enough in senses when awake, but complained of buzzing in her
+head, as if a cock-chafer were inside it. From this till the middle of
+March, the left eye did not alter, the impairment of vision remained,
+with normal pupil and no pain in the globe, and the iridectomy seemed at
+least to have done good in one direction; but on the 13th of March the
+operated eye was again attacked with pain, visual power fell to No. 17,
+pupil became dilated, and after a few days the swelling, heat, and
+tenderness of the cheek recurred. During the years 1862 and 1863 the
+condition remained pretty much the same; _i. e._, the right eye sound,
+the left painful (in spite of the iridectomy) with dilated pupil,
+concentrically narrowed visual field, visual power fluctuating between
+No. 15 and mere finger-counting without any ophthalmoscopic appearances.
+A number of paracentesis and subcutaneous injections of morphia (which
+last were the more indicated as the supra-orbitalis was tender on
+pressure) always brought relief merely for a few hours. On the 19th of
+April, 1864, vision being complete in right eye, and No. 19 in left,
+Wegner punctured the latter. On the 2d of May the eye read No. 10
+slowly, the pains had gone and not returned, the pupil became smaller.
+On the 31st of March, 1865, the patient was pronounced well; the eye was
+painless, the pupil somewhat larger than the other; the finest type
+could be read when looked at very close.
+
+3. The next group of affections secondary to neuralgia are the paralysis
+of muscles. These are pretty common; I find them in twenty-eight of the
+hundred cases which have been referred to. But of these twenty-eight
+instances of paralytic affections no less than twelve were connected
+with neuralgia of the trigeminus, and in most of these it was one or
+more of the muscles connected with the eye that were affected. Sciatica
+is nearly always attended with much weakening of voluntary power of the
+muscles of the thigh and leg; and in some instances this reaches to
+decided or even complete paralysis. In looking for this phenomenon we
+must be very careful that we do not mistake the mere reluctance to move
+the limb, on account of the painfulness of all movements, for true
+paralytic weakness of nerve and muscle. And it is also necessary to bear
+in mind, in prolonged cases, the probability that much of the weakness
+may have been caused by degeneration of the muscles owing to forced
+inaction. Still, there is a class of secondary paralyses that are in no
+way to be confounded with such effects as these: for instance, it
+occasionally happens, almost in the very first onset of severe sciatic
+pain, that the limb hangs absolutely helpless; and in one such case
+lately, being struck with the completeness of the loss of power, I
+tested the Faradic irritability by directing a sharp current on
+comparatively exposed portions of the painful nerve (_e. g._, in the
+popliteal space, and behind the head of the fibula), and elicited only
+the most feeble contractions, entirely unlike what the same current
+evoked in the opposite limb. I regret that I have as yet found it
+impossible to carry out a regular inquiry as to the sensibility to the
+different currents of motor nerves which are centrally connected with
+neuralgic sensory nerves.
+
+Muscular viscera which are composed of unstriped fibre, like the
+intestines, or of a mixture of striped and unstriped, like the heart,
+are probably very liable to a secondary paralytic influence from certain
+special neuralgiae. It is ascertained that the pain of a certain degree
+of severity in the branches of the fifth may absolutely stop the heart's
+action for a moment--an effect which is succeeded, usually, by violent
+and disorderly pulsations. I have myself once known the operation of
+"pivoting" a tooth, which gave frightful pain, cause instantaneous and
+most alarming arrest of the heart's motion, which for a minute or two
+seemed as if it were going to be fatal. But the variety of visceral
+paralysis which is probably far the most frequent is secondary paralysis
+of the bladder, from neuralgia in one or other of the pelvic organs, or
+of the external genitalia; and next to this comes paralytic distension
+of the caecum, colon, or rectum, secondary to various abdominal and
+pelvic neuralgic affections. In one instance of acute ovarian neuralgia
+that I saw, the paralytic distention of the colon was by far the most
+remarkable circumstance, so enormously was it developed; and for some
+days after the neuralgia had ceased, and when the flatulence had nearly
+disappeared, the intestine remained absolutely torpid.
+
+4. Convulsive actions of muscles, as every one knows, are very common
+complications of neuralgia. In trigeminal neuralgias these may be
+observed (according to the division or divisions of the nerve that are
+affected) in the proper muscles of the eye, or in those supplied by the
+fourth and sixth nerves, or (perhaps only when two or three divisions
+of the fifth are neuralgic at once) by the portio dura. It is curious,
+however, that those formidable spasmodic affections of the face which
+belong to the same order as torticollis and writer's cramp, are not
+frequently, if ever, directly associated with trigeminal neuralgia. The
+only connection between them seems to be that these peculiar spasmodic
+affections are only developed in highly-neurotic families, some of whose
+members are almost sure to be found suffering from some form of regular
+neuralgia. In severe sciatica it has several times happened to me to see
+convulsive action of the flexors, bending the leg spasmodically upon the
+thigh. And in a very large proportion of all neuralgias, wherever
+situated, attentive observation of the patient during the paroxysms will
+detect the existence of local twitching or local spasm of muscles,
+though these may be slight in degree.
+
+Among the convulsive affections must be reckoned convulsive movements
+and tonic spasms of various portions of the alimentary canal. Vomiting
+is a common example of this; in migraine it is the regular and necessary
+climax of attacks which last with severity for a certain time; indeed,
+any severe attack of neuralgia involving the ophthalmic division of the
+fifth may excite vomiting. Convulsive action of the pharyngeal muscles,
+as a complication of pharyngeal or laryngeal neuralgia, occasionally
+occurs to such an extent as to render deglutition difficult or
+impossible for the time. And I have seen what I do not doubt to have
+been a spasmodic condition of the rectum induced by peri-uterine
+neuralgia. The genito-urinary organs are also not unfrequently affected
+spasmodically in consequence of a neuralgic affection either
+peri-uterine or pudendal. I have seen spasmodic stricture of the male
+urethra thus produced, and likewise vaginal spasm.
+
+5. Impairments of sensation, both common and special, are very frequent
+attendants of neuralgia. As regards the special sensations, we may first
+mention that of touch; this is almost constantly impaired, immediately
+before, during, and some little time after a neuralgic paroxysm, in the
+skin supplied by the painful nerves. I was first led to make this
+observation by my own experience; the skin all round the inner angle of
+my right eye is permanently less sensitive to distinctive impressions
+than that of the opposite side, and this impairment is always decidedly
+greater, and spreads over a larger surface, before, during, and for some
+time after, the attacks of pain. More extended observation has convinced
+me that a certain amount of bluntness of distinctive skin-sensation
+accompanies nearly every neuralgia. As regards the sense of taste, I
+have found this decidedly perverted, at the time of an attack, even in
+my own case, although the neuralgia never extends into the third branch
+of the nerve. It is interesting to notice, in connection with this,
+that the epithelium of my tongue has been seen, on one occasion, to be
+exaggerated on the side of the neuralgic affection, showing a
+probability that there is perturbed function, at any rate of certain
+fibres, of the third division. But I have seen much more decided
+alteration, indeed temporary entire abeyance of the power to distinguish
+between the tastes of different substances, with the affected side of
+the tongue, in a case of severe epileptiform tic in which the third
+division was strongly affected with neuralgia; and Notta records a
+similar instance. As regards vision, besides minor perversions and
+disturbances, I have observed more or less complete amaurosis in several
+instances of ophthalmic neuralgia; in one case it was absolute, and
+lasted, with but slight improvement in the intervals between the
+paroxysms, for nearly a month, but disappeared entirely, though somewhat
+gradually, after the final cessation of the neuralgia. As regards
+hearing, I have noticed serious impairment only in five cases, all of
+them of a severe type of trigeminal neuralgia, involving all three
+divisions of the nerve. Smell, I have never observed to be more than
+doubtfully impaired, except in one case (_vide_ Chapter III), where it
+was completely destroyed.
+
+Common sensation was reported by Notta as affected in only three cases
+out of a hundred and twenty-eight; but my own experience has afforded a
+much larger proportion of instances in trigeminal neuralgia. Indeed, in
+all situations neuralgia appears to me to involve this effect, in the
+larger number of instances, in the early stages; later, it is supplanted
+in part by great tenderness on pressure in the well known _points
+douloureux_, and sometimes the tenderness becomes diffused over a
+considerable surface. I agree with Eulenburg in thinking that anaesthesia
+is more frequent in sciatica than in other neuralgias.
+
+6. Secretion is often very notably affected in neuralgia; the phenomena
+are necessarily more easily observed in connection with affections of
+the trigeminal than of other nerves. In the great majority of cases the
+affection is in the direction of increase; at least, the watery elements
+of secretion are often poured out in profusion. Thus, profuse
+lachrymation is exceedingly common in ophthalmic neuralgia; in a large
+number of cases there is also copious thin nasal flux on the affected
+side; sometimes, however, the secretion, though copious, is
+semi-purulent, or bloody. Increased salivation has been noticed, by a
+large number of observers, in neuralgia involving the lower division of
+the fifth. In a smaller number of instances, the secondary effect on
+secretion is precisely opposite; thus both Notta and myself have
+observed complete dryness on the nostril on the affected side in
+ophthalmic neuralgia.
+
+I might expand this chapter on the complications of neuralgia to a very
+much greater length; but, as regards the clinical history of these
+affections, it is perhaps better not to occupy more time and space. It
+will, however, be necessary to return to the consideration of the
+subject in connection with Pathology.
+
+FOOTNOTE:
+
+[15] Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.
+
+
+
+
+CHAPTER III.
+
+PATHOLOGY AND ETIOLOGY OF NEURALGIA.
+
+
+The pathology and the etiology of neuralgia cannot be considered apart;
+they must be discussed together at every step. I do not mean to say that
+neuralgia is singular among diseases in this respect; it seems to me
+merely a case in which the intrinsic defects of the conventional system
+of separating the "causes" of disease from its pathology happen to be
+more glaring and more easily demonstrable than usual.
+
+Neuralgia possesses no "pathology," if by that word we intend to signify
+the knowledge of definite anatomical changes always associated with the
+disease, in a manner that we can exhibit or exactly describe. It also
+possesses no demonstrable causes, if we employ the word "causes" in the
+old metaphysical sense. And yet I am very far from admitting, what seems
+to be so generally taken for granted, that we know less about the seat,
+the nature, and the conditions of neuralgia than of other diseases. On
+the contrary, I believe, with all deference to the supporters of the
+ordinary opinion, that we know more about neuralgia, in all these
+respects, than we do about pneumonia, only our knowledge is not of the
+superficial and obvious kind, but requires the aid of reason and
+reflection to develop and turn it to account. It has long been a matter
+of surprise to me, that even able writers have been content to talk
+about this disease (as, indeed, they have been content to speak of many
+nervous diseases) with an inexplicable looseness of phraseology. They
+speak of its "protean" forms; whereas, in my humble judgment, its forms
+are by no means specially numerous. They insist on the mysterious and
+unintelligible manner of its outbreaks, remissions and departure; but I
+shall try to show that, although, in the investigation of neuralgia, we
+are continually stopped in particular lines of inquiry by what seems to
+be ultimate facts, susceptible of no further immediate solution, the
+channels of information open to us are so unusually numerous as to
+enable us to accumulate a mass of information which, upon further
+reflection, will be found to furnish the materials of a synthesis of the
+disease singularly clear and effective for every practical purpose of
+the physician. In one important particular I especially hope to convince
+the reader that a large proportion of the mystification as to the
+pathology of neuralgia is gratuitous, and the result of great
+carelessness in estimating the comparative value of different facts. I
+hope to show clearly that, as regards both the seat of what must be the
+essential part of the morbid process, and the general nature of the
+process itself, we possess very definite information indeed. I expect,
+in short, to convince most readers that the essential seat of every true
+neuralgia is the posterior root of the spinal nerve in which the pain is
+felt, and that the essential condition of the tissue of that nerve-root
+is atrophy, which is usually non-inflammatory in origin. This doctrine
+seems, at first sight, presumptuous,[16] in the confessed absence or
+extreme scarcity of dissections which even bear at all upon the
+question. But one source of the extraordinary interest which the
+pathology of neuralgia has long possessed for me resides in this very
+fact, that I am convinced we can demonstrate the above apparently
+difficult theorem by means of pathological observations on the living
+subject, taken in conjunction with physiological experiments, and with
+only the aid of a very few isolated facts of positive morbid anatomy. I
+need hardly say that I am none the less anxious for that further
+assurance which we shall one day, perhaps, obtain by means of
+greatly-improved processes for microscopic detection of minute changes
+in nerve-centres; but, looking to the necessary rarity of opportunities
+for post-mortem examinations of the nervous system in any but the most
+advanced stages of neuralgias, it will hardly be disputed that, if I am
+right in my main position, we are singularly fortunate to be so
+unusually independent of the need for this source of information.
+
+1. The first fact which strikes me as of decided importance is the
+position of neuralgia as an hereditary neurosis; and this character of
+the disease is so pregnant with significance, that I shall take some
+considerable pains to put the fact beyond doubt in the reader's mind.
+
+There are two series of facts which support the theory of the
+inheritance of the neuralgic tendency: (_a_) instances in which the
+parent of the sufferer had also been affected with the disease; and
+(_b_) instances in which the family history of the patient being traced
+out more at large it appeared that, among the members of two or more
+generations, while one, two, or more individuals had been actually
+neuralgic, other members had suffered from other serious neuroses (such
+as insanity, epilepsy, paralysis, chorea, and the tendency to
+uncontrollable alcoholic excesses), and, in many instances, that this
+neurotic disposition was complicated with a tendency to phthisis.
+
+(_a_) The question of the direct transmission of neuralgia itself from
+the parent seems the easiest of decision, though even this cannot always
+be satisfactorily cleared up by the hospital patients, among whom one
+collects the largest part of one's clinical materials. However, I have
+been at the pains of investigating a hundred cases of all kinds of
+neuralgia, seen in hospital and private practice, with the following
+results: twenty-four gave distinct evidence that one or other parent had
+suffered from some variety of neuralgia; fifty-eight gave a distinctly
+negative answer; and eighteen would not undertake to give any answer at
+all. Among the twenty-four affirmatives are inserted none in which the
+history of the parent's affection did not clearly specify the liability
+to localized pain, of intermitting type, but recurring always in the
+same situation during the same illness. In three of these twenty-four
+instances, the patient stated that both parents had suffered from such
+attacks, and, in one of these, it appeared that the grandfather had
+likewise suffered.
+
+(_b_) The question of the tendency of a family, during two or more
+generations, to severe neuroses of more or less varying kinds, including
+neuralgia, is difficult to work out perfectly, though in a large number
+of instances we may get enough information to be very useful. I have
+spent much time and trouble in endeavoring to collect such information;
+but there are two main difficulties in connection with all such
+attempts. From hospital patients you frequently can get no reliable
+information whatever respecting any members of the family farther back
+than the immediate parents; and, even respecting uncles and aunts and
+first cousins, it is often impossible to learn any thing. And when you
+get to a higher class of society, especially when you approach the
+highest, although the information may exist, it may be withheld, or you
+may be purposely mystified. One would doubt beforehand, under these
+circumstances of difficulty, whether it would be possible to obtain
+affirmative evidence of the neurotic temperament of the families of
+neuralgic patients in general; but, in truth, the evidence is so
+overwhelming in amount, that more than enough can be obtained for our
+purpose. I shall give, first, the results of one special inquiry which,
+by the kindness of a patient, I have been able to carry out with more
+than usual completeness; it relates to the medical genealogy of a
+sufferer from sciatica; the account is fairly complete for four
+generations. The great-grandfather was a man of splendid physique (an
+only son), who lived very freely, but died an old man. His children were
+three sons, one of whom (though strictly temperate) was a man of
+eccentric and somewhat violent temper, and suffered from a spasmodic
+facial affection. This one, the grandfather of my patient, married a
+lady who died of phthisis, and among the ten children she bore him, two
+sons died of phthisis, two sons became chronically insane, one son died,
+probably of mesenteric tubercular disease (aged fifty-six), two sons are
+still alive at very advanced ages, and have always been perfectly
+healthy and strong; one daughter died in middle age, it is not certain
+from what cause; one daughter lived healthily to the age of eighty, and
+then was attacked by facial erysipelas, followed by violent and
+intractable epileptiform tic, which clung to her for the remaining four
+years of her life; and the remaining daughter, an occasional sufferer
+from migraine, died at the age of sixty-seven, almost accidentally, from
+exhausting summer diarrhoea. The fourth generation, in this branch of
+the family, consisted of thirty-one individuals; of whom seven have died
+of phthisis, or scrofulous disease; one from accidental violence, one
+from rheumatic fever, one from scarlet fever; and among the surviving
+twenty-two one has been insane, but recovered; two are decided
+neuralgics; one is occasionally migraineuse, and once had a smart attack
+of facial erysipelas, corneitis, and iritis, as the climax to a severe
+neuralgic attack; one has been a sufferer from chorea; one has become
+phthisical; one developed strumous disease, but has fairly recovered
+from it. The remaining fifteen enjoy good health, but are distinguished,
+almost without exception, by a markedly neurotic temperament, indicated
+by an anxious tendency of mind, quickness of perception, aesthetic taste,
+disposition to alternations of impulse and procrastination. Of the young
+fifth generation growing up, there have been twenty-five children, of
+whom only one has died (from fever), the rest are apparently healthy
+(most of them specially so); but, as few have yet reached the age for
+the development either of phthisis or of neurotic diseases, the future
+of this generation can only be guessed at. [It is unnecessary to trace
+the other descendants of the second generation, but I may state that
+their medical history, also, strongly supports the theory of inheritance
+of the neurotic tendency, and of the influence of an imported element of
+phthisis in aggravating the latter.] I suspect that, as regards the
+young children now growing up, everything will depend on the care with
+which they are fed, and the kind of moral influences brought to bear on
+them, two subjects which will be fully dwelt on in the chapter on
+Treatment.
+
+Of less perfect inquiries on the subject of neurotic disposition
+inherited by neuralgic patients, I have made a great number, though I
+regret to say that I have not attempted the task in the whole number of
+those from whom I inquired as to direct inheritance of neuralgia from
+their parents. However, in eighty-three cases this was done with all
+possible care, and any deficiency of completeness in the results is not
+my fault. I shall take first those that were private patients,
+twenty-two in number, respecting whom, I may say, that the evidence is
+of the best, as far as it goes, since I was better able to discriminate
+as to the worth of statements, than in dealing with hospital patients,
+and have rejected every case in which the informant did not seem
+intelligent enough, or otherwise to have the means, to give a thoroughly
+reliable account.
+
+    I. Neuralgia cervico-brachialis; in a lady, aged seventy-one.
+       Mother suffered from epileptiform facial tic; uncle was
+       paralyzed; patient herself eccentric to the verge of insanity.
+
+   II. Bilateral sciatica of great severity; in a gentleman, aged
+       seventy-three. Gout, paralysis, and neuralgia, have been
+       frequent in the family.
+
+  III. Cardiac neuralgia; in a man, aged twenty-four. Father epileptic
+       and a drinker; grandfather died of softening of the brain,
+       aged thirty-eight.
+
+   IV. "Cerebral" neuralgia; in a single lady, aged thirty-eight.
+       Mother has been insane; first cousin epileptic.
+
+    V. Lumbo-abdominal neuralgia; in a gentleman, aged fifty-two.
+       Father a drinker; mother insane; maternal grandfather
+       phthisical.
+
+   VI. Severe neurotic angina pectoris; in a gentleman, aged fifty.
+       Almost every one of the graver neuroses among patient's near
+       relations.
+
+  VII. Migraine and cervico-occipital neuralgia; in a young lady, aged
+       twenty-five. Immediate causes, brain-work, and influence of
+       cold weather. Father and brother both epileptic; father's
+       family much affected with neurotic diseases.
+
+ VIII. Sciatica; highly-nervous temperament. Father died insane from
+       drink; and probably other members of the family also nearly or
+       quite insane.
+
+   IX. Auriculo-temporal neuralgia; in a married lady, aged
+       twenty-eight. Father's family markedly phthisical and neuralgic.
+
+    X. Intercostal neuralgia; in a girl (phthisical), aged twenty-four.
+       Mother and two uncles phthisical; maternal grandfather epileptic
+       and a drinker.
+
+   XI. Facial neuralgia (third branch trigeminal); in a gentleman, aged
+       fifty-four, a great whiskey-drinker. Drinking hereditary for
+       three generations; father died insane; grandfather epileptic;
+       sister phthisical; two brothers very "eccentric."
+
+  XII. Migraine, severe; in a lady, aged thirty-three. Grief was the
+       immediate cause. Mother hemiplegic at forty-second year; first
+       cousin insane; two aunts (maternal) epileptic.
+
+ XIII. Extremely severe sciatica and cervico-brachial neuralgia of the
+       left side, with singular inflammatory consequences; in a lady,
+       aged fifty-two. A family history remarkably free from neurotic
+       diseases and from phthisis. The neuralgia was probably caused
+       partly by excessive ptyalism, partly by over brain-work.
+
+  XIV. Migraine; in a young lady, aged sixteen; very profuse
+       menstruation, which had lasted for two years. Family history
+       very free both from phthisis and neuroses.
+
+   XV. Frontal and nasal neuralgia; in a man. Repeated attacks of
+       localized facial erysipelas; drinking-habits for some years;
+       fatal acute insanity in middle age. Father insane, committed
+       suicide; mother subject of violent epileptiform tic.
+
+  XVI. Angina pectoris (neurotic); spasmodic asthma, twenty years;
+       facial neuralgia and erysipelas; in a gentleman, aged fifty.
+       Family medical history scanty and imperfect; but, as far as it
+       goes, entirely without evidence of either phthisis or neuroses.
+
+ XVII. Neuralgia of testis, immediately caused by local irritation.
+       Father died of phthisis; paternal uncle epileptic and insane.
+
+XVIII. Ovarian neuralgia; in a girl, aged twenty-six, liable to
+       occasional migraine. Mother has suffered sciatica; brother
+       died of phthisis.
+
+  XIX. Gastralgia; in a man, aged twenty-seven; highly intellectual and
+       nervous. Family history very free from neuroses; but some
+       evidence of phthisis, in two previous generations, on mother's
+       side.
+
+   XX. Sciatica; in a lady, aged sixty; second attack. Ancestors, on
+       both sides, for some generations, clever, and in several
+       instances decidedly eccentric, if not insane; much neuralgia
+       in the family.
+
+  XXI. Migraine; in a young lady, aged seventeen; menstrual
+       difficulties. No neurotic nor phthisical family history.
+
+ XXII. Sciatica; in a married lady, aged twenty-seven; first pregnancy;
+       had rheumatic fever and subsequent chorea in childhood. Paternal
+       uncle epileptic; mother had rheumatic fever and cardiac disease;
+       paternal grandfather suffered from sciatica late in life.
+
+No one, I think, can look down the above list and fail to be struck with
+the great preponderance of cases in which the general neurotic
+temperament plainly existed in the patients' families; and let me add
+that, in not a few of these cases, the neuralgia in the individual under
+observation might have been easily set down as dependent merely upon
+peripheral irritation, which, indeed, plainly did act as a concurrent
+cause.
+
+Fortunately, however, I am not dependent upon my own evidence alone, for
+the proofs of the proposition that neuralgia is eminently a development
+of hereditary neuroses. The great French alienists, Morel and Moreau of
+Tours, some years ago laid the foundations of the doctrine of hereditary
+neurosis. They enforced this chiefly with reference to the manner in
+which insanity is transmitted through a chain of variously-neurotic
+members of a family stock; and Moreau laid special stress on the deeply
+interesting connection of the phthisical with the neurotic tendency.
+Since then various observers have insisted on the same thing. Of late,
+Dr. Maudsley has worked out this subject with great ability, in his work
+"On the Physiology and Pathology of Mind," and in his recent "Gulstonian
+Lectures;" and Dr. Blandford dwells on it with emphasis in his
+interesting "Lectures on Insanity." [Dr. Blandford does not, however,
+admit that the phthisical diathesis has any such close and causal
+relation with neuroses as has been imagined by some recent pathologists;
+and, on the other hand, he points out that phthisis in neurotic
+subjects, _e. g._, the insane, must, in a large measure, be considered
+the product of the accidentally unhealthy circumstances in which they
+pass their lives. In the latter opinion I entirely agree.] Indeed, it
+may be taken as a recognized fact, among the more advanced students of
+nervous diseases, that hereditary neurosis is an important antecedent of
+neuralgia, in at least a very large number of instances. I shall
+conclude this part of the argument by stating the general results of my
+inquiries respecting sixty-one hospital patients. Of these cases,
+twenty-two were migraine, or some other affection of the ophthalmic
+division of the fifth nerve; seven were sciatica; two were epileptiform
+facial tic; ten were neuralgias affecting chiefly the second and third
+divisions of the fifth nerve; three were intercostal neuralgias pure;
+one was intercostal neuralgia plus anginoid pain; seven were intercostal
+neuralgias with zoster; three were brachial neuralgias; and five were
+abdominal neuralgias (hepatic, gastric, mesenteric, etc.) Of
+eighty-three hospital and private patients [It must be understood that
+the respective numbers do not indicate with any accuracy the relative
+frequency of the different neuralgias as seen in my practice. (Sciatica,
+_e. g._, was proportionally more frequent.) They represent but a small
+part of the neuralgic patients whom I have seen during fourteen years of
+dispensary, hospital, and private practice, and they were selected for
+inquiry merely because I happened to be able to give the time for the
+necessary questions. Every one who knows out-patient practice will
+understand how seldom this happened.] I obtained evidence of the
+presence, among blood-relations, of the following diseases: Epilepsy,
+fourteen cases (eight were examples of migraine); hemiplegia or
+paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen
+cases; "consumption," eighteen cases; "St. Vitus's dance," four cases.
+I am well aware that these figures must be taken with caution, and that
+considerable doubt must rest on the accuracy of some of these details,
+more especially with regard to "epilepsy," as it was impossible, with
+the greatest care, to be sure that this was not given, by mistake, for
+hysteria in some cases; and the same may apply to the statement that
+relations had suffered from "consumption." The facts are given for what
+they are worth, and with the express reservation that their total
+reliability is far less than that of the accounts obtained respecting
+private patients belonging to the more educated classes. But, in one
+respect, viz., as regards drunken habits, it is possible that a truer
+estimate is gained from the statements of hospital patients than from
+those of private patients, who would usually be more prone to reticence
+on such a topic.
+
+The evidence as to the hereditary character of neuralgia assumes a yet
+higher importance when supplemented by the facts respecting the
+alternations of neuralgia with other neuroses as the same individuals.
+Every practitioner must be aware how frequent is the latter occurrence.
+Nothing is more common, for example, than to see insanity developed as
+the climax of minor nervous troubles, especially of neuralgia. And there
+is one form of neuralgia, the true epileptiform tic, which is intimately
+bound up with a mental condition of the nature of melancholia, and even
+with the markedly suicidal form of the latter affection. I have lately
+had under my care a lady in whom the prodromata of a severe facial
+neuralgia were mental; the disturbance commenced with frightful dreams,
+and there was great mental agitation even before the pain broke out;
+this disturbance of mind, however, continued during the whole period of
+the neuralgia, and was relieved simultaneously with the cessation of the
+attacks of pain. This is contrary to what happens in some cases; thus,
+Dr. Maudsley quotes the case of an able divine who was liable to
+alternations of neuralgia and insanity, the one affection disappearing
+when the other prevailed. Dr. Blandford has met with several instances
+in which neuralgia has been followed by insanity, the pain vanishing
+during the mental disturbance, and reappearing as the latter passed
+away. And he remarks that, in the transition of a neuralgia (to mental
+affection), we may well believe that the neurotic affection is merely
+changed from one centre to another, from the centres of sensation to
+those of mind. He says that the ultimate prognosis of such cases is bad;
+a point to which we shall have to refer again.
+
+The prominent place which quasi-neuralgic pains hold in the earlier
+history of locomotor ataxy is a fact that cannot but engage attention.
+In this volume we have not treated these pains as belonging to the truly
+neuralgic class, for the very practical reason that they are but
+incidents in a most important organic disease, and that in a diagnostic
+and prognostic point of view it is necessary to dwell on their
+connection with that disease. But, in considering the pathological
+relations of neuralgia, it would be improper to omit the consideration
+of the pains of locomotor ataxy, which bear a striking semblance to
+neuralgic pains. The fact that they are an almost if not quite constant
+feature of a disease which is from first to last an atrophic affection
+(mainly of the posterior columns of the cord), in which the posterior
+roots of the nerves are almost always deeply involved, has a bearing on
+our present inquiry too obvious to need further remark.
+
+Equally important to our investigation is the fact that pains, closely
+resembling neuralgia, are not very uncommonly a part of the phenomena of
+commencing, and more frequently of receding, spinal paralysis. I have
+the notes of three cases of partial recovery from paraplegia, in all of
+which the patients remained for years, in one case for nearly twenty
+years (ending with death), the victims to a singularly intractable
+neuralgia of both lower extremities. In the worst of the cases the
+patient was the victim of excessive and continuous labor at literary
+work of a kind which hardly exercised the mental powers, but was
+extremely exhausting to the general power of the nervous system; he
+broke down at about the age of fifty, but dragged on a painful existence
+for the long period above mentioned.
+
+We are also certainly entitled to adduce the example of the so-called
+neuralgic form of chronic alcoholism as an instance of the close
+relationship of neuralgia to other central neuroses. I refer to those
+cases, more common perhaps than is generally admitted, in which pains in
+the extremities, often quite resembling neuralgia in their
+intermittence, are either superadded to or take the place of the
+muscular tremors and general restlessness that are more popularly
+considered as the essential nervous phenomena of chronic alcoholic
+poisoning. That the pains are usually bilateral, and more diffuse in
+their character than those of ordinary neuralgia, is a fact which it is
+not difficult to explain by the _modus operandi_ of the cause; but we
+shall have more to say on the general relations of alcoholic excess to
+neuralgia presently. The pains themselves will be fully described in the
+second part of this book, which treats of the affections that simulate
+neuralgia; here we need only remark that it is not uncommon for them to
+occur interchangeably with true neuralgia in the same person.
+
+The occasional interchangeability of migraine with epilepsy is a
+well-known fact; every practitioner who has seen much of the latter
+disease will have seen some cases in which the patient had been liable,
+at some point of his medical history, to "sick-headaches" of a truly
+neuralgic kind; although it is quite true, as Dr. Reynolds points out,
+that the kind of sensorial disorder specially premonitory of the
+attacks consists rather in indefinable distressing sensations, than in
+actual pain. The genealogical connection between migraine and epilepsy
+is, as I have already stated, apparently very close. Such instances as
+one mentioned by Eulenburg are rightly explained by him; it is the case
+of a girl who suffered at an unusually early age (nine) from migraine;
+her mother had been a migraineuse, and her sister was epileptic; the
+strong neurotic family tendency is believed by Eulenburg to account for
+the appearance of migraine at such a period of life.
+
+This seems the fitting place to introduce some special remarks on
+migraine in its relations to other neuralgias of the head, because
+Eulenburg has mentioned and combated my view, according to which
+migraine is a mere variety of neuralgia of the ophthalmic division of
+the fifth nerve. I call it my view, because, though several other
+authors had previously expressed it, I was first lead to entertain it by
+observations made before I had studied their works, and especially by
+the impressive teaching of my own case, as to which more will be
+presently said. Eulenburg, though he fully allows that migraine is a
+neuralgia, urges a series of objections to the identification of
+migraine with ophthalmic neuralgias; of which objections one, based on
+the doctrine of Du Bois Reymond as to the action of the sympathetic in
+migraine, must be reserved for consideration when we discuss the general
+pathology of the vaso-motor complications of neuralgia. The other
+grounds of distinction that he urges are the following: In the first
+place, he remarks that the site of the pain is by far less distinctly
+referred to definite foci on the outside of the skull than in trigeminal
+neuralgia; the patient's sensations very usually lead him to declare
+that the pain is in the brain itself. Secondly, he says that the points
+douloureux (in Valleix's sense) are almost constantly absent in true
+migraine. Thirdly, he specifies the character of the pain in
+migraine--dull, boring, straining, etc.--as differing from that of
+trigeminal neuralgia, which is ordinarily much more acute and darting.
+Fourthly, he notes the long duration of individual attacks of migraine,
+and the long intervals (very commonly three or four weeks) between them.
+Fifthly, he dwells on the frequent prodromata of migraine referable to
+the organs of sense (flashes before the eyes, noises in the ears), or to
+the stomach (nausea), or more generally to the reflex functions of the
+medulla oblongata (_e. g._, convulsive rigors, excessive yawning, etc.)
+
+Now, I should have nothing to say against the accuracy of this
+description, did it apply merely to the distinctions between
+highly-typical cases of the "sick-headache" of the period of bodily
+development, and highly-typical cases of the ophthalmic neuralgias which
+are commonest in the middle and later periods of life; nor indeed should
+I greatly care if it were finally decided that migraine and clavus
+should be separated from the true trigeminal neuralgiae, provided the
+following points were well impressed on the minds of practitioners. In
+the first place, I must insist that in my own experience the great
+majority of undoubtedly neuralgic headaches, which subordinate stomach
+disturbance, are far less sharply separated than the above description
+would allow from the unmistakable trigeminal neuralgias; it is only a
+minority of cases that wear this extreme type, and a far larger number
+shade imperceptibly away toward the type of ophthalmic neuralgia pure
+and simple. And so, again, of the so-called clavus there is every
+variety, from a form bordering closely on the migraine type to another,
+differing in nothing from an unusually severe ocular and frontal
+neuralgia of the fifth, except in the presence of a tremendously painful
+parietal focus. But the fact on which I would most particularly insist
+is one that was first taught me by my personal experience, viz., that
+migraine is, with extraordinary frequency, the primary or youthful type
+of a neuralgia which, in later years, entirely loses the special
+characters of sick-headache, and assumes those of ordinary frontal
+neuralgia, with or without complications. In my own case, the
+"sick-headache" character of the affection was strongly marked during
+the first two or three years, after which time it gradually but steadily
+lost all tendencies to stomach complications, and, what is more, the
+type of the recurrence became entirely changed. Yet it is quite
+impossible to believe that the malady is now a different one, in any
+essential pathological point, from what it was at first; if any disproof
+of this were needed, it might be remarked that the singular series of
+secondary trophic changes which have complicated my case have been
+impartially distributed between the respective periods when the
+affection was frankly migraineuse, when it was mixed, and when it was
+simply ophthalmic neuralgia (as it is at present;) indeed, some of the
+most decided of these trophic complications (orbital periostitis,
+corneal ulceration, fibrous obstruction of the nasal duct) occurred
+within the period in which every attack of pain, unless I succeeded in
+getting to sleep very shortly, ended in violent vomiting. The experience
+thus gained has made me very attentive to the past history of those who,
+in later life, complain of frontal neuralgia without stomach
+complication, and it is surprising to find in how many cases patients,
+who at first declare that they never had neuralgia before, on reflection
+will recall the fact that they were often "bilious" in their youth;
+which "biliousness" turns out to have been regularly preceded by
+one-sided headache, and to have been severe in proportion to the
+severity and duration of that previous headache.
+
+I ask the reader to dwell with fixed attention on this fact of the
+exclusiveness, or almost exclusiveness, with which the neuralgias of
+the anterior part of the head are represented during the period of
+bodily development, and especially in the years just succeeding puberty,
+by migraine or by clavus. When this fact has thoroughly entered the
+mind, we can hardly help joining with it that other and most important
+fact already noticed, of the close connection between the predisposition
+to migraine and the predisposition to epilepsy, and reflecting further
+on the strong tendency which epilepsy likewise shows to infest the
+earlier years of sexual life. In view of these things, it is difficult
+to avoid the inference that both the epileptic and the neuralgic
+affections of this critical period of life are the expression of a
+morbid condition of the medulla oblongata, in which the sensory root of
+the trigeminus has its origin; and further, that this morbid condition
+(tending to explosive and atactic manifestations of nerve-force) must
+have its basis in defective nutrition. For, be it remembered, the epoch
+of sexual development is one in which an enormous addition is being made
+to the expenditure of vital energy; besides the continuous processes of
+the growth of the tissues and organs generally, the sexual apparatus,
+with its nervous supply, is making by its development heavy demands upon
+the nutritive powers of the organism; and, it is scarcely possible but
+that portions of the nervous centres, not directly connected with it,
+should proportionally suffer in their nutrition, probably through
+defective blood-supply. When we add to this the abnormal strain that is
+being put on the brain, in many cases, by a forcing plan of mental
+education, we shall perceive a source not merely of exhaustive
+expenditure of nervous power, but of secondary irritation of centres
+like the medulla oblongata, that are probably already somewhat lowered
+in power of vital resistance, and proportionably irritable. Let us
+suppose, then, that to all these unfavorable conditions there was added
+the circumstance that the structure of the medulla oblongata, or of
+parts of it, was congenitally weak and imperfect; then surely it would
+be scarcely possible for these loci minimae resistentiae to escape being
+thrown into that state of weak and disorderly commotion which eminently
+favors pain in the sensory, and convulsion in the motor apparatus.
+
+2. We have so far been mainly considering the relations to the
+production of neuralgia of certain conditions of the central nervous
+system which indisputably are inherent from birth. Let us now pass quite
+to the other extreme, and consider a class of momenta which take a
+decided part in producing many neuralgiae, but which are altogether
+accidental and factitious, and cannot be included among the necessary
+hostile conditions of life. To push the contrast to the utmost, let us
+inquire first, what amount of influence in the production of neuralgia
+can be given by such a purely "functional" influence as educational
+misdirection of intellect and emotion?
+
+It is somewhat strange, though every one accepts as a mere truism the
+maxim that sudden emotional shock may produce almost any degree or
+variety of nervous disorder, the slower but far surer influence of
+long-continued mental habit is often practically ignored. It cannot,
+indeed, be left out of sight as a cause of disorders of the mind itself,
+nor are there many who would deny that such diseases as cerebral
+softening are, in a considerable number of cases, the premature ending
+to a life that has been broken down by harassing work and anxiety. But
+what is far less appreciated is the tendency of certain unfortunate
+mental surroundings and modes of mental life to produce a generally
+neurotic condition, which may express itself in a variety of functional
+disorders, among which not the least common is neuralgia.
+
+I may fairly hope to be acquitted of any predisposition to lay
+exaggerated stress on this kind of influence in the production of
+neuralgia, considering all that I have said of the importance of that
+inevitable cause, the neurotic inheritance, and all that I shall have to
+say presently as to the effects of a variety of external influences of a
+totally different kind. But I confess that, with me, the result of close
+attention given to the pathology of neuralgia has been the ever-growing
+conviction that, next to the influence of neurotic inheritance, there is
+no such frequently powerful factor in the construction of the neuralgic
+habit as mental warp of a certain kind, the product of an unwise
+education. This work is not intended as a treatise either on religion or
+psychology, and yet it is impossible for me to avoid some few words that
+may seem to trench on the province of each: for I believe that there are
+certain emotional and spiritual and intellectual grooves into which it
+is only too easy to direct the minds of young children, and which
+conduct them too often to a condition of general nervous weakness, and
+not unfrequently to the special miseries of neuralgia. As regards the
+working of the intellect, it is easier to speak in a free and
+unembarrassed manner than respecting the other matters. There can be no
+doubt that, of intellectual work, that sort which exhausts and harasses
+the nervous system is the forced, the premature, and the unreal kind;
+and this it is which predisposes, among other nervous maladies, to
+neuralgia. It is more difficult to speak the truth about emotional
+influences generally, and especially about those which are concerned
+with the highest spiritual matters; but I should do wrong were I to
+suppress the statement of my convictions on this point. I believe that a
+most unfortunate, a positively poisonous influence upon the nervous
+system, especially in youth, is the direct result of efforts, dictated
+often by the highest motives, to train the emotions and aspirations to a
+high ideal, especially to a high religious ideal. It is not the object
+that is bad, but the machinery by which it is sought to be attained. In
+modern society there are two principal methods which are popularly
+employed for this purpose; I shall describe them, by two epithets which
+are selected with no offensive intention, as the Conventual and the
+Puritan methods of spiritual training. By the former is meant that kind
+of education which deliberately dwarfs the nervous energy, with the hope
+of preserving the mind from the contamination of unbelief and of sinful
+passion. It is a system which is not peculiar to the Roman Church, nor
+even to the Christian religion, and it need the less detain our
+attention, as its effects, so far as they are evil, are mainly seen in
+general nervous and mental enfeeblement, rather than in the outbreak of
+explosive nervous disorders, such as convulsion, insanity, or neuralgia.
+There are doubtless exceptions to the rule; but that is the rule. It is
+far otherwise with the spiritual education which is here called Puritan,
+but which is confined to no party in the Church. This is a system which
+seeks to purify and exalt the mind, not by enforcing obedience to a
+series of spiritual rules for which another mind is responsible, but by
+compelling it to a perpetual introspection directed to the object of
+discovering whether it comes up to a self-erected spiritual standard.
+The reader will understand that I have not the remotest intention to
+depreciate either a true and manly self-restraint in obedience to the
+direction of "pastors and masters," or an honest watchfulness over one's
+own conduct and thoughts. But the lessons which our psychologists are
+rapidly learning, as to the evil effects on the brain of an education
+that promotes self-consciousness, are sorely needed to be applied to the
+pathology of nervous diseases generally, and of neuralgia among the
+rest. Common sense and common humanity, when united with the physician's
+knowledge, cry out against the system under which religious parents and
+teachers subject the feeble and highly mobile nervous systems of the
+young to the tremendous strain of spiritual self-questioning upon the
+most momentous topics. More especially is such a practice to be
+condemned in the case of boys and girls who are passing through the
+terrible ordeal of sexual development--an epoch which, as we have
+already seen, is peculiarly favorable to the formation of the neurotic
+habit, and I must emphatically state my belief that among the
+seriously-minded English middle classes, more especially, whose life is
+necessarily colorless and monotonous, the mischief thus worked is both
+grave and widely spread.
+
+Perhaps the maximum of damage that can be inflicted through the mind
+upon the sensory nervous centres is effected when to the kind of
+self-consciousness that is generated by an excessive spiritual
+introspection there is added the incessant toil of a life spent in
+sedentary brain-work, and checkered with many anxieties, and many griefs
+which strike through the affections. Doubtless, such a combination of
+morbid mental influences is sufficient of itself to generate the
+neuralgic disposition in its severest forms, without any hereditary
+neurotic influence, and without any other peripheral irritations; I have
+more than one such instance in my mind at this moment. But, if they can
+do this, much more can such influences arouse inherent tendencies to
+neuralgia; to persons who are predisposed in this manner they are most
+highly deleterious.
+
+3. We come now to the peripheral influences which in a more obvious
+manner become factors in the production of neuralgia. Of such influences
+there are an immense variety, and the only common quality that can be
+predicated of all is the tendency directly to depress the life of the
+sentient centre upon which their action impinges.
+
+If we search among the external influences which contribute to the
+production of neuralgia for one that is apparently trivial as to the
+amount of material disturbance which it can cause, and yet is very
+frequently effective, we may select the agency of cold. The effect of a
+continuous cold draught of air impinging on the naked skin for some time
+is comparatively frequently seen in the provocation of neuralgic attack:
+we say comparatively, because this influence is more frequently
+effective than blows, wounds, or temporary irritations of any kind,
+applied to the peripheral ends of sensory nerves. But if neuralgia be a
+more frequent consequence of cold than of these other influences, a
+moment's reflection will show that it is by no means an absolutely
+common result. One has only to think of the numerous omnibus-drivers,
+engine-drivers, cab-drivers, etc., etc., who pass their whole working
+lives in presenting the (more or less) naked expanse of their trigeminal
+and their cervico-occipital nerves to every variety of wind, to perceive
+that, were this sort of influence very potent in itself, male neuralgic
+patients should swarm as thick as bees in our hospital and dispensary
+out-patient rooms; which is notoriously quite contrary to the fact. The
+same remarks, in both directions, may be applied to the direct influence
+of atmospheric moisture, either with or without the effect of wind (of
+course I am not speaking of the more recondite effects of damp soil on
+the persons who live about it). [Among the hundred patients who formed
+the basis of the inquiries mentioned in this work, forty-one accused
+external cold of producing the attack, but many of these produced
+insufficient evidence that such was the case.] In short, the direct
+effects of atmospheric cold would seem to be these. Mere lowness of
+temperature goes for something, but not much; [The most marked instance
+of the effect of cold, _per se_, that I have seen, was exhibited by a
+young lady who was under my care during the past severe winter
+(1870-'71). During much of the time she was confined to a
+carefully-warmed apartment, on penalty of a violent paroxysm if she left
+it.] for about as much, perhaps, as it does in the way of aggravating
+all neurotic tendencies. Cold joined with wind is much more powerful.
+And the maximum of ill-effect seems reached by very cold wind mingled
+with sleet or driving rain, which keeps the skin sodden. But the
+conclusion at which I long ago arrived is, that none of these influences
+ever take more than a small (though it is sometimes an important) part
+in the production of neuralgia; and that in the majority of cases there
+is no pretence for supposing that they had the slightest share in its
+causation.
+
+A word or two must be said as to the _modus operandi_ of cold and cold
+wind, as these are the most frequent of external, so-called "exciting"
+causes. The popular use of such phrases as the latter has an
+extraordinary influence in disguising the plain fact, which is, that
+these influences operate wholly in the direction of robbing the nerves
+of force. The continuous abstraction of heat from the surface, which of
+course is materially aided by rapid movement of the air, must
+necessitate a readjustment of the distribution of energy, the only
+result of which must be to drain the sensory nervous centre of its
+reserve of force. But, in fact, there is an experiment, ready performed
+to our hands, which may amply satisfy us as to the kind of influence
+exerted by cold on superficial nerves, viz., the sensations experienced
+in recovering from frost-bite, which has been severe enough to paralyze
+the nerves without causing actual gangrene of the tissues. The passage
+of the nerves back from temporary death to full functional life is
+marked by a half-way stage in which there is agonizing pain.
+
+4. We must next consider the effects of a class of peripheral influences
+which act, where they exist, in a more constant manner than any others;
+viz., those in which the trunk or periphery of a sensory nerve either
+receives a severe injury, or becomes more or less engaged in
+inflammatory processes, or compressed or otherwise damaged by the growth
+of tumors or the spread of destructive ulcerations.
+
+With regard to ordinary nerve-wounds as a cause of neuralgia, we have
+already said (_vide_ Chapter II.) nearly as much as it is necessary to
+say; we need only here point out that, like the influence of cold
+applied to superficial nerves, that of wounds must necessarily be a
+depressing one to the centre with which the wounded nerve is connected,
+and the resulting neuralgia must be regarded as an expression of impeded
+and imperfect nerve-energy, not of heightened nerve-function. The pain
+is set up during the process of nerve-healing; that is to say, at a
+stage intermediate between those of abolished function and completely
+restored function; and there can be little doubt that the obstinacy with
+which it is often protracted is due to the slowness with which a wounded
+nerve recovers its full functional activity; when once the latter is
+completely restored there is an end of neuralgic pain. It is exactly
+analogous to the course of events in recovery from freezing.
+
+There remain for consideration, however, (a) a small class of cases of
+nerve-wounds in which the healing process is not simple; but the lesion
+is followed by the development of a tumor of the kind denominated true
+neuroma. The process consists of hyperplastic changes in the
+nerve-fibres; its commonest examples are seen in the extraordinarily
+painful swellings that occur on the ends of nerves left in stumps after
+amputations; but, in fact, a neuroma of this kind may occur after any
+kind of severe nerve-injury, as, _e. g._, a cut from broken glass, the
+impaction of foreign bodies, etc. The true neuromata are composed mainly
+of nerve-tissue, with a relatively small element of connective tissue:
+the nerve-fibres can be traced directly to the nerve-tumor. Besides the
+traumatic neuromata which form permanent tumors, incapable of being got
+rid of except by actual excision, a minor variety of the same kind of
+change has in several cases been known to take place in consequence of
+an abiding local irritation from the impaction of a foreign body, on the
+removal of which the neuromatoid enlargement completely disappeared. (b)
+There are likewise a certain number of cases in which a tumor is
+developed from the neurilemma, and does not consist of nervous tissue;
+these are distinguished as false neuromata, and may be of various kinds,
+the fibromatous and gliomatous being far the most common, but cysts and
+cystic tumors also sometimes occurring.
+
+The case of the neuromata is well worth reflecting upon, in the course
+of our endeavors to clear up the Pathology and Etiology of Neuralgia. If
+ever we could find a merely peripheral influence which would of itself
+be invariably competent to excite neuralgic pains, it would surely be
+found in neuroma; but the case is not merely not so, it is strikingly
+contrary. Just as wounded and inflamed nerves frequently go through the
+whole processes of disease and recovery without once eliciting a
+neuralgic pang, so is it with neuromata; they are not unfrequently quite
+indolent, and neither excite neuralgia, nor are themselves at all
+particularly tender to the touch. And what is most remarkable is, that,
+as Eulenburg correctly remarks, among the pseudo-neuromata the kind of
+tumor which is most frequently associated with neuralgia is by no means
+the dense fibroma or glioma, which might be expected by its mechanical
+pressure to excite inevitable neuralgic pain, but the far softer and
+more yielding cystic tumors. I do not know how the facts may affect the
+reader, but to me they suggest the strongest possible arguments against
+the belief that peripheral irritation can of itself produce neuralgia
+without the intervention of some centric change. The tendency to such
+change (from inherent constitution) in the sensory root of the nerve
+must surely be the reason why neuroma causes neuralgia in a given number
+of subjects, instead of letting them go scot-free, as it does other
+persons.
+
+The same remarks apply to the result of observations on the effect of
+tumors commencing in tissues altogether unconnected with the nerve, and
+merely coming to involve it, secondarily, in pressure. It has been often
+noted that, among these tumors, fluid-containing cysts and soft
+medullary cancers are far more frequently the cause of decided and
+distressing neuralgia than the denser and less yielding neoplasms. Of
+kinds of tumors that are specially apt to produce severe and even
+intolerable neuralgia by the pressure on nerves, it has been remarked
+that aneurisms are among the worst: here every pulsation often sends a
+dart of agony through the nerve. There is a reason here, however, which
+is often left out of sight; not merely is the perpetually varying
+pressure specially harassing and exhausting to the nerve, but in many of
+these cases there is general arterial degeneration, and the sensory root
+of the nerve is exceedingly likely to be very badly nourished. [This
+result will be more directly brought about when the aneurism happens to
+press on the ganglion of a posterior root.] We pass now to the
+consideration of the influence exerted by other great series of
+peripheral impressions in the production of neuralgia. These impressions
+are connected chiefly with the functions of the digestive and of the
+genito-urinary organs, the functions of the eye, and the nutrition of
+the teeth.
+
+To take the least important of these first, I may surprise some readers
+by the statement, which I nevertheless make with much confidence, that
+irritation of any part of the alimentary canal is, on the whole, a rare
+concurrent cause, even in the production of neuralgia. There are, as has
+been already fully explained, cases of neuralgia seated in these viscera
+themselves (or the plexuses in their immediate neighborhood), although
+their number is immensely smaller than that of the neuralgias of
+superficial nerves. But it is not at all common--it is even exceedingly
+rare--for irritation conveyed from the alimentary canal to take any
+important part in setting up neuralgia of a distant nerve, even when
+that nerve has close connections, through the centres, with those coming
+from the irritated portion of the alimentary canal. Valleix had the
+great merit to perceive this, even in the case of neuralgias of the
+head, where appearances are so likely to lead the observer to a contrary
+opinion. And it is not a little remarkable that this should be the case,
+when we consider the close central connections which the vagus, the
+great sensory nerve of a large portion of the alimentary canal, has with
+the sensory root of the trigeminus. In fact, however, there are certain
+peculiar forms of gastric irritation which do react upon the trigeminus;
+for instance, a lump of unmelted ice, suddenly swallowed, almost
+invariably produces acute pain in the supra-orbital branch of the fifth,
+on one side or the other, and occasionally (as in a case cited by Sir
+Thomas Watson) in other nerves. But that common dyspeptic troubles at
+all frequently or importantly contribute to the production of neuralgia,
+I do not for a moment believe: it needs some very powerful irritation,
+such as that just mentioned, or as impaction of great masses of scybalae
+in the intestines, or severe irritation from worms, to produce such an
+effect.
+
+It is far otherwise with the genito-urinary apparatus; in a large number
+of cases, irritations proceeding from these organs do undoubtedly
+contribute to the production of neuralgia, though by no means in the
+important degree which many authors seem to have assumed. There can be
+no doubt, for example, that the irritation of a calculus, either within
+the kidney itself, in the ureter, or in the bladder, may set up violent
+neuralgia, which for the most part is localized in the branches of the
+lumbo-abdominal nerves. The instance of the eloquent Robert Hall is an
+example of renal calculus acting in this way: he suffered the most
+excruciating agony for years, and was obliged to take enormous
+quantities of opium in order to make life endurable. An instance of
+calculus impacted in the ureter, in a gentleman somewhat past middle
+age, occurred in my own practice; the lumbo-abdominal neuralgia occurred
+in frequent paroxysms of dreadful severity; and another case, already
+referred to was that of a woman, in whom ovarian neuralgia was
+undoubtedly in great part due to the irritation of an impacted calculus
+in the ureter. These cases, however, are very rare in comparison with
+others in which the peripheral source of the neuralgia is either the
+uterus or ovary, or the external genitals. I have no means of
+ascertaining, with anything like accuracy, the frequency with which the
+internal sexual organs are the starting-point of neuralgia, because the
+majority of such cases pass, naturally, to the care of physicians who
+practice chiefly in the diseases of women, and consequently not
+adequately represented either in my hospital or my private practice;
+still, I have seen a good many of these affections, and, though I speak
+with the reserve necessitated by the circumstances just named, I am much
+inclined to believe that even such powerful centripetal influences as
+those of the states of commencing puberty, of pregnancy, of the change
+of life, and uterine diseases generally, are very rarely the cause of
+true unilateral neuralgia, except in subjects with congenital tendencies
+to neuralgia. But in predisposed subjects there can be no doubt that
+these influences assist most powerfully in producing the malady.
+
+Of the power of irritation of the external genitalia to act as a
+so-called "exciting cause" of neuralgia, there is abundant evidence. I
+would especially call attention to the remarkable monograph of M.
+Mauriac, ["_Etude sur les Nevralgies Reflexes symptomatiques de
+l'Orchi-epididymite blenorrhagique_" Par C. Mauriac, Medecin de
+l'Hospital du Midi. Paris, 1870.] on the neuralgias consecutive to
+blenorrhagic orchi-epididymitis, as illustrating this with a force that
+was to me, for one, surprising. I shall, perhaps, have further occasion
+to these researches; here it will be enough to mention that M. Mauriac's
+enormous experience of blenorrhoea and orchitis at the Midi has shown
+that, in an exceedingly large number of cases, certainly not less than
+four per cent., this combination is followed by reflex neuralgias, of
+which a large number are not seated in the genital apparatus, but affect
+the track of some distant sensory nerve, through the intermediation of
+the spinal centres; and that with these reflex pains there is often
+profound general disturbance, including very often an extremely profound
+general anaemia. The most frequent kind of these neuralgias is
+rachialgia, _i. e._, pain in the superficial posterior branches of
+spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and
+crural, visceralgic (abdominal), etc.; and besides all these there are
+numerous instances of neuralgia in the testis. As to the nervous
+"reflection," more hereafter.
+
+It has surprised me, somewhat, that while M. Mauriac has seen so many
+reflex neuralgias set up by orchi-epididymitis, he does not appear to
+have noticed cases of trigeminal neuralgia from this source; because, in
+the very analogous instance of the peripheral irritation produced by
+excessive masturbation, we undoubtedly do frequently get a development
+of the tendency to migraine, and also to other forms of neuralgia of the
+fifth: moreover the effect of such local irritation can be occasionally
+traced with much distinctness in the trigemini, by a tendency to certain
+forms of eye-disease without positive neuralgia. This was remarkably
+exemplified in a case which was under my care some years ago, and in
+which both eyes were greatly damaged by vaso-motor and trophic changes;
+partial insanity also supervened with hallucinations of sight and
+hearing.
+
+We come now to one of the most powerful sources of peripheral irritation
+tending to set up neuralgia; viz., functional abuse of the eye. This is
+one of the very few peripheral influences which occasionally we see
+producing neuralgia unaided by hereditary predisposition, or any other
+observable cause whatever, and in a far larger number producing it with
+the sole aid of more or less defective general nutrition. The latter
+occurrence is well exemplified by a case which Mr. Carter sent me the
+other day, and which also illustrates (second attack) the effect of the
+superaddition of syphilitic taint:
+
+Matilda W----, aged thirty-three, married, and has three very healthy
+children. Comes of a remarkably healthy family, of which she told me the
+entire history for three generations, with unusual intelligence and
+clearness. No neuroses, properly so-called, in any of her relatives
+during all this time. She herself was a very strong and hearty girl
+until the age of seventeen; between this date and her marriage, three
+years later, she was obliged to work tremendously hard at fine sewing,
+by which means she gained a very scanty livelihood. After a
+comparatively short period of this work she began to suffer from typical
+attacks of migraine, very severe, and recurring every three or four
+weeks, but in no particular connection with the menstrual function,
+which was normal. On her marrying and ceasing to do needle-work, the
+migraine entirely disappeared, and she retained perfect health till the
+commencement of 1871. At this time she had suckled a very hearty baby
+for ten months, and was not able to furnish such good living as usual.
+She was attacked early in January, with violent neuralgia affecting all
+three branches of the right fifth, and she the more readily applied for
+advice because she soon found that the neuralgia was becoming
+complicated with dimness of vision in the eye of the affected side, "as
+if she was going to have a cast." Was quite unconscious of ever having
+had syphilis. The medical man encouraged to believe that the whole
+malady was nervous, and would soon disappear under appropriate remedies,
+and gave her quinine, under which treatment she declares that she was
+rapidly improving, both as to pain and vision, but that her resources
+came to an end, and she could no longer pay for the medicine. She then
+neglected herself, and rapidly got worse in all regards, till at last
+she was compelled to apply to the South London Ophthalmic Hospital,
+whence Mr. Carter sent her to me, on the 6th of April. At this time the
+paroxysms were excessively violent and frequent, though brief. On
+examination, tender points were found at the supra-orbital notch, at the
+infra-orbital foramen; in front of the ear; in the temporal region; in
+the parietal region, and the inferior dental region. There was strongly
+marked anaesthesia of the skin of the right half of the face, of the
+gums, and of the side of the tongue. The teeth were absolutely perfect:
+not one spot of caries could be seen. Taste was completely destroyed in
+left half of anterior part of the tongue. Smell was totally lost on both
+sides, and had been so, the woman declared, from a very early period in
+the illness. The right eye showed complete paralysis of the levator
+palpebrae and of the external rectus; nearly complete paralysis of the
+superior and inferior rectus, rather less marked paralysis of the
+internal rectus. Pupil normal, conjunctiva moderately congested,
+lachrymation profuse, photophobia partial. The functions of the retina
+were perfect. Accommodation was affected in the following degree and
+manner. The vision of the affected eye was perfect at long distances,
+very imperfect at short distances. With both eyes open she saw every
+thing double, but could still count all the bricks in a whitewashed wall
+at sixteen feet distant. There was no secondary disturbance of the
+stomach whatever. On the first visit she assuredly had no visible
+signs, in skin or throat, of syphilis; the perfect health of her
+children, and absence of abortions, made syphilis the less probable. But
+on her second visit she complained of sore throat, and a week later a
+palpably specific sore appeared on the soft palate. She declared, with
+apparent sincerity, that it was the first symptom of the kind she had
+ever had. The neuralgia rapidly disappeared under thirty grains of
+iodide of potassium daily. The lesions of taste and smell disappeared
+exactly pari passua with the trigeminal pains. The ocular paralysis
+threaten to be much slower in departing. I think we must believe that
+this woman contracted syphilis after the birth of her last child. It is
+at any rate certain that the migraine of her youth was perfectly
+unconnected with syphilis, being as unlike the pains evoked by the
+latter as it is possible for two kinds of pain to be. In all probability
+she was infected during her last lactation.
+
+Last among the peripheral influences of sufficient importance to be
+specially mentioned as effective factors in the production of neuralgia,
+must be mentioned caries of the teeth, and the comparatively rare
+accident of the mal-position or abnormal growth of a "wisdom-tooth." It
+is an undoubted fact that these things may cause neuralgia even of a
+very serious type, and attended with extensive complications; as in Mr.
+Salter's cases, already mentioned, of reflex cervico-brachial neuralgia
+from carious teeth. Looking to the extreme frequency of caries, however,
+as compared with the rarity of true neuralgia (not mere toothache) as a
+consequence of it, it is impossible not to suppose that the share of the
+carious teeth in the production of such neuralgia must be very small,
+compared with that of other influences.
+
+5. The next influence which we shall mention as undoubtedly very
+effective in assisting the production of neuralgia in certain cases is
+that of anaemia and mal-nutrition generally; but it is not necessary to
+dwell on this at any length. The fact is notorious that severe loss of
+blood is always followed by headache; and if there be the least
+predisposition to neuralgia, this headache will very commonly take the
+form of the severest clavus. And, in like manner, chronic states of
+anaemia and of mal-nutrition undoubtedly aggravate every existing
+neuralgia, and bring out lurking tendencies to the disease. But I do not
+believe that anaemia, or starvation pure and simple, ever generates true
+neuralgia by its sole influence.
+
+6. The question how far, and in what way, the neuralgic tendency is
+helped by certain constitutional diatheses, such as rheumatism and gout,
+and by certain toxaemiae, such as malaria, alcoholism, lead-poisoning,
+etc., is a very much more difficult one than might be supposed from the
+off-hand manner in which many writers speak of the "rheumatic," the
+"gouty," or the "alcoholic" forms of "neuralgia." We may, however,
+simplify it a good deal. In the first place, it seems obvious to me that
+the only manner in which alcohol helps the production of true neuralgia
+is by its tendency, after long abuse, to produce degeneration of the
+nervous centres: it will therefore be considered, shortly, under another
+division of the present subject. Lead-poisoning, again, only produces so
+highly special a form of neuralgia (if colic be neuralgia at all) that
+it need not detain us here. The influence of malaria is, for the most
+part, an utter mystery to us, but by so much as we can see it appears
+plain that one of the most important features in the disease is a
+powerful disturbance of the spinal vaso-motor centres. But the most
+interesting consideration that we have to deal with is the question of
+the supposed relations of the rheumatic and the gouty diatheses, and the
+syphilitic dyscrasia, to the neuralgic tendency. On this point I am
+obliged to disagree _in toto_ with the popular view that assigns these
+diatheses among the most frequent predisposing causes of neuralgia.
+
+To take the case of rheumatism first, I am willing to allow that there
+are a number of facts which superficially appear to countenance the idea
+of a close connection of this disease with neuralgia. But of these facts
+a considerable proportion consist only of examples of inflammation of
+the nerve-sheath, with a certain amount of effusion within and around
+it, occurring in persons who have never shown any symptoms which warrant
+the assumption of a general rheumatic diathesis; and these local
+phenomena really differ in nothing from many trophic and vaso-motor
+changes which have been already described as plainly secondary to
+ordinary neuralgia in which there could be no pretence of a rheumatic
+pathology except on the slender foundation of a suspicion that the
+affection was immediately excited by the influence of cold, which is
+really no argument at all. Such patients will be found to have
+exhibited, not special rheumatic, but special neuralgic tendencies in
+their past history. On the other hand, there undoubtedly are a certain
+number of patients who, having previously given signs of a tendency to
+generalized rheumatic inflammation of fibrous membranes, are, on some
+particular occasion, attacked with similar inflammation extending over a
+more or less considerable tract (not a small limited spot) of a nerve
+sheath. But so far from agreeing with those who think that this is a
+frequent case, my experience teaches me that it is quite exceptional;
+nor do I believe that the common opinion could ever have arisen had it
+not been for the rage that exists for connecting every disease with a
+special diathesis which the profession flatters itself that it
+understands. Few persons have taken more pains than myself to ascertain
+the frequency with which neuralgic patients show a history of previous
+rheumatism, whether in the so-called "fibrous," or in the synovial
+form; but it is remarkable how seldom I have found this to be the
+case--a result which surprised me, because it happened that I, a
+neuralgic subject, had suffered in youth from regular acute rheumatism,
+and had fancied that I should discover a close connection between
+rheumatism and neuralgia. Eulenburg states that neuralgia caused by cold
+more frequently attacks the sciatic nerve than any other, and thinks
+that the tendency to sciatica is characteristic of the relations of
+rheumatism to sensory nerves. For my own part, I see no reason to call
+in the rheumatic diathesis as a _deus ex machina_ to explain the
+frequency with which sciatica follows comparatively trifling peripheral
+impressions like that of cold. The true reason I believe to be, that
+what would have been a slight and trivial neuralgia elsewhere, becomes a
+serious affection in the instance of the sciatic nerve, by reason of the
+strong muscular pressure end dragging which are always going on in the
+thigh in locomotion. I shall return to this subject when speaking of
+Treatment.
+
+As regards the relations, of gout to neuralgia, I can hardly express my
+own view better than by quoting the words of Eulenburg:[17] "Much more
+doubtful is the influence of gout, which in rare cases, perhaps,
+produces neuralgia directly, by means of neuritis, or by the deposit of
+tophus-like calcareous concretions in the nerve-trunks. Gout has been
+reckoned as a great influence among the causes of superficial neuralgias
+(sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but
+this influence is more probably only an indirect one, operating through
+circulation changes which are often produced by chronic liver-diseases
+or by diseases of the heart and vessels, (_e. g._ Valvular diseases and
+narrowing of the coronary arteries in angina)." To which I will add this
+argument against any close connection of gout with neuralgia, that it is
+exceedingly seldom that colchicum effects any decided good, a fact which
+is as unlike the relations of colchicum to true gout as any thing could
+be. For, whatever may be thought of the advantages or disadvantages, on
+the whole, of employing colchicum against gout, at least no one with any
+experience will deny that in the immense majority of cases of true gouty
+pain, it gives rapid relief to the acute suffering. I doubt if it
+ever[18] acts in that way in real neuralgia, though I have occasionally
+seen it apparently useful in a more limited way, as will be said
+hereafter.
+
+As regards the relation of the syphilitic dyscrasia to neuralgia, I
+agree in general with Eulenburg. "Syphilis," he says, "may be the direct
+cause of neuralgia, either by the development of specific gummata in
+the nerve-trunks or in the centres, or by arousing chronic irritative
+processes in the nerve sheaths, the membranes of the brain and spinal
+cord, or, especially, in the bones and periosteum (syphilitic osteitis
+and periostitis)." The case of periostitis, however, is a doubtful one:
+it may be questioned whether this affection (which will be among the
+diseases discussed in Part II. of this work) ever give rise to true
+neuralgia. Persons who are, by inheritance, highly predisposed to
+neuralgia, may from the mere general lowering of their health produced
+by constitutional syphilis, become truly neuralgic simultaneously with,
+or subsequently to, the appearance of painful nodes on their bones. And
+as regards the whole relations of syphilis to neuralgia, I must, from my
+experience, conclude that the former is, after all, but rarely concerned
+in the production of the latter. Syphilis has a strong specialty for
+producing limited motor paralyses, but a much weaker one for producing
+limited affections of the sensory system.
+
+7. We now come to the discussion of a group of momenta whose influence
+in the production of neuralgia is at once very powerful, and of the
+highest significance as regards the general pathology of the disease.
+These are the degenerative changes of the arterial and capillary systems
+which are a part of the normal phenomena of old age, but may occur at
+earlier periods of life, in consequence either of certain constitutional
+diseases, especially gout, or of special toxic influences on nutrition,
+of which persistent alcoholic excess is very far the most important.
+
+The reader does not need to be told the familiar story of the
+degenerative changes in the vessels which, commencing usually some time
+during the fifth decenniad, by degrees convert the elastic arterial
+coats, and the almost membranous walls of the capillaries, into more or
+less rigid tubes; nor does he need to be informed that the tendency of
+these changes, as they operate in the great motor and intellectual
+centres, is notoriously to produce innutrition of the tissues that
+depend for their blood supply on the affected vessels, whence cerebral
+softening so commonly results. That analogous changes take place in the
+vessels supplying the spinal centres is certain; but it is a remarkable
+fact that these do not very commonly produce motor paralysis. What they
+do produce is rather a slow enfeeblement both of (spinal) sensation and
+motion, but where the process of decay has been prematurely forced, or
+the inheritance of neurotic weakness is very marked, the process of
+sensorial decay (the decline, that is, of true sensorial function) is
+apt to be mingled with pain. That this pain should be localized, often
+in a single nerve, is no more surprising than the fact that the
+degenerative process itself should vary so greatly in the degree of its
+development at one point from that which it shows at others. I have
+already insisted (_vide_ Chapter I.) on the marked correspondence
+between the period of life in which degenerative changes commence and
+progress (the last third, roughly speaking, of a fairly long life), and
+that in which the most severe, intractable, and progressively increasing
+neuralgias are developed. I must here notice a singular statement of
+Eulenburg's, that neuralgia never attacks people who are over seventy.
+That statement shows that persons of a greater age than seventy are rare
+in this world, and that no such patient happened to come under
+Eulenburg's notice; for I have (by mere chance, doubtless) seen several
+instances of first attacks occurring after seventy; and almost the worst
+case of epileptiform tic I ever saw began when the patient was eighty;
+she was a member of a highly neurotic family whose medical genealogy is
+given at a previous page. In general terms, it may be said that every
+additional year of life after fifty increases the probability that a
+neuralgia, should such arise, will be severe and rebellious to
+treatment; and in the very aged the cure of such affections is probably
+impossible.
+
+8. This seems the proper place to introduce such facts as have been
+observed, and they are very few, that directly illustrate the material
+changes occurring in neuralgia.
+
+Very much the most important of these facts is the history of a
+remarkable case recorded by Romberg. ["Diseases of Nervous System," Syd.
+Soc. Trans., vol. i.] The patient, a man sixty-five years old at the
+time of his death, had suffered for several years from the most violent
+and intractable epileptiform trigeminal neuralgia, complicated with
+interesting trophic changes of the tissues. Post-mortem examination
+showed that the pressure of an internal carotid aneurism had almost
+destroyed the Gasserian ganglion of the painful nerve, that the trunk
+and posterior root of the nerve were in a state of advanced atrophic
+softening, and the atrophic process had extended in less degree to the
+nerve of the opposite side. Now, the value of this case is by no means
+restricted to the fact that it records the existence of a particular
+anatomical change in one example of neuralgia. Its most striking
+teaching is the fact that the acutest agonies of neuralgia can be felt
+in a nerve, the central end of which is reduced to such a pitch of
+degeneration that conduction between centre and periphery must very
+shortly have entirely ceased had the patient lived. And hardly less
+important is its illustration of the fact that permanent injury to the
+ganglion of the posterior root of a spinal nerve impairs the vitality of
+the posterior root itself--a fact which has been independently made out
+by the physiological researches of Bernard and of Augustus Waller.
+
+On the other hand, if we examine the tolerably numerous histories of
+cases in which the painful nerves have been examined at the apparent
+site of pain, we discover nothing to lead us to connect neuralgia
+definitely with any one sort of change. Assuredly, for example, local
+neuritis is by no means universally, it is probably even not commonly,
+present in the early stages of neuralgia; it has also been repeatedly
+detected in nerves that had been wholly free from neuralgia; and, on the
+other hand, it has been entirely absent in nerves that have been the
+seat of the severest pains. Moreover, many facts which have been put
+down without reflection, as showing a local peripheral cause for
+neuralgia, are at least open to another and, as I believe, truer
+explanation; as (_e. g._) in the following remarks of Eulenburg on
+mechanical irritations of nerves as causes of neuralgia: "Diseases of
+bones are extraordinarily frequently the cause of neuralgias in
+consequence of compression or secondary disease, which affects the
+branches of nerves passing through canals, foramina, fissures, or over
+processes of bone. The appearances which the opportunities of resections
+of the trigeminus for facial neuralgia have permitted to be discovered,
+have given us valuable information in that direction. Flattening and
+atrophy of nerves from periostitis, or from concentric hypertrophy in
+narrowed bony canals, have frequently been discovered. The neurilemma at
+the narrowed parts was often seen reddened, ecchymosed, infiltrated with
+serum, or surrounded with fibrous exudation; occasionally inflammation
+had been followed by partial thickening of the neurilemma (fibrous
+knots) and turbidity (Trubungen) of the nervous cord at the
+corresponding spot. Similar appearances have been noted in other
+neuralgias (neuralgia-brachialis, sciatica)." For my own part, I believe
+that the above description represents the facts from an erroneous point
+of view. True neuralgia, if by that we understand a pain of intermittent
+character limited to one or more nerves, is in my experience an
+extremely uncommon result of periosteal disease, or of inflammation of
+the linings of bony canals; but in a great number of instances such
+diseases appear to be set up as the secondary consequence of the
+neuralgic process (whatever the essential nature of that may be) going
+on in sensory nerves which supply the parts when these inflammations
+appear. And it must be remembered that the specimens obtained by
+resection of nerves are comparatively few in number, and are taken
+universally from old-standing and desperate cases of disease; in short,
+from cases which are just in those advanced stages of neuralgia in
+which, as has already been amply shown, these secondary inflammations
+are almost always present. On the other hand, I have myself had one
+opportunity of examining the local condition of an intercostal nerve,
+which during life, and quite up to death, had been the site of the most
+pronounced neuralgia, which, however, had only existed for a few days.
+The patient, a young man, aged twenty-seven, was probably insane, and
+had attempted suicide. Not a trace of inflammation, either in the nerve
+itself or in any of the tissues to which it was distributed, could be
+detected. (This was a case in which I greatly regretted the
+impossibility of getting a family history that was at all reliable.) The
+spinal cord, unfortunately, could not be examined. And I strongly
+believe, from the marked absence of tenderness on pressure which is
+almost universally observed in ordinary cases of neuralgia at an early
+stage, that primary inflammation of neurilemma, periostem, etc., as a
+cause of neuralgia, is altogether exceptional; so much so, that we are
+entitled to believe it can never be more than a concurrent, and then not
+the most important, cause.
+
+It is necessary here to inquire, more particularly than we have yet
+done, into the nature of the "painful points" first signalized by
+Valleix as a distinctive symptom of neuralgia. Very great differences of
+opinion have prevailed among subsequent writers, both as to the
+frequency and the significance of these points. It may be said, however,
+to be now quite settled that the presence of definite points, painful on
+pressure, and also corresponding to the foci of severest spontaneous
+pain, is far from universal in neuralgia. Upon this point there is
+probably no reason to doubt the correctness of Eulenburg's observations
+made in the surgical clinic of Greifswald and the polyclinic of the
+University of Berlin; he says that he discovered the existence of tender
+points in "Valleix's sense," in rather more than half the cases of
+superficial neuralgia, but in the rest he could not by any means
+discover them. In many other cases, however, he found more indefinite
+points of tenderness, not accurately corresponding to nerve-branches,
+but affecting individual portions of skin, bone, or joints; the relation
+of these to the neuralgic symptoms was difficult of explanation.
+Eulenburg lays down the principle that "hyperaesthesia" may depend on
+three sorts of causes--(1) On local disease of the peripheral ends of
+nerves; (2) on alterations of the psychical centres; and (3) on morbidly
+exaggerated conduction in the nerve-trunks themselves; and it is to this
+third source that he attributes many of the phenomena of the neuralgic
+painful points, and especially their multiplicity, in many cases. The
+_locus in quo_ of the mischief which sets up this exaggerated conduction
+of sensory impression is, upon this theory, between the psychical centre
+and the main point of branching of the nerves; hence a large number of
+peripheral nerve-termini might be practically sensitive to touch,
+because the mischief, though localized in a comparatively small spot,
+might easily affect many bundles of fibres, which diverge widely from
+each other in their course. It will be seen presently with what limits
+and for what reasons we believe this to be a true theory. But to return
+to the question of painful points in Valleix's sense, we must state one
+or two facts which seem certain from our own experience, but have not
+been adequately recognized, we believe, by others. The first is, that
+localized tender spots, accurate pressure on which will set up or
+aggravate the neuralgic pain, are not early phenomena, save in
+neuralgias of exceptional severity of onset; but that a certain
+persistence and severity of neuralgia are always followed by the
+formation of one or more true points douloureux. The second fact relates
+to the clinical history of migraine. Roughly speaking, it is true, as
+Eulenburg states, that, in pure migraine, painful points in Valleix's
+sense are not to be found; in place of them we observe, after the
+paroxysms have passed away, a more generalized soreness of considerable
+tracts of the scalp, forehead, etc., or diffuse tenderness of the
+eyeball. But I must here again refer to the fact, first observed in my
+own case, and afterward verified in many others, that migraine may be
+only the youthful prelude to a regular trigeminal neuralgia attended
+with the formation of characteristic localized painful points at a later
+period. And the third fact that must be specially mentioned is that the
+true Valleix's point, when it has become established for some time, is
+not a mere spot of sensitive nerve, but is the scene of trophic changes,
+involving hyperaemia and thickening of parts surrounding the nerve. To
+give one example, it is quite a frequent thing to find a patch of tender
+and sensibly thickened periosteum of irregular shape, but equal
+sometimes to a square inch in size, over the frontal bone at and
+immediately above the inner end of the eyebrow, in cases where
+supra-orbital neuralgia has recurred frequently during some years,
+although no such thing was present when the neuralgia first commenced.
+In my own case, the bone has become sensibly thickened at that point.
+
+The general result of such post-mortem and clinical information as can
+be had seems clearly to be that positive anatomical changes, either of
+nerve-terminals or superficial nerve-branches, are but casual and
+infrequent factors in the first production of neuralgia, and, in
+particular, it would seem that inflammation of a nerve itself by no
+means necessarily produces neuralgic pain, but (far more commonly)
+simple paralgesia or anaesthesia of the parts external (peripheral) to
+the lesion. The one marked exception to this general proposition is to
+be found in the case of the severe and peculiar injuries inflicted on
+the trunks of nerves by gunshot-wounds which, as we have seen (from the
+American experiences), can produce some of the most dreadful forms of
+neuralgia. But the nature of the injury here inflicted is, it must be
+remembered, quite different from any thing which either disease or
+accident in civil life would produce, save in the most exceptional
+instances. For the chief material element in the production of the
+neuralgias of ordinary life we are really driven, by exclusion, to the
+condition of the posterior roots of special nerves, in some cases,
+perhaps, to the (spinal) ganglia on which the nutrition of these roots
+probably is considerably dependent.
+
+With the field thus narrowed for us, it is surely legitimate, in the
+necessary scarcity of anatomical records referring directly to the state
+of the nerve-roots in ordinary neuralgia, to place great weight on the
+facts of a disease like locomotor ataxy, in which the main anatomical
+change is a progressive atrophy of the posterior columns which usually
+falls with peculiar severity on the posterior nerve-roots, or on the
+parts of the gray matter immediately adjoining these, and in which
+neuralgia may be said, for practical purposes, to be a constant and most
+characteristic phenomenon. If any one desires to see how strikingly the
+connection of the neuralgic phenomena with the anatomical-change comes
+out, I recommend him to study Dr. Lockhart Clarke's papers on locomotor
+ataxy (_vide_ "St. George's Hospital Reports, i." 1866; _Lancet_, June,
+10 1865; "Med.-Chir. Soc. Transactions," 1869), or the excellently
+reported case by Nothnagel (_Berlin Klin. Wochensch._, 1865). It is
+really not too much to say that the only important difference between
+the clinical aspect of the pains of locomotor ataxy and those of
+ordinary neuralgia is simply such as depends on the fact that the
+anatomical change in the former case is bilateral, and usually affects
+the roots of several, sometimes of a great many pairs of nerves. I
+infer, from a conversation with Dr. Clarke, that he fully recognizes the
+force of the analogy, and the great strength of the presumption which it
+sets up in favor of an atrophic change of the posterior roots in
+neuralgia.
+
+It may, of course, be urged, against the view that neuralgia depends on
+any change analogous to those which occur in ataxy, that quantities of
+cases of the former recover speedily, and must be supposed to be either
+independent of material change altogether or, at any rate, to have
+involved only very trivial anatomical changes, not formidable diseases,
+like atrophy of nerve-centres. I find it impossible to admit that this
+argument has the slightest force. Are we to suppose that the posterior
+nerve-roots alone, of all tissues and organs of the body, are incapable
+of minute and partial changes in the direction of molecular death which
+may be perfectly recovered from in weeks, months, or even days? I, for
+one, cannot doubt, that such changes are of frequent occurrence, in all
+parts of the central nervous system, when I can consider the absolute
+dependence of these portions of the organism upon a perfect
+blood-supply, and the immense number of possible causes of temporary
+interference with that source of nutrition. And I can see no probable
+difference, except in degree and persistence between the effects on
+sensation which would be produced by such a change of the posterior
+roots as this, and that which would result from the more serious and
+fatally continuous change which is involved in locomotor ataxy.
+
+9. We come now to a most important but most complex and difficult
+portion of the argument respecting the _locus in quo_ of the essential
+pathological process (if such there be) in neuralgia; viz., as to the
+paths and the character of the so-called "reflex" influences which
+intervene in the causation, both of neuralgia itself, and also of the
+numerous complications with which we have seen that neuralgia is liable
+to be attended. The clinical facts which confront us here, and demand
+explanation, are the following: (1) Irritation so called, of sensory
+fibres may apparently evoke pains attributed to the site of the
+irritation, or to the parts on the peripheral side which are supplied by
+the same sensory nerves. (2) Peripheral irritation of a particular
+sensory nerve may evoke neuralgic pains in nerves connected with that
+irritated only through the spinal centre. (3) Neuralgia in a sensory
+nerve may (and almost always does, to some extent) produce secondary
+vaso-motor paralyses: these paralyses may affect fibres which run in the
+same branch of the nerve as that which is painful, or fibres that run in
+another branch of the same nerve, or fibres that run with another
+sensory nerve, or the ganglionic chain of the sympathetic itself. (4) In
+like secondary manner, neuralgia may produce vaso-motor spasms in any of
+the directions just specified; this is usually a short-lived phenomenon,
+giving place quickly to paralysis; but Du Bois Reymond's often-quoted
+analysis[19] of his own sufferings from migraine seems to show that
+spasm-producing irritation of the trunk of the sympathetic may last
+during some hours. (5) Neuralgia in a sensory nerve may increase, alter,
+or (more rarely) suspend the secretions of glands supplied by fibres
+bound up either in the same branch, or in another branch of the same
+nerve, or in a different nerve with which it is connected only through
+the centre or (possibly) only through a plexus. (6) Neuralgia in a
+sensory nerve can produce paralysis of muscles supplied by motor fibres
+bound up with the painful branch, or with another branch of the same
+nerve, or in muscles supplied by a totally distinct nerve connected only
+through the centre. (7) It may produce convulsion and spasms of muscles,
+in all the above directions; this usually alternates with great
+weakness, or actual paralysis of the same muscles. (8) It may produce
+partial or complete loss of common or special sensation in nerve-fibres
+that run either with the same branch, or with another branch of the same
+nerve. (9) It may produce trophic changes, either in the direction of
+simple atrophy or of subacute inflammation with proliferation of
+lowly-vitalized tissue (_e. g._, connective) in the parts with which are
+supplied with sensation by the painful branches or by other branches of
+the same nerve.
+
+It is necessary to go over again the proof of these facts; they are
+given pretty copiously in the chapter on Complications; and could have
+been made much more numerous. But the point to which I desire to compel
+the reader's attention is the impossibility as it seems of me, of
+accounting for the variety and complexity of these phenomena, except by
+the supposition that there is in every case of neuralgia a central
+change, which is the one most important factor in the producing both of
+the pain and of the secondary phenomena. For the result of my experience
+is that neuralgia, unless very slight and brief, is never unattended by
+these complications and in the great majority of cases involves several
+different secondary alterations of function which must (so to speak)
+radiate from the central end of the sensory nerve, and from no other
+place whatever. And it must be remembered that the most elaborate
+"_symptome-complexe_" is found equally in cases where no suggestion of
+any peripheral origin of the pain can be made, and in cases where, at
+first sight, one might fancy there was a very obvious peripheral cause
+for pain. I am quite willing to admit, with Eulenburg and others, that
+the evidence, powerful and varied though it be of the relations of
+neuralgia to hereditary neuroses, to alcoholic and senile degeneration,
+etc., only raises a strong probability that some part of the central
+nervous system is the _locus in quo_ of the essential morbid processes
+in the majority of neuralgias. But the case stands far otherwise now
+that we are able to show, not merely that the majority of neuralgic
+patients suffer from such influences as those above mentioned, but that
+every variety of neuralgia is liable to be complicated with secondary
+affections of the most divergent nerves, the only common meeting-place
+of which is in the spinal centre of the painful nerve; and when we find
+moreover, that many of these secondary affections can equally be
+produced by undoubted atrophic changes (as in ataxy of those same
+posterior roots).
+
+At this point we must introduce a remark relative to the true nature of
+so-called "reflex" effects. The word is constantly used, and is also
+much abused, as Eulenburg remarks. We all understand, of course, what is
+intended by the commonest use of the word: the case of sneezing produced
+by the irritation of snuff applied to the peripheral branches of the
+fifth nerve in the nose is a stock example. But another application of
+the phrase, of much more questionable propriety, is that where it is
+employed to designate functional nervous actions, which merely arise
+simultaneously with or subsequently to sensory phenomena as to which
+there is no proof whatever that they were produced by peripheral
+irritation. This particular inaccuracy of customary speech has probably
+contributed largely to the inveteracy with which writers on nervous
+disease have insisted on assuming a peripheral origin in every case for
+neuralgia itself. In the case of sciatica, for example, complicated,
+secondarily, with paralysis of the flexors of the limb, it seemed easy
+and scientific to speak both of the neuralgia and the paralysis as
+"reflex" effects of a local peripheral mischief--gouty, rheumatic, or
+the like; and it appears to have been perfectly forgotten by many that
+the whole phenomena might be explained by an original morbid action in
+the sensory root of the nerve, extending subsequently to the motor root,
+without any intervention of peripheral irritation whatever, or under the
+influence only of the ordinary peripheral impressions, which, in health,
+evoke no painful nor paralytic symptoms. It is by this kind of extension
+of a central morbific process, leading to radiation of the perturbing
+influence centrifugally along divers nervous paths, that I believe we
+must explain the facts observed in complicated cases.
+
+Take, for example, the following case, which, in its history of
+twenty-three years, presents a fair example of a type of trigeminal
+neuralgia which I believe to be the rule rather than the exception,
+though the trophic changes were somewhat unusually varied and
+interesting. The following would be the pathological order of events,
+according to the radiation theory: First or true migrainous stage;
+failure of nutrition of a portion of the sensory root of the right fifth
+nerve within medulla oblongata, lesser degree of the same condition in
+the adjoining and closely-connected vagus root (hence supra-orbital
+pain, local anaesthesia and vomiting); extension of the morbid process to
+the motor root (hence vaso-motor paralysis and secretory and trophic
+changes in the cornea, superciliary periosteum, etc). Second period:
+recovery, to a large extent, of the nutrition of the posterior root of
+the trigeminus, complete recovery of the root of the vagus (hence
+alteration of the type of recurrence of the pains, which now occur at
+increasingly long intervals, and needed special provocation, _e. g._,
+excessive fatigue, to bring them on; hence, also, disappearance of the
+stomach symptoms); continuance of the affection of the motor portion of
+the nerve (hence, continuance of the tendency to trophic, secretory, and
+vaso-motor changes); development of the true points douloureux during
+and after the paroxysms, instead of the diffused tenderness following
+the old attacks of migraine. Third stage: neuralgic attacks become rare
+and comparatively unimportant; tendency to trophic changes greatly
+lessened; local anaesthesia persists. Presumption, that the nutrition of
+the nerve-centre has nearly recovered itself, but that that centre is
+still the _locus minimae resistentiae_ of the central nervous system,
+liable to suffer from any cause of general nervous depression.
+
+Now, in interpreting the above phenomena, as I do, upon the theory of
+one essentially uniform nutritive change affecting the fifth nerve
+within the medulla oblongata, I shall be met with the following
+objections: First, there is the common and superficial difficulty that
+pain and paralysis of sensation must be opposite states, and that it is
+impossible to refer them both to one and the same pathological process.
+I have already in many places given instances how constantly pain and
+sensory paralysis interchange in a manner which is totally
+incomprehensible except upon the supposition that their physiological
+basis is essentially the same; but the most satisfactory evidence,
+perhaps, that could possibly be produced on this point is to be found in
+the perusal of a group of cases observed by Hippel,[20] and entitled by
+him "Anaesthesia of the Trigeminus," the loss of sensation being the most
+remarkable feature. The cases are so deeply interesting that I would
+gladly transfer them bodily to these pages, but must abstain from want
+of space. Suffice it to say here, that, in the first place, the
+anaesthesia was accompanied, in every one of these cases, by a most
+distinct and typical neuralgia; and, secondly, that trophic changes
+occurred which most interestingly (though not with absolute
+completeness) reproduced the phenomena observed after complete section
+of the trigeminus at the Gasserian ganglion.
+
+The second objection sure to be raised to the theory of a simple
+spreading of a nutritive central change, as the cause of all the
+phenomena in such a case as the above, is this: It will be asked how the
+process extended itself to the motor root, which, in the case of the
+fifth nerve, is removed by a somewhat formidable anatomical distance
+from the sensory root. I am, of course, well aware of the latter fact,
+and it is an additional reason for selecting neuralgia of the fifth, as
+an extra difficult test of the value of my theory. A few words must be
+premised, reminding the reader of the physiological anatomy of the
+nerve.
+
+The trigeminus is in all its characters a spinal nerve; but it has
+sundry peculiarities both of structure and of connections with other
+nerves. Its posterior or sensory root is enormous, and, as Schroder van
+der Kolk showed, takes a direction from behind downward and forward,
+which is intended to facilitate its numerous and important connections
+with the nuclei of other nerves: of these the most notable are its
+connections with the vagus, facial, glosso-pharyngeal, and hypo-glossal
+nuclei. The motor root, much smaller than the sensory, was shown by
+Lockhart Clarke to be traceable as low as the inferior border of the
+olivary body, as a column of cells which occupies a situation
+corresponding to that of the anterior course of the spinal gray matter.
+
+As this column passes onward in the medulla oblongata, on a level with
+the glosso-pharyngeal nerve, it forms a group of cells of large size.
+Besides numerous other connections which it forms, Clarke describes the
+motor root as sending processes forward, like tapering brushes or tails
+of fibres, in connection with more scattered cells lying in their
+course, which may be frequently seen to communicate with the transverse
+bundles which traverse the "gray tubercle" and the sensory roots of the
+fifth contained therein. In this way the sensory root, though seemingly
+much separated from, is really in very direct connection with, the motor
+root.
+
+Now, proofs, which must be considered almost positive, have recently
+been adduced to show that the nerve-fibres concerned in those peculiar
+alterations in the tissues supplied by the ophthalmic division of the
+fifth, which occur in section of the trigeminus, come entirely from the
+motor root of the fifth, and form a very small band in the inner or
+medial margin of the ophthalmic trunk. The observation of Meissner[21]
+goes to show that it is possible (by good luck) to divide the trunk in
+such a partial manner as to cut only the inner fibres, and thereby
+produce the trophic eye-changes without any anaesthesia, or only the
+sensory fibres, and thereby induce anaesthesia without any trophic
+changes; and it must be owned that this really affords the only
+reasonable explanation of the discrepancy between the experimental
+results obtained by Magendie and Bernard; and also the facts of such
+cases as those related by Mr. Hutchinson,[22] who in two instances found
+that a completely anaesthetic eye recovered perfectly well from the wound
+made in a surgical operation. The nature of the nervous influence
+(whether ordinary vaso-motor only, or a special trophic function) has
+been greatly disputed. Dr. Wegner,[23] from observing the remarkable
+group of glaucomatous cases under Horner (of which one has been
+related), made experiments, from which he concluded that the
+augmentation of intra-ocular pressure in glaucoma was a phenomenon
+dependent upon the sympathetic, which was irritated by reflection from
+the trigeminus. But the researches of Hippel and Grunhagen, especially
+their latest,[24] give a different explanation, excluding the
+sympathetic; they found that irritation of the medulla oblongata, in the
+neighborhood of the trigeminus root, produced a lasting and very
+pronounced augmentation of intra-ocular blood-pressure, an effect which,
+they remark, could not depend on irritation of the vaso-motor centre,
+since that must produce contraction of the vessels and lowering of the
+blood-pressure. They conclude that "the trigeminus contains specific
+fibres which possess the property of actively dilating the blood-vessels
+of the eye;" and in reference to the secretion of the fluid humors of
+the eye, they conclude also that "the trigeminus also plays the part of
+an (active) nerve of secretion."
+
+Of these conflicting opinions I can have no difficulty in at any rate
+rejecting that of Wegner; for the clinical phenomena of the
+complications attending trigeminal neuralgia, such as they are described
+in my last chapter (and could have been described at much greater
+length), seem to me utterly to exclude vaso-motor spasm except as a
+temporary phenomenon at the commencement of the attacks of acute pain.
+Vaso-motor palsy undoubtedly is very often present, in fact every attack
+of neuralgia of a certain severity is thus complicated; and there is no
+reason to doubt that this paralysis could be caused by lesions within
+the medulla. Are we, then, to admit functions of active dilatation of
+vessels, and active impulse to secretion in certain fibres of the fifth?
+It is necessary at any rate to clear the ground in one respect: it must
+not be supposed that I for a moment entertain the idea that there can be
+direct active dilatation, _i. e._, that there can be any system of
+muscular fibres (and nerve-fibres stimulating them) whose office is to
+open the calibre of the vessels; the idea is wildly improbable--in fact
+almost inconceivable by any one who reflects on the necessary
+machinery--and there is not a single observed anatomical fact to give it
+support. If, then, I speak of the possibility of "active" dilatation, it
+must be understood that I refer to a theory of "inhibition," which
+supposes certain fibres to be gifted with the power of paralyzing or
+inhibiting the vaso-motor nerves. It is my duty to speak with all
+reasonable reserve on that most difficult _quaestio vexata_, the
+existence of special inhibiting systems of nerves, and the extent to
+which a double series of opposed nervous actions is generalized in the
+body; but it is impossible to avoid the subject altogether, and I offer
+the following remarks, with deference, to our professional
+physiologists. The strongest instances of the apparent inhibiting action
+are probably afforded by the _nervi erigentes_, as shown by Loven, the
+cardiac depressor, by Ludwig and Cyon, and the splanchnics (upon the
+intestine), by Pfluger. But there is not a single one of these examples
+that has not been challenged by experimenters of repute. Thus the theory
+of the distinctive restraint-action of the splanchnics upon the
+intestine, and of the vagus upon the heart, has been especially
+controverted by Piotrowski, who, indeed, rejects the whole theory of
+special inhibitory nerves.[25] And, from another point of view, Mr.
+Lister long ago attacked the views of Pfluger, maintaining that it was
+possible to produce exactly opposite effects through the medium of the
+very same nerves, according as the experimental irritation applied to
+them was weak or strong. To Dr. Handfield Jones[26] this seems a still
+unanswerable objection to the inhibitory theory. And in the remarkably
+able and judicial summary of the "Physiology and Pathology of the
+Sympathetic or Ganglionic System,"[27] by Dr. Robert T. Edes, a less
+decided but still tolerably strong acquiescence is given to Mr. Lister's
+criticisms of this theory. Personally, I must express very strongly the
+distrust (which is probably felt by many others) of doctrines which
+assert an exact opposition between the functions of any two nerves, on
+the basis of an observation that the same apparent effects may be
+produced by section of the one and galvanization of the other; both
+processes seem far too pathological, and too remote from the conditions
+of ordinary vitality, to admit of any such absolute deductions from
+their results.
+
+In the present state of our information I am inclined to explain all the
+congestive complications of trigeminal neuralgia on the basis of
+vaso-motor paralysis. And I further believe that the cause of that
+paralysis is a direct extension of the original morbid process from the
+sensory root to the motor, affecting the origin of fibres in the latter,
+which are destined to govern the calibre as ocular and facial vessels.
+These fibres I suppose it is that Meissner succeeded in dividing when he
+partially cut the trigeminus, and got nutritive and vascular changes
+without anaesthesia.
+
+There must be more than this, however, to account for the whole of the
+trophic phenomena; for there is a great body of evidence to show that
+mere vaso-motor paralysis does not produce any phenomena of such an
+actively morbid kind as those we are endeavoring to explain. The
+phenomena on the side of secretion might indeed be possibly explained by
+vaso-motor paralysis. [It must be remembered that I am speaking of such
+augmented secretion as is seen in neuralgia. I agree with Prof.
+Rutherford (Lectures on Experimental Physiology, Lancet, April 29, 1871)
+that it is difficult thus to explain the effects of galvanization of the
+chorda tympani on the submaxillary gland.] Consisting as they do (a), in
+the great majority of cases, of a mere outpour of what seems little more
+than the aqueous part of the secretion, and (b) in a few cases of
+arrested secretion, a phenomenon otherwise by no means unfamiliar as the
+result of sudden, passive engorgement of glands. But the mere cessation
+of vaso-motion will not account for such facts as the rapid and
+simultaneous development of erysipelatous inflammation, of corneal
+clouding and ulceration, of iritis and glaucoma, of nutrition-changes in
+hair and mucous membrane. I must, for the present, be content to believe
+it probable that there is a special set of efferent fibres in the
+trigeminus, emanating from the motor-root, whose office it is in some
+unknown way to preside over the equilibrium of molecular forces in the
+tissues to which the nerve is distributed; trophic nerves, in fact,
+though not active dilators of blood-vessels.
+
+It seems to me that, without enlarging further on this almost endless
+topic, I should be justified in assuming that I had shown the very high
+probability that the common starting-point both of the neuralgia and of
+its vaso-motor secretory, and trophic complications, was in the sensory
+root of the trigeminus. But the argument is greatly strengthened when we
+consider the fact that loss of peripheral common, and also tactile
+sensation, to a greater or less degree, is constantly observed to occur
+simultaneously with the pain and with the other complications. When we
+observe a patient suffering from racking supra-orbital and ocular
+neuralgia, and discover that at the very same period the skin round the
+eye is markedly insensitive to impressions, except in the _points
+douloureux_, what can we rationally suppose, except that both pain and
+insensibility are the result of one and the same influence, which
+radiates from the sensory centre?
+
+Nor are we likely to reach a different conclusion, if we test the matter
+by the consideration of a rarer, but still sufficiently common kind of
+case, such as I have described in Chapter I., in which a very strong
+peripheral influence (traumatic) produces neuralgia, accompanied by
+vaso-motor and secretory phenomena, and by anaesthesia, but not in the
+district of the painful nerve, but in the territory of a quite different
+nerve. How can we doubt, in the case, _e. g._, of a trigeminal neuralgia
+thus complicated, the exciting cause of which was a wound of the ulnar
+nerve, that the morbid influence, traveling inward from the lesion,
+would have passed without any special consequences (as happens in
+thousands of such nerve-wounds), had it not, in its passage along the
+medulla, encountered a _locus minoris resistentiae_ in the roots of the
+trigeminus? It seems impossible to account for the phenomena on any
+other theory. [Eulenburg says, in reference to my reported cases of the
+kind: "_Solche Falle begunstigen in hohem Grade die Annahme
+pradisponirender Momente, die in der ursprunglich schwacheren
+Organisation einzelner Abschnitte des centralen Nerven-apparates
+beruhen._" _Op. cit._, p. 56.]
+
+It is necessary, in the next place, to consider a very important
+question, how far irritation can pass over from one nerve to another,
+without reflection through a spinal centre, solely in virtue of a
+connection through the medium of a nervous plexus. The case which
+apparently presents such phenomena in the most unmistakable way is that
+of _angina pectoris_.
+
+The site to which the essential heart-pain is referred in this disease
+is probably the cardiac, or this and the aortic plexus; in a
+comparatively small number of cases the pain does not extend farther.
+But much more frequently it spreads in various directions, and we have
+to account for its presence (_a_) in intercostal nerves, (_b_) cervical
+nerves, (_c_) nerves springing from the brachial plexus.
+
+Before we inquire into the mechanism by which this extension of the pain
+takes place, we ought in strictness to ask ourselves whether the
+essential heart-pain is felt only in the spinal sensory branches, or
+whether the sympathetic fibres are themselves capable of feeling pain.
+The latter supposition, notwithstanding all that has been argued in its
+favor from the supposed analogies of the pain of colic, gall-stone,
+etc., seems to me very doubtful. It would appear more probable that both
+the latter pains, and also those of angina, are really connected with
+branches either of the vagus or of other spinal nerves. And there is no
+need to invoke the sympathetic as a sensory nerve, to account either for
+the essential heart-pain of angina, or for its extension into arm,
+chest-wall, and neck. For the plexus cardiacus receives spinal branches,
+both from the vagus and also (through the medium of the sympathetic
+ganglia of the neck) from the whole length of the cervical and the
+uppermost part of the dorsal cord-centres. And, in this way, it would
+seem quite possible intelligibly to account for the pain radiating into
+intercostal, cervical, and brachial nerves, merely by extension of a
+morbid process essentially seated in the cord. Usually, however, one
+sees it explained not in this way, but by the inter-communications that
+exist outside the spine, between the branches from the cervical ganglia
+and the lower cervical and upper dorsal nerves; and the pain in the arm
+is especially explained by the connection (outside the spinal canal) of
+the inferior cervical ganglion, on the one hand with the lower cervical
+nerves, which go to the brachial plexus, and, on the other hand, with
+the heart itself. There remains to be explained, however, the singular
+tendency of the arm-pain to be one-sided (this happens in at least four
+cases out of five); and this explanation seems to me insuperably
+difficult, on the theory that the transference of morbid action to the
+brachial nerves takes place through external anastomoses. It appears
+greatly more probable that angina is essentially a mainly unilateral
+morbid condition of the lower cervical and upper dorsal portion of the
+cord; liable of course to be seriously aggravated by such peripheral
+sources of irritation as would be furnished by diseases of the heart,
+and especially by diseases of the coronary arteries; the latter
+affection probably involving constant mechanical irritation of the
+cardiac and the aortic plexuses. It is noteworthy that the arm-pain is
+sometimes (I do not know how often) accompanied by vaso-motor paralysis
+in the limb; this phenomenon could also certainly be more easily
+accounted for on the supposition of radiation from a spinal vaso-motor
+centre (to which the morbid process had extended from a posterior
+nerve-root) than on that of communication between painful sensory nerves
+and vaso-motor nerves; through either of the plexuses independently of
+the spinal centres.
+
+In truth, I suspect that, whatever part the plexuses, with their
+reenforcing ganglionic cells, may play during physiological life, they
+are not often the channels of mutual pathological reaction of one kind
+of nerve with another. It would be possible to argue this even more
+strongly in the case of trigeminal neuralgias; but I must not
+unnecessarily expand this already too lengthy discussion.
+
+From the varied considerations which have now been adduced, the reader,
+unless I altogether miscalculate the value of the facts, will probably
+have arrived at the following conclusions: (1) That the assumption of a
+positive material centric change as the essential morbid event in
+neuralgia is almost forced upon us; (2) that, whereas the morbid
+process, if centric, is _a priori_ infinitely more likely to be seated
+in the posterior root of the painful nerve, or the gray matter
+immediately connected with it, than anywhere else; so, again, the
+assumption of this locality will explain, as no other theory could
+explain, the singular variety of complications (all of them nearly
+always unilateral, and on the same side as the pain) which are apt to
+group themselves around a neuralgia; and some of which are very seldom
+absent in neuralgia of any considerable severity. To this we may
+certainly add that it is extremely probable that the vast majority of
+neuralgic patients inherit the tendency to this localized centric
+change; in support of this we may finally mention two considerations
+derived from the sex and the ages most favorable to neuralgia. Eulenburg
+saw a hundred and six cases of neuralgia of all kinds, of which
+seventy-six were in women and only thirty in men; my own experience is
+very similar; namely, sixty-eight women and thirty-two men out of a
+hundred hospital and private patients. The strong connection between the
+hysteric and the neuralgic temperament in women, and the great
+preponderance of women among neuralgics, strengthen in no small degree
+the probability of inherent tendencies to unstable equilibrium as a very
+common predisposing factor in neuralgia. And, on the subject of age, I
+need only recall what I have said so strongly about the coincidence of
+neuralgia with particular epochs in life, as affording evidence of the
+most powerful kind that neuralgics are, save in exceptional instances,
+persons with congenitally weak spots in the nervous centres, which break
+down into degeneration, temporary or permanent, under the strains
+imposed by one or other of the physiological crises of the organism, or
+the special physical or psychical circumstances which surround the
+patient's life.
+
+Having thus decidedly expressed my belief in the essential material
+participation of the nerve-centre in neuralgia, it remains for me to
+discuss two points: first, as to the character of the material change in
+the nerve-root, and next, as to the extent to which mere peripheral
+influence, without special inherited tendencies, may suffice to set this
+process going.
+
+The morbid change in the nerve-centre is probably, in the vast majority
+of cases, an interstitial atrophy, tending either to recovery, or to the
+gradual establishment of gray degeneration, or yellow atrophy, of
+considerable portions of the whole of the posterior root, and the
+commencement of the sensory trunk as far as the ganglion.
+
+It is probable, however, that in a certain number of cases, the atrophic
+stage may be preceded by a process of genuine inflammation, and that
+this inflammation is centripetally produced in consequence of
+inflammations of peripheral portions of the nerve. The considerations
+which make this probable are chiefly derived from the analysis of cases
+in which a more or less chronic, but severe, visceral disorder has been
+followed by so-called reflex paralysis, but in which neuralgic
+phenomena, have been conspicuous. In reference to this subject I
+recommend to the reader's attention the very interesting paper on
+"Reflex Paralyses" by Prof. Leyden, of Konigsberg.[28] He is immediately
+commenting upon a case in which dysenteric affection of the bowel were
+followed by the symptoms of myelitis, attended with febrile
+exacerbations, and also with severe pains in the region of the sacrum,
+in the course of the dorsal intercostal nerves of the right side, and in
+the knees, and semi-paralytic weakness of the lower extremities, and
+with pains between the shoulder-blades and the left arm. Leyden
+discusses the doctrine of reflex paralyses in general, starting from
+the cases of urinary paraplegia brought forward by Stanley, in 1835, and
+tracing the growth of opinion through the phases represented by Graves,
+Henoch, and Romberg, by Valentine and Hasse, then by Pfuger, and other
+professors of the inhibitory doctrine; by Brown-Sequard (in his
+well-known, and now very generally discredited, theory of spasm of the
+vessels in the nervous centres), by Jaccoud in the "Erschopfung"
+(exhaustion) theory, down to the more careful and reliable researches of
+Levisson on the temporary reflected paralyses induced by experimental
+squeezing of the kidney or uterus of animals; and then gives the history
+of the more recent doctrine of a positive material change in the cord
+centripetally introduced. Gull[29] (1856) may be said to have
+inaugurated the new doctrine of a morbid process transmitted along the
+pelvic nerves to the cord, and causing material changes there.
+Remak,[30] on the other hand, suggested a material change operating in
+the opposite direction; _a neuritis descendens_, starting in the very
+nerves (within the pelvis) which showed the paralysis in the
+extremities. The symptoms are supposed by him to be distinctive,
+inasmuch as there is both violent pain in the nerves of the soles of the
+feet, and also tenderness of the same. On the other hand, Remak said
+that myelitis, with neuritis, might be the origin of paraplegia and
+simultaneous palsy of bladder and rectum. The theory of neuritis
+descendens was supported by Kussmaul,[31] in the record of a case where
+disease of the bladder was complicated with pelvic inflammation,
+atheromatous degeneration of the arteries, and consequent fatty
+degeneration of the sciatic nerves, causing direct paraplegia. We return
+to the centripetal theory of urinary paralysis with Leyden's own cases,
+published in 1865; of three patients with urinary paraplegia, two died,
+and the existence of a secondary (centripetal) myelitis seems to have
+been established, and by all analogy it must have existed in the third
+case, which recovered. The only puzzle and doubt that ensued was caused
+by the fact that there was an absence of neuritis in the different
+nerves themselves; though it seemed plain that the starting point of the
+myelitis was at the entrance of these nerves into the cord. This mystery
+seemed to be cleared up by the important experiments of Tiesler, ("Ueber
+Neuritis" Konigsberg, 1860) a pupil of Leyden's. This observer excited
+local traumatic inflammation in the sciatic nerve of rabbits and dogs;
+the rabbit became paraplegic and died three days afterward. At the site
+of the artificial irritation there was a localized formation of pus, and
+there was a second similar formation within the vertebral canal at the
+point where the posterior roots of the sciatic enter the cord; but
+there was no neuritis of the intervening portion of the nerve.
+
+Upon this and similar evidence is based the modern doctrine of a
+neuritis migrans, with centripetal tendencies, upon which it is supposed
+that a very large proportion, at least, of the urinary, dysenteric, and
+uterine paraplegias, miscalled "reflex," depend; and it is clear that
+the application of the word "reflex" in such a case is a grave abuse,
+tending to produce such confusion of thought and error in practice. In
+relation to the subject of our own inquiry--neuralgia--it is obviously
+of the highest consequence to investigate the question whether
+peripheral irritations, analogous to those which produce urinary
+paraplegia, are at all frequently the cause of the changes in the
+posterior roots which produce true neuralgia; for of course an
+inflammation may be the beginning of an atrophy which may presently
+exhibit no distinction whatever from one of which the origin was
+altogether non-inflammatory. I think that there is strong reason for
+thinking that this is not at all frequently the case. In the first
+place, all the evidence that exists respecting these centripetal
+inflammations of the cord is opposed to the idea that, save in the
+rarest instances, the inflammatory process limits itself to one small
+segment of the cord. Secondly, the description of the pains that have
+usually accompanied such inflammations of the cord is considerably
+different from the strictly localized, frankly intermittent character of
+a true neuralgia; in fact, all we know of the history of myelitis
+(except when complicated with a large amount of meningitis) forbids us
+to suppose that severe pain would be an immediate symptom. But, thirdly,
+a far more important objection to the theory of an origin in localized
+centripetal myelitis, the result of a neuritis migrans, is the rarity of
+motor paralysis as an early symptom, instead of which we ought to find a
+very distinct history of decided paralysis (much more decided than those
+secondary paralyses which actually do occur in some neuralgias) of the
+muscles supplied by the anterior roots of the painful nerve, in every
+case in which such a peripheral origin could be assumed. Again, the
+totally feverless commencement of neuralgias, a character which is
+maintained throughout the progress of the milder cases, is entirely
+opposed to the idea of a direct connection between myelitis and
+neuralgia. The superficial appearance of pyrexia is sometimes given by a
+local vaso-motor paralysis, which makes the neuralgic part, after a long
+bout of pain, hot and red; but of general pyrexia there is nothing.
+
+Taking every thing into consideration, one is inclined to say that there
+is a probability that in a very limited number of cases peripheral
+irritation does cause actual limited myelitis, which escapes recognition
+at the time, but which issues in an atrophy, the subjective expression
+of which is actual neuralgic pain. We may well ask ourselves, also,
+whether there is not some likelihood that a peripheral irritation, which
+stops short of producing an actual neuritis migrans capable of
+centripetally exciting a myelitis, may not, by a lower degree of
+centripetal irritation, give a bias toward certain forms of
+non-inflammatory atrophy in cells of posterior nerve-roots which are
+congenitally of weak organization. I am inclined to believe strongly
+that this does occur. For example, I should explain thus the majority of
+the peripheral cases of ciliary neuralgia, migraine, etc., that we meet
+with in poor young needle-women, especially the hypermetropic, who, at
+an age when they can ill afford the strain, work so constantly and
+strenuously at an occupation which fearfully taxes the eye.
+
+I would also go farther, and express the opinion that peripheral
+influences of an extremely powerful and continuous kind, where they
+occur with one of those critical periods of life at which the central
+nervous system is relatively weak and unstable, can occasionally set
+going a non-inflammatory centric atrophy which may localize itself in
+those nerves upon whose centres the morbific peripheral influence is
+perpetually pouring in. Even such influences as the psychical and
+emotional, be it remembered, must be considered peripheral--that is,
+they are external to the seat and centre of the neuralgia. And there are
+probably few practitioners of large experience who have not seen a
+patient or two in whom the concurrence of some unfortunate psychical
+with some other noxious peripheral influence, the whole taking place at
+some critical period of life (especially in the years between puberty
+and marriage), seems to have totally deranged the general balance of
+nervous forces, and induced morbid susceptibilities and morbid
+tendencies to some particular neurosis. It is a comparatively frequent
+thing, for example, to see an unsocial solitary life (leading to the
+habit of masturbation), joined with the bad influence of an unhealthy
+ambition, prompting to premature and false work in literature and art.
+The bad peripheral influence of constant fatigue of the eyes in study
+may so completely modify a young man's constitution as to make a wreck
+of him in a very few years, changing him from the state of habitual and
+conscious health to that of chronic neurosis of one sort or another.
+And, though it is doubtless on persons with congenital tendencies to
+nervous diseases that such a combination of bad influences produces its
+most serious effects, yet there unquestionably are a few persons in whom
+they appear to entirely generate the neurotic constitution. I have
+already touched upon the part that misdirected psychical influences,
+especially religious and other forms of emotional excitement, may play
+in this unfortunate perversion of the natural and healthy nervous
+functions, more especially in youth; and need only add, here, that
+perhaps the most fatal combination of all the bad influences is the
+melancholy union of highly-strained religious sentiment with peripheral
+sexual irritation, which is, unfortunately, a too common phenomenon
+under certain systems of education. The most frequent neurotic
+consequences of the class of influences which have now been referred to
+are probably neuralgia--in the form either of migraine, of nervous
+angina, or of sciatica--or else asthma.
+
+But, if the combination of several such centripetal influences may
+generate the neurosis unaided, even a single one of them operating
+powerfully for a long period may produce most serious consequences in
+those who are hereditarily predisposed. The influence of prolonged
+fatigue of the eyesight, independently of any special intellectual or
+emotional strain, was strongly illustrated in my own case about three
+years ago. I was then engaged upon a piece of scientific writing which
+demanded no great intellectual effort, but was being done against time,
+and by working, night after night, many hours by gas-light. My neuralgic
+(trigeminal) attacks came on with great severity, accompanied by
+vertiginous sensations of so alarming a kind as to make me fear the
+invasion of some serious brain-mischief. I broke off all work, and went
+to the sea-side, but was greatly disappointed to find, for the first few
+days, that the symptoms were not in the least mitigated. The mystery was
+soon explained. The weather had been such as to confine me a good deal
+to the house, and, thinking it would do no harm, I amused myself with
+reading newspapers and novels. At last I suspected that the use of my
+eyes in reading was altogether mischievous; I desisted from reading any
+thing, and in forty-eight hours every symptom had vanished.
+
+Among peripheral influences of a more mechanical kind there is one cause
+of neuralgia, the force of which has been variously estimated, but which
+some authors rate as very important, viz.: the influence of the
+pressure, and especially of the varying pressure, of blood-vessels, or
+other hollow viscera, upon the trunks of the nerves. We must set aside
+one such action which is undoubtedly very powerful, as essentially
+differing from the others; I mean the pressure of dilated blood-vessels,
+especially aneurisms, when this happens to be exerted upon the ganglion
+of the sensory trunk. Here there can be no doubt of the mischief; for
+the pressure, if at all severe, gradually destroys the life of the
+ganglion, upon which, as was proved by Waller, the nutrition of the
+posterior nerve-root hangs with very intimate dependence, and the
+pulsations of the vessel seem greatly to aggravate both the irritation
+and the centripetal tendency to atrophy. In short, it is plain that such
+lesion of a ganglion may be the whole and sufficient cause of a
+neuralgia of the most desperate and incurable kind. It is another matter
+when we are asked to believe that the mere varying pressure of
+intestines, in different states of fullness, or plexuses of pelvic veins
+liable to temporary congestions, can so affect the sciatic nerves as to
+set up neuralgia. Considering the extreme frequency of cases in which
+such momenta must be partially coming into operation, especially in
+women--a frequency altogether out of proportion to that of sciatica--I
+cannot admit the probability that this influence is more than an
+occasional and very secondary factor, and that only in cases where the
+disposition to neuralgia is uncommonly strong.
+
+A sufficiently complete explanation of my theory as to the pathology and
+etiology of neuralgia has now been given, although the subject might be
+elaborated at far greater length; and I hope it will be apparent to the
+reader that the view now advocated is at once important, and also
+vouched for by strong evidence. I claim for it that the whole argument
+shall be taken together, for it is a case of cumulative proof; every
+link must be weighed and tested, before the remarkable strength of the
+chain can be felt. And it may fairly be said that, if the proof of a
+definite kind of material change in a definite organ, as the essential
+factor in neuralgia, has been established upon reasonable grounds, an
+important step has been taken toward removing a serious opprobrium and
+difficulty in practical medicine. Although the true neuralgias are not
+among the most frequent of human diseases, they form a class of enormous
+practical importance, for they are sufficiently common to be sure to
+occur in considerable numbers in the practice of every medical man, and,
+both from the suffering which they inflict, and the rebelliousness which
+they often show to treatment, they are among the gravest sources of
+anxiety which the practitioner is likely to encounter. There are
+probably few disorders which so often occasion mortification and loss of
+professional credit to the physician. The helplessness which men, who do
+not enjoy special opportunities of seeing those diseases with frequency,
+so often show in dealing with them, is largely caused by the extreme
+timidity and vagueness with which the standard treatises on medicine
+deal with the question of their pathology; and a very unfair advantage
+has thus been given to the specialists, who, by the mere force of
+opportunity, and continual blind "pegging away" in an entirely empiric
+manner, have acquired a certain rude skill in the treatment of these
+maladies which enables them to outshine practitioners who often have far
+more in them of the veritable _homme instruit_ as regards general
+scientific education and habits of mind. It will be evident, as a mere
+abstract proposition, that the enunciation of a reasonable pathology of
+the disease, and the sweeping away of a mass of unmeaning phrases about
+"mysterious functional affections" and the like, must be a distinct gain
+to practitioners of plain common-sense and good general knowledge, to
+whom neuralgia is merely one of a vast number of different diseases
+among which their attention and study are divided. And I hope that, in
+the further remarks on Diagnosis, Prognosis, and Treatment, yet to be
+made, the value of clear pathological ideas of disease will be brought
+more practically and clearly into view. [The reader will find, at the
+end of Part I. of this volume, a note which contains a brief discussion
+on the "Erschopfung" theory of Jaccoud, and the doctrines of Dr.
+Handfield Jones respecting inhibition, with which I thought it best not
+to encumber the text of the present chapter.]
+
+FOOTNOTES:
+
+[16] Eulenburg, to whose excellent work ("Lehrbuch der functionellen
+Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to
+refer, has partly misunderstood the drift and scope of my argument, a
+misfortune which I owe to the impossibility of giving, in the "System of
+Medicine," more than the briefest and most superficial sketch, both of
+my ideas and of the facts on which they rest.
+
+[17] _Op. cit._, p. 60.
+
+[18] This opinion is somewhat stronger than that expressed in my article
+in the "System of Medicine." I can only say it is the result of much
+increased experience.
+
+[19] _Journal de la Physiologie, v._
+
+[20] "Ernaehrungsstoerungen der Augen bei Anaesthesie des Trigeminus."
+Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f.
+Ophthalm. Band. xiii.
+
+[21] Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from
+independent sources, of the truth of Meissner's views. His own
+observation only proved half the case; but he quotes an observation of
+Buttman's in which the exact converse of his own experience happened,
+the external fibres being affected without the inner band, and
+anaesthesia without trophic changes being the result. Moreover, Schiff
+(Gaz. hebdom., 1867) obtained experimental results (in operating on cats
+and rabbits) which coincide with Meissner's.
+
+[22] London Hospital Reports, vol. iii., p. 305.
+
+[23] Wegner, loc. cit.
+
+[24] Archiv f. Ophthalm., xv., 1.
+
+[25] "Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware
+whether Piotrowski has at all altered his opinions since the
+(subsequent) observations of Ludwig and Cyon upon the "depressor" nerve.
+
+[26] "Functional Nervous Disorders." Churchill, 2d edit., 1870.
+
+[27] "Prize Essay of the New York Academy of Medicine." New York: Wood &
+Co., 1869.
+
+[28] Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex
+Lahmungen," von E. Leyden. Leipzig, 1870.
+
+[29] "Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.
+
+[30] Wurzburg. Med. Zeitsch., iv., 56-64.
+
+[31] Med. Cent. Ztg. 21, 1860.
+
+
+
+
+CHAPTER IV.
+
+DIAGNOSIS AND PROGNOSIS OF NEURALGIA.
+
+
+_Diagnosis._--This subject is much simplified and shortened, in regard
+to our present purpose, by the plan of the present work, which, by
+separately describing (in Part II.) the other disorders which resemble
+neuralgia, and are liable to be confounded with it, avoids the necessity
+for stating here the negative diagnosis of neuralgia itself. We are only
+concerned here to give a clear picture of the positive signs which it is
+necessary to verify before we can suppose disease to be neuralgia. The
+special modes of searching for these are interesting, and in some
+respects peculiar;
+
+(1) The first and most essential characteristic of a true neuralgia is,
+that the pain is invariably either frankly intermittent, or at least
+fluctuates greatly in severity, without any sufficient and recognizable
+cause for these changes.
+
+(2) The severity of the pain is altogether out of proportion to the
+general constitutional disturbance.
+
+(3) True neuralgic pain is limited with more or less distinctness to a
+branch or branches of particular nerves; in the immense majority of
+cases it is unilateral, but when bilateral it is nearly always
+symmetrical as to the main nerve affected, though a larger number of
+peripheral branches may be more painful on one side than on the other.
+
+(4) The pains are invariably aggravated by fatigue or other depressing
+physical or psychical agencies.
+
+The above are characteristics which every genuine neuralgia possesses,
+even in its earliest stages; if they be not present, we must at once
+refer the diagnosis to one or other of the affections described in Part
+II. of this work.
+
+Supposing the above symptoms to be present, we expect to find--
+
+(5) In by far the largest number of instances that the patient has
+either previously been neuralgic, or liable to other neuroses, or that
+he comes of a family in which the neurotic disposition is well marked.
+Failing this, we are strongly to doubt the neuralgic character of the
+malady, unless we detect that there has been--
+
+(6) A poisoning of the blood by malaria (but this very rarely causes
+neuralgia, save in the congenitally predisposed); or--
+
+(7) A powerfully operating or very long-continued peripheral irritation
+centripetally directed upon the sensory nucleus of the painful nerve;
+which irritation may be (_a_) "functional," as where the eye has been
+persistently and severely over-strained and trigeminal pain results, or
+a sudden severe shock has been received; or, (_b_) coarsely material, as
+where inflammation, ulceration, etc., of surrounding tissues involve the
+periphery of the painful nerves in a perpetually morbid action, or
+chronic but profoundly depressing psychical influences; or--
+
+(8) A constitutional syphilis. In this case there will either be marked
+syphilitic local affection of the trunk of a nerve, or if, as is more
+common, the syphilitic change is in the nerve-centre, there will most
+likely be other syphilitic centric mischiefs, leading to scattered motor
+or vaso-motor paralyses, characteristic modifications of special
+sense-functions, etc.
+
+If the neuralgia be of some standing and a certain degree of severity,
+there will inevitably be found--
+
+(9) Some of the fixed tender points of Valleix, in such situations as
+have been described in Chapter I.; and--
+
+(10) Secondary affections (_a_) of secreting glands, or (_b_) vaso-motor
+nerves; or (_c_) of nutrition of tissues; or secondary localized
+paralyses of muscles, or localized anaesthesia of a somewhat decided
+though not complete kind, as described in Chapter II.; any one or any
+number of these various complications may be present.
+
+I must insist that the above picture includes only the essentials for a
+diagnosis of neuralgia; if the painful affection will not answer to the
+conditions therein included, we have no right to call it a neuralgia--it
+belongs, for every practical purpose, to some other category of disease.
+Let me add one more essential characteristic, which is, that the pain
+begins and assumes its characteristic type before any other of the
+phenomena appear, with the single and partial exception of anaesthesia.
+
+There are some special modes of diagnosis of the varieties of
+neuralgia, developed of late years, that require notice here; they are
+chiefly the result of the researches of Moriz Benedikt.
+
+As regards the quality of the pain, Benedikt says that the curve of
+intensity has an intimate relation to the _locus in quo_ of the
+neuralgia (_i. e._, whether in the periphery, trunk, or roots). An
+inflammatory irritation set up at the periphery of a nerve (by a
+joint-inflammation, for instance) produces a continuous pain; the same
+kind of irritation, attacking a nerve-trunk (_e. g._, in the bony
+canals), produces a paroxysmal pain; an inflammation spreading from the
+vertebrae to the nerve-roots or the cord-centres produces momentary
+lancinating pains. The latter characteristic he supposes to be
+especially characteristic of the centrally-produced neuralgias; and I
+may observe, as so far confirmatory of this idea, that this is
+especially the character of the pains in locomotor ataxy. There are
+sundry special cases to be considered, however: thus, Benedikt himself
+remarks that the pain set up by the pressure of a pulsating aneurism is,
+from the nature of things, lancinating from moment to moment.
+Eulenburg,[32] moreover, says that Benedikt's tests of the locality of
+the primary mischief only hold good under the following circumstances:
+(1) When the irritability and the exhaustibility of the nerves are in a
+normal condition during the neuralgia; (2) when the irritation that
+calls forth the paroxysm is either identical with the original cause of
+the disease, or at least operates upon the same spot. The two
+conditions, however, do not concur. The irritability and exhaustibility
+may be sometimes excessive in neuralgias, sometimes normal, and perhaps,
+in certain cases, beneath the normal standard; by which means the form
+of the curve of intensity must be considerably modified. Moreover, the
+irritation that provokes an attack may from the periphery attack the
+primary seat of the disease, even when this is central, on account (says
+Eulenburg) of exaggerated conductivity of the nerves (his second
+cause[33] of "hyperaesthesia"), as is, in fact, very frequently the case.
+He also thinks the distinction between paroxysmal and lancinating pains
+too indefinite to serve as a sufficiently reliable basis of diagnosis,
+especially considering the endless _nuances_ of the form which the pain
+is apt to take. I agree with Eulenburg upon this point; and am
+convinced, from my own observations, that such a distinction as that
+between lancinating and paroxysmal pains is illusory, [I have taken some
+pains to investigate the character of the pains, not only in neuralgia,
+but in locomotor ataxy. It is true that the lancinating character
+predominates, on the whole, in the latter disease; but there are great
+differences in different individuals, and even in the same patient at
+various times, which plainly depend on subjective influences. Compare
+for instance, Dr. Headlam Greenhow's report on an ataxic patient, with a
+report on the same man by Dr. Buzzard and myself. ("Trans. Clin. Soc.,"
+vol. i., 1868, pp. 152-162.)] the two kinds being frequently found
+alternate in the same case. The only useful distinction, in my opinion,
+is Benedikt's first one: he is probably right in saying that, where such
+an affection as an inflamed joint forms the source of peripheral
+irritation that immediately provokes a neuralgia, the pain is apt to be
+unusually continuous.
+
+The extent to which the pain of neuralgia spreads into different termini
+of the same nerve has been made the basis of distinctions as to the seat
+of the original mischief. For example, it has been said that pain in the
+mental branch of the third division of the trigeminus, which does not
+invade the auriculo-temporal branch, can hardly depend on an irritation
+operating on the trunk of the inferior dental; it must be distinctly
+peripheral, or else it must act upon limited portions of the central
+origin of the fifth nerve. But the fact seems rather to be that, whether
+the neuralgia was excited by lesions at the periphery, in the
+nerve-trunk, or in the centre, it is equally possible that either a
+small or a large part of the peripheral expanse of the nerve may become
+the seat of the pain: this almost necessarily follows from the entire
+independence of individual fibres in nerves.
+
+As regards the evidence afforded by the motor, vaso-motor, and trophic
+complications, there is this very positive diagnostic value in
+them--that they enable us to say, with greater assurance than we could
+otherwise do, that the disease is a real neuralgia. But, the only
+evidence that they afford as to the situation of the mischief is, that
+they uniformly point to the central end of a particular nerve; and
+accordingly I have already shown, in the chapter on Pathology, that the
+attentive study of these very complications furnishes us with some of
+the most powerful arguments upon which rests my theory that in neuralgia
+there is always centric mischief. What share in the production of the
+malady, in any given case, has been taken by the centric disease, and
+what if any by a peripheral irritation, the existence of these
+complications in no way helps us to determine; far less does it enable
+us to localize a peripheral lesion which may have acted as a concomitant
+cause; on the contrary, I believe that there is no more fertile source
+of erroneous judgment on this very point, than some of these
+complications, especially the vaso-motor and trophic. I suspect that it
+has happened, in hundreds of instances, that a localized congestion or
+inflammation, which is a mere secondary phenomenon, produced in the
+centrifugal manner already so fully explained, has been taken for the
+veritable _fons et origo_ of the malady: hence the neuralgia has been
+confidently reckoned as one peripherally produced, and, what is even
+worse, the whole energy of treatment has been directed to a mere
+outlying symptom, under the idea that the primary source of mischief was
+being attacked.
+
+The application of electricity as a test of the nature of a neuralgia
+has been employed by Benedikt,[34] who lays down certain laws as the
+result of his researches. He says that (_a_) in idiopathic peripheral
+neuralgias the nerves are not sensitive to the current; (_b_) in
+neuralgias dependent on neuritis or hyperaemia of the nerve-sheath there
+is general electric tenderness of the nerve; (_c_) in cases where the
+pain has been set up by morbid processes in tissues surrounding the
+nerve, there is electric tenderness only at the site of these changes. I
+may, in general terms, express concurrence in these statements; but I
+must add that, as diagnostic rules they apply only to the early stages
+of neuralgia; for the occurrence of secondary complications may and does
+altogether change the condition of electric sensitiveness. It need
+hardly be said that the above remarks on diagnosis apply for the most
+part only to the superficial neuralgias, which, however, include an
+immense majority of the cases of neuralgias. The diagnosis of visceral
+neuralgias is, it need hardly be said, in most cases, a far more
+difficult and complicated matter. In these diseases we have often little
+more to guide us, in the actual symptoms, than (_a_) the intermittence
+of the pain, and (_b_) the absence of commensurate constitutional
+disturbance, especially the complete freedom from sense of illness in
+the intervals between the pains. We shall be obliged to rely greatly on
+such historical facts as the presence or absence of neurotic tendencies
+in the patient and his family; the possibility of his having been
+exposed to blood-poisoning (_e. g._, from malaria or chronic alcoholic
+excess, or extreme over-smoking); the circumstance that he has been
+habitually overworked, or greatly exposed to agitating psychical
+influences; perhaps that he has been subject to a combination of several
+of these morbific momenta. To say truth, the diagnosis of visceral
+neuralgias must, at the best of times, be a difficult and anxious
+matter, and we can hardly ever thoroughly satisfy ourselves until we
+have procured some decided results from treatment; fortunately, however,
+it happens tolerably often that we can do this, and sometimes in a very
+striking way.
+
+_Prognosis._--The prognosis of neuralgia varies exceedingly, according
+to the form and situation of the disease, and many other considerations.
+There are, of course, in the first place, certain neuralgias in which
+the prospect is perfectly hopeless as to cure; such are the cases in
+which the nerve is involved in a continuously growing tumor (especially
+within a rigid cavity, like the skull), or a slow but persistent
+ulcerative process.
+
+Supposing, however, that the case is none of these, the very first
+prognostic consideration is that of age.
+
+Of the neuralgias of youth, the majority either disappear altogether
+after a first attack, or recur a certain number of times during some
+years, the neuralgic tendency either disappearing or becoming greatly
+mitigated when the process of bodily consolidation is over. In another
+group the neuralgic tendency is never lost, but the form of the attacks
+changes, and there is far less spontaneity in the manner of their
+production. It is exceedingly common to see delicate boys and girls
+between puberty and the age of eighteen or twenty, attacked with typical
+migraine, which recurs regularly every three or four weeks for perhaps
+two or three years, then ceases to occur at regular periods, then loses
+the tendency to stomach complication; and, by the age of twenty-five or
+somewhat later, has left, as its only relic, a tendency to attacks of
+ophthalmic neuralgia, which come on when the patient is excessively
+fatigued, or encounters the close air of a theatre, or undergoes an
+unusual strain of mental excitement or anxiety, etc.; but which never
+come on without some such special provocation. So, again, there is a
+variety of sciatica which belongs mainly to the period between puberty
+and the twenty-fifth to thirtieth year, and which seems really to
+belong, pathologically, to the age of unsettled and irregular sexual
+function, the tendency to it usually disappearing after the patient has
+settled down happily in married life. Ovarian and mammary neuralgia have
+very commonly a similar history.
+
+On the other extreme we find the neuralgias of the period of bodily
+decay: these are of very bad prognosis. A neuralgia which first develops
+itself after the arteries and capillaries have begun to change decidedly
+in the direction of atheroma is extremely likely, even if apparently
+cured for a time, to recur again and again, with ever-increasing
+severity, and to haunt the patient for the remainder of his days. It
+therefore becomes exceedingly important, in a prognostic point of view,
+to assure ourselves as soon as possible whether this arterial
+degeneration has decidedly commenced; and for this purpose I am in the
+habit of insisting to pupils on the great importance of sphygmographic
+examination for all neuralgic patients who have passed the middle age.
+Where we get the evidence which is furnished by the formation of a
+distinctly square-headed radial pulse-curve, even though there be no
+palpable cord-like rigidity of superficial arteries, we are bound to be
+exceedingly cautious of giving a favorable prognosis.
+
+In women the period of involution of the sexual apparatus forms a crisis
+which, in regard to neuralgias, is of great prognostic importance. On
+the one hand, if the general vital status be good, and the arterial
+system fairly unimpaired, we may look to the completion of the process
+of involution as a probable time of deliverance from neuralgic troubles
+that have hitherto beset a woman; we know that she will probably suffer
+a temporary aggravation of her pains, but we hope to see her lose them
+altogether. On the other hand, if it should happen that she enters on
+the period of sexual involution with her general nutrition considerably
+impaired and her arterial system decidedly invaded by atheroma, it is
+only too likely that neuralgias recurring now, or attacking her for the
+first time, will assume the worst and least manageable type.
+
+Of almost or quite equal importance with the question of the
+physiological age of the patient is that of his personal and family
+history with regard to the tendency to neuralgia and to other severe
+neuroses. Upon this subject I have dwelt so very fully in other parts of
+this work, that it is merely necessary here to repeat, that the balance
+of chances is most heavily swayed to the bad side by all evidence
+tending to prove congenital neurotic tendencies in the patient and vice
+versa.
+
+Of prognostic hints that are to be gathered from our knowledge of the
+immediate causes of the attack, there are none so valuable as those
+which we gather from the detection of a malarial or a syphilitic factor
+in the production of the malady. In the former case, we hope to cure the
+patient either with quinine or arsenic, with almost magical certainty
+and rapidity; in the latter, we expect an almost equally brilliant
+result from iodide of potassium.
+
+The particular nerve in which the neuralgia is seated does not so
+decidedly influence the prognosis, according to my experience, as is
+stated by some authors; nevertheless, there are differences of this
+kind. For instance, sciatica, though by no means so frequently a mild
+and trifling complaint as Eulenburg would make it to be, is certainly,
+on the whole, more curable than the trigeminal neuralgias taken as a
+group. I, however, cannot share Eulenburg's opinion as to the rarity of
+a central cause for sciatica, nor his consequent explanation of its more
+frequent curability; the latter I explain by the fact that it is
+possible far more completely to remove the concomitant causes in
+sciatica than in trigeminal neuralgia. By simply keeping a sciatic
+patient in the prone posture, shielded from cold and from pressure on
+the nerve, we have it in our power to remove nearly all peripheral
+sources of irritation; but in trigeminal neuralgia there are many
+influences, particularly psychical ones, which cannot be shut out, and
+which will continue to act with disastrous effect in many cases. With
+all this, however, we see a sufficiently large number of incurable
+sciaticas, on the one hand, and of severe trigeminal neuralgia cured on
+the other. It is only the genuine epileptiform tic, occurring in
+subjects whose arterial system is an advanced stage of degeneration,
+that stands out clearly and unmistakably pre-eminent among neuralgias
+for rebelliousness to treatment of every kind.
+
+FOOTNOTES:
+
+[32] _Op. cit._, pp. 65, 66.
+
+[33] Idem, p. 8.
+
+[34] "Elektrotherapie." Wien, 1868.
+
+
+
+
+CHAPTER V.
+
+TREATMENT OF NEURALGIA.
+
+
+I now approach what is really the most difficult portion of my task;
+for, although it would be easy enough to write copiously on the
+treatment of neuralgia, it is extremely difficult to keep a just medium
+between the opposite extremes of undue meagreness and of useless
+profusion of detail in the handling of this subject. There are also
+difficulties connected with the present uncertain and transitional state
+of opinion, even among high authorities, as to the value of particular
+remedies, and even of large groups of remedial agents, altogether there
+has been more hesitation in my mind as to this part of the present work
+than about any other, and the present chapter has been rewritten more
+than once. I mention this only to account for what there may very likely
+be found in it--an imperfect literary style such as too commonly marks
+work which has been repeatedly patched and corrected. At the same time,
+it should be said that my hesitation does not apply to the main
+principles of treatment which will be recommended below; it proceeds
+rather from the fear of seeming to ignore from carelessness modes of
+treatment which are still much used, but which I have really rejected,
+because, after full trial, they appeared to me valueless. Space is,
+after all, limited, and a complete account of all the remedies for
+neuralgia in vogue, in English and Continental clinics, would of itself
+fill a large volume.
+
+The treatment of neuralgia may be divided into four branches: (1)
+Constitutional remedies; (2) narcotic-stimulant remedies; (3) local
+applications; (4) prophylaxis.
+
+1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_)
+anti-toxic, and (_c_) medicinal tonic.
+
+(_a_) The importance of a greatly-improved diet for neuralgic patients
+is a matter which is more fully appreciated by the English school of
+medicine than by either the French or the German; it has, for instance,
+very much surprised me to notice the almost entire silence of Eulenburg
+on this topic. For my part, the opinions expressed three years ago[35]
+on this matter have only been modified in the direction of increasing
+certainty; I have learned by further experience that the principle is
+even more extensively applicable than I had supposed.
+
+That neuralgic patients require and are greatly benefited by a nutrition
+considerably richer than that which is needed by healthy persons, is a
+fact which corresponds with what may be observed respecting the chronic
+neuroses in general; and it gives me much satisfaction to point out this
+position of neuralgia as belonging to this large class of disorders, not
+merely by its pathological affinities, but by its nutritive demands. In
+a very excellent and suggestive paper by Dr. Blandford[36] it is stated,
+as the result of a large experience in mental and other nervous
+disorders, that the greater number of chronic insane and hypochondriacal
+cases, as well as neuralgic patients, are remarkably benefited by what
+might seem at first sight almost a dangerously copious diet.
+Occasionally it happens that the patients discover this by the teaching
+of their own sensations, and the apparent excesses in eating which some
+epileptic and hypochondriacal persons habitually commit are looked on by
+many practitioners as the mere indications of a morbid _bulimia_ which
+represents no real want, but only the craving of a perverted sensation
+which ought to be interfered with and allayed rather than encouraged. It
+is now many years since I began to doubt the justice of this opinion;
+the particular instance which called my attention to it being that of
+epilepsy, of which disease I saw a considerable number of cases, within
+a short period of time, that were distinguished by the presence of
+enormous appetite for food; and I finally came to the conclusion that,
+so far from this symptom being of evil augury, and likely to lead to
+mischief, it is, with certain limitations, a most fortunate occurrence.
+It is hardly necessary to say that over-eating, such as produces
+dyspepsia and distention of a torpid intestine with masses of faeces, may
+distinctly aggravate the convulsive tendency; but the truth is that,
+with a little careful direction and management of the unusual appetite,
+these bulimic patients can in most cases be allowed to satisfy their
+desires without harm of this kind following; a larger portion of food
+really gets applied to the nutritive needs of the body, and the nervous
+system unmistakably benefits thereby, the tendency to atactic disorder
+being visibly held in check.
+
+That which I have thus observed in the case of epilepsy, and which Dr.
+Blandford more particularly affirms concerning chronic mental diseases
+and the large number of neuroses that hover on the verge of insanity,
+has been most distinctly verified in my experience of the treatment of
+neuralgia. It is, unfortunately, by no means a frequent occurrence that
+the sufferer from this malady is inclined to eat largely, but the few
+patients of this type that I have seen were, in my judgment, distinctly
+the better for it. Far more common in neuralgia is a disposition of the
+patient to care little for food, to become nice and dainty, and in
+particular to develop an aversion--partly sensational and partly the
+result of morbid fear about indigestion--for special articles of diet.
+Dr. Radcliffe pointed out the special tendency of neuralgics to neglect
+all kinds of fat; partly from dislike, and partly because they believe
+it makes them "bilious;" and I have had many occasions to observe the
+correctness of this observation. In fact, by the time patients have
+become sufficiently ill with neuralgia to apply to a consulting
+physician, they have already, in the great majority of cases, got to
+reject all fatty foods, and have cut down their total nutriment to a
+very sufficient standard. Young ladies suffering from migraine are
+especially apt to mismanage themselves, to a lamentable extent, in this
+direction: this is natural enough, because the stomach disorder seems to
+them the origin of the pain, instead of being, as it is, a mere
+secondary consequence of the neurosis. But it is not only the sufferers
+from sick-headache in whom we find this tendency to insufficient eating,
+especially of fat; not to mention that all severe pain usually tends to
+disorder appetite and make it fastidious, there is nearly always some
+wiseacre of a friend at hand, ready to suggest that neuralgia is
+something very like gout, that gout is always aggravated by good living,
+and, _ergo_, that the patient should be "extremely cautious as to diet;"
+the end of which is that the poor wretch becomes a half-starved
+valetudinarian, but, so far from his pain getting better, it steadily
+becomes worse. I cannot too strongly express the benefits that I have
+seen accrue, in the most various kinds of neuralgic cases, from
+persistent efforts to remedy this state of things, and to convert the
+patient from a valetudinarian to a hearty eater; and I wish particularly
+to say that this success has always been most marked when I have from
+the first insisted on fat forming a considerable element of the food.
+Cod-liver oil is the form in which I much prefer to give it, if this be
+possible; there can be no mistake about the relatively greater power of
+this than of any other fatty matter, I believe simply from its great
+assimilability. But the very cases in which we most urgently desire to
+give fat are often those in which the patient's fantastic stomach openly
+revolts at the idea of the oil; we must then try other fats; and we
+should go on trying one thing after another--butter, plain cream,
+Devonshire cream, even olive or cocoanut oil (though these are the
+poorest things of the sort we can use)--till we get the patient well
+into the way of taking a considerable, if possible a decidedly large,
+daily allowance of fat, without provoking dyspepsia. It is surprising
+what can be done in this way by perseverance and tact, and it is no less
+striking to observe the good effects of the treatment. Nothing is more
+singular than to see a girl, who was a peevish, fanciful, and really
+very suffering migraineuse, brought to a state in which she will eat
+spoonful after spoonful of Devonshire cream, and at the same time lose
+her headaches, lose her sickness, and develop the appetite of a
+day-laborer; and, though such very marked instances as this are
+uncommon, they do sometimes occur, and a minor but still important
+degree of improvement is very frequent.
+
+As for the _modus operandi_ of the fatty food, there is no certainty.
+Dr. Radcliffe believe it acts as a direct nutrient of the nervous
+centres; and I also cannot help feeling that there is some evidence in
+favor of this idea. But, whether this be so or not, there is another
+kind of action of fat that is more simple and obvious; namely, it seems
+to be certain that the enrichment of the diet by fat greatly assists the
+assimilation of food in general, and thus the patient's nutrition is
+altogether improved.
+
+It is not merely, however, by increasing any one element of food that we
+should seek to enrich the diet of neuralgics, but rather by such a
+steady and persistent effort as Dr. Blandford describes, to increase the
+total quantity of nutriment to perhaps as much as one-third more than
+the patient would probably have taken in health. To those who from
+prejudice are incredulous of the propriety of this method, I would say,
+"Try it, and I venture to say your incredulity will disappear." More
+especially I would urge the great importance of this system in modifying
+the nervous status of very young, and also of aged, sufferers from
+neuralgia; it is the indispensable basis of a sound treatment for such
+patients.
+
+This seems the proper place for such remarks as must be made upon the
+function of alcohol in neuralgia; for, though this agent is a true
+narcotic when given in large doses, it is not under that aspect that I
+can recommend its use in neuralgia at all. I have written so much on
+this subject lately, that I shall here content myself with an emphatic
+repetition of my protest against the use of alcoholic liquors as direct
+remedies for pain. They ought only to be given, in neuralgia, in such
+moderate doses, with the meals, as may assist primary digestion without
+inducing any torpor, or flushing of the face, or artificial
+exhilaration. I cannot too expressly reprobate the practice of
+encouraging neuralgics, especially women, to relieve pain and depression
+by the direct agency of wine or spirit; it is a system fraught with
+dangers of the gravest kind.
+
+(_b_) The anti-toxic remedies include agents addressed to the
+modification of a special condition of the blood and tissues induced by
+the presence of morbid poisons, of which syphilis, malaria, and (more
+doubtfully) gout and rheumatism, are the representative examples.
+
+Of syphilitic neuralgia the treatment may be summed up in a few words:
+Give iodide of potassium in doses rapidly increased up to a daily
+quantum of twenty to thirty grains. If this fails, give one-twelfth of a
+grain of bichloride of mercury thrice daily.
+
+Of malarial neuralgia I can only speak from such a limited experience
+that I am by no means in a position to give an exhaustive account of the
+treatment. Quinine is, of course, the remedy that should first be tried;
+and, as the paroxysms are usually regular in their recurrence, I prefer
+to give the drug after the plan which is, I think, incontestably the
+best in ordinary ague--_i. e._, to administer one large dose (five to
+twenty grains) about an hour before the time when the attack is
+expected. With a few exceptions the malady, unless it had taken very
+deep root before we were consulted, will yield to a few doses given in
+this way; after the morbid sequence has been thus interrupted, it will
+be proper to continue the action of quinine in smaller and more frequent
+doses, given for three or four weeks continuously. For the comparatively
+rare cases in which quinine fails, the prolonged use of arsenic
+(Fowler's solution, five to eight minims three times a day), especially
+with the simultaneous employment of cod-liver oil, is to be recommended.
+
+The part which gout may play in inducing neuralgia is, as I have already
+said, a far more doubtful question than the popular medical traditions
+assume it to be; and treatment directed to gout as a cause is an
+extremely uncertain affair. The direct relief of neuralgic pain by the
+administration of colchicum, for example, is, in my experience, a very
+rare occurrence, even where the gouty diathesis is unmistakably present;
+and, on the other hand, the depressed vitality which gouty neuralgics
+usually show in a marked degree, renders it very doubtful whether the
+relief of the pain may not be too dearly purchased at the cost of the
+general lowering effects of colchicum. It is probable that neuralgia
+occurring in gouty subjects is more safely, and equally effectually,
+treated upon general principles. At the same time it may be admitted
+that, in the subordinate function of an adjuvant to the aperients which
+it is sometimes advisable to give, small doses of the acetic extract of
+colchicum seem to possess some value.
+
+The question of treatment addressed to a supposed rheumatic element in
+neuralgia will, of course, be differently judged according to the
+respective ideas of various practitioners as to the pathological
+affinities of the two diseases; and the reader already knows that I
+believe these affinities to be different in kind from what is generally
+believed. The utmost that I should concede is, that in a certain very
+limited number of cases the peripheral factor in neuralgia is an
+inflammation of the nerve-sheath, or surrounding tissues, which forms
+part of a chain of phenomena of local fibrous inflammations in different
+parts of the body. Iodide of potassium, in five or ten grain doses
+three times a day, is the proper treatment for such cases. I have never
+found alkalies do any direct good to the pain.
+
+(_c_) The medicinal tonic variety of constitutional treatment is more
+especially represented by the use of iron and arsenic in cases where
+poverty of the blood seems to exist in a marked degree, and by the
+administration of certain tonics--quinine, phosphorus, strychnia, and
+zinc--which are supposed to exert a specially restorative influence upon
+the nervous tissues.
+
+The use of quinine as an anti-malarial agent has been already referred
+to; its employment in non-malarial cases is of much more restricted
+scope and benefit. Experience has taught me to agree in general with the
+opinion of Valleix, that it is a very unreliable agent; the one marked
+exception to this being the case of ophthalmic neuralgias. What the
+reason may be I cannot in the least say, but it is a fact that quinine
+does benefit these neuralgias, in cases where there is no room for
+suspicion of malaria, with a frequency which is very much greater than
+in the treatment of the painful affections of any other nerve in the
+body. The quantity given should be about two grains three times a day.
+
+The preparations of phosphorus which I have employed in the treatment of
+neuralgia are the phosphuretted oil, the hypophosphite of soda (five to
+ten grains three times a day), and pills of phosphorus (according to Dr.
+Radcliffe's recommendation) containing one-thirtieth of a grain, given
+twice or thrice daily. Either of the two last will do all that
+phosphorus can do, but its utility is not very extensive or reliable. I
+have found it to do most good in cases where there was a high degree of
+anaesthetic complication.
+
+Preparations of zinc have, in my hands, done no particular good,
+although I have tried them in all manner of doses.
+
+Strychnia, on the other hand, is a remedy which I have learned to prize
+much more highly during the last few years than previously. Its most
+decided efficacy has been shown in some of the visceralgiae, especially
+gastralgia, and (to a less extent) angina pectoris. Its internal use for
+these complaints is best effected by giving doses of five to ten minims
+of tincture of nux-vomica three times a day; but a method which I have
+several times employed with good effect is the subcutaneous injection of
+very small doses of strychnia (one-eightieth to one-fiftieth of a grain)
+twice daily. For the superficial neuralgias, on the other hand, I
+generally administer one-fortieth of a grain, with ten or fifteen minims
+of tincture of sesquichloride of iron, by the stomach, three times a
+day; this is a very powerful prophylactic remedy to prevent the
+recurrence of the attacks when once the sequence of them has been broken
+through by other means.
+
+Of iron generally, as a remedy in anaemic cases, I have only to remark
+that, in order to get its full benefits, it is necessary to use large
+doses. I give the saccharated carbonate in twenty-grain doses twice or
+three times a day.
+
+But of the sesquichloride of iron I am inclined to say something more;
+it has seemed to me that, besides its effects on the blood, it has a
+marked and direct influence upon the nervous centres, which is different
+from anything which one observes in the action of other preparations of
+iron. It is certain that the action of sesquichloride of iron, in those
+cases of chlorosis which are distinguished by profound nervous
+depression, is something quite peculiar; and the effect which it
+produces in the anaemic neuralgias, more especially of young women, is
+equally remarkable. I cannot help alluding here to the striking effects
+which large doses of the tincture, as recommended by Dr. Reynolds,
+produce in acute rheumatism; the severest pain is often checked within
+twenty-four hours after the commencement of this treatment. Both in this
+disease and in neuralgia, I employ the old-fashioned tincture: if given
+alone it should be used in large doses (thirty or forty minims three
+times a day); but an excellent combination is that, already mentioned,
+of ten-minim doses of this tincture with one-fortieth of a grain of
+strychnia. There is something in the revivifying effects of this mixture
+that is quite peculiar. I have very lately employed it in the case of a
+gentleman, aged thirty-five, who was the subject of frontal neuralgia
+complicated with paralysis of the internal rectus, and who was decidedly
+anaemic, and greatly depressed and worried in mind by the consciousness
+of his inability to overtake professional work which had accumulated
+upon him. This patient improved with great rapidity, and in the course
+of three weeks lost, not merely his neuralgia, but also his strabismus,
+almost entirely; but he then got into a condition which, though not of
+permanent importance, was sufficiently undesirable to make me mention it
+here, especially as I have seen the same thing in more than one patient
+besides him. It is a peculiar state of restlessness during the day and
+sleeplessness at night, without any positive exaltation of reflex
+excitability such as one used to see from strychnia in the days when
+mischievously large doses of that drug were very commonly given, and
+patients used to complain of decided twitchings and startings of the
+limbs. It is clearly not a strychnia effect pure and simple, nor an iron
+effect only; it is a _tertium quid_ compounded of the actions of both
+drugs.
+
+The direct effects of arsenic in the improvement of the quality of the
+blood seem to me incontestable; and its use for this purpose in anaemic
+neuralgias is certainly something over and above its special neurotic
+action. No one, who has employed it much in the cases of anaemic children
+suffering from chorea after rheumatism, can have failed to observe its
+frequently striking influence upon blood-formation even long before the
+nervous ataxia is materially reduced. The misfortune is, however, that
+we possess no indications by which to judge beforehand whether we may
+reckon on its most favorable action in any given (non-malarious) case,
+with certain special exceptions. In angina pectoris it has a most direct
+effect, which is rarely altogether missed, and is sometimes surprising:
+the cases in which it succeeds best are those distinguished by anaemia,
+but we may well suppose, from its remarkable action upon other neuroses
+of the vagus, that it is something more than an action on the
+blood-making process which produces such powerful effects in allaying
+the tendency to recurrence of the paroxysms. My attention was called to
+its action in this disease chiefly by the remarkable case published by
+Philipp;[37] this was a purely neurotic angina, but one of the severest
+type, and the influence of arsenic was very striking. Since that time I
+have employed it in several cases, and, after trying various forms of
+administration, I conclude that nothing is better than Fowler's
+solution, in doses of three minims (gradually increased, if the remedy
+be well tolerated, up to eight or ten) three times a day. Unfortunately,
+there are some neurotic patients who cannot bear arsenic, the
+irritability of their alimentary canal is such that the drug always
+provokes vomiting, or diarrhoea, or both; this was the case with one
+of my patients, in whose case I had allowed myself to hope for the very
+best results from arsenical treatment. But where the patient tolerates
+it--and usually he tolerates it extremely well--the prolonged use of
+arsenic seems really to root out the anginoid tendency, or at least to
+confine it to the more trivial and manageable manifestations. I believe
+that in at least three patients, I have so completely broken down a
+succession of cardiac neuralgic attacks as to substitute for them a mere
+remnant of a tendency to "tightness at the chest" after any severe
+bodily exertion or mental emotion. It might be a question, in cases
+where the stomach does not tolerate the ordinary administration of the
+agent, whether it would not be worth while to try the effect of
+subcutaneous injection (two to four minims of Fowler), or inhalation of
+the smoke of arsenical cigarettes. But, in truth, it is not certain that
+even in this case we escape the characteristic effects of the drug upon
+those persons who are abnormally sensitive to it.
+
+A remarkable instance of the beneficial influence of arsenic occurred in
+the case of a woman, aged forty-six, the solitary example of severe
+angina in a female that I have ever seen. [It is by no means uncommon,
+however, to see the milder forms of cardiac neuralgia in women; the
+remarkable statistics of Forbes, quoted in Chapter I., must certainly
+have been taken exclusively from cases of the severest type of the
+disease.] This was a hospital patient, who had always suffered much
+from hysteria, and from childhood had been liable to hemicranic
+headache; she had entered on the period of "change" at the time the
+attacks began, but menstruation, though irregular, still continued, and,
+in fact, did not cease till four years later, long after the anginal
+attacks had been subdued. The patient had been attacked for the first
+time at the end of a heavy day's washing; she dropped on the ground with
+the sudden agony and faintness, and thought she should "never come to
+life again." The paroxysms returned five times within the next month,
+though not always so severely as on the first occasion; but the poor
+woman lived in a constant state of terror. On the occasion of her second
+visit to me, she had a most severe attack in the waiting-room at the
+hospital: being called to her I found her very nearly pulseless,
+gasping, and with the kind of complexion which is so suggestive of
+approaching death. She was recovered by a large dose of ether. It was a
+rather uncommon feature in this case that the pain was only at and
+around the lower end of the sternum, except that occasionally it shot
+along the sixth intercostal space. The employment of Fowler's solution
+(in doses gradually mounting to twenty-one minims daily) for six months
+completely eradicated the anginal tendency; the proof that it was a real
+therapeutic effect was given by the result of an attempt to leave the
+medicine off at the end of eight weeks' treatment; the patient
+immediately began to suffer again. When she really left off, at the end
+of six months' treatment, she had had no tendency to heart-pang for more
+than a month, and, besides this, looked quite another creature in her
+improved vitality and vigor. Yet the menstrual troubles went on, and the
+function was not finally suppressed for a long time afterward.
+
+I suspect, however, that the most frequent successes with arsenic will,
+after all, be made in the cases of more or less anaemic male patients who
+are attacked with the neurotic form of angina in the midst of a career
+(as is especially the case with some professional careers) that implies
+not merely incessant labor, but great anxiety of mind. The drug does
+little good, however, if not positive harm, in that form of angina
+pectoris minor which is not the result purely of these causes, but of
+these, or some of these, plus the morbid action of the alcoholic excess,
+to which the patient has fled in order to relieve mental harassment and
+the fatigue that comes from overwork, especially overwork at tasks that
+are not congenial to his natural disposition; there is usually in such
+cases a heightened irritability of the alimentary canal, which is almost
+sure to cause arsenic to disagree: the really useful treatment is
+quinine for the first few days, and then, when the stomach will bear it,
+cod-liver oil in increasing doses, up to a large daily amount given for
+a long time together.
+
+On the whole, arsenic, from its singularly happy combination of powers
+as a blood-tonic, a special stimulant of the nervous system, and withal
+as a special opposer of the periodic tendency, must be regarded as one
+of the most powerful weapons in the physician's hands, and (although it
+seems to act best in the neuralgias of the vagus and of the fifth) there
+is a possibility of its proving the most effective remedy in almost any
+given case which may come before us.
+
+2. The narcotic-stimulant treatment for neuralgia includes some of the
+most powerful remedies for the disease which we possess. These remedies
+have very different properties, but they all agree in this, that in
+small doses they appear restorative of nerve-function--in large doses
+depressors of the same.
+
+Four very different types, at least, of narcotic-stimulant drugs are
+useful in neuralgia: (_a_) There is the opium type, by which pain is
+very directly antagonized, and, besides this, sleep is also directly
+favored. (_b_) There is the belladonna type, by which pain is also much
+relieved, though with far greater certainty in some regions than in
+others (_e. g._, much the most powerful effect is seen in cases of pelvic
+visceralgia), but sleep is by no means so certainly or directly produced
+as by opium. (_c_) There is the chloral type, which is almost purely
+hypnotic; it is represented almost solely by chloral itself, which is
+resembled by scarcely any other drug. (_d_) There is bromide of
+potassium, which stands alone for its powerful action on the cerebral
+vaso-motor nerves, and which is useful in neuralgia simply by its power
+to check psychical excitement directly (through the circulation) and
+indirectly (through the production of sleep).
+
+(_a_) Opium and the remedies that resemble it are, for the treatment of
+neuralgia, fully represented by the hypodermic use of morphia, which is
+the only kind of opiate treatment that ought ever to be employed, save
+in very exceptional instances. The great reasons for the preference of
+the subcutaneous administration over the gastric are, the economy of the
+drug which it affects and the much smaller degree of disturbance of
+digestion which it causes. The hypodermic injection of morphia, if
+conducted on correct principles, enables us, when necessary, to repeat
+the dose a great number of times with but little loss of the effect, and
+consequently with a much smaller rate of progressive increase of the
+quantity required; and the absence of depressive action on digestion
+enables us to carry out simultaneously that plan of generous nutrition
+which has already been shown to be so important a part of treatment.
+Indeed, the case is hardly expressed with sufficient strength, when we
+say that hypodermic morphia is usually harmless to the digestive
+functions; for in a great number of instances it will be found actually
+to give an important stimulus both to appetite and digestion; and the
+patient, who without its aid could hardly be persuaded to take food at
+all, will not unfrequently eat a hearty meal within half an hour after
+the injection.
+
+The remarkable effects of hypodermic morphia have, however, caused it to
+be rashly and indiscriminately used, and so much harm has been done in
+this way that it is necessary to be exceedingly careful in the rules
+which we lay down for its employment. Upon these grounds I must hope to
+be excused if, in order to render this work complete, I repeat a good
+deal of what I have already said in other places. In the first place, I
+shall speak of the mode of administration, and then of the dose.
+
+As regards the mode of administration, I prefer the use of a solution of
+five grains of acetate of morphia to the drachm of distilled water; if
+the acetate be a good specimen, this will dissolve easily (and keep some
+time without precipitation) without the use of any other solvent. With a
+solution of this strength we require nothing elaborate in the form of
+the syringe; a simple piston arrangement does well; only it is advisable
+that the tube shall have a solid steel triangular point, and a lateral
+opening. As regards the place of injection, I must repeat the
+opinion[38] which I have already published, that Mr. Hunter's plan of
+injection at an indifferent spot is, in the great majority of instances,
+fully as effective as the local injection would be; nevertheless, there
+is one consideration which in some cases may properly induce us to adopt
+the latter plan. Very nervous and fanciful patients will sometimes be
+much more readily brought to allow the operation when it seems to go
+directly to the affected spot, when they would be sufficiently
+incredulous of the benefits of an injection performed at a distance to
+indulge their dislike of incurring pain by refusing to submit to it. And
+there is one class of cases in which it is likely that there are real
+physical advantages in the local injection; in instances of old-standing
+neuralgia with development of excessively tender "points," which are
+also the foci of the severest pain, it will sometimes be advisable to
+inject into the subcutaneous tissue at these points. There is undeniable
+reason for thinking that the sub-inflammatory thickening of tissues
+around a certain point of nerve delays the transit of the morphia into
+the general circulation, and enables it to act more directly and
+powerfully on the nerve, which it thus renders insensitive to external
+impressions; an important respite is thus gained, during which the
+nerve-centre has time to recover itself somewhat. At the same time it
+must be remarked that this immediate injection of a tender point is apt
+to be exceedingly painful, and it may be absolutely necessary to apply
+ether-spray before using the syringe. In early stages of neuralgia,
+before the formation of distinct tender points, there is no advantage
+whatever (except the indirect one above mentioned) in the local
+injection. And, on the other hand, it is often of great consequence not
+to run the chance of disfiguring such a part as the face, the neck,
+etc., when the injection can easily be done over the deltoid, or in the
+leg, or in some other part which even in women is habitually covered by
+the dress.
+
+The dose to be employed is an exceedingly important matter, and one as
+to which practitioners are still very often injudicious. We ought never
+to commence with a larger dose than one-sixth of a grain; but very often
+as little as one-twelfth of a grain will give effective relief, and in
+not very severe cases it is well worth while to try this smaller
+quantity. When no larger quantity than one-sixth of a grain is employed
+we commonly observe no narcotic effects, _i. e._, there is no
+contraction of pupil, no heavy stupor, and, although the patient very
+often falls asleep, on waking he does not experience headache, nor is
+his tongue foul. I cannot too strongly express the opinion that it is
+advisable by all means to content ourselves with this degree of the
+action of hypodermic morphia, unless it fails to produce a decided
+impression on the pain. But in very severe cases our small doses will
+fail; and then, rather than allow the patient to continue having severe
+paroxysms unchecked, we must frankly admit the necessity of using a
+narcotic dose from one-quarter to one-half of a grain, according to
+circumstances. Whatever actual dose be employed, it is important not to
+repeat it with unnecessary frequency; once a day in the milder, and
+twice a day in the more severe cases, will be all that is advisable,
+save in very exceptional cases: the point being to administer it as
+quickly as possible after the commencement of an exacerbation. If by
+these means we can prevent the patient having any severe pains during a
+period of several days, we often give time to the affected nerve to
+recover itself so completely, especially with the aid of other measures
+to be presently mentioned, that the tendency to neuralgia is completely
+broken through, and we can drop the injections, either at once or by
+rapid diminution of the dose, and thereafter treat the case merely with
+tonics, and with the precautionary measures to be dwelt upon under the
+heading of Prophylaxis. But, if we have been driven to the use of
+distinctly narcotic doses, and these do not very speedily break the
+chain of neuralgic recurrence, it will not do to continue to rely upon
+hypodermic morphia; it will be best to try some of the local remedies
+(blistering, galvanism) with it. If this combination fails, we should
+then try the effect of atropine, the sulphate of which, hypodermically
+injected, fully represents for all useful purposes the mydriatic class
+of narcotics.
+
+(_b_) The commencing hypodermic dose of atropine should be one-one
+hundred and twentieth grain; it is not often that so small a quantity
+will do any good, but it is necessary to use this agent with great
+precaution, as we occasionally meet with subjects in whom extremely
+small doses provoke most uncomfortable symptoms of atropism, as dry
+throat, dilated pupil, delirium, and scarlet rash. Commonly we shall
+find ourselves obliged to increase the dose to one-sixtieth,
+one-fiftieth, or one-thirtieth of a grain; and in a very few cases it
+may be necessary to go even as high as the one-sixteenth or one-twelfth.
+In my experience such instances are excessively uncommon; and I cannot
+but suppose that the practitioners who use the high doses frequently
+must inject in such a manner as to fail to get the whole dose taken up.
+[Absolutely inexplicable to me is the statement of the illustrious
+Trousseau--that hypodermic remedies are "less active" (!) than gastric
+remedies--except on his hypothesis.]
+
+The most remarkable effects that I have seen from hypodermic atropia
+were obtained in cases of peri-uterine neuralgia, especially
+dysmenorrhoeal neuralgia. Speaking generally of atropine, it must
+undoubtedly be counted far inferior to morphia as a speedy and reliable
+reliever of neuralgic pain, but for all pelvic neuralgias it appears to
+me on the whole to surpass morphia. And besides this, in other
+neuralgias, where opiates altogether disagree (as with some subjects
+they do), it is not uncommon to find that atropia acts with
+exceptionally good effect. And to some extent I am inclined to confirm
+Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does
+so more permanently than morphia.
+
+There is another special use of hypodermic atropine which I have not
+seen mentioned by any one but myself, but which is probably very
+important, namely, in ophthalmic neuralgia where acute iritis, or
+especially glaucoma, seems coming on. I may be mistaken, but I believe
+that in three cases I have succeeded, by prompt injection of sulphate of
+atropine (one-sixtieth to one-fortieth of a grain), in saving a
+neuralgic eye from damage, and possibly from destruction, from impending
+glaucoma.
+
+(_c_) The class of cases for which merely hypnotic remedies are of much
+value is limited; nevertheless, in the milder kinds of migraine and
+clavus, especially when they have been brought on or are kept up by
+mental worry or hysterical excitement, these remedies will sometimes
+prove very useful. In former days, before we knew chloral, I used to
+employ camphor for this purpose; three or four grains being administered
+every two hours: and in hysterical hemicrania of a not very severe type
+this not unfrequently produced a short sleep, from which the patient
+awoke free from the pain. But chloral infinitely transcends in value any
+agent of this kind that was known before. Perfectly valueless for the
+really severe neuralgias, it is of the greatest possible use as a
+palliative in migraine and clavus, where the great object, for the
+moment, is to get the patient to sleep. A single dose of twenty to
+thirty grains will often effect our object: it may be repeated in two
+hours if sleep has not been induced; it should be given as soon as the
+pain has at all decidedly commenced.
+
+And here I wish to make some special remarks on the subject of
+"palliation," and the relation it bears to "cure." Nothing is more
+common than to read serious admonitions, in medical works, about the
+folly of trusting to remedies which only palliate for the moment but
+leave the root of evil untouched; and, of course, there is a certain
+respectable modicum of the fire of truth behind all this orthodox smoke.
+In the case of neuralgia, however, it is most important to understand
+that mere palliation, that is, stopping of the pain for the moment, may
+be either most useful or highly injurious, according to the way in which
+it is done. The unnecessary induction of narcosis for such a purpose,
+doubtless, is most reprehensible; but if it were possible simply to
+produce sleep from which the patient should awake refreshed, without any
+narcotic effects, then, certainly, that sort of palliation must be good.
+That is precisely what the judicious use of chloral does; and I may
+mention, as resembling though not equalling it, the action of Indian
+hemp, which has been particularly recommended by Dr. Reynolds. From
+one-fourth to one-half of a grain of good extract of cannabis, repeated
+in two hours if it has not produced sleep, is an excellent remedy in
+migraine of the young. It is very important, in this disease, that the
+habit of long neuralgic paroxysms should not be set up; and if the first
+two or three attacks are promptly stopped, by the induction of sound,
+non-narcotic sleep, we may get time so to modify the constitution, by
+tonics and general regimen and diet, as to eradicate the neuralgic
+disposition, or at least reduce it to a minimum. But I would decidedly
+express the opinion that such remedies as either opium or belladonna are
+mostly unsuited to this purpose. If the migraine of young persons does
+not yield to chloral, to cannabis, or to muriate of ammonia (in twenty
+or thirty grain doses), it will not be advisable to ply the patient with
+any remedies of the narcotic-stimulant class, but to trust to tonic
+regimen and the use of galvanism.
+
+The mention of muriate of ammonia, which, for migraine and clavus and
+the milder forms of sciatica, not unfrequently proves useful in stopping
+the violence of a paroxysm and enabling the patient to get some
+refreshing sleep, leads me to notice that not only may a variety of the
+milder narcotic-stimulants be employed in this way, but the external
+stimulus of heat to the extremities (very hot pediluvia) greatly
+assists the action of any such remedies; especially if mustard-flour be
+added, so that a mild vapor of mustard rises with the steam and is
+inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is
+to give twenty grains of chloral, and make the patient plunge his feet
+in very hot mustard-and-water and breathe the steam. He can hardly fail
+to fall asleep for a longer or shorter time, and awake free from pain.
+
+(_d_) The use of bromide of potassium in neuralgia is a subject of great
+importance, and which requires much attention and discrimination. In
+common with, I dare say, many others, I made extensive trial of this
+agent when it first began to be much talked of, but was so much
+disappointed with its effects in neuralgias, that at one time I quite
+discarded it in the treatment of those affections. Renewed experience
+has taught me however, that, though its use is restricted, it is
+extremely effective if given in appropriate cases and in the right
+manner. For the great majority of neuralgias it is quite useless, and,
+what is more, proves often so depressing as indirectly to aggravate the
+susceptibility of the nervous system to pain. The conditions, _sine quis
+non_, of its effective employment seem to be the following: The general
+nervous power, as shown by activity of intelligence, and capacity of
+muscular exertion and the effective performance of co-ordinated
+movements, must be fairly good, find the circulation must be of at least
+average vigor; the patient must not have entered on the period of
+tissue-degeneration. Among neuralgics who answer to this description,
+those who will benefit by the bromide are chiefly subjects--especially
+women--in whom a certain restless hyperactivity of mind and perhaps of
+body also, seems to be the expression of Nature's unconscious resentment
+of the neglect of sexual functions. That unhappy class, the young men
+and young women of high principle and high mental culture to whom
+marriage is denied by Fate till long after the natural period for it,
+are especial sufferers in this way and for them the bromide appears to
+me a remedy of almost unique power. But I wish it to be clearly
+understood that it is not to the sufferers from the effects of
+masturbation that I think the remedy specially applicable: on the
+contrary, it is rather to those who have kept themselves free from this
+vice, at the expense of a perpetual and almost fierce activity of mind
+and muscle. The effects of solitary vice are a trite and vulgar story;
+there is something far more difficult to understand and at the same time
+far more worth understanding in the unconscious struggles of the
+organism of a pure minded person with the tyranny of a powerful and
+unsatisfied sexual system. It is in such cases, which it heeds all the
+physician's tact to appreciate, that it is sometimes possible to do
+striking service with bromide of potassium; but it will be necessary to
+accompany the treatment with strict orders as to generous diet, and,
+very likely, with the administration of cod-liver oil.
+
+Having decided that bromide of potassium is the proper remedy, we must
+use it in sufficient doses. Not even epilepsy itself requires more
+decidedly that bromide, to be useful, shall be given in large doses. It
+is right to commence with moderate ones (ten to fifteen grains), because
+we can never tell, beforehand, that our patient is not one of those
+peculiar subjects in whom that very disagreeable phenomenon--bromic
+acne--will follow the use of large doses. But we must not expect good
+results till we reach something like ninety grains daily. Let me add
+that it is not so far as I know, by reducing any "hyperaesthesia" of the
+external genitals, of which the patient is aware, that the remedy acts;
+I have not seen such a nexus of disease and remedy in these cases.
+
+3. Local Measures.--The external remedies which may be applied for the
+treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_)
+paralyzers of peripheral sensory nerves; (_c_) remedies adapted to
+diminish local congestion; (_d_) remedies adapted to diminish arterial
+pulsation; (_e_) electricity; (_f_) mechanical means of protection.
+
+(_a_) Among the skin-stimulants blisters hold the highest place as a
+remedy for neuralgia; indeed the assertion of Valleix, that they are the
+best of all remedies, is still not very wide of the truth. They are by
+no means universally applicable, and the degree to which their action
+should be carried varies materially in different forms of the disease,
+but they are of the greatest possible service in a large number of
+instances.
+
+It is possible to view the action of blisters in neuralgia in more than
+one way. When applied in such a manner as to vesicate decidedly, and
+especially if kept open and suppurating for some time, they cause
+considerable pain of a different kind from that of neuralgia itself and
+the mental effect of this, operating as a diversion of the patient's
+thoughts from his original trouble, may be thought to assist in breaking
+the chain of nervous actions by which he is made to feel neuralgic pain.
+There may be something in this, but I confess that I do not believe this
+kind of effect goes for much in genuine neuralgia. It is rather in the
+pain of hypochondriasis, and the so-called spinal irritation (to be
+described in the second part of this work), that such an action of
+blisters proves useful.
+
+Another action of blisters, which some authors hold to be perhaps the
+most effective portions of their agency, is that which is produced by
+the drain of fluid, specially when they are kept open, by which means a
+kind of depletion is set up, and the morbid irritation that causes the
+nerve pain removed. I cannot at all assent to this view. In the first
+place, I believe that any one who has large experience of blistering in
+neuralgia will ultimately come, as Valleix did, to believe that
+prolonged drain from a blister is rarely or never useful, and that a far
+better plan is that of so-called flying blisters, renewed at intervals
+if necessary. The most genuine successes that I have procured from
+blistering have certainly been got in this way. But I should go further,
+and say that the prolonged drain and the peculiar kind of chronic
+irritation produced by a suppurating blistered surface can very
+decidedly aggravate a neuralgia; this is more especially the case when
+the blister is applied immediately over the focus pain.
+
+The view which I am strongly convinced alone explains the beneficial
+action of blisters is that which supposes them to act as true stimulants
+of nerve-function. In order that this effect shall be produced, it will
+be necessary that the skin-irritation be either produced at some
+distance from the seat of the greatest pain, or that, if applied in that
+spot, it shall be comparatively mild in degree. And accordingly, I have
+been led, in my observations to apply the blister at some distance from
+the focus of pain. An indifferent point, however, will not do--there
+must be an intelligible channel of nervous communication between the
+irritated portion of skin and the painful nerve. This object is
+accomplished by placing the blister as close as may be to the
+intervertebral foramen from which the painful nerve issues; the effect
+of this is probably a stimulation of the superficial posterior branches,
+which is carried inward to the central nucleus of the nerve. I must say
+that the results which I have derived from this plan of treatment have
+been far more satisfactory than those which I used to obtain when I
+habitually applied the vesication as near as might be to the focus of
+peripheral pain; and I think that this result tallies well with the idea
+that the essential mischief in neuralgia consists in an enfeebled
+vitality of the central end of the posterior root. An exceedingly
+interesting confirmation of this idea as to its _modus operandi_ has
+been afforded me by the fact that not merely neuralgic pain, but also
+trophic and inflammatory complications attending it, have been sensibly
+relieved, in several cases that I have seen, by this mode of reflex
+stimulation. This has been particularly the case in herpes zoster, where
+the process of inflammation and vesiculation has been very promptly
+checked by the application of a tolerably powerful blister by the side
+of the spine at the proper level; and I am gratified to mention that Dr.
+J. K. Spender, of Bath, pointed out this fact[39] at a time when he had
+only seen my statement that the pain could be relieved in this way. In
+the case of the trigeminus, the same kind of reflex stimulation is most
+effectively obtained by applying the blister over the branches of the
+cervico-occipital, at the nape of the neck; and it is remarkable what
+powerful effects are sometimes thus produced, even in cases that wear
+the most unpromising aspect. For example, in the desperate epileptiform
+tic of old age, I have more than once seen a complete cessation of
+suffering, which lasted for a very long time--so long, in fact, as to
+make me hope against hope that it might never return. I do not now
+entertain any such expectations from this remedy; still, its value is
+very great.
+
+There are curious differences between the effects of blistering in
+trigeminal or intercostal neuralgia and in sciatica. On the whole, it
+would appear that blistering in the neighborhood of the spine is less
+frequently effective in the latter, and we sometimes, after failing with
+this method, obtain immediate success by two or three repetitions of the
+flying blister, somewhere over the trunk of the nerve, especially just
+outside the sciatic notch. I have one lady patient in whom this series
+of phenomena has several times been observed; and I have seen it occur
+in a particular attack, in other patients, in whom, nevertheless, on
+another occasion the spinal blistering has been promptly effective.
+
+I consider blistering of the posterior branches to be an important, and
+usually an essential, element in the treatment of all cases of sciatica
+in the middle period of life which have reached some severity and lasted
+long enough to become complicated with decided secondary affections.
+
+In all cases where blistering is employed it is advisable to adopt the
+simultaneous use of hypodermic morphia or atropine; this combination of
+remedies is exceedingly powerful.
+
+Lastly, it must be said of blistering, that, on the whole, it is a
+remedy not well fitted to be applied to aged subjects; and in its
+severer forms it should never be applied to patients who are greatly
+prostrated in strength. For it must be borne in mind that the remedy may
+miss its aim of relieving the neuralgia, in which case it is necessary
+to remember, more accurately than many practitioners appear to do, what
+a very serious element of misery and prostration will be introduced into
+the case by the vesication itself.
+
+I am not convinced that any of the other forms of severe skin-irritation
+(_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to
+such a degree as to produce not the anaesthetic but the irritant effects)
+are of any particular value; if blistering failed, I should not expect
+to see them succeed.
+
+A milder degree of skin-stimulation is represented by rubefacient
+liniments of various kinds, which may be briskly rubbed into the skin
+along the track of the painful nerve, without any danger of producing
+vesication. Among this class I continue to prefer chloroform diluted,
+with six or seven parts of chloroform, to any other; in the milder forms
+of neuralgia, especially in young persons and first attacks, it is
+surprising how frequently the paroxysm may be greatly relieved, if not
+arrested. Still, this can only be regarded as the merest palliative; and
+in severer cases such applications are useless. Occasionally, when
+chloroform-liniment has failed, a mustard plaster will do good.
+
+The mildest degree of skin-stimulation is represented by the continuous
+application of moist warmth, which is best effected by the simple
+application of moistened spongio-piline; so far as I have observed,
+however, it is rather in cases of myalgia than in true neuralgia that
+this does good; in the latter it is probably little more than a mere
+protector against cold.
+
+(_b_) A variety of agents can be employed with the object of temporarily
+interrupting the conductivity of the painful nerve; by this means a
+period of rest is obtained during which the centres--sensory and
+psychical--have time to regain a juster equilibrium, and the habit of
+pain is, _pro tanto_, broken through.
+
+There is one agent of this class which for general purposes I do not
+think is worth retaining on our list of sensory paralyses--namely, cold.
+Cold, to be of any value, ought to be of the degree which is represented
+by ice allowed to melt slowly in contact with the skin; and for the
+majority of neuralgias this is decidedly inferior to other remedies that
+can be applied by painting or inunction. The one case in which ice is
+supremely useful is in neuralgia of the testis; here I make no doubt
+that it is almost, if not quite, the most useful remedy we can employ,
+although of course other means must be taken to modify the neuralgic
+temperament. It should be applied the moment an attack comes on.
+
+Far more useful, in neuralgias generally, is the external application of
+aconite or of veratrine. Aconite may be employed in the milder or the
+stronger form; in the former case, we simply paint the ordinary tincture
+on the skin over the painful nerves (avoiding any cracks or sores); in
+the latter, we rub in an ointment containing one grain of the best
+hydrate of aconitine to the drachm of lard, about twice a day, and to
+such an extent as to maintain complete numbness of the parts
+continuously, for two, three, or four days. I do not believe that this
+will ever, by itself, cure a true neuralgia of any considerable
+severity; but I have more than once known its intervention, at a crisis
+in treatment when it seemed that other remedies might fail, produce a
+striking change in the progress even of a very bad case.
+
+A milder, but still very useful form of the same kind of action, is
+produced by veratrine-ointment. I would recommend, however, as a rule,
+that it be employed, at any rate at first, of weaker strength than that
+recommended in the Pharmacopoeia, for with some persons it is easy to
+pass the anaesthetic, and to enter on the irritant, action of veratrine
+upon the skin. This leads me to give a caution that should properly
+have come earlier, when I was speaking of skin-stimulants. In aged
+subjects, especially, we rather frequently meet, in neuralgia, with a
+specially irritable state of the skin, even although there may be at the
+same time some loss of common and tactile sensation; and the
+practitioner must be warned against the danger of producing an amount of
+skin-irritation which will fearfully annoy his patient. I speak
+feelingly, having by such an indiscretion lost the richest patient who
+ever favored my consulting-room with his presence!
+
+The inunction of mild veratrine-ointment is extremely useful, as an
+adjunct to other treatment, in migraine and supra-orbital neuralgias of
+suckling women, and of chlorotic girls. I have also seen it do much good
+in mammary neuralgia.
+
+The last division of the subject of paralyzing agents in the treatment
+of neuralgia includes the surgical operations for division or resection
+of a painful nerve. Upon this question there is much difficulty in
+speaking decidedly. I admit at once, of course, that surgical
+interference is evidently indicated when, along with decided and
+intractable neuralgic pain, there is plain evidence either of the
+existence of a neuromatous tumor, or the presence of a foreign body
+impacted, or a tight cicatrix pressing upon a nerve. I admit, also,
+though with much greater qualifications, that carious teeth may need to
+be extracted before we can cure a neuralgia; but even here I should put
+in the decided caveat that we must consider whether the system is in a
+state to bear the shock, and that in any case we probably ought to
+mitigate the effects of the operation by performing it under chloroform.
+And I need hardly tell any one, who is familiar, either practically or
+from reading, with the subject, that thousands of carious teeth have
+been extracted from the mouths of neuralgic patients, not only without
+benefit, but with the effect of distinctly aggravating the disease. And
+I am yet more doubtful as to the advisability of such surgical
+procedures as the division or the resection of a piece of the painful
+nerve. Theoretically, as the reader will understand from the strong
+opinion I have given as to the mainly central origin of neuralgias, I
+never could anticipate that such a procedure would be more than
+temporarily successful; on the contrary, the mischief in the central end
+of the nerve remaining, I should suppose that the trying process of the
+reunion of the nerve (which always takes place) would be almost
+certainly attended with a revival of the neuralgia, too probably in an
+aggravated form. The only two cases of excision of a piece of the nerve,
+that I have ever seen, completely answered to this anticipation. In
+common fairness, however, I must admit that there is a large amount of
+evidence on the other side. Neuralgias of the trigeminus are pretty
+nearly the only cases in which the proposal of neurotomy or neurectomy
+ought to be entertained; in mixed nerves the inconvenience of the
+muscular paralyses that would follow would be usually too serious to
+allow of our incurring them. But resection of painful branches of the
+trigeminus has been performed in a great number of instances, more
+especially by German surgeons, with results that merit our attention;
+the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be
+especially referred to. On the other hand, with the exception of simple
+division of the nerve, which can be subcutaneously performed, and is a
+trivial proceeding (but has very short-lived effects), these operations
+are by no means without danger, especially when they are pushed to such
+a length as the opening of bony canals, and the resection of
+considerable portions of bone in order to get sufficiently far toward
+the centre, and fatal results have in more than one case followed. Above
+all, we can never too seriously reflect on the most interesting case of
+Niemeyer's reported by Wiesner,[40] in which the most formidable
+operations of this kind have been performed, in an apparently desperate
+case of epileptiform facial tic, and in which, after all, the
+application of the constant current painlessly effected an infinitely
+greater amount of good than had been done by all those severe and
+painful surgical manipulations. I think it is impossible, after this,
+not to conclude that neurectomy ought never to be even thought of except
+as a last resort, in cases of extreme severity, after other measures had
+been patiently tried and had decisively failed.
+
+(_c_) Of remedies that are intended to relieve local congestion, I must
+speak with very doubtful approbation. Leeches or scarifications are, I
+think, very seldom of value. The only remedy that has sometimes seemed
+to do good is local compression, and, after all, it is quite as likely
+that this acts by anaesthetizing the nerve as by reducing congestion.
+
+(_d_) Remedies that interfere mechanically with arterial pulsation are
+of considerable value where they can be effectively applied. I have
+already pointed out the specially aggravating effect of the
+momentarily-repeated shocks of arterial pulsation upon neuralgic pain.
+Where, then, it is possible, effectively to control an artery pretty
+near to the point where it divides into the branches that lie close to
+the painful part of the nerve, it is always worth while to try the
+experiment. But such a measure as the compression of the carotid in
+trigeminal neuralgia is of very doubtful propriety; I suspect the
+consequent anaemiation of the brain more than does away with any benefit
+that might be mechanically produced. And any attempt to interfere with
+the general arterial circulation by cardiac depressants is not to be
+permitted for an instant.
+
+(_e_) We enter now upon a most important subject, the treatment of
+neuralgia by electricity. It is necessary to exercise much caution in
+speaking upon this topic, and, as I shall have to express somewhat
+decided opinions, I may be excused for referring to the circumstances
+under which I have arrived at my present stand-point upon this question.
+I can hardly be accused of having, with any very rash haste, espoused the
+cause of medical electricity in the therapeutics of pain, as any one will
+see who cares to turn to my article on Neuralgia[41] written only three
+years ago. At that time I had already been studying the subject for a
+considerable period, but was so convinced of the multitude of
+opportunities for fallacy that beset the student of electro-therapeutics,
+that I was unwilling to state more than the minimum of what I hoped and
+believed might be affected by this mode of treatment. Since that time I
+have become more fully acquainted with the researches of foreign
+observers, and, with the help of their indications, have been able to
+apply myself more fruitfully to my personal inquiries into the matter.
+The result is, that I am now able to speak with far greater assurance of
+the positive value of electricity as a remedy for neuralgic pain. I shall
+make bold to say that nothing but the general ignorance of the facts can
+account for the extraordinary supineness of the mass of English
+practitioners with regard to this question.
+
+In the first place, I have arrived at a decided conviction that Faradic
+electricity is of little or no value in true neuralgias, and that the
+cases which are apparently much benefited by it will invariably be
+found, on more careful investigation, to belong to some other category.
+
+On the effect of frictional electricity I have had such very small
+experience that I cannot venture to speak with any confidence, and the
+accounts that I have heard from others whose experience is much larger
+have not led me to attribute much importance to this agent. If I am to
+judge at all, I should say it merely acts as a skin-stimulant, and is,
+in that capacity, inferior to many other simpler and more facile
+applications.
+
+Very different is the verdict of experience as regards the effects of
+the constant current; here the results which I have obtained have been
+so remarkable that even now I should distrust their accuracy, were it
+not that they are in accord with the general result which (among minor
+discrepancies) may be gathered, we may fairly say, from all the more
+important researches that have lately been carried out in Germany. The
+constant current, as I now estimate it, is a remedy for neuralgia
+unapproached in power by any other, save only blistering and hypodermic
+morphia, and even the latter is often surpassed by it in permanence of
+affect; while it is also applicable in not a few cases where blistering
+would be useless or worse.
+
+The English medical profession has not as yet adequately appreciated the
+necessity for great care in the choice of apparatus and the mode of
+application of electricity. It is all-important, however, and especially
+in the case of applying galvanism for the relief of pain. The first
+quality that must be absolutely required in a battery, that is to be
+used for this purpose, is that it shall deliver its current with as
+little as possible variation of tension, in fact that it shall be
+constant, and not merely continuous; a vast majority of all the various
+galvanic apparatus that have been used have been merely the latter, and
+have consequently been almost valueless for the relief of pain. Such are
+Pulvermacher's chains, the voltaic piles made with elements of metallic
+gauze, Cruickshank's battery, and many others that have been used. A
+sufficiently constant current may be obtained from either of the
+following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's.
+For hospital use, the Daniell battery (in Muirhead's modification, or
+with the form of cells introduced by Siemens-Halske) is perhaps the most
+desirable; but for private practice it is worth while to sacrifice
+something of the superior constancy which we gain in the Daniell battery
+for the sake of comparative portability. All purposes which we aim at in
+the electric treatment of neuralgia may be sufficiently obtained by the
+use either of the Bunsen battery (zinc-carbon, excited by dilute
+sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc
+and platinized silver, excited by dilute sulphuric acid), as in the
+highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It
+must be remarked that, for the purpose of treating neuralgia, we shall
+never need to employ more than fifteen, or at the utmost twenty, cells
+of either of these batteries. Both the Stohrer's Bunsen and the modified
+Smee of Weiss are made so that the elements are not immersed in the
+exciting fluid until the moment when the battery is going to be used; a
+simple mechanism at once throws the battery into or out of gear. In this
+way, destruction of the elements is minimized; and either of these two
+batteries may be used for from three to six months without any renewal,
+supposing the average work done to be one or two daily seances. If the
+battery is worked harder, it will require more frequent revivification.
+I strongly recommend London practitioners to deliver themselves from all
+care and trouble about the repair of their batteries, by making an
+agreement with the manufacturers to inspect and set them in order at
+stated intervals. The country practitioner, on the other hand, will do
+well to familiarize himself with the process of renewing the acid, of
+cleaning the plates, of amalgamating the zinc, etc.; in fact, to make
+himself independent of the manufacturer in every thing short of an
+actual renewal of the elements, when that becomes necessary. For all
+further details respecting the above-named, and other batteries, I must
+refer the reader to systematic works on medical electricity.[42] I must
+now pass on to the various modes of application, and the cautions to be
+observed.
+
+It is, in the first place, necessary to say, that all the best observers
+coincide in the statement that the use of a current intense enough to
+produce actual pain or severe discomfort is never to be thought of in
+the treatment of true neuralgias; such practice will infallibly do harm.
+Only such a current is to be employed as produces merely a slight
+tingling, and (on prolonged application) a slight burning sensation,
+with a little reddening of the skin at the negative electrode. This
+being the case, it is perhaps not unnatural for those who have not had
+practical experience, to suspect that an application which causes so
+little palpable perturbation is devoid of any positive influence at all.
+Such skepticism will certainly not survive any tolerably lengthened
+observation of the actual facts; but, as some persons may be deterred by
+this _prima-facie_ view of the case from making any fair trial of the
+current, it may be worth while, here, to allude to the unmistakable
+physical effects which similarly painless constant currents are
+repeatedly observed to produce in cases of motor-paralysis attended with
+a wasted condition of muscles. Those who have had experience of the
+treatment of such cases know that it is a by no means infrequent thing
+to see both muscles and nerves aroused from a state of complete
+torpidity, and brought into a condition in which the Faradic current,
+quite powerless before, is again able to excite powerful contractions,
+while, at the same time, the bulk of the muscles has increased most
+sensibly. These, surely, are sufficient indications of a positive action
+of the painless constant current; and such facts have now been recorded,
+in multitudes, by most competent observers.
+
+The next maxim of first-rate importance is that the applications of the
+current should be made at regular intervals, and at least once daily; in
+most instances, this is enough, but occasionally it will be found useful
+to operate twice in the day. The matter of regularity is, I find, of
+great consequence, and it will not do to intermit the galvanism
+immediately on the occurrence of a break in the neuralgic attacks: it
+should be continued for some days longer.
+
+The length of sittings is a point as to which there is considerable
+difference of opinion between various authorities; but my own
+experience coincides with that of Eulenburg, that from five to ten, or,
+at the utmost, fifteen minutes, is almost the range of time.
+
+Closely connected with the question of the length of sittings, is that
+of the continuity with which the current is to be applied. I have seen
+the best results, on the whole, from passing a weak current, without any
+breaks, for about five minutes. But, where there are several foci of
+intense pain, it will often be advisable to apply the current to each of
+these, successively, for three or four minutes.
+
+The places to which the electrodes should be applied vary much according
+to the nature of the case.
+
+Benedikt's rule, that the application of electricity, to be useful, must
+be made to the seat of the disease, is undoubtedly true; but it is
+capable of being applied in a somewhat different manner from that which
+he recommends in particular cases, the difference being due to the view
+of the pathology of neuralgia which is taken in this work. That view is,
+that the essential _locus morbi_ is always in the posterior nerve-root
+(and usually in that portion of the root which is within the substance
+of the cord), and that the peripheral source of irritation, if any, is
+only of secondary--though sometimes of considerable--importance. Hence
+the main object, in electrization, would seem to be to direct the
+influence of the current upon the posterior nerve-root. This may,
+however, be done in different ways, according to the situations in which
+we place the electrodes, and the direction in which we send the current.
+
+There are, as yet, very considerable differences of opinion among
+electro-therapeutists as to the principles which should govern us, both
+in the localization of the effect and the direction of the current.
+Benedikt, for example, recommends that the current should be directed
+toward the supposed seat of the mischief. Thus, if we suppose a
+neuralgia to depend on morbid action within the spinal cord, then we may
+galvanize the spine, taking care to make the current come out through
+any vertebra over which we detect tenderness. If we suppose the seat of
+the disease to be in the nerve-root in the mere ordinary sense of the
+word, then we apply the positive pole to the vertebra opposite the
+highest nerve-origin that can be concerned, and we stroke the negative
+pole down by the side of the spinous processes, some forty times in
+succession. The proportion of cases of idiopathic neuralgia in which
+this treatment succeeds is, according to Benedikt, very large. In other
+cases, he sends the current from the cord to the apparent seat of pain.
+
+On the other hand, Althaus[43] tells us that, whether the application
+be central or peripheral, it is the positive pole, alone, which should
+be applied to the part which we intend to affect: and that the
+application of the negative pole in this situation is rather likely to
+do harm than good, as proving too exciting. Eulenburg, also, says that
+in general the positive pole should be applied to the seat of the
+disease, the negative on an indifferent spot, or on the peripheral
+distribution of the nerve.
+
+It is, however, very doubtful to me whether, in the majority of cases,
+the direction of the current makes any considerable difference in its
+effects, provided only that the stream is fairly directed so as to
+include the _locus morbi_ in the circuit, and care is taken to apply it
+with sufficient persistence and with not too great intensity. Upon this
+point I am glad to be able to cite the authority of Dr. Reynolds, whose
+experience is very large. This author, while admitting that in theory
+the "direct" and the "inverse" currents would seem likely to have
+different effects, declares that in practice this does not prove to be
+the case, either in the instance of pain of nerve or of spasm of muscle.
+Dr. Buzzard, also, in relating a very striking case (which I had the
+advantage of personally observing) before the Clinical Society,
+particularly mentioned that the direct and the inverse currents had a
+precisely similar effect in relieving the pain. The patient suffered
+from severe and probably incurable cervico-brachial neuralgia; the poles
+were placed, respectively, on the nape of the neck and in the hand of
+the affected limb, and whether the positive was on the nape and the
+negative in the hand, or _vice versa_, the effect was the same. Very
+striking remission of the pain was always produced, and the immunity
+from suffering sometimes lasted for a considerable time, while no other
+plan of treatment seemed to have more than the most momentary effect.
+
+My own experience tells the same story very decidedly, for I have on
+very many occasions obtained great benefit, both by the direct and by
+the inverse currents, in the same patient. I shall here relate a few
+instances:
+
+CASE I.--A married woman, aged forty-eight, whose menstrual periods had
+ceased quietly some six years previously. She was, on the whole, a
+healthy person, but had suffered from migraine in her youth, and came of
+a neurotic family. She was attacked with severe cervico-brachial
+neuralgia, which resisted all treatment for nearly three months, and, on
+her then trying a month's change of air and absence from medication,
+became worse than ever. The constant current was applied, from ten (and
+afterwards fifteen) cells of Weiss's battery, daily for twenty-four
+days, the pain vanished finally at the end of thirteen days, and the
+accompanying anaesthesia and partial paralysis disappeared before the
+treatment was concluded. In this case the negative pole was applied by
+the side of the three lower cervical vertebrae, and the positive was
+applied, successively, to three or four different parts of the most
+intense peripheral pain.
+
+CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the
+leg. Galvanization (twenty cells Daniell), from the anterior tibial
+region to the spine was found invariably to cut short the pain. I now
+reversed the current; the effect was the same. After ten sittings I
+suspended the treatment, as there had been no attack for three days; but
+a week later the neuralgia returned in full fury. I resumed
+galvanization from periphery to spine; after twelve more sittings the
+attacks had become rare and slight. I continued treatment for eight days
+longer, during the whole of which time there was no pain. It had not
+recurred when I saw her fifteen months afterward.
+
+CASE III.--H. G., a footman, aged twenty-three, applied to me at
+Westminster Hospital, with neuralgia of the first and second divisions
+of the right trigeminus, of six weeks' standing. The right eye was
+bloodshot and streaming with tears, the skin of the right side of the
+nose and right cheek was anaesthetic, the right levator palpebrae was
+partially paralyzed. Hypodermic injections of morphia proved only very
+temporarily beneficial. After a fortnight's treatment with this and with
+flying blisters to the nape of the neck and the mastoid process, I
+commenced the use of the constant current daily (ten cells, Weiss). The
+first application (positive on nape, negative on infra-orbital foramen)
+stopped the pain, and procured fourteen hours' immunity. On the next day
+I reversed the current; the pain stopped after three minutes'
+galvanization; it did not recur for four days, during which time,
+however, I continued the daily use of the direct current. On the sixth
+day of treatment the patient came to me with a somewhat severe paroxysm,
+almost limited to the ophthalmic division; it was accompanied by
+spasmodic twitchings of the eyelid, and copious effusion of altered
+Meibomian secretion, looking like pus. Galvanization from supra-orbital
+foramen to nape stopped the pain in five minutes. The next day the
+patient presented himself, quite free from pain, which had not returned;
+the conjunctiva was clear, and there was no visible Meibomian secretion.
+Inverse galvanization was continued for ten days; but no recurrence of
+the pain took place. The cure was permanent three months later.
+
+On the contrary, we sometimes see complete failure of the current to
+affect any good whatever; and in these cases the reversal of the current
+has not, so far, appeared to me to make any particular change in the
+result. Such was the case with a patient whose history I detailed (along
+with that of Case I.) to the Clinical Society. She was an ill-fed and
+overworked unmarried needle woman, aged thirty; the neuralgia was a most
+violent double occipital pain, with foci, on each side, where the great
+occipital nerves become superficial. The current was passed daily, for
+some days, from one focus to another (necessarily passing through the
+nerve-roots and the spinal cord), and the positions of the conductors
+were occasionally reversed; this not succeeding, the current was applied
+altogether to the spine, the negative pole being placed on the highest
+cervical vertebrae, but no good effect was produced after a treatment,
+altogether, of sixteen days.
+
+Notwithstanding these, and a good many similar facts that could be
+adduced, I should hesitate to go so far as to say that there is never
+any importance in the direction of the current. In old-standing cases,
+where there are well-marked _points douloureux_ that are exceedingly
+sensitive, I have found that the application of the positive pole,
+successively, on the most tender points, the negative being placed on
+the spine opposite the point of origin of the nerve, has had a more
+beneficial effect than any other mode of application.
+
+There are very considerable differences, both as to the best manner of
+galvanization, and also as to the chances of doing good with it, in the
+case of neuralgias of different nerves; and, on the whole, I find
+Eulenburg's conclusions on this matter very just. He indicates sciatica
+as the affection which is by far the most curable by the constant
+current; he says that many cases are cured in from three to five
+sittings, while others require as many weeks, or even months of
+treatment; and that a total absence of benefit is only seen in rare
+cases dependent on central causes, or on diseases which are irremovable
+(like malignant pelvic tumors). On the other hand, he reports that
+intercostal neuralgia has never been materially benefited by
+galvanization in his hands. With regard to ordinary trigeminal
+neuralgias, he speaks strongly of the current as a palliative, but very
+doubtfully of its power to cure, in genuine and severe cases. In
+cervico-brachial neuralgia he speaks of it as dividing with hypodermic
+morphia the whole field of useful treatment, in the majority of cases.
+In cervico-occipital neuralgia he says it rarely does much good. I shall
+return to Eulenburg's estimate of its utility in migraine, presently.
+Let me here say that I am inclined to indorse everything in the
+above-detailed statements, excepting that I should place a considerably
+higher estimate on the curative powers of the current in ordinary
+trigeminal neuralgias. The remedy, like every other, will doubtless fail
+in a considerable number of those very bad cases which occur in the
+degenerative period of life; but if anyone desires to see the proof of
+the power it sometimes exerts, even in extreme cases, he should study
+the two most remarkable cases treated by Prof. Niemeyer, of Tubingen,
+and reported by Dr. Wiesner.[44] The patients were respectively aged
+sixty-four and seventy-four, and the duration of the neuralgia had been
+respectively five and twenty-nine years; in both the pain was of the
+severest type, and in both the success was most striking. In one of them
+every possible variety of medication, and several distinct surgical
+operations for excision of portions of the affected nerve, had been
+quite vainly tried. The cases are altogether among the most interesting
+facts in therapeutics that have ever been recorded. Dr. Russell Reynolds
+has also told me of a case under his own care, in which a lady, who had
+been the victim, for twenty years, of an extremely severe neuralgia of
+the ophthalmic division of the fifth, which attacked her daily, and had
+caused great injury to her general health and nutrition, was not merely
+benefited, but the affection absolutely removed, at any rate for a long
+period, by a single application of the current. I have personally seen
+no such remarkable cases as these but I have had some extremely severe
+cases under my care in which the effect of the current was to arrest the
+pain in a few applications, and procure a remission for several days, or
+even weeks. And I have had several slighter cases which were as much
+cured, to all appearance, as any disease can be, by any remedy.
+
+As a general rule, neuralgia of the limbs requires to be treated with a
+more powerful current than neuralgia of the face (twenty cells instead
+of ten). In the latter case, indeed, it is necessary to be exceedingly
+cautious (commencing with five cells), since a current of high power has
+been known to produce most serious effects upon the deeper-seated
+organs; the retina has been permanently paralyzed, by too strong a
+current applied on the face, and still graver dangers attend the
+incautious use of galvanization of the brain or of the sympathetic, of
+which we have now to speak.
+
+Galvanization of the brain is a remedy chiefly employed in true
+migraine, and is certainly very effective in that disease. I have not
+found it useful to apply the current in the long axis of the cranium,
+but transmitted from one mastoid process to the other it has proved most
+useful; and I am glad to find that my experience on this point coincides
+with that of Eulenburg. But the use of this remedy is highly perilous in
+careless hands. In working with either Daniell's or Weiss's battery, it
+is necessary to use at first only three or four cells, and to increase
+the number only with the greatest caution. The sittings should never
+last more than half a minute; but the slightest giddiness should make us
+stop even sooner. On the other hand, the applications ought to be made
+daily, and usually twice a day. Ten cells (Daniell or Weiss) is the
+utmost that will ever be required, few patients will bear so much; and,
+apart from the possibility of more serious mischief, there is nothing
+which annoys and frightens patients more seriously than the sudden and
+intense vertigo which over-galvanization of the brain may induce.
+
+Even more ticklish than the galvanization of the cerebral mass is
+galvanization of the sympathetic. I am not going to raise here the vexed
+question in physiological electricity as to the possibility of a
+galvanization the effects of which shall be accurately limited to the
+sympathetic. The fact is unquestionable, that very powerful and peculiar
+effects, utterly unprocurable in any other way, can be produced by
+placing one pole on the superior cervical ganglion (just behind and
+below the angle of the jaw) and the other on the manubrium sterni. This
+is a mode of galvanization which has been highly praised, more
+especially by Remak, and after him by Benedikt, but it has yielded
+rather disappointing results in neuralgia in my hands. Either I have not
+observed any distinct effect at all, or, if a current even a very little
+too strong were applied, I have repeatedly seen most uncomfortable, and
+sometimes very alarming, symptoms. I shall not easily forget a patient
+who applied at the Westminster Hospital, suffering from a severe form of
+facial neuralgia, and who was persuaded to come to my house and have his
+sympathetic galvanized. I used only twenty cells of Daniell, but the
+current had not been applied more than a few seconds when the patient
+fell on the floor, and remained in a state of half swoon for a
+considerable time. I allude to this and other less dangerous accidents
+that I have seen follow galvanization of the sympathetic, not with the
+view to prove that the method is useless in trigeminal neuralgia--I
+should certainly hesitate to say that, considering the large amount of
+respectable evidence in its favor--but I think that it is a procedure
+requiring the utmost caution, and meantime I have not personally found
+it nearly so useful as the methods already described.
+
+There are sundry special applications of galvanism to particular forms
+of neuralgia which require a few words of notice. Of electrical
+treatment in regular angina pectoris I have had no experience; and in
+the one case of intercostal neuralgia, complicated with quasi-anginal
+attacks, in which I applied the constant current to the spine and the
+cardiac region, in the direction of the affected intercostal nerve, no
+effect was produced. I shall, however, mention the experience of
+Eulenburg, as he is a sober and dispassionate writer on the effects of
+electric treatment in general. He says he believes that in the proper
+use of the constant current we shall discover the chief, possibly the
+only direct, remedy for angina; and he describes the apparently
+favorable results he has already obtained in three or four cases. The
+current was from thirty cells; the positive pole was placed on the
+sternum (broad electrode), the negative on the lower cervical vertebrae.
+The alternative method which Eulenburg suggests, but has not, so far,
+put in practice, is direct galvanization of the sympathetic and vagus
+in the neck.
+
+The application of the constant current in neuralgic affections of the
+larynx and pharynx is of most indisputable service; the experience of
+Tobold[45] upon this point is fully borne out by my own, as far as it
+goes. In many cases it will be sufficient to place the positive pole
+(from fifteen cells Weiss) on the pomum Adami, and the negative on the
+nape of the neck, and to keep up a continuous current for five or ten
+minutes daily; but in some cases the direct application of the current
+to the pharynx or larynx may be required; in such, a modification of Dr.
+Morell Kackenzie's laryngeal conductor will be found useful. [I shall
+have occasion, in Part II., to notice the superior action of
+Faradization in mere hysteric throat-pain, as distinguished from true
+neuralgia.]
+
+Neuralgia of the testicle can be best treated, if galvanism be thought
+necessary, by immersing the whole scrotum in a basin of salt and water,
+in which the positive pole is placed: the negative pole is to be placed
+on the upper lumbar vertebrae; the current should be from fifteen cells
+Weiss, and the application should last continuously for ten minutes. In
+neuralgia of the urethra, I should be inclined to adopt a plan,
+mentioned to me by Dr. Buzzard, of attaching one conductor to an
+ordinary silver catheter introduced into the urethra, and placing the
+other pole upon the perinaeum.
+
+Neuralgia of the neck of the bladder I have found to be materially
+relieved by the constant current from twenty cells passed through from
+pubis to perinaeum; the sittings being rather long. I have also, on one
+occasion, tried the introduction of a proper _porte-electricite_,
+insulated, except at the tip; but the result was not superior to that
+obtained in the other way.
+
+As a general rule, it may be said that electricity, like other local
+measures which tend to concentrate the patient's attention on the parts,
+is only to be applied to the genital organs as a last resort. This is,
+of course, especially true in the neuralgias of these organs in women.
+
+In concluding what will doubtless seem to some English readers an
+over-long and over-favorable estimate of the employment of galvanism in
+neuralgias, I must carefully guard myself against the supposition that I
+consider it a remedy to be applied in all cases, or likely to meet with
+uniform success, even in the forms of the disease to which it is most
+appropriate. It is a weapon which I seldom employ in the first instance,
+for many reasons; the principal of which is the costliness of the
+proceeding to the patient. Either the physician must personally
+administer the remedy, daily, often for a considerable period, or he
+must make the patient provide himself with an expensive battery; and in
+the latter case there is, after all, the unsatisfactory consideration
+that the application (even after the most careful directions have been
+given) will perhaps be unskilfully and inefficiently made. On the other
+hand, it is not desirable to delay the employment of galvanism too long,
+if other remedies have been fairly tried; and the practitioner will do
+well to remember the distinctions above laid down as to the varieties of
+neuralgia in which it is specially likely to prove decidedly and quickly
+beneficial. More especially in sciatica it would really, with our
+present knowledge, be a decided neglect of duty were we to allow the
+disease to run any considerable length without giving the constant
+current a thorough trial. [I can only briefly refer, here, to the novel
+mode of galvanization introduced by Dr. Radcliffe, and based upon his
+ingenious theory, according to which the true effects of the voltaic
+current upon nerve are the result of the charge of free electricity
+which it sets up, and not of the current directly. The reader will find
+the whole argument elaborately worked out in Dr. Radcliffe's recent work
+on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be
+enough to say, here, that the object to be attained, according to this
+view, is to replace the neuralgic nerve in its healthy physiological
+state, by charging it with free positive electricity. The manner in
+which this is done is as follows: In a case, _e. g._, of
+cervico-brachial neuralgia, we place the positive pole as near as may be
+to the central origin of the affected nerve; the negative pole is held
+in the hand of the same side, which is immersed in a basin of warm salt
+and water. In this same basin is another electrode, the wire from which
+is put in communication with the earth--most conveniently by putting it
+in contact with a gas-pipe. The patient, and the battery, ought properly
+to be insulated. The result of this arrangement is, that the free
+negative electricity is carried off by the earth-wire, and the limb
+remains charged with free positive electricity. I have had no sufficient
+experience of this method to give any opinion of its merits, but the
+inventor thinks it decidedly superior to the ordinary modes of applying
+the constant current.]
+
+(_f_) The last kind of local remedies for neuralgia of which we have to
+speak are those by which we seek to mitigate the paroxysm by thoroughly
+excluding the air from the site of apparent pain. These are chiefly of
+value in those cases where a distinct inflammation (herpetic or
+erysipelatoid), or an unusual degree of sensitiveness on pressure, etc.,
+has become developed around the superficial branches of the neuralgic
+nerve. Very much the best agent of this kind with which I am acquainted
+is the flexible collodion; in neuralgic herpes and erysipelas the effect
+of this application, conjoined with the hypodermic injection of morphia
+(preferably in the immediate neighborhood), is of the greatest possible
+service in mitigating the pain. In herpes it has this further special
+advantage, that it prevents the occurrence of sores after the vesicles
+fall, an accident which otherwise will sometimes happen, and which very
+much increases the severity and intractability of the consecutive
+neuralgic pain.
+
+4. Lastly, we have to speak of prophylactic measures, which really ought
+never to be thought of as a separate matter, but always as an essential
+and most important part of the treatment of neuralgia. The prophylaxis
+of neuralgia is divisible into (_a_) measures for preventing the
+development of the neuralgic habit in those who may be supposed to have
+a predisposition to it; (_b_) measures between the paroxysms; (_c_)
+measures to be adopted after the attacks have ceased.
+
+(_a_) The measures that should be taken to avert neuralgia, in those who
+may be reasonably assumed to be predisposed to it, have scarcely
+received any consideration at the hands of systematic writers; yet this
+is a most important subject. The persons in question are children who
+belong to families known to be infected with tendencies to neurotic
+diseases, or persons whose daily occupations submit them to peculiarly
+strong predisposing influences of an external kind. The hostile
+influences that should be avoided, or at any rate compensated, are of
+several kinds: (1) Psychical; (2) defects of nutrition; (3)
+mismanagement of the muscular system; (4) sexual irregularities; (5)
+over-fatigue of the special senses, and insufficiency of sleep,
+especially the latter; (6) unhealthy atmosphere and climate.
+
+(1) The psychical influences which must be especially avoided, if we
+would avert the formation of the neuralgic habit, form a large and
+somewhat indefinite group, which it is doubtless difficult to deal with
+satisfactorily. The matter is, however, highly important, and the
+attempt must be made. And there are, at any rate, some leading
+principles that I feel justified in laying down with confidence.
+
+We shall best commence the inquiry by directing our attention once more
+to the fact, so often insisted upon in this work, that the large
+majority of neuralgic patients carry in them the seeds of their malady
+from their birth. It has been amply proved that every child born of a
+family that has shown strong tendencies to insanity, epilepsy,
+paralysis, etc., etc., ought to be looked on as a neurotic subject, and
+as a potential sufferer from neuralgia. It has been shown that such
+children will be exposed, even under favoring external circumstances, to
+the danger of neuralgia at certain important stages of their
+physiological history. The earliest of these critical periods is marked
+by the occurrence of puberty; and it is not till this time that
+psychical influences, as such, come to have any serious bearing on the
+formation of the neuralgic habit. Mischief may, indeed, be done to the
+brain and the general nervous system, by injudicious mental training, at
+a far earlier period; but this mischief, serious or even fatal as it may
+be, usually takes some other form than that of neuralgia. It will be
+necessary, here, to reflect a little upon certain features of the
+childish mind, in order that we may rightly estimate the kind of
+influence which puberty exerts upon it.
+
+A very young child is selfish, in the purely animal sense; it is
+greedily acquisitive, and its selfishness is unchecked by any sense of
+shame. With later childhood there comes a sense of right and wrong, and
+a sensitiveness to shame, which check this tendency; still it is the
+exception rather than the rule to find any great capacity of
+self-abnegation in young school-boys. But a moderately healthy-minded
+child, up to the age of puberty, is only acquisitively selfish; he is
+not self-centered in the sense of dwelling upon his own mental state,
+and reflecting upon the nature of his motives and feelings. It is with
+the age of puberty that self-consciousness begins to be a feature in the
+mind of the young, and its appearance marks the entrance of a dangerous
+element into the character. It is an inevitable stage in mental growth,
+and, if wisely dealt with, is ultimately productive, not of evil, but of
+good; but it is more perilous to some children than to others, and it is
+especially fraught with danger to those whose nervous centres are, by
+inheritance, weak and unstable in whole or in parts. The mental antidote
+to its possible evil effects is to be found in a vigorous (but not
+excessive) training of the mind in studies which shall be as far as
+possible external, and the discouragement of all tendencies to
+introspection. I would venture to express the decided opinion that the
+common idea, that close study injures the young, is only true in a
+modified sense. It is, however, unquestionably the fact, that hasty and
+imperfect cram-work does very seriously impair the stability of the
+brain and the nervous system in young people; there is a spurious
+excitement about this kind of learning (especially when it is mainly
+competitive, and directed to the gaining of prizes and medals) which
+must be injurious. But I think it is quite ridiculous to suppose that,
+in this country, the actual amount of intellectual labor undergone by
+boys and girls at school is sufficient to do harm, were it only regular
+and systematic, and carried out in a conscientious manner; on the
+contrary, though I think that the total daily period occupied in study
+ought not to exceed some six or seven hours, I believe that the
+insisting on strenuous diligence during school hours, and the
+maintenance of a high standard as to the quality of the work exacted, is
+all on the side of nervous health. But, an even more serious and
+difficult matter than the regulation of the amount of intellectual work
+to be done is, the question how we are to deal with the unfolding
+emotional instincts of the boy or girl who has reached the age of
+puberty. It is useless to ignore this side of the mental life; it will
+assert itself either for good or for evil. At the risk of seeming to
+meddle with matters that belong to the school-master rather than to the
+physician, I would urge very strongly that a portion of the training be
+deliberately directed to a serious study of one or other of the fine
+arts--to that one, whether poetry, painting, sculpture, or music, to
+which the boy or the girl instinctively leans. I am aware that there is
+a prejudice among parents that the study of the fine arts renders young
+people idle and indifferent to other branches of education and other
+duties of life. I believe that this only applies to the miserably
+inefficient way of teaching these subjects which prevails at present in
+all but a few English schools; and that, in truth, a thorough knowledge
+of the principles of either music or painting, and a real study of the
+best masters, would be sure to prevent the development of that lazy,
+conceited manner, and that neglect of other duties, which no doubt
+unfavorably distinguish a good many of the young ladies and gentlemen
+who dabble a little in music, or painting, or versification. We want the
+German rather than the English type of training, we want the acquirement
+of sound knowledge of the principles of music (at any rate) to be made
+so common that the accidental possession of two pennyworth of
+superficial accomplishment in that line shall not enable young ladies
+and gentlemen to give themselves airs in society. The truth is, that the
+young people who make music or painting an excuse for idleness
+respecting other matters are invariably imposters even in that which is
+their own supposed _forte_. On the other hand, the serious study of art,
+a certain definite portion of time being set apart for it, and
+thoroughness being insisted upon, is, I believe, an admirable vent for
+the emotional effervescence of commencing sexual life; and I no less
+firmly believe that the things that are usually substituted for it are
+intensely pernicious. I have already, in the chapter on Pathology,
+remarked on the mischief which is often done by the anxiety of religious
+parents to make their children (usually somewhere about this perilous
+time of puberty) experience the emotional struggle which is believed to
+end in a change of heart and principles. I need, therefore, only now
+repeat the expression of my intense conviction that the results of this
+process, as seen by the physician to occur within that mental region
+where the emotions and the organic nervous system come into closest
+relations, are simply disastrous. It is not my business to suggest the
+proper alternative to a mode of spiritual training which I think
+deleterious; I can only intimate, in the most general way, my belief
+that a calm and systematic training in the simplest principles of duty
+and religion is greatly more suitable to the immature mind and brain of
+youth than any strong emotional excitement on such topics. But if
+ill-regulated spiritual emotion of a religious kind be a dangerous thing
+for young persons in the most serious crisis of bodily development, far
+more decidedly pernicious is the spurious excitement of feeling which is
+directed to lower and often most unworthy objects. The increasing
+precocity of boys and girls, in their familiarity with the most
+objectionable aspects of passion and intrigue, is steadily fed, in the
+present day, by a system that allows them, too often, unlimited access
+to light literature which (as is strikingly the case with many novels of
+our day) is at once devoid of true literary and artistic merit and at
+the same time replete with sensational incident of a vulgarly exciting
+kind. The same degrading tendency is very distinctly to be noted in the
+character of the dramatic and other public exhibitions which are most
+popular at the present day; the main characteristics being, bad art, and
+thinly-veiled sensuality, all the more pernicious for being veiled at
+all. It would be a hundred times better that a boy, or even a girl,
+should study the frank and outspoken descriptions to be found in
+Shakespeare or Fielding, with all their occasional coarseness, than that
+they should enervate their minds with the sickly trash that is most
+current and most popular at the present day, in theatre and circulating
+library.
+
+(2) The defects of nutrition that assist the development of the
+neuralgic tendency are often the consequence of a system which, it is to
+be hoped, is to a large extent becoming effete, but which, nevertheless,
+survives in sufficient vigor and extent to demand express reprobation.
+It was till lately the general, and it is still a too common practice,
+to keep children and young persons on a very insufficient allowance of
+the most important elements of food; the state of things in this
+respect, both in public and private schools, in the first half of the
+present century, is a lasting reproach to the medical practitioners of
+those days, who scarcely lifted a finger to amend it, even when they did
+not expressly approve it, under the influence of absurd theories about
+the dangers of excessive "grossness of blood." It is indeed amazing
+that, with the palpable fact staring them in the face, of the rapid and
+incessant additions to tissues which are being made by children and
+young people, medical men should have failed to perceive the necessity
+for supplies of food practically unlimited except by the capacity of
+digestion. Yet this seems hardly ever to have been thought of, and the
+unfortunate results seem scarcely to have been noticed, except when they
+led to emaciation or consumptive disease. But the effects were perhaps
+even more disastrous where, with a maintenance of a fair amount of
+muscular nutrition, there was only a little dyspepsia, and perhaps some
+slight tendency to nervousness, to show that anything was wrong. The
+children who were born of strong and healthy parents, may have suffered
+comparatively little from this regimen as regards their nervous system,
+but those who were born of neurotic ancestors undoubtedly suffered
+extensively. The crisis of puberty was, in such ill-nourished children,
+too frequently the signal for an explosion of epilepsy, chorea, or
+neuralgia; and too often the mischief was yet further increased by a
+most injudicious medical treatment, including a deterioration rather
+than an improvement in the already insufficient dietary system. At the
+present day, however, we may fairly hope that common sense is
+prevailing, so as to put an end to this mischief as regards the children
+of the upper and middle classes. Unfortunately, with the poor a similar
+ill-nourishment of the young is too often inevitable, and the
+consequences are constantly to be traced in enfeeblement of the nervous
+system, of which neuralgia is a pretty common result.
+
+It cannot be too frequently repeated that for those children, more
+especially those who come of nervous families, any considerable error in
+this direction has a fatal tendency to awaken the disposition to nervous
+disease. At every step of the infancy, childhood, and youth of such
+persons, the most generous allowance of the more nutritive elements of
+food is of the first importance. At the same time I am entirely opposed
+to the practice of giving stimulants to any considerable extent, or
+indeed to any extent, save in exceptional instances. Good meat, bread,
+milk, butter, fruit, and vegetables, are really the efficacious means of
+fortifying the nervous system against the impending dangers. With
+hospital out-patients, for whom we cannot command such diet, our best
+course, whenever they show signs of deficient nutrition, will be the
+steady administration of cod-liver oil for a long period.
+
+(3) The true and proper training of the muscular system is among the
+most important means of antagonizing the tendency to the development of
+the neuralgic habit. It is a great mistake to suppose that over-training
+in athletics of any kind is of use; but the systematic employment of
+means which tend to make the muscular system hardy and efficient is of
+very great benefit. The parents of children who may be supposed by
+inheritance to possess a tendency to neuralgia would do well to study
+such a methodical series of directions as those which are given by Mr.
+Maclaren, in his excellent work on physical training. I suspect that the
+benefit of judicious gymnastics is wrought in two ways: first, by its
+improving circulation and general nutrition, including the nutrition of
+the nervous centres; and, secondly, that it gives the nervous centres an
+education, so to speak, by the variety of difficult co-ordinative
+movements over which it trains those centres to preside. But
+unquestionably the matter is a science, not a mere rude art, and
+requires to be studied as such.
+
+(4) Of unspeakable importance to the object of averting the formation
+of the neuralgic habit is the prevention of sexual irregularities in the
+young. Under this heading is included a large and various group of
+influences; of these the first that requires notice is the prevention of
+precocious sexual stimulation, whether by talk or by acts, which may
+precipitate the occurrence of puberty at an unnaturally early age. I
+know very well how difficult it is to devise any scheme which really
+would effectively control and antagonize the worst mischief of schools;
+but it is at least a duty to say here, that no experienced physician can
+doubt that such a scheme must be found, if we are ever to hope for a
+healthier race of children and of young men and women, and if we are to
+break down one of the most potent of the influences that go to the
+production and maintenance of the neurotic disposition. I would be
+clearly understood not to suppose for a moment, either that this sort of
+cause is usually at work in the production of neuralgia in the young, or
+that of itself it is sufficient to produce the disease; but I would say,
+for certain, that on children of nervous families such influences act
+with disastrous energy; and, moreover, that where we see signs, in a
+neuralgic young person, of that general form of bad health which is
+connected with precocious puberty, we may be nearly certain that such
+influences have actually been at work. At all cost, and by all
+conceivable means, all children, but most especially the delicate and
+nervous ones, ought to be shielded from the risk of this occurring.
+
+Another form of sexual irregularity which can be counted as a
+contributor to the formation of the neuralgic habit is menstrual
+irregularity, especially at the commencement of sexual life. By far the
+most mischievous in this way is menorrhagia of the young. I have seen
+exceedingly severe and intractable neuralgia set up by it. As regards
+the influence of simple amenorrhoea, I am by no means clear: it seems
+pretty nearly as likely that the deficient excretion (when not dependent
+on mechanical cause) is a mere sign of the general weakness which also
+predisposes to the neuralgia, as that the neuralgia is in any way the
+direct consequence of the amenorrhoea.
+
+Leucorrhoea, especially when profuse and long-continued, is a much
+more indisputable factor in many neuralgias. It is a point of real
+importance to put an end promptly to such a discharge, if it exists, and
+the usual remedies--cold bathing, mild astringent injections,
+etc.--should be at once prescribed.
+
+Dysmenorrhoea, a painful menstruation, when not dependent on a purely
+mechanical cause, affords a strong example of neuralgia connected with
+sexual difficulty; but there is every reason to think that the neuralgia
+is the primary and not the secondary affection. The only effective
+prophylaxis, therefore, is the adoption of such general measures as will
+raise the whole tone of nervous health. It often happens that marriage
+completely cures the tendency to these attacks.
+
+(5) Insufficiency and irregularity as to the allowance of sleep are
+potent influences in developing neuralgia in those who are hereditarily
+predisposed. It is needless to say a single word to prove the imperative
+need of the young for periodical and prolonged repose from the conscious
+actions of the nervous system. Full ten hours of sleep in the
+twenty-four, for boys and girls who are at or near the period of
+puberty, is an absolute necessity if we would prevent any existing
+irritability of the nervous system from developing into the fully-formed
+neurotic temperament. Indeed, I believe that, for all young people (but
+especially girls) up to the age of twenty-five, this allowance is not
+the least beyond what is necessary: only the need is most pressing at,
+and just before, the development of the sexual organs. Of course a much
+larger allowance of sleep is necessary in actual infancy: from seven to
+twelve we may be content if we get nine hours clear sleep; but during
+the two or three years preceding puberty we should insist upon ten
+hours, at any rate for children who possess the nervous temperament.
+
+(6) Impurity of the atmosphere in which they habitually or daily reside
+must be carefully shunned for young children, especially for the
+nervous. The kind of dull and diffused headache which children often
+complain of, after study for some time in a close, ill-ventilated
+school-room, is very likely (if the bad influence be continued for a
+number of years) to develop itself, at puberty, into a regular migraine.
+Purity of air in the school-room must therefore be scrupulously provided
+for; and the same thing must be attended to as regards the sleeping
+rooms.
+
+Of the climatic influences we may speak in a few words. Besides the
+avoidance of distinctly malarial districts, and also of places where,
+although there is no distinct ague, there is a prevalence of neuralgic
+or even of so-called "rheumatic" complaints, it is necessary very
+carefully to shun damp soils, and places where there is a great deal of
+harsh and cold wind. Mere lowness of average temperature is not in
+itself a strong predisposer to neuralgia, at any rate if guarded against
+by abundant food and the use of such clothes as will prevent children
+from ever feeling chilly and depressed. But damp and harsh winds are
+actively bad; and when joined to habitual or frequent lowness of
+temperature, they constitute very unfavorable surroundings for the
+nervous systems of delicate children.
+
+(_b_) We come now to the prophylaxis which is to be adopted in the
+intervals of the paroxysms when neuralgia has been actually set up. This
+consists essentially in three things: (1) Physiological rest, as perfect
+as possible, of the affected parts; (2) protection from cold; (3)
+protection from sunlight; (4) avoidance of injurious mental emotions.
+
+(1) The maintenance of physiological rest, to the greatest extent that
+is possible, is an absolute necessity, if we would shield a nerve, which
+has lately been attacked with neuralgia, from fresh paroxysms. The most
+evident illustrations of this fact are afforded by those neuralgic
+affections in which it is most difficult to adopt this precaution. Thus
+the greatest embarrassment from this cause is met with in the case of
+sciatica; a mild case is often converted into one of great severity and
+intractability because the patient, in the early stages, either cannot
+or will not maintain the recumbent posture. So, too, though in less
+marked degree, the cure of cervico-brachial neuralgia is often greatly
+impeded by the difficulty of maintaining complete rest of the limb.
+Again, in neuralgia affecting the third division of the fifth, the
+movements of mastication and of speech are a terrible hinderance to the
+progress of recovery; and it often becomes necessary, in severe cases,
+to prescribe absolute silence, and even to feed the patient exclusively
+with such liquid or semi-liquid food as shall require no efforts of
+chewing.
+
+(2) Preservation from external cold is highly important. When a nerve of
+the arm, or leg, or trunk, is affected, warm flannel under-clothing
+ought immediately to be adopted. The patient who has been suffering from
+cervico-occipital neuralgia should for some time, in anything but quite
+summer weather, never go out without wearing a warm comforter round the
+neck. The sufferer from facial neuralgia should for some time after the
+cessation of actual attacks never face wind without wearing a thick
+veil.
+
+(3) Exposure to bright light must be scrupulously avoided by sufferers
+from ophthalmic neuralgia. The affection known as "snow-blindness" is
+really a neuralgia, with vaso-motor complications, produced by the glare
+of light reflected from snow; and one of the severest attacks of
+neuralgia which I personally ever experienced was provoked in this way.
+Even the comparatively slighter, but for an Englishman unusual, glare of
+sunlight which one meets with during the first days of a Continental
+holiday, in wandering about towns made up of clean white stone or
+whitewashed houses, is enough to provoke an attack, unless the eyes are
+carefully guarded with colored glasses.
+
+(4) It is scarcely necessary, after what has been already said, to
+insist upon the absolute necessity of mental quietude, as far as this
+can be obtained. This precaution is more or less important in all
+neuralgic affections; but in migraine and in other trigeminal neuralgias
+it is almost of more consequence than any other prophylactic measure;
+and in angina pectoris it is so essential that adoption or neglect of it
+may easily turn the scale between life and death. All forms of abdominal
+visceral neuralgia, also, are greatly affected by emotion, and passion
+or strong excitement of any kind must be scrupulously shunned if the
+neuralgic habit is to be broken through. Unfortunately, it too often
+happens that the mental surroundings of the patient cannot be so changed
+as to enable us to carry out this kind of prophylaxis effectually; and
+neuralgic cases of this class are among the severest trials of the
+physician's tact and skill, and too frequently defy his efforts.
+
+(_c_) The precautionary measures which are to be adopted, after the
+neuralgic habit has apparently been fairly broken through, in order to
+prevent the patient from sliding again into the old vicious groove, can
+hardly be defined with exactness though their general character will be
+readily gathered from the picture of the clinical history and pathology
+of the disease which has been exhibited at large in this work. They
+mainly consist in the avoidance of severe, and especially of unequal,
+strains upon bodily or mental powers; and in redoubled carefulness in
+these respects at those natural crises in the life of the organism which
+have been shown to exercise so important an influence upon the neuralgic
+tendency. To a certain extent, also, but with much precaution, we may
+attempt to modify the peripheral sensibility by what is commonly called
+a hardening regimen. Thus, with great care, and proceeding in a very
+gradual manner, we may by degrees accustom the patient to a larger
+amount of exposure to free air, and even at last to rough weather, so
+that in the end he may become less sensitive to some of the commonest
+immediately exciting causes of neuralgia. If one were to construct an
+advancing scale of such measures, one might arrange them something like
+this: First, in-door gymnastics, and gentle horse-exercise for out-door
+work, in fine weather only; then horse-exercise alternated with
+pedestrianism, sea-bathing in warm weather; and, finally, we should try
+to reach a stage at which the patient can well endure a ten or fifteen
+miles' walk or ride every day, and be comparatively careless about the
+weather. In reaching this latter stage I have seen some patients helped,
+in an extraordinary degree, by the frequent use of the Turkish bath,
+followed by douche. Upon this latter subject I beg to offer some
+remarks, which are the result of pretty careful and extensive study of
+the effects of the Turkish bath in a variety of chronic nervous
+diseases. I believe it to be a very great mistake to suppose that,
+either in rheumatism or in true neuralgia, the process of the bath
+should be prolonged to such an extent as is commonly done. Instead of
+the usual slow heating process, gradually carried to a point at which
+excessive sweating occurs, I believe that the really scientific is the
+following: The patient should as quickly as possible get into the
+hottest atmosphere he intends to expose himself to, which should never
+be more than about 170 deg. Fahr. He should stay in this place just long
+enough to get thoroughly hot, and, with the assistance of a glass or so
+of water drunk, throw himself into a free but gentle perspiration. He
+should then be rapidly shampooed, exposed to the spinal douche for two
+or three minutes, and then pass to the cooling-room. Let him beware of
+too long dawdling in the latter place, and let him avoid smoking there.
+It is a positively dangerous thing to cool one's self quite down to the
+normal heat, still more so to induce the slightest chilliness; the body
+should be still in a universal glow when one issues into the street.
+Over and over again I have proved upon myself that it is the beneficial
+method, whereas the prolonged use of the bath, the production of very
+copious sweating, and above all a lengthened cooling process, most
+seriously exhaust the nervous energy.
+
+There are certain special considerations as to the habits of life that
+require a word or two. I need say nothing more to enforce the views
+already put forward as to the necessity of copious supplies of food. I
+need only refer to what I have already said about the decidedly
+mischievous tendency of anything like habitual excess in the use of
+alcohol, merely adding a special caution against such indulgence during,
+and particularly toward, the end of the period of sexual activity. There
+is one more topic upon which something must be said, namely, the extent
+to which sexual intercourse should be allowed. Speaking of neuralgia
+generally (excluding neuralgic affections of the sexual organs
+themselves), it may decidedly be said that the regular and moderate
+exercise of the function, during the natural period of sexual life, is
+beneficial; but that excess is always dangerous, and that the
+continuance of sexual intercourse, after the powers naturally begin to
+wane, is extremely pernicious in its tendency to revive latent
+tendencies to neuralgia. As regards neuralgias of the sexual organs, it
+is very difficult to speak positively; and yet I believe that (once the
+neuralgic habit broken through by other means) it is very desirable that
+the patient should live according to the laws of normal physiological
+life.
+
+
+NOTE I.
+
+ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE.
+
+The following cases must be now added to those recorded in my list of
+private patients whose family history has been ascertained with reliable
+accuracy.
+
+CASE I. is that of a gentleman, aged forty-seven, the subject of
+lumbo-abdominal neuralgia: no history of nervous disease in the family;
+his mother, however, was of a "nervous" temperament.
+
+CASE II.--A gentleman, aged sixty-four, suffering from angina. His
+family nervous history is fearful. On the father's side it is not
+possible to get a clear account. But on the maternal side there has been
+a strong tendency to insanity and suicide; and in the patient's own
+generation one brother committed suicide from insanity, and one sister
+is still alive, insane. An interesting fact is, that the mother's family
+have shown an extraordinary proclivity to erysipelas.
+
+CASE III.--The young gentleman, whose single but extremely severe attack
+of angina is previously described, comes of a family in whom the
+tendency to neuralgia is undoubtedly very strongly inherited. His father
+is frequently and very severely _migraineux_, and in early life suffered
+cardiac symptoms not unlike his son's. A brother was also liable to
+attacks of true migraine between puberty and the age of twenty-one.
+
+CASE IV.--On the other hand, a case of angina which I saw in the
+country, last year, occurred in a gentleman, aged fifty, whose family
+presented no traceable neurotic history. But the damage inflicted upon
+his nervous system by various external influences was quite
+extraordinary. In some way or other he got some attacks of migraine at
+the age of fifteen or sixteen; for these he was treated with bleeding,
+and with a most savage antiphlogisticism generally. From that time he
+never got free of the neuralgic tendency. He used to have not only
+facial, but intercostal neuralgia; for this last he was repeatedly bled,
+under the idea that it was pleurisy. Added to all this he habitually did
+an immense deal of brain-work in his study, and for years had performed
+clerical duties of the most exacting and exhausting character. It is not
+much wonder that these combined circumstances had sufficed to generate
+the neurotic temperament.
+
+
+NOTE II.
+
+THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD.
+
+In the present transitional state of opinion concerning the mode in
+which the phenomena are produced that are popularly known under the name
+of "reflex paralysis," I cannot pass without notice the doctrines of
+these two observers. The reader will have perceived that, as regards the
+secondary paralytic symptoms observed in neuralgias, I explain the
+phenomena mainly on the theory of a process which is central, and not
+peripheral, in origin. And, even where, as in some few instances, it
+seems possible that the starting-point was an organic affection of some
+viscus, we must always consider the possibility that the link between
+this and the neuralgia and paralyses was a neuritis migrans travelling
+inward to the sensory centre, and from that passing over to motor
+centres and thus producing paralysis; or that, without the intervention
+of any truly inflammatory process, the continual impressions streaming
+in upon the cord from the original seat of organic disease may damage
+the nutrition of the sensory nerve-root, producing a partial atrophy,
+and that this process may extend to the motor root.
+
+It remains, however, to inquire whether the influence of powerful
+peripheral agencies may not, in a purely "functional" manner, disable
+the nerve-centres for a time, causing paralysis with or without
+neuralgia. The main supporters of such a doctrine are Dr. Handfield
+Jones[46] and M. Jaccoud.[47]
+
+Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to
+spasm of the vessels in the nerve-centres, and we need not repeat his
+arguments on that head, because it seems to be generally felt that the
+vascular spasm theory will not account for the facts. Jones believes
+that the state produced in the nerve-centre by the peripheral influence
+is one of paresis from shock-depression, and that from the sensory
+centre this state can communicate itself to motor and vaso-motor
+centres, though commissural fibres. He does not believe in the existence
+of a special inhibitory portion of the nervous system: he believes that
+an impression may prove stimulating when it is mild, or paralyzing when
+it is strong; and that any afferent nerve may convey either the one
+influence or the other to the centres and thus produce secondary
+stimulus or secondary paralyses in various efferent nerves. Jones has
+the distinguished merit of being one of the first authors distinctly to
+perceive that pain must rank on the same level with paralysis: hence he
+sees nothing unintelligible in the communication of paralysis to a motor
+centre from a sensory centre that was in the state which the mind
+interprets as pain.
+
+The _theorie d'epuisement_ of Jaccoud (Erschopfungs-theoric) also denies
+the possibility of Brown-Sequard's idea of prolonged spasm of the
+vessels of the centres. It imagines that powerful peripheral excitements
+exhaust the irritability of the nerve, and through that of the centres,
+and induce a state of unimpressibility--analogous to that which exists
+in a nerve or nerve-centre, which is included in the circuit of a
+constant current. The nervous force is wasted, and, until an opportunity
+of repose is afforded to the centre, the faculty of impressibility
+cannot again revive.
+
+I must say that of these two theories I decidedly incline to that of
+Handfield Jones (though I imagine that in reality the cases are
+extremely rare, if there be any, in which the change in the centres is
+really only functional and non-organic), I prefer the idea of
+paralyzing shock to that of exhaustion from over-excitement, from a
+consideration of the nature of that form of peripheral influence which
+has been specially mentioned by authors as competent to produce this
+sort of "reflex" affections, namely, intense and persistent cold. It
+seems to me a mere abuse of words to speak of this as an agent that
+could exhaust the nerve by over-stimulation; it must surely exhaust it
+in a much more direct manner than this, namely by the direct physical
+agency of withdrawing heat from the nerve, and spoiling its physical
+texture, _pro tanto_. If such an effect as that which must thus be
+produced on the nerve, and through it on the centre, is to be looked on
+as a case of over-stimulated function, then, it seems to me, there is no
+meaning in language, and no possibility of attaining to clear ideas on
+the subject of nervous influence.
+
+
+NOTE III.
+
+ARSENICAL TREATMENT OF VISCERALGIAE.
+
+Since writing the above chapter on the Treatment of Neuralgia, I have
+had two fresh and very striking examples, in private practice, of the
+power of arsenic to break the morbid chain of nervous actions in angina
+pectoris.
+
+The first example was that of a medical man, aged seventy-five, in whom
+a neuralgia, originally malarial in origin, and of some years' duration,
+had fixed itself for some time in the fifth and sixth left intercostal
+spaces, and of late had become complicated with anginoid attacks of an
+unmistakable character, though not of the highest degree of severity.
+The case certainly seemed very unpromising, looking at the patient's age
+and the consequent high probability that there was much arterial
+degeneration. However, the use of Fowler's solution (five minims three
+times a day) was commenced and steadily pushed. The anginoid attacks
+rapidly diminished in frequency and at the end of ten days' time were
+entirely gone, and after one month of treatment he still had no return
+of them, although they had previously been of daily occurrence. It is a
+curious fact, whether a mere coincidence or not I cannot say, that, some
+few days after the anginoid attacks ceased, he began to experience
+somewhat severe pains, rheumatic in feeling, but unattended with heat or
+swelling, in the elbows, wrists, and fingers, symmetrically. This has
+nearly disappeared, but he is still free from angina. There is no
+discoverable heart-lesion in this patient.
+
+The other case was that of a fine old man of sixty-four, who, but for
+some few slight attacks of gout, a few small calculi, and a troublesome
+prostatic affection, had always enjoyed remarkably good health, until
+about five months ago, when he began to notice tightness across the
+chest, etc., when he walked uphill. About a fortnight before he came to
+me, he was seized with very violent and alarming paroxysms of pain
+across the chest and running down both arms, extreme intermittence
+of pulse, and a sense of impending dissolution. The attack had recurred
+daily, at the same hour (6 P. M.), ever since; besides which there was
+an abiding sense of uneasiness in the cardiac region, and a
+consciousness that the least excitement or exertion would bring on the
+paroxysm. I put the patient on five minims of Fowler, three times a day,
+with directions to take ether when the paroxysms came. At the end of the
+first week there was already much improvement, the paroxysms having been
+both less frequent and less severe. At the end of a fortnight's
+treatment he reported that there had been nothing like a paroxysm for
+the last eight days, although there was still a good deal of uneasiness
+from time to time. The hour at which the attack was expected passed by
+absolutely without a trace of angina. It remains to be seen how long
+this improvement will last, but the altered state of things, and
+particularly the suddenness of the change, cannot be overlooked, and has
+very much struck the patient himself. It is now six weeks since he had
+any paroxysm.
+
+It becomes more and more apparent that arsenic is generally applicable
+to neuroses of the vagus. In asthma, I have long held it to be the most
+powerful prophylactic tonic that we possess. It is also an excellent
+remedy in gastralgia; although I have rather dwelt (in the text of this
+work) on the action of strychnia in this disease, I would not omit my
+testimony to arsenic. Dr. Leared has related some exceedingly
+interesting cases bearing on this point. (See _British Medical Journal_,
+November 23 and 30, 1867.)
+
+
+NOTE IV.
+
+INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT.
+
+Dr. Reynolds pointed out to me the exceedingly curious fact, which I have
+several times verified, that the constant current, in relieving facial
+neuralgia, not unfrequently disperses, almost instantaneously, the brown
+skin-pigment that has collected in the painful region; _e. g._, near the
+orbit.
+
+
+NOTE V.
+
+THE ACTUAL CAUTERY.
+
+A remedy for inveterate neuralgia which of late years I had almost
+discarded--the actual cautery--has quite recently yielded me very good
+palliative results in two cases. Its omission from the text of the
+chapter on Treatment was an accident due to the effect of habit in
+making one, half unconsciously, reckon this remedy as a
+"counter-irritant." The longer I practise, however, the more decidedly I
+am convinced that the actual cautery, if properly applied, does not act
+as an irritant at all; and this fact was sufficiently in my mind, when
+writing of irritant remedies, to make me omit the cautery from that
+section. I should have inserted it under the heading of remedies that
+interrupt the conductivity of nerves, and thus give the centres
+temporary rest. The only useful way to apply it is, to make an iron
+white hot, and very lightly brush the skin over so as to make an eschar
+not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is
+the best for the purpose, but I have made the flat-iron cautery serve
+very well.
+
+FOOTNOTES:
+
+[35] Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)
+
+[36] Practitioner, vol. iv., 1870.
+
+[37] Berlin. klin. Wochensch., 1865.
+
+[38] In a paper on the "Hypodermic Use of Remedies," in the
+_Practitioner_ of July, 1868, I gave the reasons for this opinion in
+full; and I see no reason to alter any thing I then said.
+
+[39] Practitioner, vol. iv.
+
+[40] Berlin. klin. Wochensch., 17, 1868.
+
+[41] "System of Medicine," vol. ii.
+
+[42] The English reader may consult Althaus ("A Treatise on Medical
+Electricity," second edition, Longmans), or Meyer ("Medical
+Electricity," translated by Hammond: Trubner & Co.)
+
+[43] "A Treatise on Medical Electricity," second edition, Longmans.
+
+[44] _Op. cit._
+
+[45] Berlin. klin. Wochensch., 22, 1865.
+
+[46] _Op. cit._
+
+[47] "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris,
+1864.
+
+
+
+
+PART II.
+
+DISEASES THAT RESEMBLE NEURALGIA.
+
+
+
+
+CHAPTER I.
+
+MYALGIA.
+
+
+Of all the diseases which superficially resemble neuralgia, none are so
+likely to be confounded with it, on a cursory glance, as myalgia. More
+careful inquiry, however, furnishes, in nearly all cases, ample means
+for distinguishing between the two affections.
+
+Myalgia is an exceedingly painful affection, and it is also much more
+common than was formerly supposed. It is to Dr. Inman that we
+undoubtedly owe the demonstration of the frequent occurrence of this
+malady, and the facility with which it may be mistaken for other, and
+sometimes much more serious, diseases, with very disastrous results. At
+the same time, I must express the opinion that this ingenious author has
+decidedly exaggerated the importance of this local disease at the
+expense of an unjust depreciation of the frequency and significance of
+other painful disorders which have their origin within the nervous
+system.
+
+Myalgia proper includes all those affections which are severally known
+as "muscular rheumatism" (for the muscles generally), and "lumbago,"
+"pleurodynia," etc. (according to locality). It is essentially pain
+produced in a muscle obliged to work when its structure is imperfectly
+nourished or impaired by disease.
+
+The clinical history of the different varieties of myalgia absolutely
+requires this key for its interpretation; otherwise, the appearance of
+the sufferers from different kinds of myalgia is so widely dissimilar
+that we should be exceedingly likely to miss the important features of
+treatment, which must be applied to them all in common. Nothing, for
+instance, can be more strikingly unlike than the appearance of the
+pallid, stunted, under-nourishment cobbler who complains of epigastric
+myalgia, and that of the ruddy and muscular navvy who suffers from acute
+lumbago, or the similarly plethoric-looking country commercial
+traveller, who has been driving in his gig against wind and rain, and
+complains of violent aching pains in one or both shoulders; yet one and
+all of these individuals are suffering from precisely the same cause of
+pain, viz., a temporarily crippled muscle or set of muscles which has
+been compelled to work against the grain. Why this state of things
+should invariably be interpreted as sensation in the form of acute pain
+never absent, but severely aggravated by every movement of the affected
+part, is a matter beyond our powers of explanation, we must accept it as
+an ultimate fact for the present.
+
+There is scarcely any need to describe the pain of myalgia, since almost
+every one has suffered either from lumbago, or from a stiff neck
+produced by cold. The pain is essentially the same in all cases; it is
+an aching actually felt either in or toward the tendinous insertions of
+the affected muscles, and sharply renewed by every attempted contraction
+of those muscles. The variations in the character and severity of the
+pains are really entirely due to the greater or the less opportunity for
+physiological rest which the muscle can obtain. Thus the most obstinate
+and the most severe, kind of myalgic pain is undoubtedly that of
+pleurodynia--pain in the intercostal muscles and their fibrous
+aponeuroses--a fact which depends on the incessant movements which these
+muscles are compelled to perform in the act of respiration. And next to
+this in severity and obstinacy are myalgias of the great muscles which
+are incessantly engaged in maintaining, by their accurately opposed
+contraction, the erect position of the spinal column and of the head.
+This rate of proportional frequency and severity, however, must be taken
+as strictly relative; _i. e._, it is correct upon the supposition that
+the different sets of muscles were equally worked and that the state of
+nutrition was equal in the different parents. It is otherwise when the
+conditions are reversed. Thus, the unfortunate cobbler or tailor, who
+sits for long hours in one cramped and bent posture, is continuously
+exerting his recti abdominales (probably suffering from an
+under-nutrition common to all his tissues) to a degree perfectly
+abnormal, and out of all proportion to the functional work he is getting
+out of any other part of his muscular system. The consequence is, that
+he comes to us complaining of acute epigastric, and sometimes pubic,
+pain, rising to agony when he assumes his ordinary sitting posture, and
+only reduced to any thing moderate by the most complete extension of the
+whole trunk in the supine posture.
+
+There is no need to dilate at greater length upon the varieties in the
+symptoms of myalgia, according as it affects one or another part of the
+body. We must consider, briefly the different kinds of cause that
+produce it. The immediate source of the pain being, as we have seen, the
+sense of embarrassment in a muscle obliged to contract when unfit for
+the work, we have to ask what are the remoter causes that can produce
+this special unfitness for the work of contraction. They are three:
+(_a_) Overlabor pure and simple (_i. e._, in proportion to the existing
+bulk and quality of the muscle); (_b_) cold, and especially damp cold,
+producing a semi-paralyzing effect on the vaso-motor nerves, and causing
+congestion and sometimes a little effusion among the fibres or within
+the sheath of the muscle; (_c_) fatty degeneration of muscle which is
+exposed to inevitable and incessant work. Either of these conditions may
+so disable the muscle that its unavoidable contractions will set up the
+myalgic state.
+
+Undoubtedly however there is something further, in the shape of a
+natural predisposition not yet understood, which makes some patients so
+much more liable to suffer myalgic pain as a consequence of this sort of
+influences than other persons are. I am in no condition to decide what
+the nature of this predisposition is; I feel sure it is heightened by an
+inherited or acquired gouty taint, but I have seen it in people whom
+there is no reason to suspect of gouty tendencies. It appears to have no
+connection with true rheumatism.
+
+Still after all that can be said, myalgia remains a disease chiefly of
+local origin, and depending for nine-tenths of its causation upon a
+derangement between the balance of work and nutrition in the muscle.
+
+As regards the diagnosis of myalgia from neuralgia, which is a very
+important matter, the following are the main points that we should
+recollect:
+
+          _Neuralgia._                        _Myalgia._
+
+  Follows the distribution of a      Attacks a limited patch or
+    recognizable nerve or nerves.      patches that can be identified
+                                       with the tendon or aponeurosis
+                                       of a muscle which, on inquiry,
+                                       will be found to have been hardly
+                                       worked.
+
+  Goes along with an inherited or    As often as not occurs in persons
+    acquired nervous temperament,      with no special neurotic
+    which is obvious.                  tendency.
+
+  Is much less aggravated,           Is inevitably, and very severely,
+    usually, by movement than          aggravated by every movement of
+    myalgia is.                        the part.
+
+  Is at first accompanied by no      Distinguished from the first, by
+    local tenderness.                  localized tenderness on pressure
+                                       as well as on movement.
+
+  Points douloureux, when            Tender points correspond to
+    established at a later stage,      tendinous origins and insertions
+    correspond to the emergence of     of muscles.
+    nerves.
+
+  Pain not materially relieved by    Pain usually completely and always
+    any change of posture.             considerably relieved by full
+                                       extension of the painful muscle
+                                       or muscles.
+
+The treatment of myalgia is not only satisfactory in itself, but often
+affords, in its results, a very desirable confirmation of diagnosis.
+
+For a very large number of cases, all that is required is (_a_) to put
+and keep the affected muscle in a position of full extension, which is
+only to be changed at somewhat rare intervals; (_b_) to cover the skin
+all over and round it with spongio-piline, so as to maintain a perpetual
+vapor-bath; (_c_) on the subsidence of the acutest pain and tenderness,
+to complete the treatment by one or two Turkish baths, to be taken in
+the manner that I have recommended by speaking of the prophylaxis of
+neuralgia.
+
+When treatment such as this cures a pain which was greatly aggravated by
+muscular movement, we may be sure that pain was myalgic and not
+neuralgic.
+
+The pain, however, is not unfrequently rebellious to such simple
+remedies as these, more especially when (as in pleurodynia) we are not
+able to enforce complete physiological rest of the part. When this is
+the case, we shall find the internal use of twenty and thirty grain
+doses of muriate of ammonia by far the most effective remedy. In the
+first very acute stage of a severe case it may be advisable to inject
+morphia hypodermically; but this is seldom necessary. The
+muriate-of-ammonia treatment may be usefully accompanied by prolonged
+gentle frictions, three or four times a day, with a weak chloroform
+liniment.
+
+When there is visibly a very great deficiency in the general nutrition,
+we shall often fail to obtain a cure until we have remedied this defect;
+and accordingly, in the majority of cases of half-starved and overworked
+needle-women, cobblers, tailors, and the like, who present themselves in
+the out-patient room, I accompany the above-named treatment with the
+steady administration of cod-liver oil for three or four weeks or more.
+
+There is one remedy for this pain which I have myself seen used in only
+a few cases, but which I believe promises exceedingly well for the
+treatment of obstinate myalgia; viz., acupuncture. I have not even
+mentioned it as a remedy for neuralgia, for I believe it to be totally
+useless in true cases of that disease, whether applied in the simple
+form or in that of galvano-puncture. I think very differently of its use
+in myalgia; and I venture to believe that it is entirely to cases of
+this disease that the exceedingly interesting observations of Mr. T. P.
+Teale, in a recent number of the _Lancet_, apply. Where (after the usual
+remedies for myalgia have been applied) we are unable to get rid of a
+deep-seated and fixed muscular pain, I believe it to be excellent
+practice to plunge two or three long needles deeply into the muscle near
+its tendinous attachment.
+
+
+
+
+CHAPTER II.
+
+SPINAL IRRITATION.
+
+
+I retain this phrase, not because it is an absolutely good one, but
+because it has become so familiar that it is difficult to dispense with
+it. We have taken a useful step, however, in separating the true
+neuralgias from the somewhat indefinite group of diseases to which this
+title has been given. I think the reader who has carefully studied Part
+I. of this work will not deny that the latter disorders present a very
+clear and definite common outline which distinguishes them essentially
+from the vaguer affections to be described under the present heading.
+
+Spinal irritation, in my sense, includes all those conditions in which,
+without any special mental affection, and without any single nerve being
+definitely affected, there are sensations varying between mere cutaneous
+tenderness, often of a large and irregular surface, and acute pain
+approaching neuralgia in character, together with fixed tenderness of
+certain vertebrae on deep pressure. A very large majority of the
+phenomena are such as would be popularly included (now that they are
+known not to be of an inflammatory character) under the term
+"hysterical." That unhappy word crosses our path at every turn in a most
+embarrassing manner, and yet it can hardly at present be said that we
+could afford to do without it.
+
+The more typical cases of so-called "hysterical hyperaesthesia" present
+the following phenomena: Along with the general symptoms of the
+hysterical temperament (tendency to causeless depression, variable
+spirits, sensation of globus, semi-convulsive attacks terminated by the
+discharge of a great quantity of pale, limpid urine) there is commonly a
+marked superficial tenderness of the surface everywhere, and an
+exaggeration of reflex irritability. The general tenderness is so far
+merely cutaneous that deep pressure is ordinarily borne better than the
+lightest finger-touch. But besides this there are usually one or several
+spots in which the tenderness is more profound and genuine. There is
+almost sure to be some point in the spinal column where firm pressure
+not merely evokes a complaint of pain, but also induces secondary
+objective phenomena connected with distant organs, such as nausea and
+vomiting when the cervical vertebrae are tender, severe gastric pain when
+the dorsal vertebrae are tender, etc. In such cases there is not only
+spinal tenderness, but very usually also a well-marked tenderness in the
+epigastrium and the left hypochondrium, the _trepied hysterique_ of
+Briquet. The reader must, however, be warned that the whole of these
+three tender points may be merely myalgic, and it is necessary very
+carefully to observe whether local movements do or do not seriously
+aggravate the pain in them. And, on the other hand, the spinal tender
+point may be merely the "point apophysaire" of a true neuralgia which
+exhibits no other symptoms of the so-called hysteric constitution.
+
+The kind of hysteria that is joined with the existence of fixed tender
+spots in definite points of the vertebral column is not commonly
+distinguished by the occurrence of cutaneous anaesthesia; but those
+writers are certainly wrong in saying that such a combination never
+takes place. I have seen examples of the most marked union of the two
+classes of symptoms in the same person.
+
+These cases of so-called spinal irritation with general hysteric
+manifestations are very commonly attended with paroxysmal pains that
+approach true neuralgia in character. Nor is it to be denied that we
+sometimes meet with the combination of general hysteria, spinal
+tenderness in definite points (with secondary spasmodic or paralytic
+phenomena always following pressure exerted on the latter), and true
+neuralgia limited to one nerve. But the more typical spinal irritation
+cases are merely complicated with a tendency to vague pains which are
+shifting both in character and position, not with definite unilateral
+neuralgia always haunting the same nerve and exhibiting more or less of
+the same type. In fact, as far as one can judge in the absence of any
+precise information as to the condition of the nervous centres in such
+cases, it would seem likely that the ordinary cases of spinal irritation
+differ from the true neuralgias chiefly in this--that the injury, or
+inherited weakness of organization, or both, which is at the root of the
+malady, is at once slighter in degree, and spread over a larger tract of
+the nervous centres, than that which produces a true neuralgia. I
+believe that Dr. Radcliffe is right in supposing it to be probable that
+a blow or other injury to the back producing general spinal shock, is
+the original but unsuspected cause of a large proportion of these cases.
+One of the most perfect examples of spinal irritation that I have ever
+seen (and which also contrasts keenly with the commoner hysteric
+affections on the one hand, and the true neuralgiae on the other) was
+that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds,
+and Dr. Bridge. This young lady was a most intelligent person, and not
+in the slightest degree inclined to the apathy and idleness so often
+seen in hysterical people. She had received what was thought at the time
+to be a very slight contusion in a railway collision, in which, however,
+her sister, who was in the same carriage, had been severely injured. She
+nursed this sister assiduously, and it was not till three or four months
+later that her own health began to fail seriously; but she then became
+anaemic and extremely depressed. About six months after the accident it
+was quite casually discovered that there was a spot over the lowest
+cervical vertebra, pressure on which gave her exquisite pain and a
+sensation of extreme nausea; and the very curious observation was made
+that such pressure instantaneously produced extinction of the right
+pulse, the left pulse remaining unaltered. In this case it cannot be
+doubted that a serious shock had been communicated to a lateral segment
+of the cord involving chiefly the vaso-motor nerve fibres, in which
+probably some decided material lesion had been gradually set up; and
+besides this there was probably slighter damage to the spinal cord
+generally, as there was great general feebleness of movement, though no
+actual paralysis of the limbs.
+
+Along with the phenomena of fixed spinal tenderness, without distinct
+neuralgia of any particular nerve, we not unfrequently observe the
+development of more or less decided tenderness of some of the internal
+surfaces of the body. I have recently had under my care a young woman in
+whom a very tender point was developed over the second cervical
+vertebra, and who suffered from such persistent tenderness of the whole
+posterior part of the pharynx, that I was for some time seriously
+apprehensive of the existence of spinal caries and post-pharyngeal
+abscess. The general character of her symptoms, however, induced me to
+hope that the case was one of spinal irritation merely, and the event
+proved that this was the case, for under the use of iron and small doses
+of strychnia she recovered completely in about three weeks. In another
+patient who came under my care about twelve months ago, there was
+extraordinary sensitiveness of the gastric mucous membrane, causing
+exquisite pain after she had eaten almost any thing: there was only
+occasional vomiting, however, and there had never been any haemorrhage,
+so that the evidence for gastric ulcer, which I otherwise inclined to
+think existed, was insufficient. I discovered that pressure on the third
+or the fourth dorsal vertebra gave great pain, and produced a strong
+inclination to vomit; this made it probable that the affection was
+spinal, and accordingly all treatment addressed to the stomach was
+abandoned. Flying blisters to the neighborhood of the painful spinal
+points quickly relieved all the symptoms.
+
+Another distressing class of symptoms, which is very commonly observed
+in connection with these cases of spinal irritation, is that of abnormal
+arterial pulsations: I am not sure whether even severe neuralgia
+produces more distress than does this pulsation. I have repeatedly seen
+abnormal pulsation of the carotids in connection with fixed
+tender-points over the cervical or the upper dorsal vertebrae; and still
+more commonly pulsation of the abdominal aorta in connection with
+tenderness over one or two of the upper dorsal vertebrae. Spasmodic cough
+and spasmodic dyspnoea frequently accompany tenderness of points in
+the upper half of the spinal column; and in one instance I have seen
+pressure on the lowest cervical vertebrae produce a paroxysm which looked
+alarmingly like angina pectoris. A case of singularly prolonged and
+obstinate spasmodic hiccough which came under my notice was
+distinguished by the presence of a fixed tender spot over the third
+dorsal vertebra.
+
+Prolonged spastic contraction of voluntary muscles, going on, sometimes
+for weeks, and even months, is a phenomenon that has often been
+observed; it may attack the arm only, or may affect all the limbs, and
+the muscles of the trunk and of the neck: it is for the most part
+symmetrical, but is occasionally unilateral. It begins in the
+extremities, and is very commonly limited to them; it is much more
+gentle than tetanic spasm, and is also painless, or nearly so; but the
+contraction is often strong enough to resist very vigorous efforts at
+artificial extension.
+
+Paralyses, both of bowel and bladder, have been recorded among the
+occasional phenomena of spinal irritation with fixed tender points; but
+I cannot say that I have ever seen such an occurrence. On the whole, I
+must say that by far the most frequent phenomena of spinal irritation
+that I have seen have been somewhat diffuse cutaneous or mucous
+tenderness and irritability (without acute pain) and the presence of
+tormenting arterial throbbings; also a marked tendency to aggravation of
+some symptoms, especially the gastric, when firm pressure is made upon
+the tender spinal points. For a further and fuller account of the
+phenomena of spinal irritation I may refer the reader to the able
+article of Dr. Radcliffe,[48] and the work of the brothers Griffin,
+already quoted; adding the suggestion, however, that both these
+authorities, and especially the Griffins, appear to me not to draw a
+sufficiently clear distinction between the class of cases that I have
+been attempting to describe and the true neuralgias.
+
+After what has been said, there is no need to draw out a formal list of
+the points of diagnosis between spinal irritation and neuralgia. It must
+be admitted, moreover, that the two forms of diseases have a strong
+connection in the fact that they are each of them most frequently
+developed in the descendants of neurotic families. It is by the more
+generalized character of the symptoms, and the absence of the tendency
+to perpetual recurrence of paroxysmal pain in one definite nerve, that
+spinal irritation is mainly distinguishable from true neuralgia. I may
+add that there is a marked distinction, also, in the results of
+treatment.
+
+The treatment of spinal irritation is, it must be confessed still in an
+unsatisfactory position; and I believe that a good deal of unnecessary
+discouragement has been occasioned to physicians by their failures to
+cure supposed neuralgias which really belonged to the spinal irritation
+class. I would assuredly by no means assert that genuine neuralgia is
+not frequently intractable, or even incurable; but it is certainly much
+more curable than spinal irritation; and for this reason, mainly as I
+believe--that there is much more possibility of aiming our remedies at
+the actual seat of the disease. On the other hand, in spinal irritation
+we are confused and distracted with a variety of phenomena for which
+even the most subtle analysis will frequently fail to trace a common
+origin. It is true that the existence of definite tender spots in the
+spine apparently suggests a strictly local application of remedies; and
+it true also that medication based upon this fact is sometimes very
+effective; but this is, in my experience, only an occasional result, and
+the practitioner who trusts to local measures will frequently be
+disappointed. And, on the other hand, the general tonic treatment, and
+the use of special medicines, like quinine and arsenic, or the
+hypodermic injection of morphia oratropia, have nothing like the
+extensive utility in the treatment of spinal irritation that they
+possess in that of true neuralgia. Of internal remedies, by far the most
+useful in my hands have been sesquichloride of iron with small doses of
+strychnia, and the milder vegetable bitters, especially calumba.
+
+There is one special phase, however, of spinal irritation which is very
+amenable to the direct, treatment, viz., cutaneous and mucous
+tenderness. Whatever the "hyperaesthetic" part is within reach, so that
+we can apply Faradization, we can almost certainly eradicate the morbid
+sensibility very quickly. The secondary current of an electro-magnetic
+or volta-electric induction apparatus is to be employed; the conductors
+should be of dry metal and the negative one, which is to be applied to
+the painful surface, should be in the form of the wire brush. The
+positive pole is to be placed on some indifferent spot, and the negative
+is to be stroked briskly backward and forward over the sensitive skin, a
+pretty strong current being employed. The process is painful so much so
+that it will often be advisable, with delicate patients, either to
+administer chloroform or to inject morphia subcutaneously before the
+Faradization. A very few daily sittings of four or five minutes length
+will generally remove the morbid tenderness completely. Where the tender
+part is within one of the cavities, at the rectum, bladder, vagina, or
+pharynx, we must of course use a solid negative conductor of appropriate
+form, and must content ourselves with applying it steadily to one point
+after another of the sensitive surface.
+
+The fact that Faradization proves so remarkably useful, in these cases
+of spinal irritation with diffuse cutaneous or mucous tenderness, is in
+itself a strong diagnostic between this sort of affection and the true
+neuralgiae, which, as I have stated are seldom benefited, and are often
+made worse, by the interrupted current, though the constant current
+frequently mitigates or cures them.
+
+Sometimes where it is not possible to apply the remedy directly to the
+sensitive surface, we may nevertheless do great good by sending the
+interrupted current through it. Thus, in gastric sensitiveness connected
+with spinal tenderness in the upper dorsal region, I have seen very
+great relief afforded by sending a current from the positive pole,
+placed on the tender vertebrae, to a broad, negative conductor placed on
+the epigastrium. And similarly, I have seen an acutely sensitive
+condition of the neck of the bladder greatly soothed by the passage of a
+current from a painful lumbar vertebra to the perinaeum immediately
+behind the scrotum.
+
+Undoubtedly, however, the more serious cases of spinal irritation will
+yield only (if they yield at all) to a prolonged treatment in which very
+skilful use is made of general hygienic measures, and especially of
+morbal influences. As the brothers Griffin long ago pointed out,
+although rest is useful in the early stages of this malady, if the
+disease does not quickly yield to this and to appropriate tonic
+medication, and perhaps local applications to the spine, it will not do
+to keep the patient recumbent and confined to the house; on the contrary
+at whatever cost of immediate discomfort, he (or she for these patients
+are by far the most frequently females) must be roused up, and persuaded
+or compelled to take out-door exercise, and if possible to travel, and
+divert the mind by complete change of scene. When such expensive
+remedies are out of the question, it seems better that patients, even
+seemingly very feeble, should take to their ordinary avocations in life
+again, and fight down the tendency to invalidism. But of course, the
+decision on such a point must rest with the tact and judgment of the
+practitioner in each individual case, for there are, doubtless,
+instances in which the attempt to carry out such a plan, even
+moderately, would break down the remaining strength, and make matters
+worse than they were before.
+
+In the worse case of spinal irritation that I ever saw, that of a young
+lady, aged twenty-eight, there were pronounced anaemia and general
+feebleness, the true hysteric _trepied_ of tender points, painful
+irritability of the stomach, which baffled all medical advisers and
+resisted almost every possible form of tonic and nervine medicines,
+counter-irritation to the spine, and, in fact every thing that one dared
+attempt with so feeble-looking a patient, but at once cleared up and was
+quite cured after marriage. And there can be no question that a very
+large proportion of these cases in single women (who form by far the
+greater number of subjects of spinal irritation) are due to this
+conscious or unconscious irritation kept up by an unsatisfied sexual
+want. In some patients there cannot be a doubt that this condition of
+things is indefinitely aggravated by the practice of self abuse; but it
+would be most unjust to think that this is a necessary element in the
+causation; on the contrary, it is certain that very many young persons
+(women more especially) are tormented by the irritability of the sexual
+organs without having the least consciousness of sensual desire, and
+present the sad spectacle of a _vie manquee_ without ever knowing the
+true source of the misery which incapacitates them for all the active
+duties of life. It is a singular fact, that in occasional instances one
+may even see two sisters inheriting the same kind of nervous
+organization, both tormented with the symptoms of spinal irritation, and
+both probably suffering from repressed sexual function, but of whom one
+shall be pure-minded and entirely unconscious of the real source of her
+troubles, while the other is a victim to conscious and fruitless sexual
+irritation.
+
+I have already causally alluded to the danger of mistaking mere myalgia
+for spinal irritation and must again enforce this consideration upon the
+reader. Myalgic tender points in the region of the spine are common
+enough; and it would be easy without careful attention, to mistake them
+for the deeper-seated vertebral tenderness which is truly characteristic
+of spinal irritation. Hence the utmost care must be taken to ascertain
+the true history of the commencement of the disorder whether it
+succeeded to great and long continued fatigue of particular sets of
+muscles, and whether it is specially aggravated by contractions of those
+muscles, and relieved by their full extension. The differences of
+treatment which depend on the diagnosis are too obvious to need dwelling
+upon.
+
+The question of administering remedies with the direct intention of
+procuring sleep, for patients suffering from spinal irritation, often
+becomes an important and a very difficult one. It is, for the most part,
+highly objectionable to commence the use of such remedies; and yet
+sleeplessness is a very distressing symptom with many patients, and is,
+of course in itself exhausting and deleterious. For as long as we
+possibly can, we should content ourselves with efforts to produce sleep
+by the timely administration of nourishment. The same general rule of a
+very generous (though not very stimulating) diet to be enforced as
+carefully as in the case of sufferers from neuralgia. But it is
+especially advisable in spinal irritation; that the patient should take
+some food shortly before bedtime; and it is well, also to place food
+within reach at the bedside, so that if he wakes up he may take some.
+If, however, we are absolutely driven to employ hypnotics, we must
+commence with the very mildest. The popular remedy of a pillow stuffed
+with hops will sometimes suffice; and a better way of administering the
+volatile principle of hops is to scatter a few hops on hot water in an
+inhaler, and let the patient breathe the steam. Hot foot-baths, with
+mustard, are also very useful. If these fail, chloral, in moderate doses
+is probably the best and safest remedy, and, with care not to give too
+much, we may go on using the same dose without increase for a good many
+times.
+
+FOOTNOTE:
+
+[48] Reynolds's "System of Medicine," vol. ii., Art. "Spinal
+Irritation."
+
+
+
+
+CHAPTER III.
+
+THE PAINS OF HYPOCHONDRIASIS.
+
+
+There is perhaps nothing, in the whole range of practical medicine, more
+difficult to seize with clear comprehension, and picture to the mind
+with accuracy, than the group of pseudo-neuralgiae which belong to the
+domain of hypochondriasis. They are among the most indefinable, and at
+the same time the most intractable, of nervous affections.
+
+To understand what hypochondriac pains are, we must first be familiar
+with the general character of the hypochondriacal temperament, for the
+pains are only a subordinate and ever-varying phenomena of the general
+disease.
+
+Hypochondriasis is not insanity, if by insanity we mean intellectual
+perversion dependent mainly or entirely on the state of the higher
+nervous centres. But it is closely allied to insanity in its phenomena,
+only that these are, as it were, manifested in a scattered form,
+unequally distributed over the whole central nervous system, and
+especially affecting the spinal sensory centres. And its radical
+relationship to true insanity is strongly indicated by the fact that the
+sufferers from hypochondriasis are nearly, if not quite, always members
+of families in which distinct insanity has shown itself; indeed, more
+often than not, of families which have been strongly tainted in this
+way. In the majority of instances there are psychical peculiarities of a
+marked kind which accompany or precede the development of the abnormal
+sensations which form the especial torment of hypochondriacs. Without
+apparent cause, they begin to evince a heightened self-feeling and an
+anxious concentration of their thoughts upon the state of one or more of
+their bodily organs. Or it may be that, before any such definite bias is
+given to their thoughts, they simply become less sociable and more
+self-centred, and are subject to fits of indefinite and inexplicable
+depression, or at least to great variability of spirits. But before long
+they begin to experience definite morbid sensations, most commonly
+connected with the digestive organs, and very often accompanied by
+positive derangement of digestion of an objective character; such as
+flatulence, sour eructation, spasmodic stomach-pain, etc. Along with
+these phenomena, or soon afterward (and not unfrequently before the
+patient has acquired that intensity of morbid conviction of his having
+some special disease which is afterward so marked a peculiarity of his
+mental state), he very often becomes the subject of the kind of pains
+which it is the special purpose of this chapter to describe.
+
+The pains of hypochondriasis, when they assume any more definite form
+than that of mere dyspeptic uneasiness, present many analogies with
+neuralgia. They are not, usually, periodic in any regular manner, but
+they have the same tendency to complete intermission, and they
+frequently haunt some one or more definite nerves for a considerable
+period of time. Of all nerves that are liable to this kind of affections
+the vagus is undoubtedly the most susceptible; hypochondriac patients
+very frequently complain of pseudo-anginoid and pseudo-gastralgic pains;
+next in frequency are nervous pain in the region of the liver, or in the
+rectum or bladder. The main distinctions by which they are separable
+from true neuralgia are two: in the first place, the character of the
+pain nearly always is more of the boring or burning kind than of the
+acutely darting sort which is most usual in true neuralgia; and,
+secondly, the influence of mental attention in aggravating the pain is
+far more pronounced than in the latter malady; indeed, it is often
+possible, by merely engaging the patient in conversation on other
+topics, to cause the pain to disappear altogether for the time. But in
+hypochondriasis it is not often that we are left, for any long time, to
+these means of diagnosis only; the special character of the disease is
+that the morbid sensations shift from one place to another, in a manner
+that is quite unlike that of the true neuralgias. The patient who to-day
+complains of the most severe gastralgia, or liver-pain, will to-morrow
+place all his sufferings in the cardiac region, or in the rectum, or
+will complain of a deep fixed pain within his head; and these changes
+are often most rapid and frequent. Frequently there are also peculiar
+skin sensations, which usually approach formication in type, and these,
+like the pains, are apt to shift with rapidity from one part of the body
+to another. Later on in the disease, especially in those worst cases
+which approach most closely to the type of true insanity, there are
+often hallucinations of a peculiar and characteristic nature, such as
+the conviction of the patient that he has some animal inside him gnawing
+his vitals, that he is made of glass and in constant danger of being
+broken, and a variety of similar absurdities. In short, it is not the
+fully-developed cases of hypochondriasis that need puzzle us, these are
+usually distinct enough; but the earlier and less characteristic stages
+in which pain may be nearly the only symptom that is particularly
+prominent.
+
+In hypochondriasis, as in hysteria, there is often great sensitiveness
+of the surface; and, as in hysteria, this sensitiveness is found to be
+very superficial, so that a light touch often hurts more than firm, deep
+pressure. As in hysteria, too, the tenderness is a phenomenon so greatly
+affected by the mind, that, if we can divert the patient's attention for
+a moment, he will let us touch him anywhere, without noticing it at all.
+
+It is a marked peculiarity of hypochondriasis that it is far more common
+in men than in women; a relation which is precisely the opposite to that
+which rules in neuralgia. Hypochondriasis is also pre-eminently a
+disease of adult middle life; it is scarcely ever seen in youth, except
+as the result of excessive masturbation acting on a temperament
+hereditarily predisposed to insanity.
+
+The results of treatment frequently assist our diagnosis in difficult
+cases. Almost any medicine will relieve the pains of the hypochondriac
+for a time, and it is generally far easier to do him good, temporarily,
+than it is to relieve a neuralgic patient; but, _en revanche_, every
+remedy is apt to lose its affect after a little while. The only chance
+of producing permanent benefit in hypochondriasis is by the judicious
+combination of remedies that remove symptoms (especially dyspepsia,
+flatulence, etc.), which mischievously engage the patient's mind, with
+general tonics, and, above all, which such alterations in the patient's
+habits of daily life as take him out of himself and compel him to
+interest himself in the affairs of the world around him. And, after all,
+our best efforts will frequently lead to nothing but disappointment.
+
+It is notoriously the fact that hypochondriasis especially affects the
+rich and idle classes; but it would be a great mistake to suppose that
+it never attacks the poor or the hard-worked: only, in the latter
+instances, it apparently needs, for it development, the existence of
+strong family tendencies to neurotic disease, and especially to
+insanity. Among the numerous debilitated persons who attend the
+out-patient rooms of our hospitals we every now and then encounter as
+typical a case of hypochondriasis as could be found even among the rich
+and gloomy old bachelors who haunt some of our London clubs. I have one
+such patient under my care now, who has been a repeated visitor at the
+Westminster Hospital during many years: he has had pseudo-neuralgic
+pains nearly everywhere at different times; but his most complaint has
+been of pain in the groin and scrotum of the right side. The existence
+of what seemed, at first, like the tender points of lumbo-abdominal
+neuralgia, at one time led me to believe it was a case of that
+affection; but I was soon undeceived by finding that the tenderness did
+not remain constant to the same points, but shifted about. This man has
+professed, by turns, to derive benefit from nearly all the drugs in the
+Pharmacopoeia; but the only remedies that have done him good, for
+more than a day or two at a time, have been valerian and assafoetida,
+with the prolonged use of cod-liver oil. He will never be really cured;
+and I suspect that the secret of his maladies is an inveterate habit of
+masturbation acting on a nervous system hereditarily predisposed to
+hypochondriasis.
+
+Sometimes it happens that the starting-point of hypochondriac pains,
+simulating neuralgia, is a blow, or other bodily injury acting on a
+predisposed nervous system. Another of my patients at the Westminster
+Hospital was a policeman, who had received a severe kick in the groin;
+he suffered pains which at first seemed to wear all the characters of
+true neuralgia in the pudic nerve, but afterward shifted to other places
+and exhibited all the intractability of hypochondriasis; the patient
+also developed the regular appearance and the characteristic
+hallucinations of the latter disease. On the last occasion when I saw
+him, he struck me as likely to become really insane, in the melancholic
+form; and the probability is that the casualty which he suffered was
+only accidentally the starting-point of a malady which was inherent in
+him since birth, and would have been developed, in any case, at some
+period of his life.
+
+
+
+
+CHAPTER IV.
+
+THE PAINS OF LOCOMOTOR ATAXY.
+
+
+Considering the vast amount that has been written about this disease
+during the last few years, it might be thought superfluous for me to
+give any description of its general features. But it unfortunately
+happens that there is still great divergence of opinion among
+authorities as to the true limitation of the group of cases that can
+properly be ranked under this title, and, indeed, as to the propriety of
+employing the title at all. The phrase ataxie locomotrice progressive,
+as every one knows, was applied by Duchenne de Boulogne to a class of
+cases which really only form a subdivision of the group known under the
+older title of _tabes dorsalis_ and the most advanced German
+pathologists maintain that the old word was better, and that Duchenne
+was altogether wrong in making the one symptom, ataxy of locomotion, the
+bases of a new phraseology;[49] more especially as his theory as to the
+seat of the morbid changes was undoubtedly erroneous.
+
+In this country, however, there is as yet no disposition to give up the
+phrase locomotor ataxy, and it only remains to define with sufficient
+care the class of cases to which the word is here meant to apply. The
+disease is understood to depend upon a degeneration of the spinal cord,
+of which the following description is given by Lockhart Clarke:[50] "In
+true locomotor ataxy, the spinal cord is invariably altered in
+structure. Its membranes, however, are sometimes apparently unaffected,
+or affected only in a slight degree; but generally they are much
+congested, and I have seen them thickened posteriorly by exudations, and
+adherent, not only to each other, but to the posterior surface of the
+cord. The posterior columns, including the posterior nerve-roots, are
+the parts of the cord which are chiefly altered in structure. This
+alteration is peculiar, and consists of atrophy and degeneration of the
+nerve fibres to a greater or less extent, with hypertrophy of the
+connective tissue, which give to the columns a grayish and more
+transparent aspect; in this tissue are embedded a multitude of corpora
+amylacea. Many of the blood vessels that travel the columns are loaded
+or surrounded to a variable depth by oil-globules of various sizes. For
+the production of ataxy, it seems to be necessary that the changes
+extend along a certain length, from one to two inches of the cord. The
+posterior nerve-roots, both within and without the cord, are frequently
+affected by the same kind of degeneration, which sometimes extends to
+the surface even of the lateral columns, and occasionally along the
+edges of the anterior. Not unfrequently the extremity of the posterior
+cornua, and even deeper parts of the gray substance, are more or less
+damaged by areas of disintegration. The morbid process appears to travel
+from centre to periphery, that is, from the spinal cord to the posterior
+roots. In the cerebral nerves, on the contrary, the morbid change seems
+to travel in the opposite direction, that is, from the periphery toward
+the centres. From the optic nerves it has been found to extend as far as
+the corpora geniculata, but seldom as far as the corpora quadrigemina.
+With the exception of the fifth, seventh, and eighth pair, all the
+cerebral nerves have occasionally been found more or less altered in
+structure."
+
+The symptoms which occur in cases in which the above are the morbid
+appearances found after death are (roughly speaking) as follows:[51] "A
+peculiar gait, arising from want of co-ordinating power in the lower
+extremities, a gait precipitate and staggering, the legs starting hither
+and thither in a very disorderly manner, and the heels coming down with
+a stamp at each step."
+
+No true paralysis in the lower extremities or elsewhere. Characteristic
+neuralgic pains, erratic paroxysmal in the feet and legs chiefly--pains
+of a boring, throbbing, shooting character, like those caused by a sharp
+electric shock.
+
+More or less numbness, in the feet and legs chiefly, in all forms of
+sensibility, excepting that by which differences of temperature are
+recognized.
+
+Frequent impairment of sight or hearing, one or both.
+
+Frequent transitory or permanent strabismus or ptosis, one or both.
+
+No very obvious paralysis of the bladder or lower bowel.
+
+No necessary impairment of sexual power.
+
+No tingling or kindred phenomenon.
+
+No marked tremulous, convulsive, or spasmodic phenomena.
+
+No marked impairment of muscular nutrition and irritability.
+
+No impairment of the mental faculties.
+
+Occasional injection of the conjunctivae, with contraction of the pupils.
+
+The probable limitation of the distinctive phenomenon of locomotor ataxy
+(the want of co-ordinating motor power) to the lower extremities.
+
+The above description includes all the necessary facts for the
+recognition of the disease, except one, namely, that the use of the
+eyesight is always needed in order to prevent the patient from falling
+during progression; and is usually necessary even to enable him to stand
+upright without falling.
+
+The pains of locomotor ataxy are early phenomena in most cases, and they
+are usually present, more or less, throughout the course of the disease.
+
+They are often preceded by strabismus, with or without ptosis; the
+strabismus, is usually accompanied by amblyopia. It may happen, however,
+that neuralgic pains are, for a considerable time, the only noticeable
+phenomena; or they may be attended with a certain amount of anaesthesia.
+
+The most frequent type of the pains is lancinating or stabbing; they are
+like violent neuralgias occurring successively in various nerves;
+shifting about from one to another. Sometimes it will happen that the
+pain remains fixed to one particular nerve for hours together; but it
+never continues long without showing the characteristic tendency to move
+about. Most commonly our diagnosis is soon assisted by the occurrence of
+a greater or less degree of ataxy. But, even before the setting in of
+definite atactic symptoms, the shifting character of the pains, and the
+development of a very noticeable amount of anaesthesia, together with the
+absence of anything like positive motor paralysis, will have given us
+the necessary clew.
+
+The effect of treatment, or rather its want of effect, usually affords
+powerful assistance in distinguishing the pains of locomotor ataxy from
+those of true neuralgia. Even where the pain has been fixed for some
+hours in a single nerve, and has been stopped by some powerful remedy
+(such as hypodermic morphia), it will be apt speedily to recur, and
+frequently in some quite distant nerve.
+
+Locomotor ataxy is a disease affecting chiefly the male sex, and
+occurring in the immense majority of cases between the thirty-fifth and
+the fiftieth year.
+
+Not merely is it strictly limited to individuals who belong to families
+with neurotic tendencies, but it is itself frequently seen to occur in
+several members of the same family, and sometimes of the same
+generation. When, therefore, we meet with neuralgic pains of the
+shifting type above described, it is very important at once to make
+careful inquiries whether any members of the family have suffered from
+symptoms of ataxy going on to a fatal result. Otherwise, we might be the
+more readily deceived into the idea that the pains were merely
+neuralgic, because the symptoms of the disease are not unfrequently
+provoked by such causes as fatigue and exposure to cold or wet, which
+are also very ordinary exciting causes of true neuralgia.
+
+FOOTNOTES:
+
+[49] The most complete and careful work of the German school, on this
+subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin,
+1867.)
+
+[50] _Lancet_, June 10, 1865. (Comment on a case of Dr. J. Hughlings
+Jackson's.)
+
+[51] Radcliffe, in "Reynolds's System of Medicine," vol. ii.
+
+
+
+
+CHAPTER V.
+
+THE PAINS OF CEREBRAL ABSCESS.
+
+
+Cerebral abscesses is, fortunately, a rare disease; but the very fact of
+its rarity makes the resemblance of the pain it causes to that of
+neuralgia the more likely to lead us into serious errors. We are apt to
+forget the possibility of suppuration of the brain on account of its
+infrequence.
+
+Pain in the head is present as an early symptom of abscess in the brain
+in a large proportion of cases in which there is pain at all. [Of
+seventy-five cases of cerebral abscess analyzed by Gull and Sutton
+(Reynolds's "System of Medicine," vol. ii.), pain was a symptom in
+thirty-nine, and most frequently an early symptom.] Many cases are
+recorded in which it preceded every other morbid sign by a considerable
+period. It is usually more or less paroxysmal, often strikingly so; in
+the latter case, it bears a great similarity to neuralgia. On the other
+hand, it sometimes takes the shape of a fixed burning sensation, much
+less resembling neuralgia. The situation of the pain by no means always,
+nor even usually, corresponds to the situation of the cerebral abscess;
+on the contrary, abscess in the cerebellum has often caused pain
+referred to the anterior part of the head, and so on. So long as the
+disease remains characterized only by pain, more or less, of a
+paroxysmal character, the diagnosis must be very uncertain; but in the
+great majority of cases certain more distinctive symptoms soon become
+superadded; either convulsions (sometimes hemiplegic), vertigo, coma,
+paralysis, vomiting, or a combination of some of these.
+
+In the stage in which there is as yet no conspicuous symptom but severe
+pain, the diagnosis of cerebral abscess from neuralgia must rest on the
+following points of contrast:
+
+       _Cerebral Abscess._                   _Neuralgia of Head._
+
+  Often occurs secondarily to caries    Rarely appears before puberty.
+    of internal ear, and purulent
+    discharge the result of scarlet
+    fever, measles, etc., in
+    childhood.
+
+  Frequently follows a blow or          Comparatively seldom caused by
+    injury.                               blow, or other external
+                                          injury or caries of bone.
+
+  No true "points douloureux."          If severe, soon presents, in most
+                                          cases, the "points douloureux."
+
+  Usually the pain does not             Intermissions of pain complete,
+    completely intermit.                  and of considerable length.
+
+  Pain often excruciating from a        Pain usually not very violent at
+    very early period.                    first.
+
+  Pain often limited in situation,      Pain superficial; follows
+    seems deep-seated, though, as         distribution of recognizable
+    often as not, it has no relation      nerve-branches belonging to
+    to the site of the abscess.           the trigeminus or the great
+                                          occipital.
+
+  No well localized vaso-motor or       Usually there are lachrymation,
+    secretory complications.              congestion of conjunctiva, or
+                                          other vaso-motor and secretory
+                                          complications, such as are
+                                          described in Chapter III.
+
+  Very rare in old age; then            Severe and intractable neuralgia
+  usually traumatic.                      is commonest in the
+                                          degenerative period of life.
+
+  Relief from stimulant narcotics       Relief from opium, etc., is much
+    very transitory.                      more considerable and
+                                          permanent.
+
+The only case of cerebral abscess that I have personally seen, in which
+the above points of distinction would have been insufficient, was that
+of a boy of sixteen, in whom the only discoverable symptom, for nearly
+three months, was pain, very strongly resembling ordinary migraine,
+recurring not oftener than once in ten days or a fortnight, lasting for
+some hours at a time, and nearly always ending in vomiting, and
+disappearing after sleep. At the end of the three months, acute pain in
+the left ear set in, and this was followed, soon, by right hemiplegia,
+coma, and death. It was then discovered, although it had formerly been
+denied, that the boy had suffered from discharge from the left ear,
+following a febrile attack which had been marked by sore-throat, and
+followed by desquamation of the cuticle--evidently scarlet fever. In all
+cases of severe pain in the head, it is a golden rule to inquire most
+carefully as to the possible existence, present or past, of discharge
+from the ear, or other signs of caries of the temporal bone; and, even
+if no positive history of this kind be given, we should still regard
+with great suspicion any case in which there has been scarlet fever
+followed by deafness.
+
+
+
+
+CHAPTER VI.
+
+PAINS OF ALCOHOLISM.
+
+
+A very important class of pains, which are occasionally confounded with
+true neuralgias, are those which occur in certain forms of chronic
+alcoholism. The diagnosis of their true nature is a matter of the utmost
+consequence, and the failure to recognize them for what they are may
+have very disastrous results. It is a curious fact that this consequence
+of chronic alcoholic poisoning has been entirely overlooked by some of
+the best known writers on that affection; it has, however, been
+described by Mr. John Higginbottom, and also by M. Leudet.
+
+It must be clearly understood that the pains of which we are now to
+speak are not among the common consequences of chronic excess in drink.
+The affections of sensation which most usually occur in alcoholism take
+the shape either of anaesthesia, or of this combined with anomalous
+feelings partaking more or less of the character of formication. Chronic
+drinking has also a tendency, in its later stages, when the nutrition of
+the nervous centres has been considerably impaired by the habit, to set
+up true neuralgia, of a formidable type, in subjects who are
+hereditarily predisposed to neuroses. But the affection of which I now
+speak may occur at any stage except the very earliest, and, though often
+severely painful, is essentially different both in its seat and in its
+general characters, from neuralgia proper.
+
+The earliest symptoms from which the patient usually suffers in these
+cases are insomnia, and intense depression of spirits, which, however,
+is not incompatible, indeed is frequently combined, with a morbid
+activity and restlessness of thought. There is generally marked loss of
+appetite, but often there is none of the morning nausea so
+characteristic of the common forms of alcoholism. Nor is there,
+ordinarily, any special unsteadiness of the muscular system. The pains
+are usually first felt in the shoulder and down the spine; but as the
+case progresses they especially attack the wrist and ankles; and it is
+in these latter situations that I have found them to be most decidedly
+complained of. Their similarity to neuralgia consists (_a_) in their
+somewhat paroxysmal character; (_b_) in their frequently recurring at
+about the same hour of the day, most commonly toward night; and (_c_) in
+their special aggravation by bodily and mental fatigue.
+
+Their differences from neuralgia are--(_a_) that they never follow the
+course of a recognizable single nerve; (_b_) that they are nearly always
+present in more than one limb, and usually in both halves of the body,
+at the same time; and (_c_) especially, that they are far less promptly
+and effectually relieved by hypodermic morphia than are the true
+neuralgias; indeed, opiates very frequently only slightly alleviate the
+pain, while they excite and agitate the patient and render sleep
+impossible. On the contrary, a large dose of wine or brandy will never
+fail to procure temporary comfort and induce sleep, at least until the
+patient reaches an advanced stage of the disorder, and is, in fact, on
+the verge of delirium tremens.
+
+I am not quite sure that I am right in believing that there is a special
+physiognomy for this form of chronic alcoholism, and yet I am much
+inclined to believe that there is. All the patients whom I have seen
+suffering with it have presented a peculiar brown sallowness of face,
+and a general harsh dryness of the skin, which has usually lost its
+natural clearness, not only in the face, but even more remarkably in the
+hands, which are so dark-colored as to appear as if they were dirty.
+There is usually considerable leanness of the limbs, and, though the
+abdomen may be somewhat prominent, this does not seem to depend much on
+the presence of fat, but rather on relaxation of the abdominal muscles,
+and sometimes flatulent distention of the stomach and intestines. The
+hands are usually hot, sometimes quite startlingly so.
+
+Some of the patients suffer, besides the pains in the limbs (which they
+often describe as resembling the feeling of a tight band pressing
+severely around the ankles or wrists), from frequent or occasional
+attacks of genuine hemicrania; such a combination is to me always a
+suspicious sign, and induces me immediately to direct my attention to
+the possibility of chronic alcoholic poisoning. Otherwise, the
+limb-pains are often spoken of as resembling rheumatism, but there is no
+swelling of joints, and usually no decided tenderness of the painful
+parts. The patient has usually a particular worn and haggard appearance,
+complains of intense fatigue after the most moderate muscular exertion,
+and is usually utterly indisposed to physical exercise even though the
+mind, as already said, may display a feverish activity.
+
+So far as I have seen, the subjects of this affection are by far the
+most frequently women; and I am inclined to attribute this
+predisposition of the sex not to inherent peculiarities of female
+organization, but to the fact that a much larger proportion of
+intemperate women than of intemperate men indulge in secret excess. They
+never get drunk, probably, but they fly to the relief of alcohol upon
+every trivial occasion of bodily or mental distress; and this habit may
+have been going on for years before it comes to be suspected by their
+friends or their medical attendant. Meantime, they have been more or
+less looked upon, and have looked upon themselves as, "debilitated" and
+"neuralgic" subjects, and have come, either with or without mistaken
+medical advice, to consider free stimulation as the proper treatment for
+the very ailments which have been produced by their own unfortunate
+habits. I cannot avoid the expression of the misgiving, that imperfect
+diagnosis, and consequent erroneous prescription, have done great harm
+in many such cases. It has happened to me no less than three times
+within the last six months to be called to lady patients, all suffering
+from alcoholism induced by a habit of taking stimulants for the relief
+of so-called neuralgic pain; and in the most distressing of these the
+mischief had been greatly aggravated by a prescription of brandy, based
+on the erroneous idea that the pains were truly neuralgic. I have
+already protested against this kind of medication, even in cases that
+are truly neuralgic in character; but it is doubly mischievous where
+given for a state of things which actually depends on alcoholic excess.
+
+It is undoubtedly very difficult, sometimes, to elicit the truth, even
+in cases where we may entertain considerable suspicion that alcoholic
+excesses are the real cause of the pains which the patient calls
+neuralgic; more especially where the patient is aware that he or she is
+taking an amount of alcohol which is seriously damaging to health. And
+it is therefore necessary to look out for every possible additional help
+to our diagnosis. Besides the cardinal features of the disease--the
+insomnia, loss of appetite, foul breath, haggard countenance, and pains
+encircling the limbs near the joints rather than running longitudinally
+down the extremities there are certain moral characteristics of the
+patient that often tells a significant tale. The drinker, especially if
+a woman, is shifty, voluble, and full of plausible theories to account
+for this and the other phenomenon. It will be well to try the effects of
+a somewhat sudden though not uncourteous remark, to the effect that the
+diet should be strictly unstimulating. If this be introduced with some
+abruptness, in the course of a conversation not apparently leading to
+it, the patient's manner will not unfrequently betray the truth; while,
+if our suspicions are groundless, we shall also probably perceive that,
+in the unconscious, or frankly surprised, expression of the countenance.
+We may sometimes derive crowning proof of the existence of alcoholic
+excess by cautious questions which at least reveal the fact that the
+patient suffers from spectral hallucinations; this is a far commoner
+occurrence in chronic alcoholism than is generally supposed; it needs to
+be inquired for with great tact, but, when established beyond doubt, and
+joined to insomnia and the peculiar foul breath, is of itself sufficient
+to establish a positive diagnosis of alcoholic poisoning.
+
+The results of treatment, in true neuralgia and in alcoholic pains,
+respectively, establish an important difference between these
+affections. In the former malady, for instance, the hypodermic injection
+of morphia always produces striking palliative, and very often curative
+effects. In alcoholic pains this remedy either affords only trifling
+relief, or more commonly aggravates the malady by increasing the general
+nervous excitement; and the only true treatment is at once to suspend
+all use of stimulants, to administer quinine, and to insist upon a
+copious nutrition. If any hypnotic must be employed, let it be chloral,
+or bromide of potassium with cannabis Indica. It will be well also to
+put the patient upon a somewhat lengthened course of cod-liver oil.
+There is one special symptom from which the chronic alcoholist often
+suffers acutely, namely a hypersensitiveness to cold; for this I found
+the use of Turkish bath two or three times a week, for three or four
+weeks, very useful in one case that was under my care. It will be
+important to insist that the patient shall take the bath only after that
+shorter method which I have described in speaking of the prophylaxis of
+true neuralgia.
+
+
+
+
+CHAPTER VII.
+
+THE PAINS OF SYPHILIS.
+
+
+Syphilis, as has already been shown in Part I. of this work, may excite
+true neuralgia in subjects already predisposed to the latter. The case
+of Matilda W., previously given, is an example. The pains, however,
+which are now to be described, are those which occur in the ordinary
+course of a constitutional syphilitic infection, and have nothing to do
+with neuralgia proper, from which they should be carefully
+distinguished.
+
+There are two varieties of syphilitic pains proper, which are quite
+distinct. The first kind is represented by the so-called _dolores
+osteocopi_, which occur in the early stages of the constitutional
+affection, coincidently with, or just before, the secondary
+skin-eruptions. The second kind are those which occur in the tertiary
+stage, and are the immediate precursors of the formation of periosteal
+nodes.
+
+It is the first of these varieties of syphilitic pains which is least
+commonly confounded with neuralgia. The pain is referred to the
+superficial bones, of which those most frequently attacked are the
+forehead, sternum, clavicle, ulna, and tibia, pretty much those selected
+for the growth of nodes at a later stage of the disease. Besides the
+bones, the shoulders, elbows, and nape of the neck are attacked
+sometimes simultaneously, sometimes successively. The pains are readily
+controlled by proper treatment; if untreated, their course is very
+uncertain. When they manifest themselves at the outset of the disease,
+they usually cease when the cutaneous eruption is fairly out. Commonly,
+there is no swelling or heat at the painful places; but, when the pains
+are very severe, nodes now and then form at this early period.[52]
+
+These early syphilitic pains, in their violent aching character, and
+their intermittence, occasionally resemble true neuralgia very closely;
+but they are usually distinguished from it by their symmetrical
+disposition and by their attacking several bones at once. Moreover, they
+nearly always show the peculiarity of being distinctly aggravated by the
+warmth and repose of bed even if they be not altogether absent (as is
+not unfrequently the case) when the patient is up and moving about. A
+typical case of this kind is not so likely to be confounded with
+neuralgia as with rheumatism; but we occasionally meet with cases in
+which the pains are localized in a manner much more resembling the
+former. Thus I have met with several instances in which a patient,
+entirely unconscious (or professing to be unconscious) of having been
+syphilized, complained of violent pain in one tibia, recurring every
+night at a certain hour, and at first undistinguishable from that
+variety of sciatica in which the pain is principally felt in this
+situation, especially as it was relieved by firm pressure, just as
+neuralgia is in the early stages. And in one remarkable case, which came
+under my care at Westminster Hospital, the resemblance to clavus was
+most misleading:
+
+H. A., aged nineteen, worker in a laundry, presented herself on account
+of a violent pain in the right parietal region, recurring three times
+daily with great regularity. The first two attacks occurred in the
+day-time, the third, which was always the severest, woke her out of
+sleep about midnight; the pain of this last was so agonizing that on
+more than one occasion she had become delirious. The girl (whose
+respectable appearance was against the notion of syphilis) was very
+anaemic; not, however, with the tint either of anaemic from haemorrhage, or
+with that of chlorosis, exactly. It was rather a dirty sallowness of
+skin; but the gums and the conjunctivae were exceedingly bloodless, and
+she complained of almost constant noises in the head. Menses scanty but
+regular. There was a soft anaemic bruit with the first sound at the base
+of the heart. Having failed to make any impression on the pains with
+iron and with muriate of ammonia in large doses, I was led to observe
+the fact that there was no diffuse soreness of the scalp, such as very
+commonly occurs in clavus, in the intervals of the pains, and the mere
+fact that there was this unusual circumstance in the case led me to
+reconsider the diagnosis thoroughly. In order to be sure of not omitting
+a point, I inquired, though without any expectation of an affirmative
+answer, as to the possibility of syphilitic disease; the girl at once
+confessed to having had sores, and examination detected a papular rash
+about the shoulders and back and on both thighs. Small doses of mercury
+greatly relieved the pain within a week, and cured it in less than three
+weeks; and it was very remarkable that the anaemia, which had obstinately
+refused to yield to iron, improved at once as the mercury began to
+relieve the pains. The eruption disappeared simultaneously.
+
+It is the later pains of syphilis, however, that are most frequently
+confounded with neuralgia, and occasionally with very disastrous
+results. These pains, which are the precursors of the formation of true
+nodes, frequent the same localities as those affected by the earlier
+pains; they may exist in considerable severity for days, or even for
+many weeks, before any node-formation can be detected. The situation in
+which, of all others, they are likely to be mistaken for neuralgia is
+the scalp or face, especially when a single spot is affected on one
+side, and in the situation of one of the usual foci of trigeminal or
+occipital neuralgia. I have personally known the mistake to be made with
+syphilitic affections causing pain, respectively, in the superciliary
+region, in the malar bone, the jaw near the mental foramen, and the
+parietal eminence.
+
+The possibility of mistaking tertiary syphilitic pain for neuralgia is
+fraught with such grave dangers, that we ought to be constantly and most
+vigilantly on the watch against it. But most especially is this the case
+when the pain is situated in some part of the cranium, as the parietal
+or temporal eminences, the mastoid process, or the prominences of the
+occipital bone. For it must be remembered that the same process, which
+forms syphilitic nodes upon the external surface of bones, or within
+bony canals, can produce them on the lining membrane of the skull, with
+most serious consequences, should the symptoms be neglected or
+misunderstood.
+
+The pains produced by nodes upon the internal surface of the cranium are
+usually of a very intense character, and are mostly continuous, though
+aggravated from time to time, especially at night. Where syphilitic
+inflammation is diffused over a considerable portion of the meninges, it
+is certain very quickly to produce symptoms which can hardly fail to
+apprise us of the gravity of the affection; there will be decided and
+rapidly increasing impairment of memory, and general cloudiness of
+intellect, tending toward complete imbecility, the special senses will
+be greatly interfered with or lost, and muscular paralysis will be
+developed. But in the case of a more limited syphilitic affection of the
+dura mater, pain, of the kind already described, may be for some days
+the only very noticeable symptom. The following is an instance:
+
+J. E., aged forty-seven, a street and tavern singer, applied to me
+(November 14, 1861), on account of severe pain in the right temporal
+region, which had on the whole the character of neuralgia, though rather
+more continuous than such pain usually is. He said that it commenced on
+the 10th, without any particular provocation that he knew of, and that
+it had hardly left him at all from that moment. It kept him awake at
+night, and that circumstance seemed to account sufficiently for a very
+worn and depressed look which he presented; he was otherwise a
+robust-looking man, and at first denied having suffered from any
+previous illness. The pain always came to a climax about one o'clock, A.
+M., waking him out of his first sleep in agony, and allowing him little
+rest for the remainder of the night; toward morning he would drop to
+sleep for an hour or so. There was no particular tender point,
+corresponding to any recognized neuralgic focus, yet the pain was
+limited most strictly to a spot that might be covered with two
+finger-points. There was no lachrymation nor conjunctival congestion,
+and nothing to remark in any way about either eye. The patient was
+ordered quinine in large doses, in the belief that the pain was
+neuralgic. On the following day he reported himself a trifle better,
+though still suffering greatly; and on the afternoon of that day there
+was an almost complete intermission of the pain for several hours; but
+it returned severely at the usual nocturnal period. On the 16th, at 10
+A. M., he came to my house looking exceedingly ill, but the only
+additional symptom that I could detect was a small droop of the right
+eyelid. He was subcutaneously injected with one-fourth of a grain of
+morphia and sent home, where he immediately fell into a heavy sleep that
+lasted till bedtime. He awoke, undressed himself without feeling much
+pain, and got to bed; after an hour or so of dozing he was awakened by
+the pain, which was exceedingly severe. On the 17th he called on me in
+the morning, and I at once perceived that the ptosis of the right eyelid
+was much greater, and the right pupil was much dilated and insensitive,
+and the external rectus was paralyzed; the man also wore a look of
+stupidity, and answered questions with an apparent mental effort. I now
+cross-questioned him more closely; and also explored the tibiae and other
+superficial bones: on the sternum a distinct though not very advanced
+node was found. Upon this he was induced to confess that he had suffered
+from chancre three years and a half previously, and subsequently had
+"blotches" on the skin, which had quickly disappeared under treatment,
+of which all that could be learned was, that it was fluid medicine and
+did not make his mouth sore. He was immediately ordered to take two
+grains of calomel in pill, with a little opium, every four hours. He had
+only taken one dose when I was sent for to him, and found him in an
+epileptiform convulsion, in which the left side of the body was almost
+exclusively affected; the convulsions recurred several times during the
+next twenty-four hours, and in the intervals he remained almost
+completely unconscious. The mercurial treatment was pushed, in the form
+of calomel-powders placed on the tongue. On the evening of the 18th he
+began to recover consciousness, and then had a little natural sleep; the
+next morning, at 10 A. M., he was found to be fully conscious, had had
+no return of convulsions, but the left arm and leg, especially the
+latter, were almost entirely powerless; the parietal headache had
+vanished; the gums were slightly tender; the third and sixth nerves of
+right side were completely paralyzed. Mercurial treatment was very
+gently continued, so as to keep the patient on the borders of ptyalism
+for the next three or four days; and he was then put on full doses of
+iodide of potassium. The pain never recurred; the left extremities
+recovered power rapidly; but it was six weeks before the ocular
+paralyses were completely well.
+
+Late in the autumn of 1865 I was sent for hastily one evening to see
+this same man, and found him totally unconscious and apparently again
+hemiplegic, but now on the right side. He was miserably wasted, and
+covered with a rupious eruption; I was informed that he had been leading
+a most debauched and drunken life for some time past, and that, after
+looking extremely ill, and apparently half imbecile for a week or two
+past, he had suddenly fallen down unconscious in the street a few hours
+before I saw him. He remained deeply comatose, and died the next
+morning; no _post mortem_ could be obtained.
+
+The true neuralgias in which syphilis only plays the part of secondary
+factor, and which have been referred to in Part I. of this work, may
+depend for their exciting cause on local syphilitic processes, affecting
+either the peripheral distribution, the main trunk or the central origin
+of a sensory nerve; but I have pointed out the fact that, whatever the
+reason may be, syphilis does but rarely attack the central portions of
+individual sensory nerves, in comparison, with the frequency with which
+it attacks individual motor (cranial) nerves. But without any neuralgic
+predisposition at all, and without any limitation of the syphilitic
+process to a particular sensory nerve, the latter may become neuralgic
+in consequence of being involved in extensive intracranial or
+intra-spinal syphilitic mischief. The trigeminus is liable to suffer in
+this way from spreading syphilitic processes about the base of the
+brain; and my own impression is, that the cause of the neuralgic pain in
+some such cases is the extension of the mischief to the vertebral artery
+of the affected side, leading to interfering with the nutrition of the
+trigeminal nucleus in the medulla. A very interesting case is reported
+by Dr. Hughlings Jackson (who has done so much to acquaint us with
+syphilitic affections of cerebral arteries) in vol. iv. of the "London
+Hospital Reports," pp. 318-321. The patient was a woman, aged
+twenty-seven, and the initial symptoms of the malady which destroyed her
+life were violent trigeminal neuralgic pains on the right side:
+subsequently she had complete paralysis of the fifth, and of the sixth,
+seventh, and eighth nerves of the right side. After death the right
+vertebral artery was found engaged in the mass of syphilitic deposit; it
+must be added, however, that the (superficial) origin of the fifth nerve
+was itself softened, opposite the pons. Another mode in which syphilitic
+disease very probably causes neuralgia of the fifth, in a certain number
+of cases, is by injuring the Gasserian ganglion, upon the integrity of
+which (according to Waller's general law concerning the ganglia of
+posterior nerve-roots) the nutrition of the sensory root of the
+trigeminus materially depends. I have seen an example (as I cannot but
+suppose) of this sequence of morbid events; the evidence appears
+sufficiently complete, although I was unable to obtain a _post mortem_
+examination:
+
+W. M., a house painter, of extremely dissipated habits, but who had
+never suffered either from distinct symptoms of alcoholism, nor from any
+affection traceable to lead-poisoning. In March, 1867, he applied to me
+on account of neuralgic pain, affecting chiefly the right eyeball, but
+also darting along the course of the frontal nerve of that side; after a
+short time it extended also into the infra-orbital nerves. He bore
+several scars of tertiary ulcers about the nose and forehead, and made
+no secret of having suffered from chancre six or seven years before, and
+from subsequent secondary and tertiary symptoms. I was consequently not
+at all surprised at his developing severe iritis (right) after he had
+been a fortnight under my care, although I had from the first given
+large doses of iodide of potassium; but I was not prepared for the
+extensive processes of destruction which followed, notwithstanding that
+I immediately commenced mercurial treatment, and applied atropine. I
+remarked that while the inflammation of the iris proceeded with great
+violence, the cornea was also much more severely affected than is
+usually the case in syphilitic iritis; in fact, the changes closely
+resembled those which have been noted after section of the fifth at the
+Gasserian ganglion, and at the date of the patient's death (seventeen
+days from the commencement of the iritis) a corneal ulcer was on the
+point of perforating. For the first three or four days after the iritis
+set in, the neuralgic pains went on augmenting in intensity, and
+extended into all three divisions of the fifth; there was a copious
+discharge from the right nostril. Almost suddenly, on the fourth day,
+the pains abated and then ceased, and it was now evident that the whole
+surface of the right half of the face was completely anaesthetic. Two
+days later a dark-red patch appeared on the cheek, and in the course of
+the next two days this ulcerated, the ulcer presenting a somewhat livid
+appearance, and exuding a sanious discharge; at the same time,
+superficial ulcers appeared on the right side of the tongue, and
+coalesced to form one large sore. The sores both on cheek and tongue
+assumed more and more a gangrenous appearance, and on the sixteenth day
+from the commencement of iritis there was considerable loss of substance
+in both these situations. On the evening of this day (the patient having
+become extremely depressed and much emaciated) general epileptiform
+convulsions set in, and followed each other rapidly; in a few hours coma
+supervened, and the patient sank the next day. No _post mortem_ could be
+obtained; but it seems extremely probable, from the above history, that
+the Gasserian ganglion was early involved in the syphilitic
+inflammation, and that the neuralgia and subsequent anaesthesia, the
+iritis, and the other trophic lesions, were due to the injury inflicted
+upon it.
+
+The treatment of syphilitic pains will, in doubtful cases, often give us
+valuable assurance of the correctness of our diagnosis. Where the
+disease is extensively diffused, we may fail to do any good; but, in
+cases where the syphilitic mischief is limited to a small portion of the
+meninges, we may often arrest it. In all merely suspicious cases, where
+the pain is thus limited, it will be well to use iodide of potassium
+tentatively--forty to sixty grains daily. But, where the pains are very
+severe and continuous, and there is danger to the integrity of the eye,
+or threatenings of a paralytic attack are observed, it is better not to
+trust to anything short of mercury, used in such a manner as just to
+stop short of absolute ptyalism. In very bad cases, like the last one
+narrated, we may fail to produce any good effect, but, where the
+specific treatment is commenced in good time, we may not unfrequently
+succeed in arresting the symptoms with a rapidity that assures us of the
+correctness of the diagnosis of syphilis.
+
+FOOTNOTE:
+
+[52] Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.
+
+
+
+
+CHAPTER VIII.
+
+PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.
+
+
+So firmly is the idea of an essential connection between rheumatism and
+neuralgia implanted in the popular mind, and, indeed, in the minds of a
+certain portion of the medical profession, that the two complaints are
+continually confounded. In the great majority of instances, the mistake
+made is that of calling neuralgia a "rheumatism." But the opposite error
+occasionally occurs, and a patient is styled "neuralgic" who is really
+suffering from chronic rheumatism.
+
+As true neuralgia is an essentially localized disease, there can be no
+excuse for mistaking for it the more typical cases of chronic
+rheumatism, in which a number of different joints, muscles, or tendons,
+are affected, more especially in the advanced stages, when the
+characteristic fixed contractions of the limbs and extremities have
+occurred. But there are a few cases in which, either with or without a
+previous history of acute rheumatism, one, or perhaps two, joints begin
+to suffer vague pains, which after a little time begin to shoot down the
+course of the limb, and are aggravated from time to time in a manner
+which superficially much resembles neuralgia; and when the malady has
+reached a certain intensity the pains may be so much more severely felt
+in the longitudinal axis of the limb than in the immediate neighborhood
+of a joint, that the patient forgets that in reality they commenced
+either within a joint (as the elbow or hip), or in the fibrous
+structures immediately outside it. Certain localities are much more
+frequently the seat of this kind of affection than other parts of the
+body; thus it occurs, perhaps in nine-tenths of the cases, in the
+neighborhood either of the shoulder (especially involving the insertions
+of the deltoid and triceps muscles), of the elbow (particularly
+affecting the tendinous insertions of the muscles on the internal aspect
+of the forearm), or the hip (extending to the aponeuroses on the outer
+and back part of the thigh): in all these cases there is a considerable
+superficial resemblance to true neuralgic pains. Nevertheless, the
+diagnosis need not present any serious difficulties after the earliest
+stages; for there soon arises a very diffuse and acute tenderness of the
+parts, and usually an amount of generalized swelling, which, though it
+may not be readily detectable by the eye, is sensible enough to the
+touch. Movement of the parts is also very painful; but usually not with
+the acute and agonizing pain which occurs in myalgia.
+
+It is, however, upon signs which are of a more general character that we
+ought chiefly to rely for diagnosis. The fact that the patient has
+previously experienced a genuine attack of acute rheumatism, though of
+some value, is by no means to be taken as a conclusive argument that the
+present attack is of a rheumatic nature. The really important matter is,
+that whether the patient has or has not suffered acute rheumatism before
+the occurrence of the subacute or chronic form, the latter will always
+be attended by more or less of the specific constitutional disturbance
+of rheumatism. I would carefully abstain from the assumption that
+rheumatism is originally dependent on a blood-poisoning, a theory which
+I believe to be most doubtful and very probably false; but there is,
+nevertheless, a truly specific character about the general phenomena in
+acute rheumatism, and I maintain that similar though less-marked
+phenomena are always to be seen even in the mildest and least acute
+forms of rheumatism. Thus there will be, invariably, more or less of the
+peculiar sallow anaemia, together with red flushing of the cheeks when
+the pain is at the worst; and there will be a certain amount of the oily
+perspiration which makes the faces of rheumatic patients look shiny and
+greasy. No doubt these characteristics will sometimes be very slightly
+developed, but I believe that attentive observation will always discover
+them in any case which is genuinely rheumatic. One case, in particular,
+which has been under my care, very strongly impresses me with the value
+of these diagnostic signs, where otherwise the symptoms are obscure:
+
+L. P., aged thirty-one, single, a printer by trade, applied to me,
+January, 1863, suffering from what I at first decidedly thought was
+cervico-brachial neuralgia, the pain having followed exposure to cold
+and wet, situated in the lower part of the neck, the shoulder, elbow and
+inner side of the right arm, and existing nowhere else. The character of
+the pain was described as at least remittent, if not distinctly
+intermittent. The pulse was not more than 78; the tongue was thickly
+coated with white fur, but the man did not complain of thirst, and there
+were no evident signs of fever. As the pains had only existed for about
+a fortnight, it appeared an excellent case for cure by the hypodermic
+injection of morphia; and, accordingly this was used in quarter-grain
+doses twice a day. After about ten days an attempt was made to do
+without the morphia, but the pains returned, worse than before, and
+meantime the tongue had remained uniformly coated, and was now very
+yellow; the appetite was bad, and there was some increase in frequency
+of pulse. It now struck me, for the first time, that the man presented,
+in a slight degree, the sallow and red tint and oily features of a
+rheumatic patient; it was now found that sweat and urine were distinctly
+acid. Acting on this idea, I administered five grains of iodide of
+potassium, and thirty grains of bicarbonate of potassium, four times
+every twenty-four hours, after giving a moderate saline aperient. The
+result was manifest improvement within twenty-four hours, and almost
+complete relief of the pain within three or four days (the urine never
+becoming distinctly alkaline, however.) As the attack subsided, the oily
+appearance of the skin disappeared, and the rheumatic tint was replaced
+by mere ordinary pallor, which the patient lost after taking a short
+course of steel.
+
+At the time this case occurred to me, I was not aware of the importance,
+in doubtful instances, of looking to the temperature; but subsequent
+experience has convinced me that in every truly rheumatic case, however
+limited in extent, there is a real, though it may be a small, rise of
+temperature. The thermometer will be found to mark from 99-1/4 deg. to 100 deg.
+Fahr., and this, joined with the appearances above mentioned, and a
+strong acidity of urine, will be sufficient to distinguish the complaint
+as rheumatic; and the striking effect of such remedies as iodide with
+bicarbonate of potash, followed up with sesquichloride of iron, in full
+doses, helps still further to distinguish the cases from true
+neuralgias. Since the introduction of the full doses of the
+iron-tincture in the treatment of acute rheumatism, I have had the
+opportunity of treating two of these cases of subacute rheumatism in the
+same manner, viz., with the iron from the first, and the results have
+been most satisfactory in every way. These cases were independent of a
+much larger number, treated in the same way, in which the symptoms of
+rheumatism were more generalized and more severe.
+
+
+
+
+CHAPTER IX.
+
+PAINS OF LATENT GOUT.
+
+
+Pains which are connected with a chronic and more or less latent form of
+gout not unfrequently receive the designation "neuralgic," and are
+treated upon that erroneous theory of their pathology. I have already
+endeavored to show that there is by no means that intimate causal
+relation between gout and neuralgia which is very commonly assumed to
+exist: true neuralgia is, I believe, only caused in an indirect and
+secondary manner by the gouty condition setting up changes of the
+blood-vessels, which precipitate the occurrence of the neuralgic malady,
+to which the patient was otherwise predisposed from birth. But the
+common idea, both without and within the profession, seems to be that
+neuralgia is only one expression, and that a quite common one, of the
+gouty habit. Nevertheless, with strange inconsistence, the kind of truly
+gouty pains of which I am now speaking are constantly treated upon a
+special plan, upon the supposition that they are neuralgic.
+
+There are six situations in which gouty pains are apt to be developed in
+a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2)
+more indefinitely within the cranium; (3) in the stomach, simulating
+gastralgia; (4) in the chest, simulating angina pectoris; (5) in the
+dorsum of the foot, simulating neuralgia of the anterior tibial nerve;
+(6) in a somewhat diffuse manner about the hip and back of thigh,
+simulating sciatica.
+
+It is not really a common thing to find such cases very difficult of
+diagnosis, provided that the possibility of their occurrence has been
+carefully noted; for the gouty habit has a number of slight
+manifestations which are usually enough to discover it even when its
+more decided symptoms are entirely wanting.
+
+Thus, in the first place, it will be almost invariably found, on
+inquiry, that the patient has always been intolerant of beer and of
+sweet wines. Also, he has been liable (either after a single large
+excess in eating or a prolonged course of a diet too highly animalized
+in proportion to the amount of exercise taken) to attacks of general
+malaise, with or without uneasiness, just short of decided pain, about
+the metacarpo-phalangeal joint of the great-toe, and ending after a few
+hours or days with a free discharge of uric acid. Less frequently, but
+still very often, it will be found that he has some deposit of lithate
+of soda (chalk-stone) in some situation where its presence does not
+necessarily arrest attention; Dr. Garrod has shown how often these
+little tophi are found in the cartilage of the ear. Careful examination
+will sometimes detect their presence in the sclerotic of the eye. But in
+doubtful cases it would be always well to make a cautious trial of
+colchicum, which, if the case be gouty, will nearly always produce an
+amount of relief sufficient to confirm the diagnosis of gout. At least,
+this rule holds goods for the external forms; but in the case of the
+supposed gouty pseudo-angina it is far best to trust to opium, as
+colchicum may prove too depressing to a heart which may quite possibly
+be already the subject of organic disease. My own impression is, that it
+was these cases of gouty heart-pain, which are not true angina at all,
+that procured for opium its high reputation for relieving the latter
+disease, a reputation which is by no means confirmed by my own
+experience, since I have found that drug enormously inferior to
+stimulants like ether in its power to relieve genuine angina.
+
+Lastly, if there be no other possibility of making ourselves certain
+whether there is or is not a gouty taint at the bottom of the
+quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the
+serum of the blood to a search for uric acid (thread-test).
+
+
+
+
+CHAPTER X.
+
+COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.
+
+
+Colic, or painful half spasm, half paralysis of the large intestines, is
+the best example of a kind of spasmodic pains to which some authors
+accord the name of neuralgia, as it seems to me without good reason.
+They appear to be quite independent of the operation of the neurotic
+temperament, and to be caused entirely by the operation of some local
+irritant, or narcotic irritant, upon the muscular fibres of the viscus.
+In the case of colic this influence is most frequently and most
+powerfully exerted by lead, which undoubtedly becomes locally deposited
+in chronic poisoning with that metal; at other times it is produced by
+the irritation of indigestible food passing along the alimentary canal.
+
+That there may be such a thing as enteralgia, of really neuralgic
+character, I do not deny; on the contrary, so far as regards the rectum,
+I have myself seen such a case. But true neuralgia of the large bowel is
+exceedingly uncommon; what goes by the name is usually either colic from
+local irritation of the viscus; or a mere hysterical hyperaesthesia of
+the lining membrane, which is one of the occasional phenomena of spinal
+irritation; or else it is a case of neuralgia of the abdominal wall,
+such as is included in the description of "lumbo-abdominal neuralgia,"
+in Part I. of this work.
+
+There is no occasion to describe minutely the symptoms of so familiar a
+disease as lead-colic, or as colic from irritation by indigestible food,
+when they occur in their typical forms. In the former case the marked
+constipation which ushers in the attack of pain, and the peculiar
+greenish-yellow sallowness nearly always seen in the countenance, ought
+to be sufficient to direct examination to the gums (for the blue line)
+and inquiry as to any possible impregnation of the system with lead,
+owing either to the nature of the patient's occupation, or to some
+accidental entry of the poison into the drinking-water, or its
+inhalation from the walls of newly-painted rooms, etc. In the latter
+case, the fact that the attack of colic was shortly preceded by a meal,
+either of obviously indigestible food, or too copious in quantity and
+heterogeneous in kind, or too hastily eaten without sufficient
+mastication, supplies a clew.
+
+But there are a few cases representing minor degrees of either of these
+kinds of colic, that are much less easy to diagnose distinctly.
+
+Lead-poison sometimes enters the system continuously, for a long period,
+but in proportions too minute to produce the effects which we identify
+as an attack of lead-colic. I believe that for the production of the
+latter complaint it is necessary that the poisoning shall be
+sufficiently intense completely to paralyze a considerable piece of
+bowel, thus altogether hindering peristalsis, or, rather, making the
+peristaltic acts of the non-paralyzed portions above worse than
+fruitless. But there is a minor degree in which it may happen that the
+local affection (owing, I believe, to a less extensive deposit of lead
+in the bowel) does not reach the decidedly paralytic stage; the state
+then is one of irregular and painful spasm of individual fibres (quite
+possibly intermingled with paralysis of a few others), and the practical
+result is irregularity of evacuation--now diarrhoea, and again
+constipation--and the frequent recurrence of twinges of pain that are
+easily mistaken for abdominal neuralgia. Such symptoms as these are
+nearly always found to have occurred, if proper inquiry be made, in
+those examples of chronic lead-poisoning in which the toxic process goes
+on to the development of epilepsy, or marked symmetrical paralysis of
+the wrist-extensors, without the patient having ever suffered an attack
+of ordinary colic. In these slow and insidious cases the constitutional
+affection may not have reached the height at which the complexion and
+general aspect of the patient suggests metallic poisoning: and the case
+may present very neuralgia-like features. The absence of the _points
+douloureux_ is not, as we have seen, conclusive against neuralgia in its
+early stages. It is therefore an excellent rule, in all cases of chronic
+recurrent spasmodic pain in the abdomen, especially in men, to
+investigate the possibilities of lead-poisoning; and, if the slightest
+suspicious appearance of the gums be found, this track of inquiry must
+be followed up exhaustively before we abandon the idea. The absence of
+all special neurotic history in a patient's family should increase our
+suspicions respecting pains of this character that continue with an
+obstinacy which makes it unlikely they are due to improper food.
+
+Pains of abdominal irritation are, however, without doubt produced in
+some cases by unsuspected faults of diet, and may even recur in such a
+quasi-periodic manner as to strongly suggest the idea of neuralgia in
+the lumbo-abdominal nerve. One special variety of this happens, I
+believe, much more often than is thought. A patient will habitually take
+considerable quantities of some article of food which he does not
+readily digest, but which is not at all acutely irritant: under these
+circumstances a simple accumulation is apt to take place in the colon,
+especially at the top of the ascending colon, the top of the descending
+colon, or just above the sigmoid flexure, or else in the caecum. The
+result of accumulation in the last of these places is not unfrequently
+typhlitis and perityphlitis, this part of the bowel having (for some
+reason) a special tendency to inflammation. Deposits in the other
+localities named are rarely the cause of inflammation, but they very
+frequently give rise to violent pain, which is exceedingly apt to be
+taken for the pain either of gall-stone, of renal calculus, or else of
+some abdominal neuralgia. In cases, therefore, where there is any
+possibility that accumulation is the cause of pain, it is highly
+desirable to commence with a dose of castor-oil and laudanum, followed
+up, if needful, by the administration of a large warm-water enema, given
+through an O'Beirne's tube. The most violent and recurrent attacks of
+pain in the renal region, the flank, the abdomen, or the groin, will
+sometimes be instantly cured by such means, sufficiently proving the
+non-neuralgic character of the complaint.
+
+I have elsewhere explained that the impaction of a renal or an hepatic
+calculus, in the ureter or the ductus choledochus, may set up a true
+neuralgia in persons with the requisite congenital predisposition. The
+passage of renal or hepatic calculi may give rise to symptoms falsely
+suggesting neuralgia, which require just to be mentioned here. But there
+is no need to dwell much upon the diagnosis, for the passage of renal or
+hepatic calculi has always attendant symptoms and features of
+constitutional history, which ought to preserve the physician from
+mistake. The sensation of constriction, of nausea and vomiting, the
+faintness approaching to collapse, the persistent and constantly
+increasing severity of the pain up to the moment at which mechanical
+relief occurs, to say nothing of other phenomena, are distinctive to the
+skilled observer, and, when taken in conjunction with the history of
+past attacks, if any, will always prevent mistakes. In the few cases
+which might still be doubtful it will be well to try the effect of a
+relaxing dose of chloroform, which, in the case of calculus, will often
+put an end to the paroxysm at once and finally.
+
+
+
+
+CHAPTER XI.
+
+DYSPEPTIC HEADACHE.
+
+
+A final word or two must be given to the distinction between neuralgia
+of the head and an affection so utterly different that it is surprising
+that they should be so frequently confounded. One constantly hears
+medical men speak of "sick headache" (migraine) as if it were the same
+thing as headache from indigestion; and, unfortunately, they often treat
+migraine upon this confused and erroneous notion, doing no little
+mischief thereby.
+
+But, although migraine, already amply described, is entirely independent
+of the state of digestion, and its stomach-phenomena are purely
+secondary to the affection of the fifth nerve, there is a kind of
+headache really dependent on imperfect digestion. The sufferers from
+these headaches are dyspeptics whose stomach troubles are the result of
+chronic gastric catarrhal inflammation. (In the acute form of gastric
+catarrh there are even more severe headaches; but the general symptoms
+of the disorder are too marked to allow us to mistake the case for
+neuralgia complicated with secondary stomach disturbance.) The patients
+in question have frequently passed so gradually into the dyspeptic
+condition as to have become accustomed to it, and inclined to forget
+that the stomach was the organ which first gave them annoyance. The
+headaches, which occur from time to time, are either frontal or (more
+frequently) occipital in position, and they are usually quite evenly
+bilateral; still, there is not enough uniformity of difference between
+them and true migraine, in this respect, to enable us to establish a
+decided diagnosis upon it. This much may be said, however: that the pain
+is rarely or never seated in one parietal region, as is frequently the
+case with migraine and with clavus. The patient suffers very strikingly,
+in almost every case, from languor and a feeling of inability to exert
+himself; and has also much aching pain in the limbs, and usually a pain
+(sometimes very severe) in the scapular region. The tongue may vary a
+good deal in appearance, especially as regards the degree of general
+redness; but it always has enlarged papillae, most prominent toward the
+tip, and more or less thick furring at the back, and reaching forward,
+in some cases, nearly to the tip, to which the "strawberry" aspect is
+then confined. The headache is frequently joined with nausea, but never
+with absolute vomiting, unless the stomach has been provoked with a meal
+that gives it more trouble than usual. The desponding frame of mind
+which this kind of dyspeptics always exhibit distinguishes them, in most
+cases, quite sufficiently (together with the unwholesome complexion, the
+appearance of the tongue, and the great complaints of general malaise
+and aching and feebleness of the limbs) from the victims of migraine,
+who are often persons of bright spirits and lively intelligence in the
+intervals of their attacks; but, above all, there is nothing of the
+regular and characteristic sequence of events which distinguishes the
+attacks of migraine. The attacks are not periodic, but nearly always
+depend on some chance dietary indiscretion, or other imprudence, which
+has visibly aggravated the stomach irritation. And, when the pain does
+come on, it has no uniform tendency to go on intensifying for some hours
+and culminate in vomiting, followed by sleep, after which the patient is
+free. On the contrary, the digestive disturbance is the provocation, and
+the pain itself is of a heavy character, with a sense of tension or
+fulness, and it does not go on intensifying in a regular manner, up to a
+climax, but hangs about in a dull, tormenting way, and frequently is
+just as bad after sleep as it was before. The diagnosis of these
+headaches from neuralgic headache is not really difficult; it only
+requires the use of a fair amount of caution in observation. It would,
+however, be exceedingly advantageous that the word "sick-headache"
+should be dropped altogether, and that migraine should always be called
+by that name (or "megrim," if you will), and that headaches really
+proceeding from chronic catarrhal disease of the stomach should be
+called "dyspeptic" headaches. The present state of nomenclature does
+much to perpetuate a confusion of ideas which ought not to exist any
+longer, and which leads to much practical mischief.
+
+       *       *       *       *       *
+
+Transcriber's Notes:
+
+Punctuation and spelling errors fixed. Variant spellings and
+hyphenations changed when there is a clear majority. Other unusual
+spellings retained.
+
+Discrepancies in headings and outline labels repaired. In some cases,
+this required adding headings implied but not present in the original,
+to agree with headings that were present.
+
+Table of Contents, Part 1, Chapter IV: original reads "DIAGNOSIS AND
+PROGRESS OF NEURALGIA." "PROGRESS" has been corrected to "PROGNOSIS" as
+shown in the Chapter heading.
+
+P. 51, "but her mensural troubles" changed to "but her menstrual
+troubles".
+
+P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat."
+"Chim." is typo for "Chir." as in footnote just above.
+
+P. 96, "investigation of neralgi" changed to "investigation of
+neuralgia".
+
+P. 105, "genealogical connection between migraine and epilepsy": in all
+reviewed copies of this 1882 edition, original shows "aological" with 4
+or 5 spaces in front of it, an apparent printer error. However, in the
+1872 edition, the entire sentence reads as presented here.
+
+P. 206, "I have already causually" changed to "I have already causally".
+
+
+
+
+
+End of the Project Gutenberg EBook of Neuralgia and the Diseases that
+Resemble it, by Francis E. Anstie
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