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diff --git a/37592-h/37592-h.htm b/37592-h/37592-h.htm new file mode 100644 index 0000000..bf97a5b --- /dev/null +++ b/37592-h/37592-h.htm @@ -0,0 +1,12228 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> +<!-- $Id: header.txt 236 2009-12-07 18:57:00Z vlsimpson $ --> + +<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> + <head> + <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" /> + <meta http-equiv="Content-Style-Type" content="text/css" /> + <title> + The Project Gutenberg eBook of Neuralgia and the Diseases That Resemble It, by Francis E. Anstie, M.D. + </title> + <style type="text/css"> + +body { + margin-left: 10%; + margin-right: 10%; +} + + h1,h2,h3,h4,h5 { + text-align: center; /* all headings centered */ + clear: both; +} + +p { + margin-top: .75em; + text-align: justify; + margin-bottom: .75em; +} + +hr { + width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: auto; + margin-right: auto; + clear: both; +} + +table { + margin-left: auto; + margin-right: auto; +} + +td.topright { + text-align:right; + vertical-align:top; +} + +td.topleft { + text-align:left; + vertical-align:top; +} + +/* Vertical Spacing */ + +.medskip { +padding-top: 1em; +} + +.bigskip { +padding-top: 1.25em; +} + +.hugeskip { +padding-top: 3em; +} + +.pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: smaller; + text-align: right; +} /* page numbers */ + +ul li {list-style-type: none;} + +ins {text-decoration:none; border-bottom: thin dotted gray;} +.tnote {border: dashed 1px; margin-left: 10%; margin-right: 10%; +padding-bottom: .5em; padding-top: .5em; +padding-left: .5em; padding-right: .5em;} + +.center {text-align: center;} + +.smcap {font-variant: small-caps;} + +/* Images */ +.figcenter { + margin: auto; + text-align: center; +} + + +/* Footnotes */ +.footnotes {border: dashed 1px;} + +.footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} + +.footnote .label {position: absolute; right: 84%; text-align: right;} + +.fnanchor { + vertical-align: super; + font-size: .8em; + text-decoration: + none; +} + + </style> + </head> +<body> + + +<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 & 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 & 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—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—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—much more than it can be exactly opposite—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—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—an inflamed muscular structure +forced to perform its ordinary contractions as well as it can—there +must be powerful dynamic perturbation going on.</p> + +<p>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.</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>—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—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>—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>—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>—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>—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>—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>—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>.—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—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—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.</p> + +<p>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.</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>—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>—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>—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 leucorrhœa, 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—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>—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 leucorrhœa. +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. 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>—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>—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. 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>—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 dysmenorrhœa +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 dysmenorrhœal 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 dysmenorrhœal 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 dysmenorrhœal +patients is sharply brought out by the two following +cases:</p> + +<p><span class="smcap">Case I.</span>—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>—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>—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 dysmenorrhœal 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 leucorrhœa, 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 leucorrhœal 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. 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 menorrhœal 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>—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—vomiting—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>—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>—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 dyspnœa 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>—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—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. 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>—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>—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"> </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>—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. 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>—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 diarrhœa. 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>i. 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>—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 cœliac 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—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.</p> + +<p><i>Cerebral Neuralgia.</i>—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. 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>—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 œsophagus 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. 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>—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>—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>—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>—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 diarrhœa. 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. 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. 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—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 diarrhœa. 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. 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. 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—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 (<i>e. 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—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. 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—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<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 blenorrhœa 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. 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——, 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—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. 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—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. 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—(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. 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—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. 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. 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—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 <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. 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—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.</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—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—in +the form either of migraine, of nervous angina, or of sciatica—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—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.</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>—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—</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—</p> + +<p>(6) A poisoning of the blood by malaria (but this very +rarely causes neuralgia, save in the congenitally predisposed); +or—</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—</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—</p> + +<p>(9) Some of the fixed tender points of Valleix, in such situations +as have been described in Chapter I.; and—</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—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. 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. 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—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. 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>—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—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—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, <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—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<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—<i>i. 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—quinine, +phosphorus, strychnia, and zinc—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 diarrhœa, 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.</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—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. 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. 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—that hypodermic +remedies are "less active" (!) than gastric remedies—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 dysmenorrhœal 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—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<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—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.</p> + +<p>3. Local Measures.—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—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—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. 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—sensory and psychical—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—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 Pharmacopœia, +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 & 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—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.</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>—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>—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>—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—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.</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 & 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. 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—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—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 +amenorrhœa, 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 amenorrhœa.</p> + +<p>Leucorrhœa, 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.</p> + +<p>Dysmenorrhœa, 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>—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>—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>—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—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. 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—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,<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—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>i. 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. 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—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 dyspnœa 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—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 Pharmacopœia; 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 assafœtida, 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—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—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—(<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—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. 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. 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. 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—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—now +diarrhœa, 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 +<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 & 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 & 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 & 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. 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