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diff --git a/37592.txt b/37592.txt new file mode 100644 index 0000000..0576724 --- /dev/null +++ b/37592.txt @@ -0,0 +1,10939 @@ +The Project Gutenberg EBook of Neuralgia and the Diseases that Resemble it, by +Francis E. Anstie + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Neuralgia and the Diseases that Resemble it + +Author: Francis E. Anstie + +Release Date: October 1, 2011 [EBook #37592] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT *** + + + + +Produced by Bryan Ness, JoAnn Greenwood and the Online +Distributed Proofreading Team at https://www.pgdp.net (This +file was produced from images generously made available +by The Internet Archive/Canadian Libraries) + + + + + + + + + + NEURALGIA + AND + THE DISEASES THAT RESEMBLE IT. + + BY + + FRANCIS E. ANSTIE, M.D., LONDON, + +FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S +COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER HOSPITAL; +LECTURER ON MEDICINE IN WESTMINSTER HOSPITAL SCHOOL; PHYSICIAN TO THE +BELGRAVE HOSPITAL FOR CHILDREN. + + [Illustration] + + NEW YORK: + BERMINGHAM & CO., UNION SQUARE. + 1882. + + W. L. MERSHON & CO., + _Printers, Electrotypers and Binders_, + RAHWAY, N. J. + + + + +PREFACE. + + +I believe it will not be disputed that there was considerable need for +an English treatise dealing rather fully with the subject of Neuralgia, +and therefore I hope that the profession will be willing to give me a +hearing. The present work, moreover, does not profess to be a mere +compilation of standard authorities corrected down to the present time, +but puts forward a substantially new view of the subject--at least, a +view that has been only briefly sketched by me in an article that +appeared, three years ago, in Reynolds's "System of Medicine." My +principal object, in writing this volume, was to vindicate for Neuralgia +that distinct and independent position which I have long been convinced +it really holds, and to prove that it is not a mere offshoot of the +Gouty or Rheumatic diatheses, still less a mere chance symptom of a +score of different and incongruous diseases. In order to set the +diagnosis of true Neuralgia from its counterfeits in the clearest light, +it seemed advisable to draw separate pictures of each of the latter (at +least of as many as are of real importance) and present them separately, +as a kind of gallery of spurious neuralgias, and this I have done in the +second part of the volume. No one who had not tried to do it would +imagine how difficult this latter kind of work is. It was necessary for +the sketches to be very brief (unless my book was to become unmanageably +large), and yet to be as truthfully characteristic as possible; and it +was necessary also that only those diseases which so much resemble +Neuralgia as practically to lead medical men astray in diagnosis, should +be dealt with. The selection of the subjects, and the execution of this +part, took a long time, though it only covers about fifty pages. Then, +as regards Neuralgia itself, it became necessary to completely recast +the chapters on "Pathology" and on "Complications," on account of some +of the polite criticisms which Dr. Eulenburg directed (in his recent +"Lehrbuch der Nervenkrankheiten") to my argument in the article above +referred to, since it was obvious that a too brief statement of my views +had caused them to be partially misunderstood by the German physician. +These chapters (Part I., Chapters II. and III.) are certainly the most +important portion of my book, and I would particularly direct attention +to them, in order that their contents may be affirmed or corrected: the +reader will at any time find that they contain a kind of investigation +never before systematically carried out with regard to Neuralgia. The +causes above mentioned, together with others over which I had no +control, have kept back the appearance of this work so long beyond the +date for which it was originally announced, that I feel I ought to +apologize for an amount of delay that would seem hardly justified by the +moderate size of the volume. + +16 WIMPOLE STREET, LONDON, _October_ 1, 1871. + + + + +CONTENTS. + + + INTRODUCTION--ON PAIN IN GENERAL 7 + + + PART I. + + _ON NEURALGIA._ + + CHAP. PAGE + + I.--CLINICAL HISTORY 12 + + II.--COMPLICATIONS OF NEURALGIA 79 + + III.--PATHOLOGY AND ETIOLOGY OF NEURALGIA 96 + + IV.--DIAGNOSIS AND PROGNOSIS OF NEURALGIA 142 + + V.--TREATMENT OF NEURALGIA 149 + + + PART II. + + _DISEASES THAT RESEMBLE NEURALGIA._ + + CHAP. + + I.--MYALGIA 196 + + II.--SPINAL IRRITATION 200 + + III.--THE PAINS OF HYPOCHONDRIASIS 207 + + IV.--THE PAINS OF LOCOMOTOR ATAXY 210 + + V.--THE PAINS OF CEREBRAL ABSCESS 213 + + VI.--THE PAINS OF ALCOHOLISM 215 + + VII.--THE PAINS OF SYPHILIS 218 + + VIII.--THE PAINS OF SUBACUTE AND CHRONIC + RHEUMATISM 225 + + IX.--THE PAINS OF LATENT GOUT 227 + + X.--COLIC, AND OTHER PAINS OF PERIPHERAL + IRRITATION 229 + + XI.--DYSPEPTIC HEADACHE 231 + + + + +INTRODUCTION. + +ON PAIN IN GENERAL. + + +Although it is, in a general way, unadvisable to introduce abstract +discussions into a treatise which should be strictly practical, it is +almost impossible to avoid some few general reflections on the +physiological import of Pain, as a preliminary to the discussion of the +maladies which form the subject of this volume. This whole group of +disorders is linked together by the fact that pain is their most +prominent feature; and, with regard to most of them, the relief of the +pain is the one thing required of the physician. It seems, therefore, +very important that we should ascertain, at least approximately, in what +the immediate state consists, which consciousness interprets as pain. It +is not necessary to enter at this stage into any inquiry as to the +pathological causes of the phenomenon; what we know of these, and it is +unfortunately too little, will be discussed in detail under the headings +of the several affections which I shall have to describe. + +The question before us now is this: What is that functional state of the +nerves which consciousness interprets as pain? Is it, or is it not, an +exaltation of the ordinary function of sensation? + +The latter question is generally answered affirmatively, without much +thought, by those to whom it casually occurs; but indeed there is plenty +of prescriptive authority for so dealing with it. Pain has been +described by some of the most distinguished writers on nervous diseases +as a hyperaesthesia. Yet there is really little difficulty in convincing +ourselves, if we institute a thorough inquiry into the matter, that pain +is certainly not a hyperaesthesia, or excess of ordinary sensory +function, but something which, if not the exact opposite of this, is +very nearly so. + +The leading fallacy in the common view is the confusion which is +perpetually being made between function and action. Now, the function of +individual nerves is very nearly a constant quantity, at least, it +varies only within narrow limits; while the action of the same nerves +may be almost any thing. The function of the nerve is that kind of work +for which it is fit when its molecular structure is healthy; it is the +series of dynamic reactions which are necessarily produced in +nerve-tissue by the external influences which surround and impinge upon +it in the conditions of ordinary existence. The action of nerves, under +the pressure of extraordinary influences, may include all manner of +vagaries which really have nothing in common with the effects of +ordinary functional stimulation; which are, in fact, nothing but +perturbation. No one can suppose, for instance, that the explosive +disturbances of nerve-force which give rise to the convulsions of +tetanus are any mere exaggerated degree of the orderly and symmetrical +action by which the healthy nerve responds to the stimulus of volition +ordering a given set of muscles to contract; they are something quite +different in kind. And so it is with the sensory nerves. The functions +of these conductors, in health, is to convey to the perceptive centres +the sensations, varying only within a most limited range, which +correspond to a state of well-being of the organs, and which excite only +those reflex actions that are necessary to life. Thus the large surface +of sensitive nerve terminals which is represented by the collective +peripheral branches of the fifth cranial conveys to the medulla +oblongata an impression, derived from the temperature and movement of +the surrounding air, when the latter is neither too hot nor too cold, +which imparts to the brain a perception of comfortable sensations, and +excites in return the reflex action of breathing, which is necessary to +life. But the impression produced on this same peripheral expanse of +nerve-branches by prolonged exposure to cold wind may, and often does, +convey to the centres sensations which are quite different and provokes +reflex movements which are altogether abnormal. Pain is the product in +one direction; sneezing, perhaps, in the other. It seems absurd to say +that sneezing is any part of the function of those motor nerves whose +action regulates the performance of expiration. And it appears to me not +less absurd to say that pain is the function of the sensitive fibres of +the trigeminus. But the best way, perhaps, to illustrate the looseness +and incorrectness of applying the term "hyperaesthesia" (implying exalted +function) to the state of sensitive nerves when suffering pain, is to +examine the condition of distinctive perception in the very same parts +to which the painful nerves are distributed. It will invariably be +found, as we shall have occasion to see more fully proved hereafter, +that, in parts which are acutely painful, a marked bluntness of the +tactile perceptions can be detected. The tactile perceptions are, no +doubt, conveyed by an independent set of fibres from those which convey +the sense of pain.[1] Yet it is surely impossible to believe the effect +of the same influence, in functional power can be different--much more +than it can be exactly opposite--in the two cases. + +If pain be not a heightening of ordinary sensation, then we seem to be +shut up to the idea that it is a perversion owing to a molecular change +of some part of the machinery of sensation which frustrates function. +For it is to be observed that, while the sensations conveyed by the +healthy nerve are correct in the indications which they afford to the +percipient brain, the indications given by pain are vague and +untrustworthy, and often seriously misleading. Not to speak of the +nerves of special sense, or of the fibres which convey the sensations of +muscular movement, even the nerves of common sensation do carry to the +internal perception, in health, a distinct impression of the well-being +of the organs to which they are distributed. Mr. Bain[2] has well +pointed out the positive character of this feeling, which is so often +incorrectly referred to as if it were a mere negation of feeling. It is +a sensation of equable and diffused comfort, if I may be allowed to use +the expression, which streams in from all parts of the organism; and +there is no possibility of comparing it, in any scale of less or more, +with the sensation of pain; for the latter commonly conveys no correct +information as to the organ from which it proceeds, or appears to +proceed. Especially is this the case in the neuralgias, for more +commonly than not the apparent seat of the pain is widely removed from +the actual seat of the mischief which causes it. + +If we inquire a little further into the circumstances under which +various kinds of pain occur, we gain some fresh suggestions. Among the +neuralgias, those are the most acutely agonizing which occur under +circumstances of impaired nutrition incident to the period of bodily +decay, and strong reasons will be hereafter adduced for the belief that +there is especial impairment of the nutrition of the central end of the +painful nerves. To find a parallel to the severity of this kind of pains +we must turn to the case of organic tumors, which, from their position, +structure, and mode of growth, necessarily exercise continuous and +severe pressure on the branches or the trunk of a nerve; or to the class +of pains which attend severe cramp, or tonic contraction of muscles. +Now, it can scarcely be doubted that in the latter instance there is an +abnormally rapid and violent destruction of tissue going on; at the very +least there is an extraordinarily violent and irregular manifestation of +motor force. In any case the patent fact here is dynamic perturbation +of a severe kind; and, in the instance of organic tumors exercising +steady and continuously increasing pressure on nerves, one can scarcely +doubt that a similar perturbation, less intense but more enduring, is +necessarily set up. That which can be done in the way of producing +severe pain by these severe affections of the peripheral portions of +nerves, or of tissues lying outside them, we might _a priori_ expect +would be effected by slighter but continuous changes in the nutrition of +the more important portion of the nerve itself--its central gray +nucleus. One would say that a pathological process which continuously +and progressively lowered the standard of nutrition here must interfere +from hour to hour, certainly from day to day, with that regular and +equable distribution of force which is the essence of unimpeded +function. + +Take, again, the case of the very severe pain which frequently attends +inflammation of the pleura and of the peritoneum. Whatever theory of the +causation of these pains we may adopt, it is certain that one most +important element in their production and maintenance is the continual +movement and friction of the affected parts. But there is little doubt +that the moving muscles are involved in the inflammatory process, as Dr. +Inman has correctly observed. It would seem plain that under these +circumstances--an inflamed muscular structure forced to perform its +ordinary contractions as well as it can--there must be powerful dynamic +perturbation going on. + +If perturbation of nerve-function--a disturbance quite different from +mere exaltation of the normal development of nerve-force--be the essence +of pain, how comes it that pains of the severest type may be produced by +changes in structures which are usually described, for practical +purposes, as lying outside the nervous system? We must, in the first +place, remark that the externality of any bodily tissue to the nervous +system is more apparent than real. Microscopic researches are constantly +revealing nerve-fibres, in ever-increasing profusion, which penetrate to +parts seemingly the least vitalized in the organism. But, in any case, +the nerves are certainly the ultimate channel of communication between +the suffering part and the sentient centre. It seems, therefore, the +inevitable conclusion that a dynamic perturbation going on in the +non-nervous tissue is continued along the nerves themselves: and that +the severity of the pain perceived by the conscious centres is +proportionate to the tumultuousness, the want of coordination, and the +waste with which force is being evolved in the cramped muscle, or +whatever structure it may be, in which the pain takes its source. + +Not to pursue these topics further, we may sum up the considerations +which have now been adduced, in the following general propositions, +which will tend to simplify the examination of the various painful +disorders which we are about to discuss: + +1. Pain is not a true hyperaesthesia; on the contrary, it involves a +lowering of true function. + +2. Pain is due to a perturbation of nerve-force, originating in dynamic +disturbance either within or without the nervous system. + +3. The susceptibility to this perturbation is great in proportion to the +physical imperfection of the nervous tissue, until this imperfection +reaches to the extent of cutting off nervous communications +(paralysis). + +FOOTNOTES: + +[1] See, on this subject, some remarks, in my work on "Stimulants and +Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception +and Common Sensation." + +A very distinct and careful statement of the distinction between pain +and hyperaesthesia will be found in a prize essay "On Neuralgia" by M. C. +Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865. + +[2] "Senses and Intellect." + + + + +PART I. + +ON NEURALGIA. + + + + +CHAPTER I. + +CLINICAL HISTORY. + + +Neuralgia may be defined as a disease of the nervous system, manifesting +itself by pains which, in the great majority of cases, are unilateral, +and which appear to follow accurately the course of particular nerves, +and ramify, sometimes into a few, sometimes into all, the terminal +branches of those nerves. These pains are usually sudden in their onset, +and of a darting, stabbing, boring, or burning character; they are at +first unattended with any local change, or any general febrile +excitement. They are always markedly intermittent, at any rate at first; +the intermissions are sometimes regular, and sometimes irregular; the +attacks commonly go on increasing in severity on each successive +occasion. The intermissions are distinguished by complete, or almost +complete, freedom from suffering, and in recent cases the patient +appears to be quite well at these times; except that, for some short +time after the attack, the parts through which the painful nerves ramify +remain sore, and tender to the touch. In old-standing cases, however, +persistent tenderness, and other signs of local mischief, are apt to be +developed in the tissues around the peripheral twigs. Severe neuralgias +are usually complicated with secondary affections of other nerves which +are intimately connected with those that are the original seat of pain; +and in this way congestions of blood vessels, hypersecretion or arrested +secretion from glands, inflammation and ulceration of tissues, etc., are +sometimes brought about. + +The above is a general description of neuralgia which will identify the +disease sufficiently for the purpose of introducing it the attention of +the reader. We must now proceed to give a more accurate account of its + +_Clinical History and Symptoms._--These vary so greatly in different +kinds of neuralgia that it will be necessary to discuss the greater part +of this subject under the headings of the special varieties of the +disease. There are certain common features, however, in all true +neuralgias. + +I. In the first place, it is universally the case that the condition of +the patient, at the time of the first attack, is one of debility, either +general or special. I make this assertion with confidence, +notwithstanding that Valleix, and some other very able observers, have +made a contrary statement. In the first place, it is certainly the case +that the larger half of the total number of cases of neuralgia which +come under my care are either decidedly anaemic, or else have recently +undergone some exhausting illness or fatigue; and if other writers have +failed to see so many neuralgic patients in whom these conditions were +present, it must certainly be because they have limited the application +of the term "neuralgia" within bounds which are too narrow to be +justified by any logical argument; as will, indeed, be shown at a later +stage. On the other hand, although a considerable number of neuralgic +patients have an externally healthy appearance, as indicated by a ruddy +complexion and a fair amount of muscular development, it cannot be +admitted that these appearances exclude the possibility of debility, +either structional or functional, of the nervous system. The commonest +experience might teach us that, so far from the nervous system being +invariably developed with a corresponding completeness and maintained +with a corresponding vigor to those which distinguish the muscular +system and the organs of vegetative life, there is often a very striking +contrast between these in the same individual. What physician is there +who has not seen epileptic patients, in whom mental habitude, a low +cranial development, imperfect cutaneous sensibility, and other obvious +marks of deficient innervation, were marked and striking features at, or +even before, the first occurrence of convulsive symptoms, while the body +was robust, the face well colored, and the muscular power up to or +beyond the average? Now, it will invariably be found, on carefully +sifting the history of apparently robust neuralgic patients, that they, +too, have given previous indications of weakness of the nervous system: +thus, women, who, after a severe confinement attended with great loss of +blood, are attached with _clavus hystericus_ or with _migraine_; will +inform us that whenever, in earlier life, they suffered from headache, +the pain was on the same side as that now affected, and chiefly or +altogether confined to the site of the present neuralgia. In a +considerable number of cases, also, in which I have been able to observe +accurately the events which preceded an attack of neuralgia, it has been +found that the skin supplied by the nerves about to become painful was +anaesthesic to a remarkable degree; and it is very often the case that a +more moderate amount of blunted sensation was perceptible in these parts +during the intervals between attacks of pain. A somewhat delusive +appearance of general nervous vigor is often conveyed to the observer of +neuralgic patients, by reason of the intellectual and emotional +characteristics of the latter. Both ideation and emotion are, indeed, +very often quick and active in the victims of neuralgia, who in this +respect differ strikingly from the majority of epileptics. But this +mobility of the higher centres of the nervous system is itself no sign +of general nervous strength; which last can never be possessed except by +those in whom a certain balance of the various nervous functions is +maintained. Much more will be said on this topic when we come to discuss +the etiology of neuralgia. Meantime I may content myself with repeating +the fact which is indubitably taught by careful observation--that +neuralgics are invariably marked by some original weakness of the +nervous system; though in some cases this defect is confined strictly to +that part of the sensory system which ultimately becomes the seat of +neuralgic pain. + +Another circumstance is common to all neuralgias of superficial nerves; +and, as a large majority of all neuralgias are superficial in situation, +this is, for practical purposes, a general characteristic of the +disease. I refer to the gradual formation of tender spots at various +points where the affected nerves pass from a deeper to a more +superficial level, and particularly where they emerge from bony canals, +or pierce fibrous fasciae. So general is this characteristic of +inveterate neuralgias, that Valleix founded his diagnosis of the genuine +neuralgias on the presence of these painful points. Herein he appears to +me to be decidedly in error. I have watched a great many cases (of all +sorts of varieties as to the situation of the pain), and I have +uniformly observed that in the early stages firm pressure may be made on +the painful nerve without any aggravation of the pain; indeed, very +often with the effect of assuaging it. The formation of tender spots is +a subsequent affair: they develop in those situations which have been +the foci, or severest points, of the neuralgic pain. There is however, a +point which, though not always, nor often, the seat of spontaneous pain, +is nevertheless very generally tender. Trousseau, who criticises +unfavorably the statement of Valleix as to the situation of the points +douloureux, insists that this tender spot, which is over the spinous +processes of the vertebrae corresponding to the origin of the painful +nerve, and which he calls the points apophysaire, is more universally +present than any of those pointed out by Valleix. I shall hereafter +endeavor to show that these spinal points are by no means characteristic +of neuralgia; they are present in a variety of affections which were +ably described, under the heading of "Spinal Irritation," many years +ago, by the brothers Griffin. ["Observations on the Functional +Affections of the Spinal Cord," by William and Daniel Griffin. London, +1834] and they are also present with misleading frequency in cases of +mere myalgia, such as I shall have to describe at a later stage. + +Another characteristic of neuralgic patients in general is, I believe, +a certain mobility of the vaso-motor nervous system and of the cardiac +motor nerves; but I insist less on this than on the above-named +features, because a more extended experience is necessary to establish +the fact with certainty. Within my own experience it has always seemed +to be the case that persons who are liable to neuralgia are specially +prone to sudden changes of vascular tension, under emotional and other +influences which operate strongly on the nervous system. The observation +of this fact has been made accidentally, without any previous bias on my +part, in the course of a large number of experiments made upon +individuals free from manifest disease at the time, with Marey's +sphygmograph. + +Neuralgic attacks are always intermittent, or at the least remittent, in +every stage of the disease. + +The manner in which neuralgic pain commences is characteristic and +important. There is always a degree of suddenness in its outset. When +produced by a violent shock, it may, and often does, spring into full +development and severity at once, of which, perhaps, the most striking +example is the sudden and violent neuralgic pain of the eyebrow which +some persons experience from swallowing a lump of undissolved ice. +Usually, however, the first warning is a sudden, not very severe, and +altogether transient dart of pain. The patient has probably been +suffering from some degree of general fatigue and malaise, and the skin +of the affected part has been somewhat numb, when a sudden slight stitch +of pain darts into the nerve at some point which corresponds to one of +the foci hereafter to be particularized. It ceases immediately, but in a +few seconds or minutes returns; and these darts of pain recur more and +more frequently, till at last they blend themselves together in such a +manner that the patient suffers continuous and violent pain for a minute +or so, then experiences a short intermission, and then the pain returns +again, and so on. These intermittent spasms of pain go on recurring for +one or several hours; then the intermissions become longer, the pain +slighter, and at last the attack wears itself out. Such is generally the +history of first attacks, especially in subjects who are not past the +middle age, nor particularly debilitated from any special cause. + +A point of interest in connection with the natural history of the +neuralgic access is the condition of the circulation. The commencement +of pain is generally preceded by paleness of skin and sensations of +chilliness. At the commencement of the painful paroxysm, sphygmographic +observation shows that the arterial tension is much increased, owing, in +all probability, to spasm of the small vessels. This condition is +gradually replaced by an opposite state, the pulse becoming large, soft, +and bounding, though very unresisting, and giving a sphygmographic trace +which exhibits marked dicrotism. Simultaneously with this the skin +becomes warmer, sometimes even uncomfortably warm, and there is +frequently considerable flushing of the face. + +The final characteristic common to all neuralgias is that fatigue, and +every other depressing influence, directly predispose to an attack, and +aggravate it when already existing. + +_Varieties._--It is possible to classify neuralgias upon either of two +systems: first (_a_), according to the constitutional state of the +patient; and, secondly (_b_), according to the situation of the affected +nerves. It will be necessary to follow both these lines of +classification, avoiding all needless repetition. + +(_a_) In considering the influence of constitutional states upon the +typical development of neuralgia, it will be convenient to commence with +the group of cases in which the general condition of the organism +produces the least effect. This is the case when the pain is the result +of direct injury to a nerve-trunk, whether by external violence, by the +mechanical pressure of a tumor, or by the involvement of a nerve in +inflammatory or ulcerative processes originating in a neighboring part. +As regards the development of symptoms, the important matters are, that +the pain in these cases commences comparatively gradually, that the +intermissions are usually more or less complete, and that the pain is +far less amenable to relief from remedies, than in other forms of +neuralgia. The little that can be said about the form which is dependent +upon progressively increasing pressure, or involvement of a nerve in +malignant ulcerations, caries of bones or teeth, etc., falls under the +heads of Diagnosis and Treatment, and need not detain us here. The +clinical history of neuralgia from external violence, however, requires +separate discussion: + +1. Neuralgia from external shock may be produced by a physical cause (as +by a fall, a railway collision, etc.), which gives a jar to the central +nervous system; or by severe mental emotion, operating upon the same +part of the organism. Under either of these circumstances the +development of the affection may occur at once, but by far the most +frequently it ensues after a variable interval, during which the patient +shows signs of general depression, with loss of appetite and strength. +Sometimes vomiting, and in other instances paralysis, of a partial and +temporary kind, occur. When once developed, the neuralgic attacks do not +differ from those which proceed from causes internal to the organism. In +the greater number of instances, so far as my experience goes, it is the +fifth cranial nerve which becomes neuralgic from the effects of central +shock. Illustrative cases will be given in the section on Local +Classification. Meantime the important facts to note, in relation to the +influence of constitutional states, are these: In the first place, the +tendency of such accidents to excite neuralgia varies directly with the +hereditary predisposition evinced by the liability of the sufferer's +family to neuralgic affections and to the more serious neuroses. +Secondly, the likelihood of a neuralgic attack is indefinitely increased +if he has already had neuralgia. Thirdly, although debility from +temporary and special causes can rarely be sufficient to insure a true +neuralgic access after a severe shock, it probably heightens, +indefinitely, the tendency in a person otherwise predisposed. Delicate +women are many times more liable to experience such consequences, from a +physical or mental shock, than men of tolerably robust constitution. + +2. Neuralgia from direct violence to superficial nerves is produced by +cutting or, more rarely, by bruising wounds. Cutting wounds may divide a +nerve-trunk (_a_) partially, or (_b_) completely. + +(_a_) When a nerve-trunk is partially cut through, neuralgic pain +occurs, if at all, immediately, or almost immediately, on the receipt of +the injury. One such instance only has come under my own care, but many +others are recorded. In my case the ulnar nerve was partly cut through, +with a tolerably sharp bread-knife, not far above the wrist; partial +anaesthesia of the little and ring fingers was induced, but at the same +time violent neuralgic pains in the little finger came on, in fits +recurring several times a day, and lasting about half a minute. +Treatment was of little apparent effect in promoting a cure; though +opiates and the local use of chloroform afforded temporary relief. The +attacks recurred for more than a month, long after the original wound +had healed soundly; and, for a long time after this, pressure on the +cicatrix would reproduce the attacks. A slight amount of anaesthesia +still remained, when I saw the patient more than a year after the +injury. + +(_b_) Complete severance of a nerve-trunk is a sufficiently common +accident, far more common then is neuralgia produced by such a cause; +indeed, so marked is this disproportion between the injury and the +special result, that I have been led to infer that a necessary factor in +the chain of morbid events must be the existence of some antecedent +peculiarity in the central origin of the injured nerve. This opinion is +rendered the more probable because the consecutive neuralgia is in some +cases situated, not in the injured nerve itself, but in some other nerve +with which it has central connections. Two such cases are recorded in my +Lettsomian Lectures, [_Lancet_, 1866], in which the ulnar nerve, and one +in which the cervico-occipital, were completely divided; in all three +the resulting neuralgia was developed in the branches of the fifth +cranial. Here we may suppose that the weak point existed in the central +nucleus of the fifth; and that the irritation, or rather depression, +communicated to the whole spinal centres by the wound of a distant +nerve, first found, on reaching this weak point, the necessary +conditions for the development of the neuralgic form of pain, which +therefore would be represented to the mental perception as present in +the peripheral branches of the fifth nerve. In all the cases which have +come under my notice, the neuralgia set in at a particular period, +namely, after complete cicatrization of the wound, and while the +functions of the branches on the peripheral side of the wound were +partly, but not completely, restored. The same obstinacy and +rebelliousness to treatment are observed as in other instances of +neuralgia from injury. + +One of the cases above referred to may here be briefly detailed, as it +shows very completely the clinical history of such affections. C. B., +aged twenty-four, an agricultural laborer, applied for relief in the +out-patient room of Westminster Hospital, suffering from severe +neuralgic pains of the forehead and face of the left side. Then pains +were felt in the course of the supra-orbital, ocular, nasal, and +supra-trochlear branches, and also in the cheek, appearing, there, to +radiate from the infra-orbital foramen. They had commenced about three +weeks previously to the patient's first visit to the hospital, and about +six weeks after the accident which appeared to have started the whole +train of symptoms. This was a cutting wound, evidently of considerable +depth as well as external size, toward the back of the neck, and so +situated that it must have divided the great occipital nerve of the left +side: and, from the man's account of the numbness of the parts supplied +by the nerve which immediately followed the wound, there could be no +doubt that this had occurred. There was no acute nerve-pain, either +during the healing of the wound, which was rapid, or subsequently, until +more than three weeks from the date of the injury; at this time there +was still a considerable sense of numbness in the skin of the occipital +and upper cervical region; but there now commenced a series of short +paroxysms of pain in the forehead of the same side. These at first +occurred only about twice daily, at regular intervals; the pain was not +very sharp, and only lasted a minute or two. The attacks rapidly +increased in frequency and duration, however, and extended their area. +At the time when I first saw the case the pain was very formidable, it +recurred with great frequency during the day, but would sometimes leave +the patient free for several hours together. The site of the wound was +occupied by a firm cicatrix of about a line in breadth and an inch and a +quarter in length; pressure on this excited only a vague and slightly +painful tingling in the part itself, but severely aggravated the +trigeminal pains, or reproduced them if they happened to be absent. The +regions supplied by the great occipital nerve were still very +imperfectly sensitive. This patient gave me a great deal of trouble. He +continued for many weeks under my care, and I can scarcely flatter +myself that any of the numerous remedies which I administered +internally, or applied locally, had any serious effect in checking the +disorder. The subcutaneous injection of morphia gave some relief, as it +always does, but this seemed to be perfectly transitory; and, although +when the patient ceased to attend the hospital he was decidedly better, +I cannot imagine that there was anything in it except the slow wearing +out of the neuralgic tendency, very much without reference to the +administration of any remedies. + +The description of neuralgia from injury would be incomplete without +some special words on a variety of this affection which has only very +recently been described with that fulness which it deserves. I refer to +the pains which are produced by gunshot injuries of nerves, received in +battle, of which no sufficient account had been given until the +publication of the experience of Messrs. Mitchell, Moorehouse, and Keen, +in the late American civil war.[3] + +From the interesting treatise of the above-named writers it appears that +not merely is neuralgia of an ordinary type a frequent after-consequence +of wounds, but that certain special pains are not unfrequently produced. +In the more ordinary instances, pain is of the darting, or of the aching +kind; and all writers on military surgery, who have recorded their +experience of the results of wounds received in battle, have spoken of +affections of this kind, for the most part singularly severe and +obstinate, and in not a few recorded instances clinging to the patient +during the remainder of his life. These pains may at times leave the +sufferer, but they infallibly recur when from any cause his health is +depressed, and it is an especially common thing for them to be evoked in +full severity under the influence of exposure to cold, and particularly +to damp cold. + +But the American writers introduce us to another and more terrible +neuralgia which is a, fortunately, less frequent result of serious +injuries to nerves. They speak of it as a burning pain of intense and +often intolerable severity; they believe that it seldom if ever +originates at the moment of the injury, but rather at some time during +the healing process; and it is especially noteworthy that it is +sometimes felt not in the nerve actually wounded, but in some other +nerve with which it has connections. After it has lasted a certain time, +an exquisite tenderness of the skin is developed, and a peculiar +physical change of skin-tissue occurs; it becomes thin, smooth, and +glossy. It is a remarkable fact that these burning pains which are so +definitely linked with a nutrition-change of skin are never felt in the +trunk, and rarely in the arm or thigh, not often in the forearm or leg, +but commonly in the foot or hand; and the nutrition changes of the skin +are generally observed on the palm of the hand, the palmar surface of +the fingers, or the dorsum of the foot; rarely on the sole of the foot +or the back of the hand. It is very interesting to remark that these +skin-lesions correspond very nearly, not only to those observed in the +cases of nerve-injury reported by Mr. Paget,[4] in which actual +neuralgia was present (though the kind of pain is not exactly +specified), but also very nearly with the nutritive changes observed by +Mr. Jonathan Hutchinson in a number of cases of surgical injuries of +nerves.[5] The tendency of neuralgic pain accompanied by nutritive +lesions of the skin and nails to seat itself in the hands and feet will +be hereafter noted in connection with the subject of the pains of +locomotor ataxy and of those produced by profound mercurial poisoning. +And it will be seen in the section on Pathology, that very important +conclusions are suggested by the coincidence. + +Joined with the burning pains, and the altered skin-nutrition, in the +cases of gunshot injury of nerves which we are considering, there is +nearly always a marked alteration in the temperature of the parts, +either in one direction or the other. In the great majority of instances +of ordinary neuralgia after wounds, this alteration is a very +considerable reduction of the temperature of the parts supplied by the +painful nerves; a change which corresponds with what appears in the vast +majority of all cases of division of sensitive nerves, whether pain be +set up or not. But, in all examples of the burning pain after injury, +Messrs. Mitchell, Moorehouse, and Keen found the temperature of the +painful parts notably elevated. + +It would appear that there is no form of neuralgia more dreadful, and +scarcely any so hopeless, as this burning pain coming on as a sequel to +severe nerve injuries. It exercises a profoundly depressing effect upon +the whole nervous tone; the most robust men become timid and broken +down, and their condition is compared by the American writers to that of +hysterical women. + +There is another peculiar nutritive affection, first recognized as an +occasional consequence of nerve injuries by Messrs. Mitchell, +Moorehouse, and Keen, namely, an inflammation of joints, and, although +we have no concern here with this symptom, it will be referred to +hereafter as throwing interesting light on certain questions of +pathology. Certain lesions of secretion will also be specially referred +to under the heading of Diagnosis. + +II. NEURALGIAS OF INTRA-NERVOUS ORIGIN.--As regards the constitutional +conditions with which the several varieties of neuralgia that arise +independently of external violence, or disease of extra-nervous tissues, +are respectively allied, the following preliminary subdivisions may be +made: + + 1. Neuralgias of malarious origin. + 2. Neuralgias of the period of bodily development. + 3. Neuralgias of the middle period of life. + 4. Neuralgias of the period of bodily decay. + 5. Neuralgias associated with anaemia and mal-nutrition. + +1. _Neuralgias of malarious origin_ were formerly far more prevalent +than they are at present, within the sphere of the English practitioner +of medicine; with the general decline of malarial fevers, consequent on +improved drainage and cultivation of lands, they have become constantly +more scarce. The districts in which they still are found to prevail with +any frequency are carefully specified in the interesting report of Dr. +Whitley to the Medical Officer of the Privy Council, in the Blue-Book +for 1863. + +Of course, however, there are a considerable number of persons +continually returning to England from countries where malarious diseases +are common; and these often bear about with them the effects of paludal +poisoning which occasionally exhibits itself in the form of neuralgia. +Till very lately, however, I had not happened to come across such cases, +although at one time and another I have seen and treated a good many +persons returned from India and Africa, whence I judge that neuralgia +with this special history is less common than many seem to think. In +former times, on the contrary, malarioid neuralgias were so common that +they forced themselves on the notice of every practitioner. The term +"brow-ague," to this day applied by many medical men to every variety of +supra-orbital neuralgia, is a relic of the older experience on this +point, as is also the very common mistake of expecting all neuralgic +affections to present a distinctly rhythmic recurrence of symptoms. + +In the year 1864 I published the statement[6] that, "in a fair +sprinkling" of the cases of neuralgia which present themselves in +hospital out-patient rooms, ague-poisoning may be suspected; but I was +then speaking rather from hearsay than from my own experience, which, in +fact, had yielded no clear cases of this sort of neuralgia, and was till +just recently unable to reckon up more than two undoubted and one +doubtful case of the affection, in all of which the fifth cranial nerve +was unattacked. The periodicity in one of the genuine cases was regular +tertian, in the other regular quotidian. A semi-algide condition always +ushered in the attacks; but this was gradually exchanged, as the pain +continued, for a condition in which the pulse was rapid and locomotive, +but compressible, and the strength was further depressed. In both these +cases there was unilateral flushing of the face, and congestion of the +conjunctiva, to a slight degree, during the attack of pain. The pain +became duller and more diffused contemporaneously with the lowering of +arterial pressure; and, after the disappearance of active pain, moderate +tenderness over a considerable tract round the course of the painful +nerves remain for some time. There was no distinct development of +painful points in the situations described by Valleix; but it should be +remarked that the cases were rapidly cured with quinine, which very +probably accounts for this circumstance. + +Till lately I had not witnessed neuralgia as an after-consequence of +tropical malaria-poisoning, although I have had many cases of other +diseases, the relics of hot climates, under my care; but within the last +year I have seen a case of extremely severe intercostal neuralgia of a +perfectly periodic type occurring in a patient whose constitution had +been thoroughly saturated with tropical marsh poison, and in whom the +spleen was still much enlarged. The neuralgia was so terrible, and +accompanied by such severe algide phenomena at the beginning of the +attacks, and such a sense of throbbing as the pain developed, as to lead +to serious suspicions of hepatic abscess, for the moment; but the course +of events soon corrected this idea. + +2. _Neuralgias of the Period of Bodily Development._--By the "period of +bodily development" is here understood the whole time from birth up to +the twenty-fifth year, or there-abouts. This is the period during which +the organs of vegetative and of the lower animal life are growing and +consolidating. The central nervous system is more slow in reaching its +fullest development, and the brain especially is many years later in +acquiring its maximum of organic consistency and functional power. + +That portion of the period of development which precedes puberty is +comparatively free from neuralgic affections. At any rate, it is rare to +meet in young children with well-defined unilateral neuralgia, except +from some very special cause, such as the pressure of tumors, etc. Such +neuralgias as do occur are commonly bilateral, and are connected either +with the fifth cranial or the occipital nerves. + +I must here mention an affection which was quite unknown to my +experience, but was brought under my notice by the late Dr. Hillier, who +kindly called my attention to the notes of two cases which were +published in his interesting work on "Diseases of Children." The cases +are those of two female children, aged nine and eleven respectively, in +whom the principal symptom was violent and paroxysmal neuralgic +headache. In both of these children the existence of cerebral tubercle +was suspected, but this proved to be a mistake. In both there were +intolerance of light, vomiting, tonic contraction of the muscles of the +neck, and occasional double vision; but no impairment of intelligence, +no amaurosis, and no paralysis or rigidity of the limbs. Each of these +children died rather suddenly, after a violent paroxysm of pain. The +main, indeed almost the only characteristic post-mortem change was a +marked loss of consistence of tissue, in one case in the pons varolii, +in the other in the pons, the medulla oblongata, and the cerebellum. +These cases are of the highest possible interest, as are also several +other instances of headache in children recorded by Dr. Hillier; notably +one in which severe paroxysmal pains were attended with general +impairment of brain-power, and, on the occurrence of death from +exhaustion, the autopsy revealed an amount of degeneration in the +cerebral arteries (as also in the general arterial system) which was +astonishing, considering that the child was only ten and a half years +old. This case, the full significance and interest of which will be +better seen when we come to discuss the subject of pathology, is an +example of physical changes in the nervous system, which are usually +delayed to an advanced period of life, occurring altogether prematurely, +and bringing with them a kind of neuralgic pain which is far more common +in the decline than in morning of life. It will be seen presently that +functional derangements may be in like manner precociously induced, with +the parallel effect of inducing such pains as are ordinarily the product +of a later epoch. + +From the moment that puberty arrives all is changed in the status of the +nervous system. In the stir and tumult which pervade the organism, and +especially in the enormous diversion of its nutritive and formative +energy to the evolution of the generative organs and the correlative +sexual instincts, the delicate apparatus of the nervous system is apt to +be overwhelmed, or left behind, in the race of development. Under these +circumstances, the tendency to neuralgic affections rapidly increases. +It will, however, be seen later that there is a great preponderance of +particular varieties of the disease during this time. This period is +above all things fruitful in trigeminal neuralgias, especially migraine. + +There remains to be noticed the fact that sexual precocity sometimes +very much anticipates the peculiar characteristics of the period after +puberty. It is well known that in too many instances children are led, +by the almost irresistible influence of bad example, to indulge in +thoughts and practices which are thoroughly unchildish, and which +exercise a powerfully disturbing influence upon the nervous system. A +child before the age of puberty ought to be distinguished (if moderately +healthy in other respects) by the absence of any tendency to dwell upon +his own bodily health. Under the influence of precocious sexual +irritation he becomes hypochondriacal and self-centred, and often +suffers, not merely from fanciful fears and fanciful pains, but from +actual neuralgia, which is sometimes severe. The attacks of migraine +which are a frequent affection of delicate children whose puberty +occurs at the normal time, are a much earlier torment with children who +have early become addicted to bad practices. It is an anticipatory +effect upon the constitution, strictly analogous to the production of +the so-called "hysteria" in little girls under similar circumstances; +and I suppose there is no physician who has not once or twice, at least, +met with cases of the latter kind. The existence of any severe neuralgic +affection in a young child, if it cannot be traced to tuburcle or other +recognizable or organic brain-disease is _prima-facie_ ground for +suspicion of precocious sexual irritation; though, as Dr. Hillier's +cases show, it is occasionally produced otherwise. Usually, there are +other features which assist in the discovery of precocious sexualism, +when it exists; there is a morbid tendency to solitary moping, and a +moral change in which untruthfulness is conspicuous. + +3. _Neuralgias of the Middle Period of Life._--By this period is meant +the time included between the twenty-fifth and about the fortieth or +forty-fifth year. It is the time of life during which the individual is +subjected to the most serious pressure from external influences. The +men, if poor, are engaged in the absorbing struggle for existence, and +for the maintenance of their families; or, if rich and idle, are +immersed in dissipation, or haunted by the mental disgust which is +generated by _ennui_. The women are going through the exhausting process +of child-bearing, and supporting the numerous cares of a poor household, +in some cases; or are devoured with anxiety for a certain position in +fashionable society for themselves and their children; or again, they +are idle and heart-weary, or condemned to an unnatural celibacy. Very +often they are both idle and anxious. + +It must not be supposed that there is a sharp line of demarcation +between this period and the last; nevertheless, there are certain +well-marked differences, both in their general tendencies, and as +regards the local varieties which are commonest in each. We shall +discuss the latter point farther on. At present, it is interesting to +remark on the general freedom of the busy middle period of life from +first attacks of neuralgia. A person who has had neuralgia previously +may, and very likely will, during this epoch, be subject to recurrence +of the old affection under stress of exhaustion of any kind. But it is +very rare, in my experience, for busy house-mothers or fathers of +families to get first attacks of neuralgia during this period of life. +It is not the way in which a still vigorous man's nervous system breaks +down, if it breaks down at all. Men frequently do break down, of course, +at an age when their tissues generally are sound enough, and there is no +reason, except on the side of their nervous system, why they should not +remain in vigorous health for years. But it is greatly more common for +the nervous collapse to take the form of insanity, or hypochondriasis, +or paralysis, then that of neuralgia. If a man has escaped the latter +disease during the period when the growth of his tissues was active, it +is not very often that he falls a victim to it till he begins, +physiologically speaking, to grow old. + +4. _Neuralgias of Declining Bodily Vigor._--The period here referred to +is that which commences with the first indications of general physical +decay, of which the earliest which we can recognize (in persons who are +not cut off by special diseases) is perhaps the tendency to atheromatous +change in the arteries. The first development of this change varies very +considerably in date; but whenever it occurs it is a plain warning that +a new set of vital conditions has arisen, and especially notable is its +connection with the characters of the neuralgic affections which take +their rise after its commencement. The period of declining life is +pre-eminently the time for severe and intractable neuralgias. +Comparatively few patients are ever permanently cured who are first +attacked with neuralgia after they have entered upon what may be termed +the "degenerative" period of existence. I mentioned the existence of +commencing arterial degeneration as the special and most trustworthy +sign of the initiation of bodily decay; but it is needless to say that +this change is often not to be detected in its earliest stage. Something +has been done of late years, however, to render its diagnosis more easy. +Not to dwell upon the phenomenon of the arcus senilis, which though of a +certain value is confessedly only very partially reliable, we may +mention the sphygmographic character of the pulse as possessing a real +value in deciding the physiological status of the arterial system. There +is a well-known form of pulse-curve, square-headed, with marked +lengthening of the first or systolic portion of the wave, and with an +almost total absence of dicrotism, even when the circulation is rapid, +which will often seem to assure us that atheromatous change of the +arterial system has commenced, even when the physical characters of +inelastic artery are not to be recognized with the finger in any of the +superficial vessels by the touch of the finger. Indeed, the latter test +is in all cases far less reliable than the sphygmographic trace, except +when the arterial change has proceeded to a very marked degree of +development. + +To a certain extent, the presence or absence of gray hair is of value in +deciding whether physiological degeneration has begun. Like the arcus +senilis, however, this is only reliable when joined with other +indications, for it may be a purely local and separate change, having +nothing to do with the general vital status of the body. + +5. _Neuralgias which are immediately excited by Anaemia or +Mal-nutrition._--Of the neuralgic affections which can be reckoned in +this class, the sole characteristic worthy of note is the circumstances +in which they arise. It would seem that anaemia and mal-nutrition simply +aggravate the tendency of existing weak portions of the nervous system +to be affected with pain; just as they notoriously do aggravate lurking +tendencies to convulsion and spasm. It is very common, for instance, for +women to suffer severely from migraine, and other forms of neuralgia, +after a confinement in which they have lost much blood. According to my +own experience, however, those patients are generally, if not +invariably, found to have previously suffered more or less severe +neuralgic pain, at some time or other in their history, in the same +nerves which now, under the depressing influence of haemorrhage, have +become neuralgic. One of the very worst cases of clavus which I ever saw +happened after haemorrhage in labor; the pain was so severe and +prostrating that it appeared likely the patient would become insane. I +discovered, on inquiry, that this woman had been liable for many years +to headache affecting precisely the same region, on the occasion of any +unusual fatigue or excitement. + +There is, however, one variety of neuralgia from mal-nutrition which +deserves special consideration, viz., that which is occasionally +produced as an after-effect of mercurial salivation. I have only seen +one instance of this affection, but several are recorded. [Such, at +least, is my impression, but I have not been able to find the reports of +them.] My patient was a woman of somewhat advanced years when she first +came under my notice, but her malady had (though with long +intermissions) existed ever since she was a young girl in service. At +that early date she was severely salivated by some energetic but +misguided practitioner, for an affection which was called pleurisy, but +(according to her description) might well have been only pleurodynia, to +which servant girls are so very subject. At any rate, the consequences +of the medication were most disastrous. Not only did she then and there +lose every tooth in her head and suffer extensive exfoliations from the +maxillae, but after this process was over she began to suffer frightfully +from neuralgic pains in both arms and in both legs. Tonic medicines and +a change to sea-air brought about a tardy and temporary cure; but from +that moment her nervous system never recovered itself. Whenever she took +cold, or was over-fatigued, or depressed from any bodily or mental +cause, she was certain to experience a recurrence of the pains. At the +time of her application to me she was suffering from an attack of more +than ordinary severity, and which had lasted a long time without showing +any signs of yielding. She apparently could not find words to express +the acuteness of her sufferings. All along the course of the sciatic +nerve in the thigh, all down the course of the middle cutaneous and long +saphenous branches of the anterior crural, in the musculo-spiral, +radial, and the course of the ulnar nerves, and also, in a more +generalized way, in the gastrocnemii, in the soles of the feet, and in +the palms of the hands, the pains were of a tearing character, which she +described as resembling "iron teeth" tearing the flesh. The pains +recurred many times daily; her life was a perfect burden to her, and +always had been during these attacks. This patient was under my +observation, on various occasions, during several years, and I +established the fact that cod-liver oil always did very great good. But +it was evident that nothing would remove the tendency to the recurrence +of the pains. I should mention, as additional proof of the extent to +which the mercurial poison had shattered the nervous system of this +woman, that she had violent muscular tremors at the time of her first +attack, and on several subsequent occasions. A more completely ruined +life was never seen; the poor woman had been on the highway to promotion +in the service of a nobleman when she was mercurialized, but her whole +prospects were blighted by the serious danger to her health which was +caused by the preposterous antiphlogisticism of her medical attendant. + +I do not know that the poisonous action of any other metallic poison +than mercury has been distinctly shown to produce neuralgic pains of +superficial nerves. The action of lead is well known to produce colic, a +disease which will be specially dwelt on elsewhere. And undoubtedly a +certain amount of aching pain sometimes attends certain stages of +lead-palsy of the extensor muscles of the forearm. But I know of no +facts pointing to a true saturnine neuralgia. And the chronic poisonous +effects of arsenic on the nervous system seem to produce sensory +paralysis, rather than pain. + +We come now to the consideration of the local varieties of neuralgia. +The primary subdivision of them may be made as follows: + +I. Superficial Neuralgias. II. Visceral Neuralgias. + +I. SUPERFICIAL NEURALGIAS. + +Of superficial neuralgias a further classification may be made: + + (_a_) Neuralgia of the fifth (trigeminal, or trifacial). + (_b_) Cervico-occipital neuralgia. + (_c_) Cervico-brachial neuralgia. + (_d_) Intercostal neuralgia. + (_e_) Lumbo-abdominal neuralgia. + (_f_) Crural neuralgia. + (_g_) Sciatic neuralgia. + +This arrangement is that of Valleix, and appears to me substantially +correct. + +(_a_) _Neuralgia of the Fifth._--The most important group of neuralgias +are those of the fifth cranial nerve. + +Neuralgia of the fifth nerve always exhibits itself in the especial +violence in certain foci, which Valleix was the first to define with +accuracy. These foci are always in points where the nerve becomes more +superficial, either in turning out of a bony canal, or in penetrating +fasciae. In the ophthalmic division of the nerve the following possible +foci are noticeable: (1) The supra-orbital, at the notch of that name, +or a little higher, in the course of the frontal nerve; (2) the +palpebral, in the upper eyelid; (3) the nasal, at the point of emergence +of the long nasal branch, at the junction of the nasal bone with the +cartilage; (4) the ocular, a somewhat indefinite focus within the globe +of the eye; (5) the trochlear, at the inner angle of the orbit. + +In the superior maxillary division the following foci may be found: (1) +The infra-orbital, corresponding to the emergence of the nerve of that +name from its bony canal; (2) the malar, on the most prominent portion +of the malar bone; (3) a vague and indeterminate focus, somewhere on the +line of the gums of the upper jaw; (4) the superior labial, a vague and +not often important focus; (5) the palatine point, rarely observed, but +occasionally the seat of intolerable pain. + +In the inferior maxillary division the foci are: (1) The temporal, a +point on the auriculo-temporal branch, a little in front of the ear; (2) +the inferior dental point, opposite the emergence of the nerve of that +name; (3) the lingual point, not a common one, on the side of the +tongue; (4) the inferior labial point, only rarely met with. + +Besides these foci in relation with distinct branches of the trigeminus, +there is one of especial frequency which corresponds to the inosculation +of various branches. This is the parietal point, situated a little above +the parietal eminence. It is small in size--the point of the little +finger would cover it. It is the commonest focus of all. + +Neuralgia may attack any one, or all, of the three divisions of the +nerve; the latter event is comparatively rare. Valleix, indeed, holds a +different opinion; but this seems to me to arise from the fact that his +definition of neuralgia was too narrow to include a large number of the +milder cases of neuralgia, which are, nevertheless I believe, decidedly +of the same essential character with the severer affections. The most +frequent occurrence is the limitation of the pain to the ophthalmic +division, and incomparably the most frequent foci of pain are the +supra-orbital and the parietal. + +The most common variety of trigeminal neuralgia is migraine, or +sick-headache, as it is often called. This is an affection which is +entirely independent of digestive disturbances, in its primary origin, +though it may be aggravated by their occurrence. It almost always first +attacks individuals at some time during the period of bodily +development. Under the influences proper to this vital epoch, and often +of a further debility produced by a premature straining of the mental +powers, the patient begins to suffer headache after any unusual fatigue +or excitement, sometimes without any distinct cause of this kind. The +unilateral character of this pain is not always detected at first; but, +as the attacks increase in frequency and severity, it becomes obvious +that the pain is limited to the supra-orbital and its twigs, with +sometimes also the ocular branches. In rare cases, as in all forms of +neuralgia, the nerves of both sides may be affected; I have already +observed that this seems to be relatively more common in young children. +If the pain lasts for any considerable length of time, nausea, and at +length vomiting, are induced. This is followed at the moment by an +increase in the severity of the pain, apparently from the shock of the +mechanical effect; but from this point the violence of the affection +begins to subside, and the patient usually falls asleep. The history of +the attacks negatives the idea that the vomiting is ordinarily remedial. +This symptom merely indicates the lowest point of nervous depression; +but it may happen that a quantity of food which has been injudiciously +taken, lying as it does undigested in the stomach, may of itself greatly +aggravate the neuralgia, by irritation transmitted to the medulla +oblongata. In such a case vomiting may directly relieve the nerve-pain. +When the patient awakes from sleep, the active pain is gone. But it is a +common occurrence--indeed it always happens when the neuralgia has +lasted a long time--that a tender condition of the superficial parts +remains for some hours, perhaps for a day or two. This tenderness is +usually somewhat diffused, and not limited with accuracy to the foci of +greatest pain during the attacks. + +Sick headache is not uncommonly ushered in by sighings, yawning, and +shuddering--symptoms which remind us of the prodromata of certain graver +neuroses, to which, as we shall hereafter see, it is probably related by +hereditary descent. In its severer forms, migraine is a terrible +infliction; the pain gradually spreads to every twig of the ophthalmic +division; the eye of the affected side is deeply bloodshot, and streams +with tears; the eyelid droops, or jerks convulsively; the sight is +clouded, or even fails almost altogether for the time, and the darts of +agony which shoot up to the vertex seem as if the head were being split +down with an axe. The patient cannot bear the least glimmer of light, +nor the least motion, but lies quite helpless, intensely chilly and +depressed, the pulse at first slow, small and wiry, afterward more rapid +and larger, but very compressible. The feet are generally actually, as +well as subjectively, cold. Very often, toward the end of the attack, +there is a large excretion of pale, limpid urine. + +Another variety of trigeminal neuralgia which infests the period of +bodily development is that known as clavus hystericus: clavus, from the +fact that the pain is at once severe, and limited to one or two small +definite points, as if a nail or nails were being driven into the skull. +These points correspond either to the supra-orbital or the parietal, or, +as often happens, to both at once. But for the greater limitation of the +area of pain in clavus, that affection would have little to distinguish +it from migraine, for the former is also accompanied with nausea and +vomiting when the pain continues long enough; and in both instances it +is obvious that there is a reflex irritation propagated from the painful +nerve. The adjective hystericus is an improper and inadequate definition +of the circumstances under which clavus arises. The truth is, that the +subjects of it are chiefly females who are passing through the trying +period of bodily development; but there is no evidence to show that +uterine disorders give any special bias toward this complaint. Both +migraine and clavus are often met with in persons who have long passed +their youth; but their first attacks have nearly always occurred during +the period of development. + +One circumstance in connection with well-marked clavus appears worth +noting, as somewhat differentiating it from migraine. It is, I think, +decidedly more frequently the immediate consequence of anaemia than they; +but it does not appear, from my experience, that the chlorotic form of +anaemia is any more provocative of it than is anaemia from any other +cause. Some of the worst cases of clavus, probably, that have ever been +seen were developed in the old days of phlebotomy. It was then very +common for a delicate girl, on complaint of some stitch of neuralgia or +muscular pain in the side, to be immediately bled to a large extent, +with the idea of checking an imaginary commencing pleurisy. The +treatment, so far from curing the pain and the dyspepsia (which it +produced), often aggravated them; whereupon the signs of inflammation +were thought to be still more manifest, and more blood was taken. Under +such circumstances the most complete anaemia was developed, and very +often the patient became a martyr to clavus in its severest forms. One +does not now very frequently meet with the victims of such mistaken +practice; but I have seen one [since writing this I have seen another +case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus +produced by loss of blood (in a subject who was doubtless predisposed to +neuralgic affections, to judge from his family history). The case was +that of a boy who accidentally divided his radial. + +The middle period of life is not, according to my experience, fruitful +in first attacks of trigeminal neuralgia. But, when the neuralgic +tendency has once declared itself, there are many circumstances of +middle adult life which tend to recall it. Over-exertion of the mind is +one of the most frequent causes, especially when this is accompanied by +anxiety and worry; indeed, the latter has a worse influence than the +former. In women, the exhaustion of haemorrhageal parturition, or of +menorrhagia, and also the depression produced by over-suckling, are +frequent causes of the recurrence of a migraine or clavus to which the +patient had been subject when young. The middle period of life is very +obnoxious to severe mental shocks, which are more injurious than in +youth, because of the diminished elasticity of mind which now exists; +and the same may be said of the influence of severe bodily accident of a +kind to inflict damage on the central nervous system. Special mention +ought to be made, in the case of women, of the disturbing influence of +the series of changes which close the middle portion of their life, +viz., the involution of the sexual organs. It would seem as if every +evil impression which has ever been made on the nervous system hastens +to revive, with all its disastrous effects, at this crisis. Latent +tendencies to facial neuralgia are particularly apt to reassert their +existence, and they are usually accompanied and aggravated by a tendency +to vaso-motor disturbance, which not unfrequently seems to be the most +distressing part of the malady. I have several times been consulted by +women undergoing the "change," whose chief complaint was of disagreeable +flushings and chills, especially of the face; and, on inquiring further, +one has found that they were suffering from severe facial neuralgia, +which, however, alarmed and distressed them less than did the vaso-motor +disturbance, and the giddiness, etc., which were an evident consequence +of it. + +It is, however, the final or degenerative period of life which produces +the most formidable varieties of facial neuralgia. Neuralgia of the +fifth, which have previously attacked an individual, may recur at this +time of life without any special character, except a certain increase of +severity and obstinacy. But trigeminal neuralgias, which now appear for +the first time, are usually intensely severe, and nearly or quite +incurable. These cases correspond with the affection named by Trousseau +tic epileptiforme, and it is of them, doubtless, that Romberg is +speaking, when he says that the true neuralgias of the fifth rarely +occur before the fortieth year of life. These neuralgias are +distinguished by the intense severity of the pain, the lightning-like +suddenness of its onset, and the almost total impossibility of effecting +more than a temporary palliation of the symptoms. But they are also +distinguished by another circumstance which too often escapes attention, +namely, they are almost invariably connected with a strong family taint +of insanity, and very often with strong melancholy and suicidal +tendencies in the patient himself, which do not depend on, and are not +commensurate with, the severity of the pain which he suffers. It may +seem a strong view to take, but I must say that I regard a +well-developed and typical neuralgia, of the type we are now speaking +of, as an affection in which the mental centres are almost as deeply +involved as in the fifth nerve itself; though, whether this is an +original part of the disease, or a mere reflex effect of the affection +of the trigeminal nerve, I am not prepared to say. Other reflex +affections are common enough in this kind of facial neuralgia, and +especially spasmodic contractions of the facial muscles, which, indeed, +often form one of the most striking features of the malady, the attacks +of pain being accompanied by hideous involuntary grimaces. Even in the +earlier stages of the disease there is usually some degree of the same +thing, as, for instance, spasmodic winking. In the great majority of +cases, after a little time, exquisitely tender points are formed in the +chief foci of pain; in the intervals between the spasms the least +pressure on these points is sufficient to cause agony, and a mere breath +of wind impinging on them will often reproduce the spasm. Yet, in the +height of the acute paroxysm itself, the patient will often frantically +rub these very parts in the vain attempt to produce ease; and it has +often been noticed that such friction has completely rubbed off the hair +or whisker on the affected side: this happens the more easily, because +the neuralgic affection itself impairs the nutrition of the hair and +makes it more brittle, as we shall have occasion to show more fully +hereafter. The general appearance of a confirmed neuralgic of the type +now described is very distressing, and the history of his case fully +corresponds to it. He is moody and depressed, he dreads the least +movement, and the least current of air; he hardly dares masticate food +at all, more especially if the inferior maxillary division of the nerve +be implicated (as is generally the case sooner or later), for this +movement re-excites the pain with great violence. Nutrition is very +commonly kept up by slops, and is thus very insufficiently maintained: +this failure of nutrition is itself a decidedly powerful influence in +aggravating the disease. And there is a still further calamity which is +not unlikely to occur. The patient may fly to the stupefaction of drink +as a relief to his sufferings, and, if he has once experienced the +temporary comfort of drunken anaesthesia, is excessively likely to repeat +the experiment. But this is another and one of the most fatally certain +methods of hastening degeneration of nerve-centres, and the ultimate +effect, therefore, is disastrous in every way. + +Although the neuralgias of the degenerative period are thus fatally +progressive, on the whole, there are some curious occasional anomalies. +Many cases are recorded, and I have myself seen such, in which the +attacks of pain, after reaching a very considerable degree of intensity, +have ceased for many months, whether under the influence of remedies or +not it is difficult to say with certainty, but probably far more from +independent causes. Whatever may be the reason of these sudden arrests, +however, certain it is that they are very seldom permanent, the pain +returning sooner or later, like an inexorable fate. + +(_b_) _Cervico-occipital Neuralgia._--As Valleix has remarked, there are +several nerves (in fact, the posterior branches of all the first four +spinal pairs) which are more or less frequently the seat of this +affection. But among them all there is none comparable to the great +occipital, which arises from the second spinal pair, for the frequency +and importance of its neuralgic affections. This nerve sends branches to +the whole occipital and the posterior parietal region. On the other +hand, the second and third spinal nerves help to make up the superficial +cervical branch of the cervical plexus which is distributed to the +triangle between the jaw, the median line of the neck, and the edge of +the sterno-mastoid, and those to the lower part of the cheek. Then there +is the auricular branch, which starts from the same two pairs, and +supplies the face, the parotid region, and the back of the external ear. +Then the small occipital, distributed to the ear and to the occiput. +And, finally, superficial descending branches of the plexus. These, +altogether, are the nerves which at various points, where they become +more superficial, form the foci of cervico-occipital neuralgia. + +The most typical example of this form of neuralgia which has fallen +under my notice occurred (after exposure to cold wind) in a lady about +sixty years of age, who had all her life been subject to neuralgic +headache approaching the type of migraine, and who came of a family in +which insanity, apoplexy, and other grave neuroses, had been frequent. +The pain centred very decidedly in a focus corresponding to the +occipital triangle of the neck; it recurred at irregular intervals, and +in very severe paroxysms, lasting about a minute. It was interesting to +follow the history of this case in one respect. It afforded a clear +illustration of the manner in which local tenderness is developed; for +during the first three or four days the patient, so far from complaining +that the painful part was tender on pressure, experienced decided relief +from pressure, although she experienced none from mere rest, however +carefully the neck might be supported. But in the course of a few days +an intensely painful spot developed itself in the occipital triangle, +and the back of the ear became excessively tender. All manner of +remedies had been tried in this case, without the slightest success and +especially there was a large amount of speculative medication, on the +theory of the probably "rheumatic" or "gouty" nature of the affection. +Nothing was doing the least good to the pain, and meantime the old +lady's digestion and general health and spirits were suffering very +severely. Blistering was now suggested, and the affection yielded at +once. The relief afforded must have been very complete, to judge by the +warm gratitude which the patient expressed. The subsequent history of +this patient illustrates several points which will engage our attention +under the section of Pathology. It may be just mentioned here, that she +suffered, twelve months later, from a hemiplegic attack of paralysis. + +The tendency of cervico-occipital neuralgias is to spread toward the +lower portions of the face, as observed by Valleix; in this case they +become, sometimes, undistinguishable from neuralgias of the third +division of the trigeminus. In the early stages of the disease, if the +physician had been lucky enough to witness them, the true place of the +origin of the pain would have been easily recognizable; at a later date +it sometimes needs great care, and a very strict interrogation of the +patient, to discover the true history of the disease. Sometimes, even, a +cervico-occipital neuralgia which spreads in this way causes great +irritation and swelling of the submaxillary and cervical glands; and I +have known a case of this kind mistaken for commencing glandular +abscess. The pain and tension were so great in this case, and the +constitutional disturbance was so considerable, that the presence of +deep-seated pus was strongly suspected, and the propriety of an incision +(which would have been a hazardous proceeding) was seriously canvassed. + +Experience is too limited, to judge by what I have personally seen, and +the recorded cases with which I am acquainted, to enable us to say +anything with confidence of the conditions, as to age and general +nutrition of the body, which specially favor the occurrence of +cervico-occipital neuralgia. Apparently, however, there is much reason +for thinking that the immediately exciting cause of it is most +frequently external cold. I have known it produced several times in the +same person, by sitting in a draught which blew strongly on the back of +the neck. And I am inclined to think that it is seldom the first form of +neuralgia which attacks a patient, but usually occurs in those who have +previously suffered from neuralgic pains either of the trigeminus or of +some other superficial nerve. I have known it once to occur in a person, +thus predisposed to neuralgic affections, in consequence of reflex +irritation from a carious tooth, as was proved by its cessation on the +extraction of the latter, although there was no facial pain. + +(_c_) _Cervico-brachial Neuralgia._--This group includes all the +neuralgias which occur in nerves originating from the brachial plexus, +or from the posterior branches of the four lower cervical nerves. The +most important characteristic of the neuralgias of the upper extremity +is the frequency, indeed almost constancy, with which they invade, +simultaneously or successively, several of the nerves which are derived +from the lower cervical pairs. The neuralgic affections of the small +posterior branches (distributed to the skin of the lower and back part +of the neck) are comparatively of small importance. But the +"solidarite," which Valleix so well remarked, between the various +branches of the brachial plexus, causes the neuralgias of the shoulder, +arm, forearm, and hand to be extremely troublesome and severe, owing to +the numerous foci of pain which usually exist. Perhaps Valleix's +description of these foci is somewhat over-fanciful and minute; but the +following among them which he mentions I have repeatedly identified; (1) +An axillary point, corresponding to the brachial plexus itself; (2) a +scapular point, corresponding to the angle of the scapula. (It is +difficult to identify the peccant nerve here; the one to which it +apparently corresponds, and to which Valleix refers it, is the +subscapular; but we are accustomed to think of this as a motor nerve. +Still, it is certain that pressure on a painful point existing here will +often cause acute pain in the nerves of the arm and forearm.); (3) A +shoulder point, which corresponds to the emergence, through the deltoid +muscle, of the cutaneous filets of the circumflex; (4) a median-cephalic +point, at the bend of the elbow, where a branch of the musculo-cutaneous +nerve lies immediately behind the median-cephalic vein; (5) an external +humeral point, about three inches above the elbow, on the outer side, +corresponding to the emergence of the cutaneous branches which the +musculo-spiral nerve gives off as it lies in the groove of the humerus; +(6) a superior ulnar point, corresponding to the course of the ulnar +nerve between the olecranon and the epitrochlea; (7) an inferior ulnar +point, where the ulnar nerve passes in front of the annular ligament of +the wrist; (8) a radial point, marking the place where the radial nerve +becomes superficial, at the lower and external aspect of the forearm. +Besides these foci, there are sometimes, but more rarely, painful points +developed by the side of the lower cervical vertebrae, corresponding to +the posterior branches of the lower cervical pairs. + +The most common seat of cervico-brachial neuralgia has been, in my +experience, the ulnar nerve, the superior and inferior points above +mentioned being the foci of greatest intensity; an axillary point has +also been developed in one or two cases which I have seen. Rarely, +however, does the neuralgia remain limited to the ulnar nerve; in the +majority of cases it soon spreads to other nerves which emanate from the +brachial plexus. A very common seat of neuralgia is also the shoulder, +the affected nerves being the cutaneous branches of the circumflex. I am +inclined to think, also, that affections of the musculo-spiral, and of +the radial near the wrist, are rather common, and have found them very +obstinate and difficult to deal with. One case has recently been under +my care in which the foci of greatest intensity of the pain were an +external humeral and a radial point; but besides these there was an +exquisitely painful scapular point. In another case the pain commenced +in an external humeral and a radial point, but subsequently the shoulder +branches of the circumflex became involved. A most plentiful crop of +herpes was an intercurrent phenomenon in this case, or rather, was +plainly dependent on the same cause which produced the neuralgia. + +Median cephalic neuralgia is an affection which used to be comparatively +common in the days when phlebotomy was in fashion, the nerves being +occasionally wounded in the operation. I have only seen it in connection +with this cause, that is to say, as an independent affection. One such +case has been under my care. But a slight degree of it is not uncommon, +as a secondary symptom, in neuralgia affecting other nerves. The +traumatic form is excessively obstinate and intractable. + +In the neuralgias of the arm we begin to recognize the etiological +characteristic which distinguishes most of the neuralgic affections of +the limbs, namely, the frequency with which they are aggravated, and +especially with which they are kept up and revived when apparently dying +out, the muscular movements. In the case above referred to, of neuralgia +of the subscapular, musculo-spiral (cutaneous branches), and radial, the +act of playing on the piano for half an hour immediately revived the +pains, in their fullest force, when convalescence had apparently been +almost established. + +There is a special cause of cervico-brachial neuralgias which is of more +importance than, till quite lately, has ever been recognized, namely, +reflex irritation from diseased teeth. The subject of these reflex +affections from carious teeth has been specially brought forward by Mr. +James Salter, in a very able and interesting paper in the "Guy's +Hospital Reports" for 1867; and Mr. Salter informs me that he has been +surprised by the number of cases of reflex affections, both paralytic +and neuralgic, of the cervico-brachial nerves, produced by this kind of +irritation, and that he agrees with me in thinking that a peculiar +organization or disposition of the spinal centres of these nerves must +be assumed in order to account for the fact. + +The liability of particular nerves in the upper extremity to neuralgia +from external injuries requires a few words. The nerve which is probably +most exposed to this is the ulnar. Blows on what is vulgarly called the +funny-bone are not uncommon exciting causes of neuralgia in predisposed +persons, and cutting wounds of the ulnar a little above the wrist are +rather frequent causes. The deltoid branches of the circumflex and the +humeral cutaneous branches of the musculo-spiral are much exposed to +bruises and to cutting wounds. So far as I know, it is only when a nerve +trunk of some size has been wounded that neuralgia is a probable result. +Wounds of the small nervous branches in the fingers, for instance, are +very seldom followed by neuralgia. I have no statistics to guide me as +to the effect of long-continued irritation applied to one of these small +peripheral branches, but it is probable that that might be more capable +of inducing neuralgia. As far as my own experience goes, however, it +would appear that a more common result is convulsion of some kind, from +reflex irritation of the cord. + +(_d_) _Dorso-intercostal Neuralgia._--This is one of the commonest +varieties of neuralgia, and yet it is very likely to be confounded with +other affections not neuralgic in their nature. The disorder with which +it is especially liable to be confounded is myalgia, which will be fully +described in another chapter, and which, when developed in the region of +the body to which we are now referring, is commonly spoken of as +pleurodynia, or lumbago (according as it affects the muscles of the back +or of the side), or muscular rheumatism. It must be owned that the +severer forms of this affection can scarcely be distinguished from true +intercostal neuralgia by anything in the character or situation of the +pains. It will be seen, hereafter, however, that myalgia has its own +specific history, which is very characteristic; at present, it is +sufficient to remember that it is often extremely like neuralgia when +situated in the dorso-intercostal region. + +Dorso-intercostal neuralgia is an affection of certain of the dorsal +nerves. These nerves divide, immediately after their emergence from the +intervertebral foramina, into an interior and a posterior branch. The +latter sends filaments which pierce the muscles to be distributed to the +skin of the back; the former, which are the intercostal nerves, follow +the intercostal spaces. Immediately after their commencement they +communicate with the corresponding ganglia of the sympathetic. +Proceeding outward, they at first lie between two layers of intercostal +muscles, and, after giving off branches to the latter, give off their +large superficial branch. In the case of the seventh, eighth and ninth +intercostal nerves, which are those most liable to intercostal +neuralgia, the superficial branch is given off about midway between the +spine and the sternum. The final point of division, at which superficial +filets come off, in all the eight lower intercostal nerves, is nearer to +the sternum; and is progressively nearer to the latter in each +successive space downward. There are thus, as Valleix observes, three +points of division: (1) At the intervertebral foramen; (2) midway in the +intercostal space; (3) near to the sternum. And there are three sets of +branches (reckoning the posterior division) which respectively make +their way to the surface near to these points. + +In one of its forms, intercostal neuralgia is one of the commonest of +all neuralgic affections. I refer to the pain beneath the left mamma, +which women with neuralgic tendencies so often experience, chiefly in +consequence of over-suckling, but also from exhaustion caused by +menorrhagia or leucorrhoea, and especially from the concurrence of one +of the latter affections with excessive lactation. It is especially +necessary, however, to guard against mistaking for this affection a mere +myalgic state of the intercostal or pectoral muscles, which often +arises in similar circumstances with the addition of excessive or too +long continued exertions of these muscles. "Hysteric" tenderness also +sometimes bears a considerable resemblance, superficially, to true +intercostal neuralgia, in cases where the genuine disease does not +exist. + +A less common but very remarkable variety of intercostal neuralgia than +that just mentioned, is the kind of pain which attends a good many cases +of herpes zoster, or shingles. It is only of recent years that any +essential connection between zoster and neuralgia has been suspected. +The occurrence of neuralgia as a sequel to zoster had indeed been +mentioned by Rayer, Recamier, and Piorry, but the essential nature of +the connection between the two diseases was evidently not suspected by +Lecadre, when, as late as 1855, he published his valuable essay on +intercostal neuralgia. M. Notta was one of the first to present +connected observations on the subject. But it was much more fully +discussed in a paper published by M. Barensprung, in 1861. [_Ann. der +Charite-Krakenhauser zer Berlin, ix._, 2, p. 40. _Brit. and For. Med. +Rev._, January, 1862.] This author showed the absolute universality with +which unilateral herpes, wherever developed, closely followed the course +of some superficial sensory nerve, and gave reasons, which will be +discussed hereafter, for supposing that the disease originates in the +ganglia of the posterior roots, and that the irritation spreads thence +to the posterior roots in the cord, causing reflex neuralgia. We shall +have more to say on this matter. Meantime, it seems to be established, +by multiplied researches, that, though unilateral herpes may and often +does occur without neuralgia, and neuralgia without herpes, the +concurrence of the two is due to a mere extension of the original +disease, which is a nervous one. + +In young persons, zoster is not attended with severe neuralgia, but a +curious half-paretic condition of the skin, in which numbness is mixed +with formication, or with a sensation as of boiling water under the +skin, precedes the outbreak of the eruption by some hours, or by a day +or two. Painless herpes is commonest in youth. I remember, for instance, +that, in an attack of shingles which I suffered about the age of eleven, +there was at no stage any acute pain; only, in the pre-eruptive period, +for a short time, I had the curious sensations referred to above: and +the same thing has occurred in all the patients below puberty that I +have seen, if they complained at all. From the age of puberty to the end +of life, the tendency of herpes to be complicated with neuralgia becomes +progressively stronger. The course of events varies much in different +cases, however. In adult and later life the symptoms usually commence +with a more or less violent attack of neuralgic pain, which is +succeeded, and generally, though not always, displaced by the herpetic +eruption. The latter runs its course, and after its disappearance the +neuralgia may return, or not. In old people it almost always does +return, and often with distressing severity and pertinacity. Six weeks +or two months is a very common period for it to last, and in some aged +persons it has been known to fix itself permanently, and cease only with +life. In these subjects a further complication sometimes occurs. The +herpetic vesicles leave obstinate and painful ulcers behind them, which +refuse to heal, and which worry the patient frightfully, the merest +breath of air upon them sufficing to produce agonizing darts of +neuralgic pain. I have known one patient, a woman over seventy years of +age, absolutely killed by the exhaustion produced by protracted +suffering of this kind. + +The foci of pain in intercostal neuralgia are always found in one or +more of the points, already enumerated, at which sensory nerves become +superficial. In long-standing cases acutely tender points are developed +in one or more of these situations; not unfrequently the most decided of +these spots is where it gets overlooked, namely, opposite the +intervertebral foramen. H. G., a young woman aged twenty-six, who +applied to me at Westminster Hospital, had suffered for twelve months +from an irregularly intermitting but very severe neuralgia at the level +of the seventh intercostal space of the left side. The violence of the +pain was sometimes excessive, and when the paroxysm lasted longer than +usual it generally produced faintness and vomiting. This patient had no +sign of tenderness anywhere in the anterior or lateral regions, though +the pain seemed to gird round the left half of the chest as with an iron +chain, but an exquisitely tender spot, as large as a shilling, was found +close to the spine; pressure on this always induced a strong feeling of +nausea. + +As an illustration of the herpetic variety of dorso-intercostal +neuralgia, running a severe but not protracted course, I may relate the +case of a medical man whom I formerly attended. This gentleman was about +thirty-two years of age, and a highly neurotic subject: inter alia, he +had already suffered from a severe and protracted sciatica; and, very +shortly before the herpetic attack, had been jaundiced from purely +nervous causes. His nervous maladies were undoubtedly caused by +over-brain-work. In this case the neuralgia developed itself during the +latter half of the eruptive period, which was rather unusually +lengthened. It occupied the seventh, eighth, and ninth intercostal +spaces of the side affected with herpes, and was very violent and acute, +so that the patient expressed himself as almost "cut in two" with it. +The pain ceased even before the vesicles had perfectly healed; a rather +unusual occurrence in my experience. I shall refer to this case +hereafter, as an example of what I believe to be the effect of a +particular method of treatment in lessening the tendency to +after-neuralgia. The result of my experience is certainly this--that if +a case of herpes in an adult, or still more in an aged person, be left +to itself, the amount of after-neuralgia will very closely correspond +with the severity of the eruptive symptoms. + +There is a variety of intercostal neuralgia which is of more importance +than the commoner kinds. Occurring mostly in persons who have passed the +middle age, it possesses the characters of obstinacy and severity which +belong to the neuralgias of the period of bodily decay. It is at first +unattended with any special cardiac disturbance. By-and-by, however, it +begins to attract more careful attention from the fact that the severer +paroxysms extend into the nerves of the brachial plexus of the affected +side, so that pain is felt down the arm. In the midst of a paroxysm of +intercostal and brachial pain, it may happen that the patient is +suddenly seized with an inexpressible and deadly feeling of cardiac +oppression, and, in fact, the symptoms of angina pectoris, such as they +will be described in a future chapter, become developed. A case of this +kind is at present under my care at the Westminster Hospital. The +patient is a man only fifty-six years of age, but whose extreme +intemperance has produced an amount of general degeneration of his +tissues such as is rarely seen except in the very aged; he has the most +rigid radial arteries, and the largest arcus senilis, I think, that I +ever saw. This man has long been subject to attacks of violent +intercostal neuralgia, and a recent access assumed the type of +unmistakable angina. It is very probable that his coronary arteries have +now become involved in the degenerative process. In this case, before +the development of any marked anginal symptoms, the paroxysmal pain, +from being merely intercostal, had come to extend itself into the left +shoulder and arm. + +Intercostal neuralgia not unfrequently accompanies, and is sometimes a +valuable indication of, phthisis. I do not mean to say that the vague +pains in the chest-walls, which are so very common in phthisis, are to +be indiscriminately accounted neuralgia; on the contrary, they are, in +the large majority of instances, merely myalgic, and arise from the +participation of the pectorals, or intercostals, or both, in the +mal-nutrition which prevails in the organism generally. But it happens, +sometimes that a distinctly intermitting neuralgia occurs as an early +symptom of phthisis; in fact, where there is a predisposition to +neurotic affections, I believe that this is not very uncommon. The +subjects are generally women; they are mostly of that class of +phthisical patients who have a quick intelligence, fine soft hair, and a +sanguine temperament. I have had one male patient under my care: this +was a young gentleman aged eighteen, in whom a neuralgic access came on +with so much severity, and caused so much constitutional disturbance, +that the idea of pleurisy was strongly suggested. The paroxysms returned +at irregular intervals for a considerable period: they were quite +unlike myalgic pains, not only in their character, but more especially +with respect to the circumstances which were found to provoke their +recurrence. They were the first symptoms which lead to any careful +examination of the chest; it was then found that there were prolonged +expiration and slight dulness, at one apex. At this period, wasting had +not seriously commenced; but, on the other hand, there was an +extraordinary degree of debility for so early a stage of phthisis. I am +inclined to think that self-abuse was the principal cause both of the +phthisis and the neuralgia, acting doubtless on a predisposed organism, +for his family was rather specially beset with tendencies to +consumption. I may add here, that it has appeared to me that young +persons with phthisical tendencies are specially liable to neuralgic +affections as a consequence of self-abuse. + +A special variety of intercostal neuralgia is that which attacks the +female breast. The nerves of the mammae are the anterior and middle +cutaneous branches of the intercostals; and they are not unfrequently +affected with neuralgia, which is sometimes very severe and intractable. +Dr. Inman has very properly pointed out that a large number of the cases +of so-called "hysterical breast" are really myalgic, and are directly +traceable to the specific causes of myalgia; but there is no question in +my mind that true neuralgia of the breast does occur, and indeed is +frequent, relatively to the frequency of neuralgias generally. There are +several kinds of circumstances under which it is apt to occur. In +highly-neurotic patients it may come on with the first development of +the breasts at puberty; and it may be added that this is especially apt +to occur where puberty has been previously induced by the unfortunate +and mischievous influences to which we had occasion to refer in speaking +of certain other neuralgiae. A neuralgia of the left breast occurred in a +patient of mine, who attended the Westminster Hospital. She was only +twelve years of age, and small of stature, but the mammae were +considerably developed. The face was haggard, there was an almost +choreic fidgetiness about the child, and a very unprepossessing +expression of countenance; the result of inquiries left no doubt that +the patient was much addicted to self-abuse; and it seemed probable that +to this was due the fact that menstruation had come on, and was actually +menorrhagic in amount. + +A very painful kind of mammary neuralgia is experienced by some women +during pregnancy; but more commonly the mammary pains felt at this +period are mere throbbings, not markedly intermittent in character, and +plainly dependent on mechanical distention of the breast: such +affections are not to be reckoned among true neuralgiae. A true neuralgia +of a very severe character is sometimes provoked by the irritation of +cracked nipples. I have seen a delicate lady, of highly-neurotic +temperament, and liable to facial neuralgia, most violently affected in +this way. Vain attempts had been made for several consecutive days to +suckle the infant from the chapped breast; when suddenly the most severe +dorso-intercostal neuralgia set in. The attacks lasted only a few +seconds each, but they recurred almost regularly every hour, and were +attended with intense prostration, and sometimes with vomiting. +Discontinuance of suckling was found necessary, for even the application +of the child to the sound breast now sufficed to arouse a paroxysm of +pain. Complete rest, protection of the breast from air and friction, and +the hypodermic injection of morphia, rapidly relieved the sufferer. + +(_e_) _Dorso-lumbar Neuralgia._--The superficial branches of the spinal +nerves emanating from the lumbar plexus are considerably less liable to +be affected with severe and well-marked neuralgia than are the +dorso-intercostal nerves. Pains in the abdominal walls, which are a good +deal like neuralgia, are not uncommon; but the majority of them will be +found, on careful observation, to be myalgia. At least, this has been +the case in my own experience. + +When true neuralgia of the superficial branches of the lumbo-abdominal +nerves occurs, it develops itself in one or more of the following foci: +(1) Vertebral points, corresponding to the posterior branches of the +respective nerves; (2) an iliac point, about the middle of the crista +ilii; (3) an abdominal point, in the hypogastric region; (4) an inguinal +point, in the groin, near the issue of the spermatic cord, whence the +pain radiates along the latter; (5) a scrotal or labial point, situated +in the scrotum or in the labium majus. + +Such is the description given by Valleix; for my own part, I cannot say +that I have seen enough cases to test its accuracy. I believe it to be +generally correct, yet it may fairly be doubted whether the author might +not have revised his description had the natural history of myalgic +affections been as carefully investigated as it has since been. The +hypogastric foci of pain of which he speaks are at least open to +considerable suspicion, as it will be shown, in the chapter on Myalgia, +that an extremely common variety of the latter affection is situated in +this region, and the severity of the pain which it often produces might +well cause it to be mistaken for a genuine neuralgia. + +I have, however, seen three or four cases in which the very complete +intermittence of the paroxysms, without any perceptible relation to the +question of muscular fatigue, left no doubt in my mind of the really +neuralgic character of the malady. In one of these instances, oddly +enough, the exciting cause appeared to be fright; and this was as severe +a case as one often sees. The patient was a woman of middle age, and +much depressed by the long continuance of a profuse leucorrhoea. As +she was walking along the street, a herd of cattle, in a somewhat +irritable and disorderly condition, came suddenly toward her; she +immediately began to suffer pain just above the crest of the ilium, and +at the lumber region, and, most acutely, in the labium majus of one +side; and then pain returned daily, about 10 A. M., lasting for half an +hour with great severity. This woman's family history was remarkable: +her mother had been paraplegic, her sister was a confirmed epileptic, +and two of her children had suffered from chorea. + +In two other cases of lumbo-abdominal neuralgia which were under my +care, there were also very painful points in the spermatic cord and in +the testicle. One of these cases will be referred to under the head of +Visceral Neuralgia. Another case, in which severe quasi-neuralgic pain +was referred to the groin, will be described in the chapter on the Pains +of Hypochondriasis. + +(_f_) _Crural Neuralgia._--This appears to be rare as an independent +affection occurring primarily in the crural nerve. Valleix had only seen +it twice in all his large experience, and I have never seen it myself. +Neuralgic pain of the crural nerve is almost always a secondary +affection arising in the course of a neuralgia, which first shows itself +in the external pudic branch of the sacral plexus; or else occurring as +a complication of sciatica. A remarkably severe example of the latter +occurrence was observed in an old man who still occasionally attends the +Westminster Hospital. He has been a martyr to the most inveterate +bilateral sciatica for between two and three years; and, within the last +three months, it has extended itself into the cutaneous branches of the +curval nerves of both thighs. So great an aggravation of the pain is +produced by any muscular movement, that the patient can only walk at the +slowest possible pace, moving each foot forward only a few inches at a +time. The bilateral distribution of the pain is remarkable in this case; +but there can be no doubt of its really neuralgic character, from the +truly intermittent way in which it recurs, and the absence of any +history whatever to point in the direction of rheumatism, gout, or +syphilis. + +The nervous supply to the skin of the anterior and external portion of +the thigh includes: (1) The middle cutaneous, (2) the internal +cutaneous, and (3) the long saphenous branch of the anterior crural +nerve; (4) the cutaneous branch of the obturator; and (5) the external +cutaneous nerve, derived from the loop formed between the second and +third lumbar nerve. The sensitive twigs derived from the two latter +sources, equally with the branches of the anterior crural, are liable to +be secondarily affected by neuralgia, which commences in the +lumbo-abdominal nerves; but it must be a rare event for them to be the +seat of a primary neuralgia. The only occasion on which I have seen +anything which looked like the latter was in the case of a porter, who, +in straining to lift a very heavy load, ruptured some part of the +attachment of the tensor vaginae femoris. But the susceptibility of all +the nerves of the front of the thigh to secondary or reflex neuralgia +receives numerous illustrations. The extremely severe pain at the +internal aspect of the knee-joint, which is such a common symptom in +morbus coxae, is evidently a reflex neuralgia of the long saphenous +nerve, the ultimate irritation being situated in the branches of the +obturator nerve which supply the hip-joints. For some reason +unexplained, it happens that this saphenous nerve is specially liable to +be affected in a reflex manner: for instance, this happens in a +considerable number of cases of sciatica. I have a lady now under my +observation, in whom the secondary neuralgia of the saphenous nerve has +become even more intolerable than the pain in the sciatic, which was the +nerve primarily affected. The pain in these cases very frequently runs +down the inner and anterior surface of the leg to the internal ankle. +Sometimes the branches of the anterior crural become the seat of +intensely painful points in the course of a long-persisting sciatica. A +patient at present under my care has a spot, about the size of a +shilling, just at the emergence of the middle cutaneous branch from the +fascia lata, which is intensely and persistently tender to the touch, +and the skin here is so exquisitely sensitive to the continuous galvanic +current that the application of moistened sponge-conductors, with a +current of only fifteen Daniell's cells, causes intolerable burning +pain; whereas at every other part of the limb the current from +twenty-five cells can be borne without much inconvenience. + +(_g_) _Femoro-popliteal Neuralgia, or Sciatica._--This is one of the +most numerous and important groups of neuralgia; but, notwithstanding +that there are plenty of opportunities for studying it, I venture to +think it is very commonly mistaken for different and non-neuralgic +diseases, and they for it. The rules of diagnosis which will be laid +down for all the neuralgiae would nevertheless prevent these errors, if +carefully attended to. + +Sciatica is a disease from which youth is comparatively exempt. Valleix +had collected one hundred and twenty-four cases, and in not one was the +patient below the age of seventeen, only four were below twenty. In the +next decade there were twenty-two; in the next, thirty; and the largest +number of cases, thirty-five, occurred between the ages of forty and +fifty. This completely tallies with my own experience, and appears to +afford some support to a suspicion I have formed, that the chief +exciting cause of sciatica is the pressure exercised on the nerve in +locomotion, and that this cause exercises its maximum influence when the +period of bodily degeneration commences. It is further remarkable that, +in elderly persons (whose habits of locomotion are of course more +limited), the proportion of fresh cases rapidly diminishes; and also +that above the age of thirty the number of male patients greatly exceeds +that of female patients attacked. All this seems to point in the same +direction. + +According to my observation, there are three distinct varieties of +sciatica. The first of these is obscure in its origin, but may be said, +in general terms, to be connected with a nervous temperament of the +highly impressible kind, which is more or less like what we call +"hysteric," not only in the female, but also in male patients. The +subjects of this kind of sciatica are mostly young persons, and hardly +ever more than middle-aged; they are generally found to be liable to +other forms of neuralgia; and the actual attack of sciatica is produced +by some fatigue or mental distress, which at other times might have +brought on sick headache, or intracostal neuralgia, etc. Very many of +these patients are anaemic; and chlorotic anaemia seems specially to favor +the occurrence of the affection. The greater number of the victims are +females, and in very many, whether as cause or effect, there is impeded, +or at least imperfect, menstruation. This kind of sciatic pain is not +usually of the highest degree of intensity, but it generally spreads +into a great many branches, both in a direct and a reflex manner. It is +probable that this variety of the disease is, at least very often, +dependent upon, or much aggravated by, an excited condition of the +sexual organs; certainly, I have observed it with special frequency in +women who have remained single long after the marriageable age, and in +several male patients there has been either the certainty or a strong +suspicion of venereal excess. Sciatica of this kind also occurred in the +case of a single woman aged about thirty, who to my knowledge was +excessively addicted to self-abuse. + +The second variety of sciatica occurs for the most part in middle-aged +or old persons who have long been subject to excessive muscular +exertion, or have been much exposed to damp and cold, or who have been +subject to the combined influence of both these kinds of evil influence. +One must also include, I think, in this group a considerable number of +cases where the age is not so advanced, but the patient has been +obliged, by the nature of his business, to maintain the sitting posture +daily, for hours together, exercising pressure on the nerve; this is +especially liable to happen in these persons. + +The sufferers from this variety of sciatica are mostly, as already said, +of middle age or more; but this statement must be understood to be made +in the comparative sense, which refers rather to the vital status of the +individual than to the mere lapse of years. Many of these people have +hair which is prematurely gray, and in some the existence of rigid +arteries, together with arcus senilis, completes the picture of organic +involution, or senile degeneration. In particular cases, where +depressing influences have been at work for a long time, or unusually +active, these appearances rectify the false impression we should +otherwise derive from learning the mere nominal age of the person; this +is especially often the case with regard to patients who have for a long +time drunk to excess. The prematurely and permanently gray hair (it will +be seen hereafter that permanency of grayness is an important point), +together with well-marked inelasticity of arteries, very often tells a +tale which is most useful in informing us, not only of the vital status +of the patient, but of the kind of sciatica under which he labors; and +also influences our prognosis seriously. There is otherwise a somewhat +deceptive air about the appearance of many of these degenerative cases; +for instance, a ruddy complexion is not uncommon, nor the retention of +considerable, or even great, muscular strength. It is probable that +these appearances deceived Valleix and many others, or they could hardly +have failed, as they have, to observe the frequency of the degenerative +type among the most numerous group of sciatic patients, namely, those +between thirty and fifty years of age. These persons are not truly +"robust," although at a hasty glance they might at first seem to be so. +It would be a serious mistake to omit the search for the important vital +evidences which have been referred to, since these therapeutic and +prognostic indications are of the highest value. + +A prominent feature in this kind of sciatica is its great obstinacy and +intractability. Another, equally marked, is the tendency to the +development of spots around the foci of severest pain which are +intensely and permanently tender, and the slightest pressure on which is +sufficient to set up acute pain. This is a symptom much less developed, +if developed at all, in the variety of sciatica which we first +discussed. The places which are especially apt to present this +phenomenon of tenderness are as follows: (1) A series, or line of +points, representing the cutaneous emergence of the posterior branches, +which reaches from the lower end of the sacrum up to the crista ilii; +(2) a point opposite the emergence of the great and small sciatic nerves +from the pelvis; (3) a point opposite the cutaneous emergence of the +ascending branches of the small sciatic, which run up toward the crista +ilii; (4) several points at the posterior aspect of the thigh, +corresponding to the cutaneous emergence of the filets of the crural +branch; (5) a fibular point, at the head of the fibula, corresponding to +the division of the external popliteal; (6) an external malleolar, +behind the outer ankle; (7) an internal malleolar. + +I have already mentioned that in sciatica the pain frequently spreads in +a reflex manner to nerves which are connected, by their origin from the +plexus, with the sciatic. It will be remembered, also, that I related +cases in which the formation of tender points, in the course of the +nerves thus secondarily affected, was even more distinct and remarkable +than anywhere in the branches of the sciatic itself. + +Another circumstance which distinguishes the form of sciatica which we +are now describing is, the degree in which (above all other forms of +neuralgia) it involves paralysis of motion. [The subject of the +complication of neuralgia will be treated in a general manner farther +on; but it seems necessary to note here the special liability of sciatic +patients to this and to the most material complications]. By far the +largest part of the motor nervous supply for the whole lower limb passes +through the trunk of the great sciatic; it might therefore be naturally +expected that a strong affection of the sensory portion of the nerve +would produce, in a reflex manner, some powerful effect upon the motor +element. This effect is most frequently in the direction of paralysis. +Complete palsy is rare, but in a large proportion of cases which have +lasted some time there will be found, independently of any wasting of +muscles, a positive and considerable loss of motor power. It is of +course necessary to avoid the fallacy which might be produced by +neglecting to observe whether movement was restricted merely in +consequence of its painfulness. Not long since, I had occasion to test +the electric sensibility in a case of sciatica, in which there was +extremely severe pain, affecting chiefly the peroneal region of the leg, +and great weakness of the leg, amounting to inability for walking. The +gastrocnemius could hardly be got to contract at all, when the most +powerful Faradic current was directed upon the nerve in the popliteal +space of the affected limb, though the muscle of the sound side reacted +with great vigor. + +_Anaesthesia_ is also a common complication of sciatica, far commoner, I +venture to think, than it has been represented either by Valleix, or +Notta. It is necessary, however, to be explicit on this point. In the +early stages, both of this form of sciatica, and of the milder variety +previously described, there is almost always partial numbness of the +skin previous to the first outbreak of the neuralgic pain, and during +the intervals between the attacks. By degrees this is exchanged, in the +milder form, for a generally diffused tenderness around the foci of +neuralgic pain, while other portions of the limb remain more or less +anaesthetic. In the severer forms it sometimes happens that, besides an +intense tenderness of the skin over the painful foci, there is diffused +tenderness over the greater part or the whole of the surface of the +limb. But it is important to remark that both in the anaesthetic and the +hyperaesthetic conditions (so called) the tactile sensibility is very +much diminished. I have made a great many examinations of painful limbs, +in sciatica, and have never failed to find (with the compass points) +that the power of distinctive perception was decidedly lowered. + +_Convulsive movements of muscles_ are met with in a moderate proportion +of cases of sciatica in middle and advanced life, in which affection +they are entirely involuntary. They differ from certain spasmodic +movements not unfrequently observed in the milder form (and especially +in hysteric women), for these are more connected with morbid volition, +and are in truth, not perfectly involuntary. In several cases of +inveterate sciatica I have seen violent spasmodic flexures of the leg +upon the thigh. Cramps of particular muscles are occasionally met with. +I have seen the flexors of the toes of the affected limb violently +cramped, and in one case there was agonizing cramp of the gastrocnemius. +It is chiefly at night, and especially when the patient is falling +asleep, that this kind of affection is apt to occur. + +A third variety of sciatica is the rather uncommon one so far as my +experience goes, in which inflammation of the tissues around the nerve +is the primary affection, and the neuralgia is mere secondary effect, +from mechanical pressure on the nerve, which, however, is not apparently +itself inflamed. I believe that these cases are sometimes caused by +syphilis, and sometimes by rheumatism. One of the most violent attacks +of sciatic pain which ever came under my notice was in a syphilized +subject, a discharged soldier, who had been the victim of severe +tertiary affections, and had been mercilessly salivated into the +bargain. This unfortunate man suffered dreadful agony, which was +aggravated every night, but was never totally absent. The pain started +from a point not far behind the great trochanter: pressure here caused +intolerable darts of pain, which ramified into every offshoot of the +sciatic nerve, as it seemed, and made the man quite faint and sick. +Large doses of iodide of potassium, together with the prolonged use of +cod-liver oil, completely removed the pain and tenderness. It need +hardly be said that cases of this kind are essentially different, and +require perfectly different principles of treatment from neuralgias in +which the disturbance originates within the nervous tissues themselves. + +The chronic rheumatism does also, occasionally, affect the sheath of the +nerve in such a manner as to produce a deposit which sets up neuralgic +pain, must also be admitted, although I believe the number of such cases +to be preposterously over-estimated by careless observers. It has +several times happened that a patient has come under my care with +so-called "rheumatic affection of the nerves" of the thigh and leg, and +that on examination one has found all the symptoms and clinical history +of a neurosis, but not the slightest valid argument for a diagnosis of +the rheumatic diathesis. Indeed, upon this point, I think it is time +that a decided opinion should be expressed. I firmly believe that a +large number of sciatic patients have their health ruined by treatment +directed to a supposed rheumatic taint which is purely imaginary. The +state of medical reasoning, suggested by the way in which too many +practitioners decide that such and such pains are rheumatic in their +origin, is a melancholy subject for reflection. Nearly always it will be +found, on cross-examination, that the state of the urine has been made +the basis of a confident diagnosis; the practitioner will tell you that +the urine was loaded, _i. e._, with lithtaes. He ignores the fact that +nothing is more common, in neurotic patients who are perfectly guiltless +of rheumatic propensities, than a fluctuation between lithiasis and +oxaluria, neither of which phenomena, under the circumstances, indicates +any more than a temporary defect of secondary assimilation of food, +produced by nervous commotion. I may perhaps find room, on a future +page, for a few further remarks on the subject; at present I only put in +a caution against too ready an acceptance of the rheumatic hypothesis. + +II. VISCERAL NEURALGIAS. + +_Uterine and Ovarian Neuralgia._--This is an important group of +neuralgic affections, and one which I cannot help thinking is strangely +misappreciated, very often, in a therapeutic point of view. In one +aspect these affections possess a special interest, namely this, that +they are more frequently dependent on peripheral irritation for their +immediate causation than any other group of neuralgias. If we consider +the great copiousness of the nervous supply to the uterus and ovaries, +and the powerfully disturbing character of the functional processes +which are periodically occurring in these organs, we shall be at no loss +to understand how this may be. The amount force of the peripheral +influence and which are brought to bear upon the central nervous system +by the functions of the uterus and ovaries are greater than any that +emanate from the diseases and functional disturbances of any other organ +in the body. + +The most common variety of peri-uterine neuralgia is that which attends +certain kinds of difficult menstruation. It would be hardly correct to +give the name of neuralgia to the pain existing in these very numerous +cases of dysmenorrhoea in which the suffering is apparently altogether +dependent on the mere retention or difficult escape of the menstrual +fluid, although the character of the pain often resembles the neuralgic +type. There is another group of dysmenorrhoeal affections however, in +which the pain may fairly be called neuralgic, since it is apparently +independent of the circumstances of the discharge of menstrual fluid, +and simply attends the process, seemingly on account of a +naturally-exaggerated irritability of the organs concerned. There is a +large class of young women in whom, and more especially before marriage, +the time of menstruation is always marked by the occurrence of more or +less severe pain. Formerly I used to believe that this pain was relieved +on the occurrence of the discharge, but I have seen too many cases of a +contrary nature to retain this opinion. I now believe that the subjects +of the kind of menstrual pain to which I am referring are naturally +endowed with a very irritable nervous apparatus of the pelvic organs, +and that there is a certain character at once of immaturity and +excitability in their sexual organs, especially in the virgin condition. +So far from these females being disposed to sterility, as is too often +the case with those dysmenorrhoeal subjects whose troubles depend upon +occlusion, distortion, or narrowing of the outlets, they are often +extremely apt to the generative function; and, what is more, the full +and natural exercise of the sexual function appears necessary to the +health of their organs, as is shown by the fact that these menstrual +pains lose their abnormal character, completely or in great part, after +marriage, and especially after child-bearing. The contrast between the +two types of dysmenorrhoeal patients is sharply brought out by the two +following cases: + +CASE I.--S. M., a housemaid, aged twenty-three when first under my +notice, was the picture of physical health and strength, very +intelligent, and a girl of excellent character and most industrious +habits. At every menstrual period, however, she suffered, for some hours +previously to the occurrence of the flow, from severe pain in the +uterine region, which was tumefied and tender. Hot hip-baths gave some +relief, apparently by hastening the discharge; as soon as the latter was +established, the pain rapidly subsided. This young woman married a +healthy and vigorous young man, but has never had any children, and at +the date of my last inquiries still suffered periodically from her old +troubles. + +CASE II.--Mrs. B. was married at the age of twenty-six. Up to the date +of her marriage she used to suffer the most severe pain at every +menstrual period; the pain, however, bore no relation to the freedom of +the discharge, but always lasted about the same length of time, under +any circumstances, or was only less or more according as the general +bodily vigor was greater or less at the moment. From the date of +marriage these troubles steadily declined; a child was born at the end +of twelve months, and the menstrual troubles have never resumed a +serious shape up to the present time, a period of nearly nine years. +This lady is herself a neuralgic subject, liable to migraine in +circumstances of fatigue, and suffering horribly from it during her +pregnancies; and she comes of a family in whom the nervous temperament +is strongly developed. + +It must not always be concluded, because the menstrual pain is very +severe before the discharge and is relieved at or soon after its +appearance, that the case is one of occlusion, and not of neuralgia. +There is a class of cases in which the affection appears to be a very +severe ovarian neuralgia, attended with a vaso-motor paralysis which +causes great engorgement of the ovary and consequent difficulty of +"ovulation." I have seen several instances which I could not explain in +any other way. + +CASE III.--One patient I particularly remember, from the fact that she +was always attacked with dreadful pain, which was sometimes seated in +one groin and sometimes in the other, but was regularly attended with +large and palpable tumefaction of the ovary, which began to subside when +the discharge commenced. This woman married rather late, but her +menstrual troubles immediately became less, and she became pregnant and +was happily delivered, nearly as soon as was possible. She, too, was a +decidedly neuralgic subject, independently of her tendency to +dysmenorrhoeal ovarian pain. + +In some women who remain single long after the marriageable age, ovarian +or uterine neuralgia becomes a constantly-recurring torment, not only at +the menstrual period, but at various other times when they are depressed +or fatigued in body or mind. As might be expected, this tendency is +greatly aggravated in the rarer cases where the patient's mind dwells in +a conscious manner on sexual matters, especially if by an evil chance +she becomes addicted to self-abuse. Among the many reproaches that have +been thrown upon the indiscriminate use of the speculum in examining +unmarried women, it has often been urged that it tends to excite sexual +feelings. I do not for a moment doubt that this is the case, or that the +indiscriminate use of the instrument is altogether indefensible. But I +expect that neuralgic pain of the uterus or ovaries, in unmarried women, +connected with an already irritable condition of the sexual organs, has +often been the reason why such women have applied for advice and have +consequently been examined with the speculum; and that the same thing +has frequently happened in the case of women who have been left widows +at a time of life when the sexual powers were still in full vigor. These +patients deserve great pity. + +The peripheral irritation which gives rise to peri-uterine neuralgia is +not always originally seated in the organs of generation. The following +are various sources of external irritation which I have known to produce +the affection: + +1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman, +aged thirty-four, single, was under my care in King's College Hospital +many years ago, under suspicions of ulcerated cervix. On examination, no +lesion could be detected. It was discovered that the rectum was infested +with ascarides, and, after the use of appropriate vermifuges and tonics, +the patient entirely lost the uterine pains and also a tormenting +pruritus vaginae, from which she suffered. This woman had at various +times suffered from neuralgic headache a good deal. + +2. Profuse and intractable leucorrhoea, whether associated or not with +ulceration of the cervix, may produce peri-uterine neuralgia, even of +great severity, when there are strongly-marked neurotic tendencies. It +must be noted, however, that many cases of pain in leucorrhoeal +subjects, which superficially bear the aspect of neuralgia, turn out on +closer investigation to be merely examples of myalgia of the abdominal +muscles or aponeuroses. + +3. Calculus in the kidney, or in the ureter, sometimes causes +intolerable ovarian neuralgia. In the case of a woman who was under my +care at the Chelsea Dispensary, some years ago, this was the unsuspected +origin of severe neuralgic pains in the left ovary, which recurred +several times a day, and which certainly contributed to the patient's +death by the exhaustion which they produced. A calculus was found +tightly impacted in the ureter, near the kidney. + +4. Prolapsus uteri sometimes gives rise to severe peri-uterine +neuralgia, or what appears to be such; though it is difficult here to +draw the line between neuralgia and myalgia. The commonest kind of pains +from prolapsus uteri are not neuralgic in their nature at all, but are +of a "bearing down" character, and probably depend upon actual +contractile movement of the walls of the uterus. + +5. The presence of tumors, either cancerous or fibroid, in the uterus or +its appendages, gives rise, frequently, to severe and indeed almost +intolerable pains of a distinctly intermittent character. In the early +stages of cancerous diseases these pains are usually felt at the lower +part of the back; in the later stages they are felt also in the +hypogastric region, and are then much more severe. + +6. Ulcer of the cervix, of a non-malignant kind, probably sometimes +gives rise to neuralgic pain of the uterus, though this is not so severe +as in cancer. + +7. Large masses of scybalous faeces, impacted in the rectum, will +occasionally, by the pressure which they exert on nerves, set up violent +neuralgia of uterus or ovaries, the true nature of which is accidentally +discovered by the use of aperients which unload the intestine and put an +end to the suffering. No doubt it is chiefly in persons with neuralgic +predisposition that this effect is produced; for, common as is the +occurrence of extreme constipation in women, it is comparatively very +rare for us to hear of distinctly neuralgic pain being caused by it. + +8. The condition known as "irritable uterus," ever since Gooch's +classical description of it, is always attended with uterine pain, which +is continuous, but is liable to periodical exacerbations of great +severity. In this disorder there is no recognizable physical disease of +the pelvic organs, and the patient will generally be found to have +suffered neuralgia in other parts of the body on previous occasions. +[There is some difference of opinion about this affection: some authors +(_e. g._, Hanfield Jones) considering it as distinct from the true +neuralgias.] + +9. Reflex irritation, the source of which is in some quite distant part +of the body, has in many recorded instances occasioned uterine +neuralgia, in highly-predisposed persons. I have seen one case in which +severe pain of this kind was clearly proved to have been excited by the +presence of a carious tooth which was itself little, if at all, painful, +but the removal of which at once cured the pelvic pain. + +Neuralgia of the urethra is an affection which is occasionally seen, +both in males and females. I have observed it three times; all these +cases were apparently traceable to the effects of excessive self-abuse. +The male subject was an unmarried man, aged forty-two, of cadaverous +appearance, much emaciated, with clammy, perspiring skin, and habitual +coldness of the extremities; he suffered much from dyspepsia and +palpitation of the heart. The pain ran along the under side of the +penis, which was very large, with an elongated prepuce. The paroxysms +were severe, and came on chiefly in the morning, soon after he awoke. No +remedies did this man any permanent good, and he passed out of my sight, +being at that time in a condition of wretched feebleness, and with +symptoms of threatened dementia. Of the female subjects, one was a +married woman, who accused her husband of impotence, and from her +account it would certainly appear that effective connection had never +taken place; the hymen was completely destroyed, however. The neuralgic +pains recurred nightly in several paroxysms, and were especially severe +about the time of the monthly periods. In this case the patient was, she +stated, induced to give up her malpractices; at any rate, the pain +subsided in a manner which could not be well accounted for by any direct +influence of the medicinal treatment. The other female patient was a +widow in whom the morbid habit was suspected from her general +appearance, and from the existence of enlarged clitoris and other signs +of irritation about the external parts: she became rather rapidly +phthisical, and suffered severely from neuralgic headaches. + +Neuralgia of the bladder has been specially described by various +writers; the pain is usually spoken of as seated at the neck of the +bladder, and as accompanied by frequent desire to micturate. I have seen +two cases, both in women: the first was eventually discovered to be an +instance of malignant disease of the fundus of the bladder; the other +was apparently the result of a long-continued menorrhoeal flux, which +had greatly impaired the health, and produced extreme anaemia. In neither +of these instances was the pain referred to the external meatus, as in +the female patients above mentioned who were suffering from urethral +neuralgia. I have never seen the extreme examples of vesical neuralgia +described by some writers, in which actual paralysis of the coats of the +bladder was secondarily produced; but the reflex influence of the +neuralgic affection in both the examples just mentioned appeared to +produce great weakening of the muscular power of the rectum, occasioning +most obstinate and troublesome constipation. + +It would appear, from recorded cases, that both the bladder and the +uterus are liable to be affected with neuralgia from malarious +influences; but I have never chanced to see any such cases. + +Neuralgia of the kidney is spoken of by several writers, and I suppose +there is no doubt that it may exist as a special neurotic disease with +obvious organic cause. For my own part, I cannot say that I have ever +seen it except in instances where there was either the certainty, or a +very strong suspicion, that the cause was the mechanical pressure and +irritation of a calculus within the kidney. The diagnosis of the simple +functional disorder must be excessively perplexing; for in the first +place there is the greatest difficulty in making sure that the pain is +not external, and seated either in the muscles of the back, or in the +superficial dorsal or lumbar nerves, and certainly I am strongly +inclined to suspect that this has been really the case in many examples +of so-called renal neuralgia. That neuralgia of the kidney may arise +secondarily, as a reflex extension of pelvic neuralgia, does, however, +appear probable enough; for it is almost certain that in the latter +affection at least, the vaso-motor nerves of the kidneys must be +strongly influenced in a reflex manner; since the crisis or acme of a +paroxysm of pelvic pain is not unfrequently attended with a copious +secretion of pale urine. + +Neuralgia of the rectum has been carefully described by Mr. Ashton, but +is probably not often seen except by practitioners who possess special +opportunities of observing rectal diseases. In the one pure case which +has fallen under my notice the patient complained of acute paroxysmal +cutting pains extending about one inch within the anus, and, as these +were greatly increased by defecation I suspected the existence of +fissure. Nothing of the kind, however, was found on examination; and the +pain ultimately yielded to repeated subcutaneous injections of atropine. +This patient had got wet through, and had sat in his damp clothes, +getting thoroughly chilled; the pain came on with great suddenness and +severity, and the tenderness which has been mentioned was developed very +quickly. Probably the influence of cold and wet is among the commonest +causes of the complaint. Mr. Ashton also reckons as causes, reflex +irritation from other parts of the alimentary canal, and the influence +of malaria. He observes that the subjects of the affection are most +frequently anaemic, and of a generally excitable and deranged +susceptibility, and that females, who, from menorrhagia, or frequent +child-bearing with much haemorrhage, have lost a great deal of blood, are +specially predisposed. + +Neuralgia of the testis (as an independent affection and not a mere +extension of lumbo-abdominal neuralgia) is fortunately a much less +common malady than the corresponding affection of the ovary; as might +indeed be expected, from the much less degree of functional perturbation +to which, in ordinary physiological circumstances, the former organ is +exposed than the latter. Except from actual growths within the testis, +of which it was a mere symptom, I have never seen neuralgia of the +testis save from one of three causes. In one remarkable example it was +produced as a reflex effect of severe herpes preputialis. Secondly, it is +sometimes observed as a symptom of calculus descending the ureter. And, +thirdly, I have seen it several times undoubtedly produced by excessive +self abuse. + +The occurrence of testicular neuralgia, in one case of epilepsy, as to +the cause of which I had been previously much puzzled, led to the +discovery of the real origin of the fits. I should observe here that I +do not believe that self-abuse is ever more than an immediately exciting +cause of epilepsy, a predisposition to the disease having previously +existed in all cases. In the patient just referred to, there was a +family history of epilepsy, but it was difficult to explain the exciting +cause until this was suggested by the occurrence of neuralgic pain in +the testicle. The patient relinquished his habit, and both the pain and +the epilepsy ceased, and, for some twelve months during which I had him +under observation, had not recurred at all. A medical friend has +informed me of an instance in which the same habit had produced a +neuralgia of the testis so severe as to strongly tempt the patient to +castrate himself, and he would probably have done so but that he was too +much of a coward with regard to physical pain. The attacks of pain were +so severe as frequently to produce vomiting and the greatest +prostration. + +_Hepatic Neuralgia._--It must be allowed that the evidence even for the +existence of neuralgia of the liver is at present in an unsatisfactory +state. At the same time, there are carefully-recorded cases, by +Trousseau and other[7] writers of unquestionable authority, which leave +no doubt in my mind, corroborated as they are by a certain amount of +experience of my own, that such a form of neuralgia really exists. I +must, of course, be understood to refer to something altogether +different from the spasmodic pain which is produced by the difficult +passage of a gall-stone toward the bowel. I have now seen several cases +in which, as it appeared to me, there was sufficient evidence of +neuralgic pain seated in the liver itself, and not dependent either on +gall-stone or any so-called organic diseases of the viscus. + +The subjects of hepatalgia are probably never troubled only by pain in +the liver; they are persons of a nervous temperament, in whom a slight +shock to, or fatigue of, the nervous system, habitually provokes +neuralgic attacks; the pain localizing itself sometimes in the branches +of the trigeminal, sometimes in those of the sciatic, sometimes in the +intercostal nerves, etc. In one instance which has been under my +observation, the attacks of hepatalgia alternated with cardiac neuralgia +assuming the type of a rather severe angina pectoris. In another case +the patient, a man aged sixty-seven, was very liable to attacks of +intermittent abdominal agony, in which one could hardly doubt that the +pain was located in the colon, and was attended with paralytic +distention of the bowel; the peculiar feature of the case being the +sudden way in which the symptoms would appear and depart, independently +of any recognizable provocation or the use of any remedies. On two +separate occasions this patient was attacked with pain of a precisely +similar kind, but limited to the right hypochondrium, attended with +great depression of spirits, and followed by a well-pronounced jaundice. +So remarkable was the conjunction of symptoms in these two attacks that +a strong suspicion of biliary calculus was raised, but not the slightest +confirmation of this idea could be obtained; and indeed one +symptom--vomiting--which nearly always attends the painful passage of a +biliary calculus, was altogether absent. + +Putting aside a considerable number of cases in which "pain in the +liver" was vaguely complained of by patients who were plainly +hypochondriacal, and whose account of their own sufferings could not be +relied on, I have altogether seen five instances of what I regard as +genuine hepatalgia. The first of these was very remarkable in its +history and in all its features. The patient was a respectable girl of +eighteen, subject to migraine, who had reason to fear that she had +become pregnant, though this proved, ultimately, not to be the case. +Under these circumstances she was attacked with intermittent pains, in +the right hypochondrium, of intolerable severity; resembling, in fact, +the pain of biliary calculus, but without the sense of abdominal +constriction, and without any vomiting. These recurred daily at about +the same hour in the morning, for about ten days; when rather +suddenly, a jaundiced tint appeared upon the face, and very shortly the +whole skin was colored bright yellow; there was intense mental apathy; +the urine was loaded with bile-pigment, and the faeces clay-colored. This +state of things lasted only about a week and then very rapidly +disappeared; but as the jaundice subsided there was a partial recurrence +of the neuralgic pains, which, for a day or two, were as severe as they +had ever been; The other four cases of hepatalgia which I have seen, +including that of the man above mentioned, have all been in persons in +advanced life; but, except the latter, neither of them displayed any +symptoms of disordered biliary secretion; and the diagnosis (as to +situation, for the character of the attacks was manifestly neuralgic) +rested mainly on the fact that the pain radiated to the shoulder. + +There remains to be noticed one clinical feature of the disease, which, +I believe, is characteristic; namely, the peculiar mental depression +which attended all the cases I have seen, but was most marked in the two +in which jaundice occurred. In the girl above referred to, the apathy, +during the period when there was jaundice but no pain, was even +alarming; it reminded one of the mental state in commencing catalepsy; +during the painful stages it was more like the gloom of suicidal +melancholia. Of course, the acute mental anxiety which this patient had +suffered would account for a good deal of this; but the symptom was as +distinct, though less severe, in the case of an elderly lady, whom I +have attended on another occasion for migraine; here there was no +recognizable source of anxiety; and, on the other hand, there was no +reason to suspect the retention of bile-elements in the blood. It seems, +therefore, as if an essentially depressing influence on the mind was +excited by hepatic neuralgia; or else, that emotional causes are the +chief source of the malady. + +_Neuralgia of the Heart._--If there be any hesitation in treating this +disease as exactly conterminous with angina pectoris, it can, I think, +be only reasonably justified on two grounds: In the first place, it may +be urged that acute pain of the neuralgic type is not always present in +angina pectoris; and, secondly, it may be urged that many cases of +painful neurosis of the heart have been observed, in which the +recurrence of pain with some amount of cardiac embarrassment has gone on +for years, whereas the popular conception of true angina almost +necessarily involves rapid fatality. + +There is doubtless some force in these objections, especially in the +second, for it does seem rather inconvenient to call by the same name so +deadly a disorder as the worst form of angina, and so comparatively +harmless a malady as some of those instances of chronic tendency to +spasmodic pain of the heart which are not very uncommon, and in which +the patient survives, perhaps, to an old age. Yet, after all, there is +the greatest difficulty in drawing any rational line of distinction; for +the basis of the affection seems the same in every case, whether pain or +spasm be the predominant feature, and whether the course of the disease +be long or short. All that appears to be necessary for its production is +a certain originally neurotic temperament (with possibly some congenital +weakness or some post-natal disease of that part of the spinal-cord +centres which Von Bezold has described as furnishing three-fourths of +the propulsive power of the heart) and the presence of almost any kind +of difficulty or embarrassment of the action of the heart. The most +common source of this embarrassment is perhaps failure of nutrition in +the muscular walls of the heart, from disease of the coronary arteries. +Indeed, it is not known that any organic change of the heart or great +vessels, even of the slightest kind, is necessary to the production of +angina; on the contrary, there is every reason to think that mere +fatigue and depression may bring on the attacks in persons of a strongly +nervous temperament. For my own part, I am inclined to believe, however +that there really always is disease somewhere in the cardiac centre of +the spinal cord, though that disease may consist in no more than a +disposition to minute interstitial atrophy. But we shall say more about +this presently. + +It is at any rate certain that cardiac neuralgia is always a most grave +complaint, from the almost total uncertainty whether succeeding attacks +will not involve a fatal amount of spasm. As for the expression angina +pectoris, it is just one of those mischievous terms which, arising out +of the mystified ignorance in which the elder physicians found +themselves as to the pathology of internal diseases, have since been +attached in turn to various definite organic changes, with none of which +they had any essential connection; and it is therefore much to be wished +that it could be altogether done away with. At the same time, there is +so much that is peculiar in the case of cardiac neuralgia, owing to the +importance of the organ affected, that it will be necessary here to +treat not merely its symptoms, but also its diagnosis, prognosis, +etiology, pathology, and treatment, in a separate and continuous manner. + +_Clinical History and Symptoms._--Cardiac neuralgia usually shows itself +for the first time with considerable abruptness. The patient may or may +not have been consciously ill before the actual seizure, but it rarely +happens, even when the heart has notoriously been the subject of some +organic disease, that there has been any thing to lead him to expect the +kind of attack from which he now suffers. In the midst of some little +unusual effort, or even without this kind of provocation, suddenly the +patient is attacked with severe pain, usually at the lower part of the +sternum; this pain darts through to the back and left shoulder, and +nearly always runs down the left arm. Sometimes, indeed, it is felt +acutely over a large area of the chest, and runs down both arms; this is +the case in a patient now under my care, in whom the affection is more +obviously a neurosis, and less attended with coarse organic changes, +than is usually the case. Along with the pain, which is always very +distressing, but varies greatly in severity in different cases, there is +a variable amount of another sensation which can be compared to nothing +but cramp, or rather compression; the patient usually describes it as +feeling as if some one were grasping the heart in his hands, and, when +this sensation is at all prominent, the idea of impending death is most +strongly impressed on the sufferer's mind. His outward appearance seems +to confirm the idea. In cases where the sense of compression is great, +the face is of an ashen gray; the lips white, with a faint livid tinge; +the pulse small, feeble, and unrhythmical, or imperceptible, at the +wrist; cold perspiration breaks out upon the face; in short, all the +signs of approaching dissolution are present. In cases where the +suffering is chiefly or entirely confined to severe pain, of a darting +or burning character, the state of the circulation is often different. +The heart bounds against the ribs, in rapid and painful palpitation, the +face is flushed deep crimson, the pulse at the wrist is large, bounding, +but very compressible; in fact, the outward appearance of the patient is +so different from that of one who suffers from the more depressing kind +of angina, that it is difficult to consider the two affections as +essentially similar. But there can be no question, if we carefully +examine the matter, that they are mere varieties of the same disorder, +especially as they both may successively occur in the same person. + +The course of cardiac neuralgia varies extremely. Supposing the malady +to be purely neurotic, and not complicated with organic disease, which +forms a constant source of cardiac embarrassment, then the patient may +only experience one or two attacks, under some special circumstances of +exhaustion, which may never recur; or, on the other hand, he may develop +a strong tendency to cardiac neuralgia which may beset him during almost +any number of years. In the latter case, it is an even chance whether +the patient will at last sink from the anginal affection; for, even +supposing him to escape any fatal intercurrent disease of an independent +nature, the fatal event may be at last produced by cerebral softening, +or by apoplexy, or other central nervous disease. In fact, the frequency +with which the latter kind of termination occurs is very significant of +the essential nature of the disease. + +The manner in which cardiac neuralgia commences varies very greatly. In +the celebrated case of Dr. Arnold, the first attack did not occur till +he was forty-seven years of age; it at once assumed full intensity, and +proved fatal in two hours and a half. There is also reason to believe +that Dr. Arnold's father died in a first attack of angina. I have myself +known a first attack prove fatal in the course of an hour; there was +very considerable ossification of the coronary arteries and fatty +degeneration of the heart-walls. Again, there are many cases which +commence gradually, and with great mildness, and with little appearance +of danger to life in the first attacks; but the subsequent attacks are +progressively more severe and dangerous up to a fatal result, after +weeks, months, or years. On the other hand, I have known three instances +in which the first attacks of spasmodic heart-pain very nearly proved +fatal, but the subsequent fits were milder (in one there was no second +attack): all those patients are living, six, eight, and three years +respectively, after their first attacks. + +It can hardly be doubted that neuralgic spasm is the true cause of +sudden death in some cases of stenosis of the aortic orifice, which, but +for some accidental circumstances, would not have died suddenly at all, +but would have gone through a long and gradual course of deterioration. +I particularly remember an instance in which extreme and calcareous +constriction of the aortic orifice, in a boy not yet come to puberty, +was entirely unsuspected, until one day, in running fast, he screamed +out and fell down, and was almost instantaneously dead. I remember +another case very similar, in which extreme mitral constriction produced +almost as sudden death, apparently from painful spasm, under the same +kind of exertion. On the other hand, sudden death, when produced by the +form of heart-disease which (as Dr. Walshe points out) is most likely to +cause such a catastrophe, viz., aortic regurgitation pure, without +hypertrophy, does not seem to be due to painful spasm, but to simple and +complete failure of the muscular power, and is perhaps partly of the +nature of paralysis from a syncopal condition of the brain, the +unhypertrophied heart having become for the moment unable to supply +blood enough to the brain to carry on nervous function at all. + +A good instance of the form which angina takes, when the element of +organic cardiac change is well pronounced, was afforded by the case of a +young gentleman recently under my care. He was twenty-one years of age, +and from early boyhood had been accustomed to a great deal of muscular +exercise; in fact, it is probable that he had undermined his health by +the frequent and extraordinarily long walks which he took, for his frame +was particularly small and slight, and the muscles small and soft. He +came of a family in whom the tendency to neurotic disorders is obviously +very strong; both his father and his brother are subject to bad attacks +of migraine, and he had himself repeatedly suffered from the same thing. +The family disposition, altogether, is highly nervous and excitable. The +remarkable circumstance in this young gentleman's case is, that although +he had taken for years an extraordinary amount of pedestrian exercise +(including mountain-climbing), and latterly had exchanged this for the +even more trying exertion of rowing, he had never suffered from any +noticeable symptom of cardiac distress up to the very day of his anginal +attack. For some months, however, he had been growing thin and pale, and +I had given him certain cautions, and had made him take cod-liver oil +and steel, as I entertained some fears of his becoming phthisical. On +the day of the attack there was nothing particular in his appearance, +but he complained of a slight cold, and had no appetite for his six +o'clock dinner. He retired to rest at eleven o'clock, having taken a +small dose of laudanum and chloric ether for his cold. In less than half +an hour he awoke out of his sleep in fearful agony; so severe and +prostrating was the anginoid pain that he had the greatest difficulty in +crawling out of bed to unlock his door. I found him bathed in cold +sweat, pale as a sheet, and with livid lips. He groaned with pain, which +he described as "cutting him across" from the sternal notch to the +nipple, and going down the left arm; and there was so marked a catching +of the breath as to make it almost certain that there was diaphragmatic +spasm; in fact, it was this which alarmed him, and made him say that he +was certainly dying. The heart, however, appeared to be pushed up +somewhat, and it was thought that this might be partly due to stomachic +distention, but a mustard emetic produced little effect. The +heart-sounds were so weak that the presence or absence of bruit could +not be safely predicated; meantime, the pulsations intermitted in a most +alarming manner. Large doses of brandy and sulphuric ether at length +(after several relapses) seemed to subdue the pain and spasm, and in an +hour and a half from the commencement of the attack the patient, though +utterly worn out, sank into a tolerably quiet sleep. The spasms did not +recur, but for the next three or four days he was in a state of great +exhaustion. When his tranquillity of mind had been somewhat restored, a +careful physical examination was made, and it was discovered that there +was a moderately loud and somewhat thrilling systolic bruit at the site +of the aortic valves, and extending some distance into the vessels. The +pulse still remained strikingly intermittent, and, though of fair +volume, was very compressible. Percussion indicated considerable +enlargement of the heart, and the physical signs pointed, on the whole, +to dilatation without hypertrophy. Some doubtful signs of consolidation +were observed at both apices of the lungs. + +It is remarkable that, notwithstanding the serious degree of cardiac +mischief indicated by the above signs, the patient, a very few days +later, took a walk of some ten miles, and, though much exhausted, +suffered no recurrence of his formidable spasmodic symptoms in +consequence of this imprudence. He was sent to the mild climate of +Mentone, and subsequently to Nice; the angina never recurred, but the +patient remained weak, and liable to more or less dyspnoea for fifteen +or sixteen months; now he lives an ordinary life, doing his duty as a +Swiss citizen and officer. The cure of some haemorrhoids, about twelve +months after the anginal attack, seemed greatly to benefit him. What the +future of this case may be it is impossible to say, but of course there +is no security against the angina recurring on extraordinary excitement +or over-exertion. + +Of the purely neurotic variety of angina it is impossible to determine +the frequency; but it seems certain that the affection is common, and I +suspect that it occurs more often than is supposed, as a sequel to +asthma. The probable relationship between the two affections was long +ago indicated by Kneeland.[8] I have certainly seen several cases of +asthma in which spasmodic pain of the heart has occurred on various +occasions after or during a very severe asthmatic paroxysm. One case was +that of a gentleman, of a highly delicate and neurotic temperament, who +had suffered for fifteen or sixteen years from well-marked spasmodic +asthma: this case is remarkable as an illustration of several points +which will be dwelt upon in other parts of this volume. For some time +before the outbreak of cardiac neuralgia, he had suffered repeatedly +from severe facial neuralgia, and these attacks on more than one +occasion culminated in facial erysipelas, or what was entirely +indistinguishable from that affection. He then began to suffer from +cardiac pain and spasm after his asthmatic paroxysms, and these new +symptoms speedily assumed the form of a very severe intermittent angina: +in several of the attacks he appeared about to die. The pain in these +attacks is very severe; it occupies a large area in the centre of the +chest, and runs down both arms; and, what is strange, the arms become +remarkably swollen and hot after an unusually long bout of pain, I +presume from vaso-motor paralysis. At present (nearly five years from +the commencement of the cardiac neuralgia) the cardiac attacks, though +of frequent occurrence, are decidedly more tolerable than they were at +first, and the sense of squeezing or pressure, though never quite +absent, does not amount to the dreadful sort of feeling which used to +convince the patient that he was at the point of death. In this case, +the heart has been repeatedly explored without any positive result, and +the pulse has been frequently tested by the sphygmograph. The latter +instrument is the only mode of examining by which I have been able to +elicit even suspicious evidence that there is any organic change of the +heart; by means of it I have lately obtained some grounds for suspecting +that there is slight dilatation of the heart, but it is uncertain +whether anything of the kind existed at the commencement of the anginal +symptoms. In this case I am inclined, on the whole, to doubt whether the +angina will ever prove fatal, unless the bronchitis, with which the +patient's asthma has for some time past been liable to be complicated, +should occur in a severe form; in that case it is likely that the +additional embarrassment of the heart's action may bring on fatal +spasms. + +One of the best examples I ever saw of cardiac neuralgia (ultimately +proving fatal) was one of which the origin was entirely nervous. It +occurred in a gentleman in the prime of life, and naturally of a +powerful physique, whose very active and capacious mind had been greatly +overwrought. The whole weight of responsibility for an undertaking of +national importance, and which involved great difficulties and much +anxiety, for a long time rested on his shoulders. Under these influences +he broke down, and never effectually recovered himself. At first, the +symptoms were those of mere ordinary nervous exhaustion, but after a +time he became subject to frequently recurring attacks of agonizing +spasmodic heart-pain, with a sense of impending dissolution; from these +he was invariably relieved by the inhalation of a small amount of +chloroform. Not the slightest organic heart mischief could be detected, +either during life or after death. + +_Pathology._--Angina stands in so peculiar a position that I deem it +well to discuss it as a whole, and not merely its clinical history, in +this place. As I have already said, there is nothing in the morbid +appearances found after death which is characteristic of fatal angina, +and in the milder kinds of cardiac neuralgia we are driven back upon the +general probabilities which we deal with in reasoning as to the origin +of neuralgias in general. As to morbid changes, it is impossible to say +any thing more exhaustive of the facts known than the following words of +Dr. Walshe:[9] "First, there are few, if any, structural diseases either +of the heart, its orifices, and its nutrient arteries, or of the aorta, +found recorded in the narratives of the post-mortem examination of +different victims of angina pectoris. Secondly, there is no conceivable +disease of these structures and parts which has not in various +individuals reached the highest point of development, without anginal +paroxysms, even of a slight kind, having occurred during life; to this +proposition extensive calcification of the coronary arteries perhaps +furnishes a solitary exception. Thirdly, the organic changes most +frequently met with have been fatty atrophy and flabby dilatation of the +heart; obstructive disease of the coronary arteries by atheroma and +calcification of the orifice and arch of the aorta. Fourthly, the rarest +have been hypertrophy and hypertrophy with dilatation. In truth, it may +be doubted whether these conditions in their genuine form, without any +combination of fatty atrophy, have ever been the sole morbid states +present." From all this Dr. Walshe concludes that the fundamental +mischief of angina is neurotic; and, while he believes that some +textural change in the heart is necessary as an irritant to generate +this neurotic susceptibility to dynamic disturbance from slight causes, +he recognizes only one common quality in these various cardiac lesions, +viz., that they indicate mal-nutrition and weakened power. Dr. Walshe +does not appear to believe the neurotic disturbance can arise without +the kind of irritation which is kept up by such cardiac changes. In +spite, however of the great authority of this author, it certainly seems +very probable that organic cardiac change is by no means necessary to +the occurrence of angina, and this for two reasons: In the first place, +though full reliance may be placed on the details of the post-mortem +examinations made by Dr. Walshe himself, they are very few (twelve or +fourteen) in number; and other observers who have recorded cases are as +little trustworthy, considering their evident tendency to find some +disease where none exists, as the older narratives which Dr. Walshe +naturally distrusts were unreliable when they declared that no morbid +change was present. And, secondly, his view hardly takes it into account +that there are still two other alternatives, even supposing that one or +other of the above changes is always present: (_a_) it is possible that +the neurotic disturbance and the cardiac lesions might both be the +result of a common cause; and (_b_) it is even possible that the +alterations of tissue in the heart and vessels are due to a morbid +influence proceeding from a diseased nervous centre, either spinal or +sympathetic. + +As for the state of the muscular fibre which immediately causes death, +Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and +he urges in favor of this view the fact that in his large experience he +has never known the pulse to intermit during the attack--it was always +regular, however feeble. In this respect he is in opposition to some +distinguished authors, however, and, as he allows that he has not seen +original attacks in their height, but only when they were subsiding, it +would be possible that the spasm stage had subsided. However Dr. Walshe +admits that there may be exceptional cases in which spasm, or cramp (_i. +e._, spasm with rupture or dislocation of fibre), really occurs, and +suggests that this is very probable in the rare cases where death is +attended by general tetanic spasm of the muscles. As far as my own +opinion is worth anything, I could insist that at least Dr. Walshe must +be right as against Dr. Latham and Dr. Inman, in affirming that cardiac +cramp, if it occurs, is the consequence and not the cause of the +neuralgic pain. + +_Causes._--In some respects it is impossible to deal with the etiology +of angina apart from the pathology, just as we remarked with regard to +neuralgias in general. But there are certain special features in the +causation of angina pectoris which require separate notice, just as +there are special features in its pathology. + +Of predisposing causes, the majority are the same as those of which we +have spoken in our general remarks on the etiology of neuralgia. A +family history of a tendency to the graver neuroses is I believe +universal, and, indeed, direct inheritance of angina from father to +son, as in Arnold's case, has happened in many recorded instances. A +very remarkable fact is the time of life at which the disease originally +appears: Walshe says it is rare before the age of fifty, but excessively +rare before forty. This is very interesting, as placing angina in the +same category with the severe and intractable forms of facial and other +neuralgias which are so highly characteristic of the period of bodily +degeneration. One may even gather a suspicion, though it goes but a +short way toward proof, that the essence of angina is an atrophy either +of the cardiac plexus or of the nucleus of the vagus, or of that part of +the spinal cord, already mentioned, which seems to be the centre of the +major part of the propulsive force of the heart. + +On the other hand, there is a fact, even more remarkable than the +influence of age, which tells somewhat in a contrary direction. There is +a most extraordinary preponderance of males among the victims of angina. +Sir John Forbes found eighty males among eighty-eight patients suffering +from this disease. On the first blush it would seem natural, indeed +almost necessary, to explain this by supposing that, as men take a much +larger amount of strong physical exercise than women, they will furnish +a much larger proportion of subjects in whom an ill-nourished heart will +break down under its work and be seized either with paralysis or cramp +(for the two states are, after all, not opposed to each other, but only +varying shades of debility.) Upon this theory one would have to believe +that the origin of angina was far more peripheral than central, if we +are to suppose that spasm is the ordinary condition of the heart during +the anginal paroxysm. But we do not know that this is the case; indeed, +there are many arguments against it; and at any rate we must suppose +that in a considerable number of cases the muscular state is one of +relaxation from want of power. And certainly it is infinitely more +probable that paralysis or spasm of a muscular viscus should occur as a +reflex consequence of neuralgia occurring in a nerve whose central +nucleus was closely connected with the motor centre of the organ, than +that mere paralysis of the viscus should convey a reflex impression to +sensitive nerves which should express itself in the form of acute pain. +It must be confessed that the matter hangs in doubt; but the evidence +is, on the whole, very strong for the belief that central nervous +mischief is the most important element in angina. + +Another very important class of predisposing causes of angina is the +mental emotions. It is notorious that the disease is one not common in +humble life; it chiefly assails the more cultivated class, and +especially men who are much engaged in affairs in which great mental +anxiety or emotion is mingled with severe toil of intellect. Thus the +professional class has always shown a sad predominance in tendency to +this disease; a large number of the victims have been found among +overworked clergymen, lawyers, doctors, engineers, etc. The various +forms of heart-lesion which have been already mentioned must doubtless +be considered highly predisposing, when there is already a neurotic +susceptibility, more especially those which, like fatty degeneration of +the muscular structure, greatly enfeeble the heart's action. I do not +believe that these diseases will cause angina in a person who is free +from the peculiar nervous susceptibility. + +The immediately exciting causes are very various. The most common of all +is doubtless some exertion of body, or distress of mind, which at once +agitates and embarrasses the heart's action; and, where the tendency to +cardiac neuralgia has once declared itself by an actual attack, very +slight excesses of this kind will usually suffice to re-excite the +paroxysm. Sexual excitement is particularly provocative of the attacks, +in the predisposed. But much slighter causes suffice, in those cases +where the irritability of the cardiac nerves has become very intense: +thus a mere puff of cold air upon the face, and other similar slight +peripheral impressions, by acting in a reflex manner, have frequently +produced the paroxysm. I have seen an extremely severe anginal attack +brought on by the slight shock of the sudden slamming of a door. And it +would even appear that some peripheral excitements of a powerful kind +may operate with such force as to generate angina in persons who are +merely in weak health, but who cannot be supposed to be specially +predisposed to angina; it is in this way, I presume, that we must +explain the extraordinary occurrence, reported by Guelineau,[10] of an +epidemic outbreak of angina, in which numbers of men, belonging to a +ship's crew, were simultaneously affected. The men had been badly fed, +and their quarters were very unhealthy; but the powerful exciting cause +seemed to be the rapid change from a very hot to a very cold climate. +Not only were there many cases of severe angina, but other forms of +neuralgia, and severe colics, were observed in others of the crew. Among +the sources of peripheral irritation which ought to be particularly +considered, in relation to angina, are the diseases and injuries which +produce powerful irritation of the branches of the trigeminus. Lederer's +cases[11] of violent vomiting and cardiac pain, from the operation of +pivoting teeth, and Remak's instances[12] of violent palpitation and +cardiac distress, produced by disease of the last molar tooth, seem to +show that, both through the vagus and the sympathetic, the most +powerful reflex action may be produced in the heart and stomach by +irritation of the fifth cranial. + +Another occasional excitant of angina is an interesting link in the +chain of proof that angina is _au fond_ a neuralgia, namely, the +malarial poison, which has in a good many well-observed cases distinctly +induced the disease.[13] Finally, the occasional influence of excessive +tobacco-smoking in producing anginal attacks, in persons not affected +with any discoverable organic heart-disease, affords the strongest +corroborative evidence of the essentially neurotic character of angina +pectoris. M. Beau[14] has recorded many serious, and some fatal, cases +from this cause. Probably in both the malarial cases and those induced +by tobacco-poisoning the special neurotic tendency existed already. + +_Diagnosis._--The diagnosis of angina pectoris, in those severe forms +with which the popular idea of the disease is chiefly connected, can +hardly be a matter of much difficulty. When we see an elderly man lying +in a state of deathly collapse, which has suddenly come on, with cold +sweats and nearly extinguished pulse, gasping for breath, and +complaining of intolerable pain in the chest and arm, and a sense of +oppression more dreadful, even, than the pain, we can hardly doubt that +the case is angina in its worst form. On the other hand, when a young +person, especially a young female, complains even of very severe pain in +the cardiac region, together with breathlessness, especially if the +heart be palpitating and the face flushed, the diagnosis, though not +immediately certain, already very strongly indicates the probability +that the case is not one of primary cardiac neuralgia at all. These are +extreme instances, however. In more doubtful cases, the following are +the principal materials for decision: + + _Affirmative Signs._ _Negative Signs._ + + 1. Age over forty. 1. Age under forty. + + 2. Male sex. 2. Female sex. + + 3. Nervous temperament (personal 3. Temperament either not nervous + and family) without marked at all, or markedly hysterical + hysteria or hypochondriasis. or hypochondriacal. + + + 4. Existence of arterial 4. No signs of arterial + degeneration. degeneration. + + 5. Existence of valvular disease 5. No discernible valvular + of the heart. disease. + + 6. Extension of the pain to 6. Heart sounds clear and strong. + one or both arms. + + 7. Vivid sense of approaching 7. Pain fixed to one spot and + dissolution. increased or relieved by + muscular movements of the + painful parts. + + 8. Pain running round one side, + but not extending to shoulder + or arm. + +It is scarcely necessary to say that no single one of the above signs is +individually of positive worth for the decision, which must be made +after a careful review of the comparative arguments, _pro_ and _con_. +The disorders with which angina is most likely to be confused are (1) +Myalgia of the intercostal or pectoral muscles; (2) intercostal +neuralgia; (3) acute commencing pleurisy. Either of these may very +perfectly simulate the more formidable disease, as regards the two +elements of acute pain and catching of the breath; but the condition of +the circulation, taken together with the consideration of the above +named points, will generally decide the question. Especially important +is the deep persuasion of impending dissolution, when present, as a +positively affirmative symptom. + +It should be born in mind that, if we are summoned to a patient's +assistance, and have no previous history to guide us, our diagnosis, to +be useful, must be rapid; and it is always better to err on the side of +angina than in other directions, and to employ remedies boldly in that +sense, if there be any reasonable ground for believing the case to be of +that nature. A more mature and careful diagnosis may be made when the +patient has recovered from the severe symptoms of the paroxysm. + +_Prognosis._--The prognosis of cardiac neuralgia is at best doubtful, +and, in many cases, positively bad in the highest degree. If the attacks +occur for the first time in a patient who has passed middle life, and is +physiologically old for his age, _i. e._, shows tendency to degenerative +changes of vessels, arcus senilis, gray hair etc., they are of very +gloomy import; more especially if any signs exist which make a fatty +change in the ventricle probable, or if there be serious valvular +lesions. The probability here is greatly in favor of a speedy fatal +termination; if the first attack does not kill, a second or third very +probably will; at any rate, the patient is not likely to survive any +considerable number. If the attack occurs in a younger person, in whom +there is not much likelihood that arterial degeneration has seriously +commenced, or the heart-muscles become fatty, more especially if the +attacks have been brought on by such an accidental circumstance as a +very exhausting bout of mental or physical toil, then there is +considerable reason to hope that the disease may soon wear itself out. +Even patients who have serious valvular lesions may, with young and +undegenerated tissues in their favor, quiet down again into a regular +habit of semi-health, in which they may live for a long time without +any recurrence of cardiac neuralgia. The more purely neurotic form, +again, especially when it develops gradually out of some pre-existing +chronic neurosis, such as asthma, is usually slow in its progress; and +it may well happen, in such cases, that the danger to life is more on +the side of serious nervous lesions than from the anginal attacks +themselves. At the same time, it must be remembered that, even in the +milder cases, any very unusual excitement, bringing on an unwontedly +severe attack, may produce fatal results at any period of the disease. + +There is some reason to believe that cardiac neuralgia is occasionally +produced in a reflex manner in consequence of a severe existing +intercostal neuralgia. I cannot say that I have witnessed any thing +which can be considered as completely proving this; but it certainly +seems likely that, in some of the few cases of excessively painful +herpes zoster which have proved fatal (of which I have given one +example), cardiac spasm or paralysis may have been secondarily induced, +and may have occasioned the catastrophe. It is likely enough that, if +this was the case, the reflex irritation operated upon motor centres +which themselves were predisposed to take on the morbid action; but this +again is a fresh illustration of the uncertainties to which prognosis is +liable in a disease like angina, the very fundamental character of which +is that, upon increase of the irritation, the gravity of the resulting +functional affection is liable to be indefinitely and most rapidly +increased. + +_Treatment._--The treatment of cardiac neuralgia is (1) prophylactic, +and (2) palliative of the attacks. + +As regards the prophylactic treatment, it is unnecessary to repeat the +remarks which we have made elsewhere upon the general principles of +tonic and nutritive medication in neuralgias of every kind. One especial +prophylaxis, in the case of this formidable variety of neuralgia, is +concerned with the preservation of the heart from certain disturbing +influences which would render the occurrence of the fit more probable. +All violent emotions and all strong physical exercise (but especially +such forms of it as, like boating, are well known to "pump" the heart +severely) are to be carefully avoided. Even indigestion and flatulence +are to be carefully guarded against since these are quite capable of +embarrassing the action of the heart to a degree which, though it might +be trivial in the case of ordinary health, may prove fatal by exciting a +flabby ventricle to irregular and embarrassing contraction. It is even +possible that the strong irritation set up by some varieties of +indigestible food might propagate an irritation to the spinal cord which +would produce an interbitory paralysis at once. + +But besides these obvious precautions against interference with the +regular and tranquil action of the heart, there are some special +medicinal remedies which deserve particular notice. Whether we really +possess any means of so influencing the nutrition of the muscular tissue +of the heart as to prevent its lapsing into a fatty degeneration, it is +impossible to say; but this may be affirmed with some confidence, that, +in cases where awkward threatenings of cardiac neuralgia have occurred, +and simultaneously it has been noticed that the heart-sounds become weak +and the circulation languid, a most marked improvement has been produced +in all respects by the administration of iron and strychnia. I usually +give tincture of sesquichloride of iron, ten minims, and strychnia, +one-fortieth of a grain, three times a day. Still better, where it can +be borne, is the syrup of the triple phosphate of quinine, iron, and +strychnia, which undoubtedly has an extraordinary influence upon tissue +nutrition, as exemplified in its remarkable effects in many cases of +phthisis. It must be observed, however, that it is not every neuralgic +patient who will bear the combination of quinine with iron; it has +occurred to me to meet with several in whom the union of these two +remedies proved violently disturbing to the nervous system, causing +distressing headache and palpitation of the heart, which could not be +attributed to any want of care in the apportioning of the dose, or in +the mode of administration. Iron is more especially indicated, of +course, in cases where there is anaemia; but there are some cases in +which strychnia given alone seems to produce a very beneficial +influence. (_vide_ Chapter V., on "Treatment.") + +By far the most important prophylactic tonic against cardiac neuralgia, +however, is arsenic. That this drug should prove useful in cardiac +neuroses might readily be anticipated from its very great utility in +many cases of asthma, a disease which, as already remarked, has a close +relationship to the former. Dr. Philipp has recently recorded a case +which is perhaps an extreme instance of this beneficial influence of +arsenic, but is none the less encouraging, especially as it only +corroborates what has been advanced by other observers. Given in doses +of from three to five minims of Fowler's solution, twice or thrice +daily, arsenic is an invaluable remedy in cardiac neuralgia; the one +objection to it being that some neurotic patients possess such an +irritable intestinal canal that the remedy cannot be borne, as it +produces diarrhoea. Even here we may sometimes succeed by combining it +with very small doses of opium. It is more especially with regard to +those cases in which the neurotic character of the disease is very +prominent--_i. e._, in which the nervous temperament of the patient +betrays itself in other ways besides the tendency to spasmodic +embarrassment of the heart's action, that arsenic holds such a very high +place as a remedy. And it should be carefully remarked that the +prophylaxis of angina extends itself, in such cases, beyond the limits +of actually-declared and well-defined angina, which is, of course, an +uncommon disease. This remedy is important, and may be most usefully +employed in the far larger group of cases in which a marked tendency to +spasmodic pain in the chest, on the occurrence of some comparatively +trifling excitement, is observed in patients who either have some +organic heart-disease, or who are liable to severe attacks of asthma. It +cannot be too often repeated that there is no intelligible separation, +except one of degree, between these cases and the malignant forms of +angina. It may be added that, in my experience, I have found the whole +group of cases to be bound together in a singular way by the tolerance +of arsenic which, with certain exceptions already referred to, they +display. Commencing with the small doses above mentioned, I have found +it possible, in many cases, to advance to the administration of twice or +thrice the quantity, and to continue this medication for months +together, not only with no evil effect, but with the best results. + +Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but +little. Truth to say, it is a nervine tonic of occasional great value, +but which, on the whole, I have found so unreliable that I am somewhat +prejudiced against it; and perhaps have not given it a fair trial in +those milder cases of cardiac pain to which it might be suited. It does +appear, however, to have some preferential action on the vagus, and +might therefore be possibly more useful than I am at present inclined to +think it. + +The treatment of the acute neuralgic stage itself is a matter in which +we are sadly limited by the exigencies of the case. Relief must be +excessively rapid if we are to save life in the most threatening cases, +or to deliver the patient from a most prostrating agony, which might +have lasted for hours, in other instances. + +The remedy which the highest authority, Dr. Walshe, seems to put first +in efficacy is opium; and he directs the dose to be measured by the +intensity of the pain, as much as forty to sixty drops of laudanum being +given in a severe case. He says, however, that it should be given with +an antispasmodic, such as brandy, or ether, or sal-volatile; and I +confess that I believe the antispasmodic treatment to be by far the most +important. Indeed, so marked is the success which I have found to attend +the use of ether in the paroxysm, that till lately I scarcely cared to +make further experiments, with drugs, for the relief of the patient at +this stage. One teaspoonful of ether in two ounces of thickish mucilage +should be given at once, and repeated in a short time if the patient +does not rally. + +In a few instances, angina seems to be provoked by the irritation of +indigestible food, and when there is good reason to suspect this an +emetic should be given. I strongly recommend that mustard should be +used for this purpose, for the effect of a mustard-emetic is by no means +merely to empty the stomach, it has a powerfully rousing influence on +the heart. + +Upon the subject of the inhalation of chloroform for cardiac neuralgia, +I have only to say that, though I have seen it usefully employed, I +should not, with my present experience, ever think of employing it +myself. Every possible advantage which it could give is obtained by the +internal use of ether, and many serious dangers are avoided, which would +attend the use of chloroform. For it must be remembered that the only +kind of chloroform inhalation which would be useful would be that in +which a carefully measured small dose of a weakly impregnated atmosphere +should be inhaled, and, without large experience in the administration +of chloroform, the practitioner will be unable to secure this effect +with certainty. And the effect of a powerfully-charged atmosphere, +breathed only once or twice even, would be instantaneously fatal. + +Hot epithems to the epigastrium are probably of some use, and besides +this the temperature of the body should be carefully kept up by hot +bottles to the feet, hot tins to the epigastrium, etc. Brandy should be +freely administered during the attack, if we cannot immediately obtain +either ether or a remedy now to be mentioned. I refer to the nitrite of +amyl, which, at the time when the first part of this chapter was +written, I had not had the opportunity of testing. + +Nitrite of amyl is a highly-vaporizable fluid, which possesses the +following remarkable physiological action: the inhalation even of a very +small quantity is followed, after a minute or so, by a sudden +acceleration of the heart's action, accompanied by intense crimson +congestion of the vessels of the face and conjunctiva, and a sense of +enormous fulness in the head; these phenomena are extremely fugitive, +passing away completely in two or three minutes, unless the inhalation +is renewed. These characteristic effects had for some years been +experimentally exhibited by Dr. Fraser and others, but the practical +application of amyl to the treatment of angina was first suggested, I +believe, by Dr. Brunton, in the case of a patient under the treatment of +Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The +angina was in this case symptomatic, there being advanced valvular +disease of the heart. Comparative examinations with the sphygmograph, +during the intervals and during the paroxysms, made strikingly manifest +the fact that, during the attacks, there was an increase of arterial +tension which was directly proportionate to the severity of the pain and +cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that +nitrite of amyl, by relaxing the systemic arteries, might remove the +unnatural tension, and give relief to the pain; and the result confirmed +this hope. Doses of five and ten drops were inhaled from a towel, with +the uniform result of at once quieting the pain; it might return in a +few minutes, but a second dose usually removed it entirely for many +hours. Various other cases have since been reported, in which similar +relief was obtained, and I had occasion to employ it myself in one +instance. The gentleman whose case has been related above (see page +101), as an example of the relief obtainable by the use of ether began +to suffer rather more severely from his attacks than had been the case +for some time, toward the end of the year 1869. I now determined to try +the amyl, and accordingly left a small bottle containing half an ounce +of it in his possession, with exact instructions to the following +effect: On the first symptoms of a paroxysm of angina, he was to get the +bottle open, and as soon as their character was fully declared he was to +put the bottle to one nostril (closing the other with the finger, and +keeping the mouth shut) and take one long, powerful inspiration. The +result of his first experiment was very remarkable: the first sniff +produced, after an interval of a few seconds, the characteristic +flushing of the face and sense of fulness of the head; the heart gave +one strong beat, and then at once he passed from the state of agony to +one of perfect repose and peace, and at his usual bedtime slept +naturally. This experience was repeated on several occasions, and for a +considerable time the patient retained such full confidence in the +remedy that he discarded all use of ether, and greatly reduced his +allowance of stimulants, with very marked benefit to his appetite and +general health. The new remedy did not lose any of its power by +repetition, but unfortunately the patient at last conceived a horror of +it, which caused him to abandon its use. So distressing and alarming to +him was the sense of fulness in the head produced by the amyl, that, +notwithstanding his certain knowledge that he could at once cut short a +paroxysm, he could not persuade himself to continue its use, and for +some time past he has returned to the use of the ether and (though in +less quantities than previously) of the brandy, for this purpose. And +here it must be remarked that this objection, although probably needless +in the case of this particular patient, may have real importance in +certain circumstances. The admirable physiological researches of Dr. +Brunton leave no doubt that the effect of inhalation of amyl is to +relax, very suddenly, the tonic contraction of the systemic arteries, +and in the case of the brain it would appear that a serious strain must +be suddenly thrown upon the capillary net-work. This being the case, it +appears likely that, where the atheromatous change has considerably +invaded these delicate vessels, they might prove too brittle to stand +the sudden distention, and a rupture and consequent cerebral haemorrhage +might ensue. This suspicion, then, that such pathological changes exist, +ought to seriously affect our judgment as to the administration of +amyl; and this suspicion ought to be always entertained, _prima facie_, +in the case of patients who have much passed the age of fifty, more +especially if they have gray hair and an arcus senilis, or if the +sphygmograph yields a pulse-trace of the decidedly square-headed type, +or if they have been long addicted to alcoholic intemperance. In such +patients I should be disinclined to allow the use of amyl. + +[Although I have thought fit here to give an outline of angina pectoris +as a connected whole, I shall have occasion to recur to the subject +again under the heads of Pathology and Treatment of Neuralgias in +General.] + +_Gastralgia._--Neuralgia seated in the stomach itself is not to be +distinguished with accuracy from neuralgic pains occupying one or other +of the neighboring nervous plexuses. It must be remembered that not +merely is the stomach itself copiously supplied by the pneumogastric +nerves with afferent fibres, but the great solar plexus is close behind +it, the coeliac plexus springs from the fore part of the latter, and +these, with the coronary and superior mesenteric plexus, may all be said +to be well within the region in which "gastralgic" pain is felt. It is +not particularly important, however, in my opinion, to make any very +exact diagnosis here, as to the site of the pain, since all these +neuralgias must be considered to belong to the pneumogastric nerve, the +branches supplied from which are probably the sole means by which these +plexuses become the seat of neuralgia. + +Abdominal pneumogastric neuralgia is an extremely distressing and +occasionally a very intractable disorder. The subjects of it are almost +invariably in a state of marked and evident debility, and inquiry +generally elicits the fact that they have suffered at other times from +neuralgia elsewhere than in its present seat. By far the most common +history of previous affections of this kind is that of trigeminal +neuralgia, especially of the supra-orbital branch; and it has several +times occurred to me to observe the direct sequence of a gastralgia upon +a unilateral browache. Anaemia is a specially frequent attendant of +gastralgia, more so than of other neuralgias. Women are, by the general +consent of authors, more liable to gastralgia than men. + +The special mark of true neuralgic pain in the abdominal pneumogastric, +as distinguished from other deep-seated pains in the epigastrium, is the +remarkably direct relation of its severity to the patient's exhaustion, +particularly in regard to the weakness induced by want of food. While +the great majority of dyspeptic pains are increased by filling the +stomach, gastralgia, on the contrary, is invariably relieved by food, +often most strikingly and completely. Pressure from without, also, while +it aggravates most pains dependent on local organic mischief, nearly +always more or less relieves gastralgia. Equally striking is the comfort +given by stimulants, especially by hot brandy-and-water; in this respect +gastralgia resembles colic. There is something special in the degree of +mental depression which attends gastralgic pain. In this it resembles +the pains of hypochondriasis, but there is a resilience of the spirits +when the pain has been relieved which is not seen in the latter +affection. A very frequent complication of gastralgia is severe +palpitation of the heart, but during the paroxysm itself the pulse, +whether rapid or not, is commonly small, at first tense, and afterward +soft, but not acquiring any considerable volume till the pain has +ceased. + +So severe is the pain, and so complete the mental and physical +prostration in bad attacks of gastralgia, that the first aspect of the +patient might suggest--indeed often has suggested--the occurrence of +gastric or duodenal perforation; but, as soon as the paroxysm is over +all the alarming appearances vanish, leaving only a certain amount of +tenderness on deep pressure. In the more typical cases there are no +signs of dyspepsia whatever, no fulness nor excessive redness of the +tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the +neuralgic affection is complicated with more or less gastric catarrh; +but this is a much rarer occurrence, in my experience, than some writers +would lead one to believe; and, moreover, where a certain amount of +organic disorder of the stomach is observed, it is usually a mere +secondary result of the neuralgia. The most severe example of gastralgia +which I ever saw was entirely unaccompanied by dyspepsia; this patient +absolutely attempted suicide to escape from his agonizing pains, which +recurred with the greatest frequency and obstinacy, but were at last +entirely removed by strychnia. In another patient whose very interesting +case will be again alluded to under the head of Complications of +Neuralgia, violent abdominal pneumogastric pain was succeeded by a +severe attack of trigeminal neuralgia, accompanied by inflammation of +the eye, which inflicted irreparable damage; here, too, the gastralgia +was entirely uncomplicated by any other stomach-symptoms. + +_Cerebral Neuralgia._--We enter, here, on an extremely obscure and +doubtful subject: Can there be pain in the central masses of the +encephalon? There are undoubtedly a not inconsiderable number of cases +of pain, neuralgic in type on the whole, in which the suffering cannot +be referred to any recognizable superficial nerve. It seems deeply +situated within the cranium. I have also quoted cases of Dr. Hillier's +in which not merely was there deep-seated headache in children, but +there was something like a characteristic general change observed in the +brain-tissues after death, viz., a great moisture and softness of +texture. Notwithstanding all this, I am not convinced, nor indeed much +disposed to believe, that pain is ever felt in the structure of the +brain; I rather believe that, in the cases where this seems to occur, +the pain is either in the intracranial portion of the nerve trunks, or, +far more probably, in the twigs of nerves that are distributed to the +cerebral membranes. In that case they are, strictly speaking, only +varieties of neuralgia of the fifth nerve, and might have been properly +discussed under that heading; but it is more convenient to speak of them +apart, since their phenomena present considerable differences from those +of the external neuralgias of the head and face. + +I have now seen several of these cases of intracranial neuralgias, and +very perplexing and (at first sight) alarming they certainly are. The +first of these cases came under my care in 1868. The patient was a +single lady who had greatly over-tasked an intellect that was not, +perhaps, originally very strong, by trying to do hack literature on +conscientious principles; insisting, for instance, on knowing something +about every subject she wrote upon. Her age was thirty-eight when she +applied to me; menstruation was scanty but regular; and, on the whole, +she could not be said to have passed an unhealthy life, although +"nervous-headaches" and "sick-headaches" had occasionally beset her. +This time the trouble seemed to be more serious. Ten days before +applying to me, she had awaked in the morning with a feeling that +something was very wrong in her head; there was not so much pain as a +dull, brooding sort of weight, felt deeply within the cranium, and +rather anteriorly. This had not lasted many hours when she was seized +with a sensation of intense cold, amounting almost to rigors, and then +before long was suddenly attacked with acute splitting pain in the same +situation as the feeling of weight already mentioned had occupied. This +pain, which came and went, or rather intensified and remitted, without +ever completely ceasing, lasted about two hours, and then rather +suddenly disappeared, leaving the patient with a deep "bruised and sore +feeling in her brains." The pain recurred about the middle of the next +day, lasting for several hours, and again leaving behind it the sore +feeling. Day by day the paroxysms returned, and, on the day before her +visit to me, the patient had, she told me, been driven frantic by her +sufferings and had become actually delirious. Her appearance, when I +first saw her, was wretched; the face haggard, both eyes sunken and +surrounded with deep rings of dusky pigment, both conjunctivae bloodshot, +the whole face almost earthy in its pallor. At that hour (11 A. M.) the +pain had not positively recommenced, but she was in momentary dread of +its recurrence. She complained of giddiness, muscae volitantes, and great +feebleness of vision, and dreaded attempting to read, as the mere effort +of fixing her eyes on anything intently caused flashes of fire before +them. It was difficult at first to believe that there was not some +serious organic brain-mischief; but on the whole I concluded that there +was an absence of any genuine symptoms of such disease. At the same +time, the pain was decidedly not referred to any cutaneous sensory +nerve; and on the whole it appeared probable that the affection was +intracranial. There remained the diagnosis of meningeal neuralgia, and +to this I provisionally made up my mind. The opinion that the pain did +not depend on any fixed organic disease was decisively justified by the +results of treatment. One-sixth of a grain of morphia was injected on +the occasion of the first visit, and this was repeated every day, and +sometimes twice a day, for a fortnight; by this sole means, with rest, +quietude, and light nourishing food, the patient was brought to +comparative convalescence. The injections were then gradually +discontinued, and she got quite well. + +In a second case, which presented itself in the out-patient room at +Westminster Hospital, a young man of markedly-nervous temperament, who +had been somewhat given to drink, complained of similarly deep-seated +intermittent pain, which he referred, however, to a point nearer the +back of the head. He suffered, also, from vertigo, especially after +unusually long paroxysms. Blisters to the nape of the neck, and a few +subcutaneous injections of morphia, removed the pain and the vertigo +completely. + +A third example was that of a gentleman, aged thirty-four, who was sent +over from the neighborhood of Sydney, Australia, to see me. Here, also, +there was deep-seated intracranial neuralgic pain of the most severe +kind, which greatly alarmed his local medical attendants; and it was +only after a great many remedies had been tried that one medical man +gave the opinion that the disease was "neuralgia of the membranes of the +brain," and employed the hypodermic injection of morphia. This treatment +at once gave great relief, though the pain had been so severe as to +cause delirium on several occasions. In order to get thoroughly +re-established, he was sent to England, and desired to consult me. As +was expected, the voyage proved of the greatest service, as he hardly +suffered at all while on the water. On arriving in England he was at +first well, but in a week or two began to feel somewhat below par, and +one morning, feeling an attack of pain coming on, he came to me. He was +a tall and strongly-built man, with nothing peculiar in his appearance +except a certain languor and heaviness of the eyes. He appeared to have +lived somewhat freely and to have smoked decidedly to excess. His +description of the attacks left no doubt of their neuralgic character, +and in other respects they seemed quite analogous to the other cases +mentioned above, except in one thing, that there seemed a good deal of +evidence tending to show a bad local influence in the air of that part +of Australia where he usually resided. Almost any change from that had +always done him good, though nothing had done anything like so much as +the voyage to England. On the occasion of his first visit to me I +injected him with one-sixth grain acetate of morphia, thereby stopping +the pain. I prescribed muriate of iron and minute doses of strychnia, +which he took for some little time, but the pain never recurred during +his stay in England and on the Continent. Unfortunately, as he was +anxious to return to Australia, I permitted him to do so, after a stay +in the Old World of only three or four months; but, very shortly indeed +after his return to Sydney, his old complaint attacked him. This time, +unhappily, the hypodermic morphia has proved merely palliative, and I +have latterly heard very bad accounts from him; still, there has been +nothing to throw doubt on the neuralgic character of the disease. + +In reflecting upon the anatomy of the nervous branches to the dura +mater, I have formed the opinion that there are two situations, one +anterior and the other posterior, in which intracranial neuralgia may +occur; the former at the giving off of Arnold's recurrent branch from +the ophthalmic division, near the sella turcica, the other in the +peripheral twigs of this same branch, distributed to the tentorium +cerebelli. + +_Pharyngeal Neuralgia._--A rather common and extremely troublesome form +of neuralgia is that which attacks the pharynx. It is very much more +common in women than in men, and especially in hysterical persons. The +pain commonly commences in a not very acute manner; it may be felt for +some days, or even weeks, as a dull aching, coming and going pretty much +in accordance with the patient's state of fatigue, or of reinvigoration +after meals, etc. Some trivial circumstance, such as a slightly extra +degree of exhaustion, or the influence of some depressing emotion, will +then change the type to that of decided neuralgia, which may become +extremely severe. Nothing is more annoying, and even distressing, than +the suffering itself, besides which there are abnormal sensations in the +throat which almost irresistibly compel the patient to believe that +there are severe inflammation and ulceration, and that the throat is in +danger of being closed up. Although the pain is usually one-sided, it +sometimes affects both sides, and is felt also at the back of the +pharynx. The act of swallowing being painful, there is the greater +suspicion of inflammation or ulceration, but careful observation shows +that a large bolus of food is swallowed with as little, if not less, +pain than a small mouthful of solids or even liquids. + +Pharyngeal neuralgia must, I think, be considered mainly an affection of +the glosso-pharyngeal nerve; the evidence for this is found in the +distribution of the pain. A slight degree of the neuralgia will only +involve some one or two points in or behind the tonsil; but, when the +pain is strongly developed, it will be found to radiate into the tongue, +in one direction, and into the neck (following the course of the +carotid) in another, besides spreading well into the region occupied by +the pharyngeal plexus. One disagreeable reflex effect of severe +pharyngeal neuralgia consists in involuntary movements of the muscles of +deglutition, another is seen in the copious outpouring of thick mucus +similar to that which collects in the pharynx and oesophagus when a +foreign substance has become impacted. + +_Laryngeal neuralgia_ concentrates itself mainly in the twigs of the +superior laryngeal branch of the pneumogastric which are distributed to +the arytaeno-epiglottidean folds, the epiglottis, and the chordae vocales; +more rarely a neuralgia is developed lower down, within the cavity of +the larynx, apparently in one or more of the scanty twigs to the mucous +membrane supplied by the recurrent laryngeal. + +Pure neuralgias of the larynx, like those of the pharynx, are more +common in women, and especially in weakly hysterical women, than in men. +They are easily excited and greatly aggravated by movements of the +parts, and thus it happens that, among men, by far the most numerous +subjects of laryngeal neuralgia are found among clergymen, professional +singers, and others whose occupation compels them to strenuous and +fatiguing employment of the laryngeal muscles. It is rather a singular +and striking fact, however, that the so-called "clergyman's +sore-throat," which is characterized by most unpleasant sensations, and +by a more or less complete loss of voice, is not, in the majority of +cases, attended with any distinct laryngeal neuralgia. It seems that a +predisposition to neuralgia is a necessary element in the latter +affection. + +FOOTNOTES: + +[3] "Gunshot Wounds and other Injuries to Nerves." Philadelphia: +Lippincott & Co., 1864. + +[4] _Med. Times and Gazette_, March 26, 1864. + +[5] "London Hosp. Reports," 1866. + +[6] "Stimulants and Narcotics," Macmillan, 1854, p. 86. + +[7] Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du +Nevralgies," Journ de Med. de Bruxelles, tome xl. + +[8] Amer. Jour. Med. Science. Jan. 1850. + +[9] "Diseases of the Heart and Great Vessels." Third edition, 1862. + +[10] _Gaz. des Hop._, 114, 117, 120. 1862. + +[11] _Wien Med. Presse_, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p. +120. + +[12] Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120. + +[13] See Wahn, _Journ. de Med. et Chir. Prat._ 1854. Also several +original and quoted cases in Dr. Handfield Jones's "Functional Nervous +Disorders," second edition, 1870. + +[14] _Journ. de Med. et Chir. Prat._, July, 1862. + + + + +CHAPTER II. + +COMPLICATIONS OF NEURALGIA. + + +The secondary affections which may arise as complications of neuralgia +form a deeply interesting chapter in nervous pathology, and one which +has only been explored in quite recent years. The excellent treatises of +Valleix and Romberg, written only thirty years ago, make but most +cursory and superficial mention of these complications, and do not +attempt to group them in a scientific manner. The reflex convulsive +movement of the facial muscles in severe tic-douloureux had of course +been long observed; and Valleix added the correct observation that +gastric disturbance was often secondarily provoked in facial neuralgia, +thus improving greatly on the old view, which supposed that, where +trigeminal neuralgia and stomach disorder coexisted, the latter must +have been the antecedent and the cause of the former. Still, he did not +explain the pathological connection. And as regards certain other most +interesting results of neuralgia, which he could not avoid meeting with +from time to time, _e. g._, lachrymation, flux from the nostril, +salivation, altered nutrition of the hair, he only speaks of these as +occasional phenomena, and in no way classifies them, or explains their +relation to the neuralgia itself. + +There did exist, however, one too little known work of some years +earlier date, which, though not dealing specifically with neuralgia, and +though based upon the necessarily very imperfect knowledge of the +functions of the nervous system prevalent in its day, had nevertheless +done much to lay the foundation of a comprehensive view of the +complications of neuralgia; we refer to the work of the brothers +Griffin, on "Functional Affections of the Spinal Cord and Ganglionic +System," published in 1834. In this most interesting treatise, the +record of acute and extensive observations made in a quiet and +unpretending way by two Irish practitioners, numerous examples are cited +in which neuralgic affections were seen to be inseparably united with +secondary affections of the most various organs, with which the +neuralgic nerves could have no connection except through the centres, by +reflex action. The authors, while firmly grasping the fact of the common +connection of the nerve-pain and the other phenomena (convulsions, +paralysis, altered special sensation, changes in secretion, changes even +in the nutrition of particular tissues) with the central nerve system, +were doubtless in error in thinking that they could detect the precise +seat of the original malady, by discovering certain points of tenderness +over the spinal column. But their facts were observed with the greatest +care, and can now be interpreted more intelligently than was possible at +the time. Here, for example, is a case which forestalls one of the most +interesting pieces of information which more recent research has made +generally known: + +"CASE XXIV.--Kitty Hanley, aged fourteen years, catamenia never +appeared; about six months ago was attacked with pain in the right eye +and brow, occurring only at night, and then so violently as to make her +scream out and disturb every one in the house; it afterward occurred in +the infra-orbital nerve, and along the lower jaw in the teeth, and there +was inflammation of the cornea, with superficial ulceration and slight +muddiness. Tenderness was found at the upper cervical vertebrae, pressure +on any of them exciting severe pain in the vertex and brow; but none in +the eye or jaws, where it is never felt except at night." + +The above is a well-marked example of neuralgia of the trigeminus +causing secondary inflammation and ulceration of the eye of a precisely +similar kind to that which had been experimentally produced by Magendie +by section of the fifth, at or posterior to its Gasserian ganglion. We +shall see, hereafter, how extremely important are this and similar +facts, not only in regard to the clinical history, but also to the +pathology of neuralgia in general. + +The first regular attempt, I believe, to classify the complications of +neuralgia, was made by M. Notta, in a series of elaborate papers in the +"Archives Generales de Medecine" for 1854. We may specially mention his +analysis of a hundred and twenty-eight cases of trigeminal neuralgia, +which is well fitted to impress on the mind the frequency, though, as we +shall presently see, it does not adequately represent the seriousness, +of these secondary disorders. As regards special senses, Notta says that +the retina was completely or almost completely paralyzed in ten cases, +and in nine others vision was interfered with, partly, probably, from +impaired function of the retina, but partly, also, from dilatation of +the pupil or other functional derangement independent of the optic +nerve. The sense of hearing was impaired in four cases. The sense of +taste was perverted in one case, and abolished in another. As regards +secretion, lachrymation was observed in sixty-one cases, or nearly half +the total number. Nasal secretion was repressed in one case, in ten +others it was increased on the affected side. Unilateral sweating is +spoken of more doubtfully, but is said to have been probably present in +a considerable number of cases. In eight instances there was decided +unilateral redness of the face, and five times this was attended with +noticeable tumefaction. In one case the unilateral tumefaction and +redness persisted, and were, in fact, accompanied by a general +hypertrophy of the tissues. Dilatation of the conjunctival vessels was +observed in thirty-four cases. Nutrition was affected as follows: In +four cases there was unilateral hypertrophy of the tissues; in two, the +hair was hypertrophied at the ends, and in several others it was +observed to fall out or to turn gray. The tongue was greatly tumefied in +one case. Muscular contractions, on the affected side, were noted in +fifty-two cases. Permanent tonic spasm, not due to photophobia, was +observed in the eyelid in four cases, in the muscles of mastication four +times, in the muscles of the external ear once. Paralysis affected the +motor oculi, causing prolapse of the upper eyelid, in six cases; in half +of these there was also outward squint. In two instances the facial +muscles were paralyzed in a purely reflex manner. The pupil was dilated +in three cases, and contracted in two others, without any impairment of +sight; in three others it was dilated, with considerable diminution of +the visual power. Finally, with regard to common sensibility, M. Notta +reports three cases in which anaesthesia was observed. Hyperaesthesia of +the surface only occurred in the latter stages of the disease. + +To Notta's list of complications of trigeminal neuralgia must be added +the following, all of which have been witnessed, and several of them in +a large number of instances: Iritis, glaucoma, corneal clouding, and +even ulceration; periostitis, unilateral furring of the tongue, herpes +unilateralis, etc. In writing on this subject three or four years ago, I +mentioned that all these secondary affections had been seen by myself, +except glaucoma. That is now no longer an exception; indeed, my +attention has been so forcibly called to the connection between glaucoma +and facial neuralgia, that I shall presently examine it at some length. + +The trigeminus is, of all nerves in the body, that one whose affections +are likely to cause secondary disturbances of wide extent and various +nature, owing to its large peripheral expanse, the complex nature of its +functions, and its extensive and close connections with other nerves. +Moreover, its relations to so important and noticeable an organ as the +eye tends to call our attention strongly to the phenomena that attend +its perturbations. But there is every reason to think that all secondary +complications which may attend trigeminal neuralgia are represented by +analogous secondary affections in neuralgias in all kinds of situations; +and we may classify them in the principal groups which correspond to +disturbance of large sets of functions: + +1. First, and on the whole, probably, the most common of all secondary +affections, we may rank some degree of vaso-motor paralysis. It may be +doubted if neuralgia ever reaches more than a very slight degree without +involving more or less of this; for so-called points douloureux are +themselves pretty certainly, for the most part, a phenomenon of +vaso-motor palsy; and the more widely-diffused soreness, such as remains +in the scalp, for instance, after attacks of pain, even at an earlier +stage of trigeminal neuralgia than that in which permanently tender +points are formed, is probably entirely due to a temporary +skin-congestion. The phenomenon presents itself in a much more striking +way in the condition of the conjunctiva seen in intense attacks of +neuralgia affecting the ocular and peri-ocular branches of the fifth; +one sometimes finds the whole conjunctiva deeply crimson; and, in one +remarkable instance that I observed, the same shade of intense red +colored the mucous membrane of the nostril of the same side. In several +instances, I have seen a more than usually violent attack of sciatic +pain followed by the development of a pale, rosy blush over the thinner +parts of the skin of the leg, especially of the calf, which were then +extremely tender, in a diffuse manner, for some time after spontaneous +pain had ceased. + +2. Not merely the circulation, however, but the nutrition of tissues, +becomes positively affected, in a considerable number of cases. It is +difficult to judge, with any exactness, in what proportion of neuralgic +cases this occurs, but its slighter degrees must be very common. It has +very frequently happened to me, quite accidentally, in examining with +some care the fixed painful points, which are so important in diagnosis, +to be struck with the decided evidence to the finger of solid +thickening, evidently dependent on hypertrophic development of +tissue-elements; in severe and long-standing cases, I believe this +condition will always be found. Probably the change is, more usually +than not, sub-inflammatory; but it is certain, on the other hand, that +there are great variations in the kind of tissue-changes complicating +neuralgia, and that inflammation is no necessary element in them. This +subject has greatly engaged my attention, and I find myself able to give +what is probably a fuller account of the matter than any yet published +connectedly. + +The following tissues have been seen by myself to become altered under +the influence of neuralgia in nerves distributed to them, or to the +parts in their immediate neighborhood. + +(_a_) The hair has changed in color in many cases. Of twenty-seven +patients suffering from neuralgia of the ophthalmic division of the +fifth, eleven had more or less decided localized grayness of hair on +that side. The amount of this varied greatly, from mere patches of gray +near the roots of the hair to decided grayness of the majority of the +hairs over the larger part of half the head, nearly to the vertex; but +in each case it was a change of color that did not exist on the other +side of the head. In four of these cases there was also grayness of part +of the eyebrow on the affected side. A very remarkable phenomenon, which +I have sometimes identified, is fluctuation of the color, the grayness +notably increasing during, and for some time after, an acute attack of +pain, and the same hairs returning afterward more or less to their +original color. My attention was first called to this curious occurrence +in my own case. I have so often related this case [see, for instance, my +article on Neuralgia in "Reynolds's System of Medicine," vol. ii.] that +I shall merely recall the fact that, when pain attacks me severely, the +hair of the eyebrow on the affected side displays a very distinct patch +of gray (on some occasions it has been quite white) opposite the tissue +of the supra-orbital nerve, and that the same hairs (which can be easily +identified) return almost to the natural color when I am free from +neuralgia. I must, however, add the very curious fact, which I observed +accidentally in experimenting (as regards urinary elimination) on the +effects of large doses of alcohol, that a dose sufficiently large to +produce uncomfortably narcotic effects invariably caused the same +temporary change of color in the hair of the same eyebrow, even when no +decided pain was produced, but only general malaise. The subject will +be again referred to under the heading of Pathology. + +Change in the size and texture of the hairs, in neuralgia, has been +noted by Romberg and Notta, and has been several times observed by +myself. Occasionally the individual hairs near the distribution of the +painful nerve become coarsely hypertrophied; at times the number of +hairs appears to multiply, but I imagine this is only a case of more +rapid and exuberant development of hairs that would be otherwise weak +and small. In one very remarkable instance of sciatica this came under +my observation; the whole front of the painful leg, from the knee nearly +to the ankle, became clothed, in the course of about six months, with a +dense fell of hair, which strongly reminded me of similar abnormal +hair-growths that have been occasionally seen in connection with +traumatic injuries to the spinal cord. More commonly, the effect of +neuralgia upon hair is to make it brittle, and to cause it to fall out +in considerable quantities; one young lady, who consulted me for a +severe migraine, was seriously afraid of having a good head of hair +completely ruined in this way, but the hair gradually grew again after +the neuralgia had disappeared. + +(_b_) The periosteum of bone and the fibrous fasciae in the neighborhood +of the painful points of neuralgic nerves not unfrequently take on a +condition of subacute inflammation, with marked thickening and +tenderness on pressure. The most striking instance of this that I have +seen was in a lady suffering from severe cervico-brachial neuralgia. In +the neighborhood of the emergence of the musculo-spiral nerve at the +outer side of the arm, there was developed what looked for all the world +like a large syphilitic node, except that the skin was brightly reddened +over it; this disappeared altogether some little time after the +neuralgia had been relieved by ordinary treatment. I must say that, but +for the peculiar circumstances of the case, putting syphilis out of the +question, I could not have avoided the suspicion, at first, that the +swelling was specific. But I have several times seen similar, though +less developed, swellings in neuralgia, and in one case I noticed the +occurrence of such a swelling on the malar bone, in an old woman in whom +the neuralgic pain was limited to the auriculo-temporal and the +supra-orbital branches of the fifth. + +A very important point is to be noted in connection with these +sub-inflammatory swellings in connection with neuralgia. Pressure on +them will, frequently, not merely excite the neuralgic pains in the +branches of the affected nerve, but send a powerful reflex influence +through the cord to distant organs, causing vomiting, for instance, or +affecting the action of the heart in a very perceptible manner. I shall +show, when I come to speak of the phenomena of so-called spinal +irritation, that this circumstance has led to erroneous influences in +many cases. These exquisitely tender points are often found where +Trousseau places his neuralgic _point apophysaire_, namely, over, or +very near, the spinous processes of the vertebrae. The tenderness is +quite unlike that which is known as hysterical hyperaesthesia; it is much +severer, and is limited to one, two, or three points, corresponding, in +fact, to the superficial part of the posterior branches of as many +spinal nerves. + +(_c_) The nutrition of the skin over neuralgic nerves is sometimes +notably affected even when the process does not reach the truly +inflammatory stage, which will be more particularly mentioned presently. +A certain coarseness of texture of the skin has struck me much, in +several cases of long-standing facial neuralgia. And there is a most +curious phenomenon (which will be especially considered hereafter in +regard to the singular influence of the constant galvanic current upon +it), the distribution of a greater or less amount of dark pigment to the +skin near the painful part. This phenomenon is much more marked during +the paroxysms, and in the slighter cases entirely disappears in the +intervals, but in old-standing severe cases it becomes more or less +permanent. + +(_d_) The mucous membranes, in situations where we can observe them, not +unfrequently show interesting changes, the nutrition of the epithelium +of parts covering the painful nerve being exaggerated. It has been noted +by various observers, in neuralgia affecting the second and third +divisions of the trigeminus, that the half of the tongue corresponding +to the painful nerve was covered with a dense fur. This is by no means +universally the case, but I have seen it occur several times. In my own +case, in which the neuralgia is limited for the most part to the +ophthalmic division, and only rarely spreads even to the second division +of the nerve, this does not usually occur, but I have noticed it on one +or two occasions. And I once made the still more singular observation +that a large narcotic dose of alcohol, which was sufficient to cause +comparatively free elimination of unchanged alcohol in the urine, caused +furring of the tongue, which was decidedly thicker on the side of the +affected nerve than on the other half of the tongue. + +(_e_) We come now to a group of complications of neuralgia which are +exceedingly important, and by no means adequately appreciated as yet, +viz., the acute inflammations which directly result from neuralgic +affections in a certain percentage of cases, probably much larger than +has been at all generally suspected. + +The most familiar of the inflammatory complications of neuralgia is +herpes zoster, the favorite seat of which is the skin which covers one +or more of the intercostal spaces: the eruption, as occurring in this +situation, is so well known that it would be waste of time to describe +it. In young subjects zoster is commonly painless, at least the +sensations are those of heat, pricking, and irritation, rather than of +acute pain; but from puberty onward there is an increasing tendency, +especially in those otherwise predisposed to neuralgia, for zoster to be +preceded, accompanied, or followed by neuralgia of the intercostal +nerves corresponding to the distribution of the eruption. Most commonly, +the eruptive period is, in my experience, nearly or quite free from +neuralgia, but it often recurs, or breaks out for the first time, when +the vesicles are drying up, but more especially if, as is sometimes the +case, especially in elderly people, the scabs fall off and leave +superficial ulcers. Neuralgia may last, after herpes zoster, for any +time from a few days to many weeks, and I have known it so agonizingly +severe and so persistent as actually to kill an aged woman from sheer +exhaustion. In spite of sundry objections that have been raised to the +theory of the nervous origin of zoster, it appears to me that the +evidence in favor of it is overwhelming, more especially now that it is +proved that the disease, with all the same characteristics presented by +it when seen on the chest or abdomen, may occur on the face (following +the branches of the trigeminus), or on the forearm (following the course +of nerves from the brachial plexus). Two of the severest cases of +neuralgia attending herpes that I have ever seen were in private +patients (whose family history, unfortunately, I had no means of +ascertaining) who were affected, respectively, in the facial and in the +brachial nerve-territories. + +A far more formidable occasional complication of neuralgia is +inflammation affecting the eye. Mr. Jonathan Hutchinson records several +cases in which neuralgic herpes zoster of the face was attended with +iritis, with serious or even irremediable damage to the organ. For my +own part, I have witnessed several instances in which neuralgia of the +first and second divisions of the fifth has been attended with +skin-inflammation, but only in one of these (just alluded to) did the +inflammation present the characteristic appearances of herpes: in all +the rest it far more closely resembled erysipelas. The skin was +excessively reddened in an almost or quite continuous patch over the +whole territory through which ran the painful nerves; by no means only +linearly in the course of the nerves, though accurately limited to the +district of the first or first and second divisions of the fifth. In the +first case I saw (a woman, aged thirty-two), nothing could be more +startling than the rapidity with which an irregular patch of the skin, +including half of one cheek, the side of the nose, and a large part of +the forehead and scalp on the same side, became converted into the +dense, fiery-red, brawny tissue, with minute vesicles scattered over its +surface, which looks so characteristic of erysipelas; this commenced +immediately on the subsidence of severe neuralgic pain. During the +erysipelatoid inflammation, though there was no spontaneous pain, the +neuralgia could be instantly lighted up for a moment by pressure on the +infra-orbital foramen, on the supra-orbital notch, or upon the malar +bone, about its centre. Since that time I have seen several cases of a +similar character; two of these, which were reported in the _Lancet_ for +1866, I shall here reproduce: [Extensive inquiries convinced me that the +tendency to erysipelatous complication of facial neuralgia is +exceedingly common. Eulenburg expressly confirms my original statement +to this effect, and extends it to all neuralgias.] + +CASE I.--A woman, aged sixty-three, presented herself in the out-patient +room at Westminster Hospital, suffering from neuralgia of ten days' +standing (which for the present, however, seemed to have abated +considerably), but asking advice chiefly for an erysipelatoid +inflammation which had come on a day or two before, and occupied the +area of the painful nerve-district. The neuralgia had affected the +supra-orbital nerve, running up toward the vortex, and the +auriculo-temporal branch of the third division of the fifth; although +there was no very acute pain present at this time, pressure over the +supra-orbital notch, or at a point just in front of the ear, would at +once cause a brief paroxysm of pain. It was curious to find that there +was a thickened and tender spot over the malar bone (and corresponding +to the exit of some nerve filaments from the bone) which had never been +the seat of spontaneous neuralgia, but pressure here sent a dart of pain +into the auriculo-temporal and supra-orbital nerves. The inflammation +was markedly limited to the general area of distribution of the twigs of +the auriculo-temporal and of the ophthalmic division; it was of a +continuous deep-red color, and attended with much thickening of the +skin. The conjunctiva was intensely congested, and there were +lachrymation and very marked photophobia, but there were no signs of +iritis, and no corneal clouding. + +CASE II.--M. W., a woman, aged forty-two, well-nourished and +healthy-looking, married and had one child; had never suffered any +serious ailment except once, about five years previously. She then had a +decided attack of "erysipelas," very accurately limited to the right +half of the face. Five months before coming to me she sustained a severe +shock from being thrown out of a chaise, without suffering any external +or visible damage. An hysterical tendency, which she had always +possessed, became more marked; it revealed itself by palpitations, +occasional dysphagia, and a disposition to weep causelessly. The menses +were flowing at the time of the accident; they ceased abruptly soon +after (they had been scanty for some time previously), and did not recur +till four months later. The hysteric disturbance progressively increased +during a fortnight, and then the patient was attacked with violent +intermittent neuralgia, commencing in the eyeball and spreading over +the district supplied by the branches of the first and second divisions +of the trigeminus. The pain was accompanied by intense conjunctival +congestion and photophobia [Dr. Handfield Jones remarks that +photophobia, in his experience, is only a rare accompaniment of facial +neuralgia. I have latterly come to the same opinion. Redness of the eye +and lachrymation are very common; true photophobia uncommon. Notta's +experience would seem to have been similar]. It lasted on the first day +fourteen hours, and returned daily for the next fifteen or sixteen days. +An attack of erysipelas, strictly limited to the district of the painful +nervous branches, then set in. From that moment the neuralgic attacks +became less frequent and severe. A second similar onset of erysipelas +occurred some three or four weeks after the first. Finally, the +neuralgia disappeared about four months after its first occurrence, and +the menses reappeared in tolerable abundance about the same time. About +a fortnight before this the patient had discovered that her right eye +was dim; as the photophobia had previously disabled her from opening the +eye, she could not be sure how long this dimness had existed. At the +time of her visit to me the cornea was blurred with a large patch of +interstitial lymph, with the remains of a superficial ulcer in the +centre; the iris was turbid and discolored, showing the traces of recent +but past iritis; the pupil was regular in form and active to light; the +conjunctiva was slightly congested. Ophthalmoscopic observation was +attempted by a skilled observer, but could not be satisfactorily carried +out, from the turbid state of the media. The conjunctiva was slightly +congested. In place of the lachrymation that had prevailed during the +neuralgic period, there was a remarkable insensibility of the lachrymal +apparatus, for the patient had noticed that the smell of onions, which +would make the other eye weep profusely, had no influence on the +affected one. + +The family history of this patient is a most remarkable one. All the +members of her mother's family, for two generations back, had died at +middle age, either from apoplexy or some disease involving hemiplegia. +This case has, by a mistake, not been added to the list of twenty-two +private cases in which the family history was carefully investigated, +that will be found in the chapter on Pathology; this arose from the fact +that the patient was not properly under my care, but was sent to me as a +medical curiosity; the notes of her case were therefore taken in a +different book from the others. The case certainly ought to be taken as +a counterpoise to such a one as No. XVI. in the list, which is that of a +gentleman who suffered from the most complicated neurotic maladies +(asthma, angina pectoris, facial neuralgia, more than once attended with +erysipelas), but whose family history, so far as it was known, presented +no traces of tendency to neurotic disease. + +To these two cases of inflammation, secondary to neuralgia, I shall add +a third, which is even more interesting, and which came under my notice +not long since. + +CASE III.--H. T., watchmaker's assistant, aged forty-two, suffered for +about three weeks with very severe remittent abdominal pain, entirely +unconnected with dyspepsia, constipation, or diarrhoea. It was +intermittent in character, but observation soon showed that the times at +which it came on were simply those at which the stomach had gone longest +without food, especially the early morning, and that nourishment never +failed to relieve it. The suffering was great, and the man failed +considerably in general health, notwithstanding that his appetite and +digestion were unimpaired. He had only been under my care about ten days +when he presented himself one day at the hospital, and stated that the +pains in the stomach had entirely left him, but that he suffered the +most frightful pains in and around the right eye. I found a well-marked +conjunctival congestion and lachrymation, but there were as yet no +tender points; the neuralgia was felt most severely in the globe of the +eye and in one tolerably straight line, darting up toward the vertex +from the brow. The iris seemed clear and free, and the cornea was not +cloudy. I gave the man a subcutaneous injection of one-sixth grain +acetate of morphia, for present ease, and ordered him muriate of iron +and small doses of strychnia three times a day. When he next appeared, +four days later, I was alarmed to perceive that unmistakable iritis had +fully developed itself, the iris was already turbid and discolored and +the pupil irregular, from a serious amount of adhesions. By this time +there were fully-developed tender points, supra-orbital and parietal; +besides this, pressure on the globe caused paroxysms of pain, in all the +branches of the ophthalmic division, but there was not much spontaneous +pain. I dropped atropine in the eye, applied blistering fluid to the +back of the neck, [the nape of the neck is the point most suitable for +blistering which is intended to affect the eye, and the ophthalmic +division of the fifth, generally,] and desired the man to come to see me +at my own house next day, intending to take him to an ophthalmic +surgeon. Unfortunately he failed to do this, and three days later, when +he came to see me at the hospital, the cornea was studded with +opacities, the pupil was almost closed with effused lymph, there was +violent ocular pain, and a great and increasing sense of tension. I +begged him to go without loss of time to the Eye Hospital, as my own +ophthalmic colleague was not at Westminster that day; and I have never +heard any more of the patient. + +Glaucoma is a still more serious disease of the eye, which I think there +is now sufficient evidence to show is sometimes entirely, and very often +in considerable part, neuralgic in its origin. Since my attention was +directed, some six years ago, to the frequent connection between the +so-called rheumatic iritis and neuralgia, I have taken much interest in +the subject of acute eye-affections; and the occurrence of one or two +cases of glaucoma in personal friends of my own has made this interest +even painfully strong. I am necessarily without the means of personally +observing glaucoma on the large scale, but I have now seen two cases in +which, if I possess any faculty of clinical observation whatever, the +whole genesis of the disease was a neuralgic disorder of the trigeminus; +and it was to me a melancholy reflection that nothing better than +iridectomy in one case, and excision of the eyeball in the other, could +be done in the present state of ophthalmic science. There are now a good +many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell +Carter, of St. George's, and the South London Ophthalmic Hospital, +recently assured me that nervous aspect of some form of glaucoma +presents itself the strongly to his mind, though he does not commit +himself to any theory. Two cases were reported by Mr. Hutchinson, in +Ophthalmic Hospital Reports IV. and V.; but the most complete and +interesting cases that I have met with are recorded by Dr. Wegner;[15] +they are two out of four that occurred within a very short time in the +clinic of Prof. Horner at Zurich, and they form the basis of some +researches by Wegner into the nature of the influence of the trigeminus +upon ocular tension, which will be referred to, along with others, in +the chapter on Pathology. The second of these cases is so important that +I shall reproduce it in full. + +A. Hediger, aged twenty-four, a moderately strongly-built young woman, +seen first in August, 1860. From her own and her mother's account, it +seemed she had long suffered from convulsive attacks that did not appear +to have been truly epileptic. Some days previously her left eye became +very painful, and the sight failed, without any inflammatory symptoms. +On inspection the pupil was somewhat dilated, the eye somewhat +hypermetropic, fundus normal; No. 5, Jager's type, was read with +difficulty. Wegner could not explain the condition. At the end of +October the eye was much worse; after severe paroxysms of pain, No. 16 +type was the smallest legible, the field of vision was decidedly limited +in all directions, but especially on the inner and upper portions. An +unusually long hysteric attack was now observed. The patient was for +twenty-four hours in a half-sleep, the extremities, meantime, were much +jerked, the speech sometimes coherent and sometimes incoherent; she +cried out to her friends, etc., but had no severe convulsion-fit with +spasm of glottis. She was removed to the hospital, where she stayed six +weeks. The hysteria improved under treatment with valerian and morphia +(Prof. Greisinger had confirmed the opinion that there was no true +lesion of the centres), but the neuralgia of the globe was +extraordinarily severe, both day and night. From January to June, 1861, +Wegner saw her occasionally. The visual power of the left eye fluctuated +between 15 and 19 Jager. Field of vision very limited. Pupil very +dilated and insensitive, the globe painful to the touch, and injected. +The right eye weakly hypermetropic; normal field of vision, normal +pupil, no pain. The scene suddenly changed on the 29th of June. She was +attacked with fearful pain, and an enormous mydriasis with extreme +amblyopia of the right eye; the fingers could hardly be counted when +placed quite close. The optic disc appeared somewhat cloudy, with very +evident venous pulsation. The mydriasis, amblyopia, and neuralgia lasted +some time, while simultaneously the left eye could only read 19-17 type, +but was painless. The pathology seemed quite obscure, and the surgeon +remained almost passive till August, when he performed paracentesis on +the left eye. The patient could distinguish fingers at that time at a +foot's distance with the right eye; with the left read No. 11, but +suffered fearful pains. These diminished after the puncture; the eye +could read No. 20 next day, and improved after that to 19; the pains +recurred in the next day, but for the first time ceased to disturb +sleep. The scene again changed in the most surprising manner on the 27th +of August. The most frightful pain again attacked the left eye. The +pupil was dilated to the maximum (far beyond what occurs in oculo-motor +paralysis); the globe was extremely painful on touch, visual power +fallen to 19 Jager. On the other hand, the right eye had a normal pupil, +was painless, and could read No. 12. Paracentesis of the left eye +improved its vision and diminished pain, but only temporarily, so that +it had to be repeated at short intervals. The condition was so far +stationary toward the end of October that the right eye continually +gained visual power, but the left stood still and fluctuated from worse +to better, with the greater or less severity of the neuralgic paroxysms. +Pupils always in extreme dilatation. In the end of October and beginning +of November (the patient had worn a large seton for a month) remarkable +changes occurred; the neuralgia of the left globe diminished steadily, +the pupil got smaller, the visual power increased, the neuralgia now was +only on the lower lid, which was slightly red and painful to the touch, +and had continual spontaneous pain. Visual power of right eye No. 3, of +left eye No. 5. Visual field intact; with full illumination by weak +light there is a peripheral torpor, but only in a narrow zone. The +hyperaemia now extended more and more over the lower lid and the upper +part of the cheek; this was apparent during the paroxysms, which were +very severe, and destroyed sleep; it did not allow the skin to be +touched; the color was deep (with high temperature) and extended to the +angle of the mouth. This phenomenon lasted till the beginning of +December, when neuralgia again attacked the left globe, with strong +mydriasis and diminution of visual power (15 to 20 Jager), till at last +the movements of the hand could hardly be distinguished, and this state +of things continued with fluctuations up to the end of the month. The +seton had been taken off just before the new outbreak; it was put in +again on December 31st. In January the pains continued severe in the +eye, with only one remission (from the 17th to the 20th), when the +hyperaemia recurred in the cheek. On the 26th the pupil was very dilated, +and fingers could not be seen at half a foot's distance. Visual field +very limited, globe hard. A large upper iridectomy was made. After this +the pupil was contracted, the pains diminished, visual power 10 Jager, +field seven inches. In the middle of February the hysterical attacks +recurred with great force; the patient was unconscious half the day; she +was clear enough in senses when awake, but complained of buzzing in her +head, as if a cock-chafer were inside it. From this till the middle of +March, the left eye did not alter, the impairment of vision remained, +with normal pupil and no pain in the globe, and the iridectomy seemed at +least to have done good in one direction; but on the 13th of March the +operated eye was again attacked with pain, visual power fell to No. 17, +pupil became dilated, and after a few days the swelling, heat, and +tenderness of the cheek recurred. During the years 1862 and 1863 the +condition remained pretty much the same; _i. e._, the right eye sound, +the left painful (in spite of the iridectomy) with dilated pupil, +concentrically narrowed visual field, visual power fluctuating between +No. 15 and mere finger-counting without any ophthalmoscopic appearances. +A number of paracentesis and subcutaneous injections of morphia (which +last were the more indicated as the supra-orbitalis was tender on +pressure) always brought relief merely for a few hours. On the 19th of +April, 1864, vision being complete in right eye, and No. 19 in left, +Wegner punctured the latter. On the 2d of May the eye read No. 10 +slowly, the pains had gone and not returned, the pupil became smaller. +On the 31st of March, 1865, the patient was pronounced well; the eye was +painless, the pupil somewhat larger than the other; the finest type +could be read when looked at very close. + +3. The next group of affections secondary to neuralgia are the paralysis +of muscles. These are pretty common; I find them in twenty-eight of the +hundred cases which have been referred to. But of these twenty-eight +instances of paralytic affections no less than twelve were connected +with neuralgia of the trigeminus, and in most of these it was one or +more of the muscles connected with the eye that were affected. Sciatica +is nearly always attended with much weakening of voluntary power of the +muscles of the thigh and leg; and in some instances this reaches to +decided or even complete paralysis. In looking for this phenomenon we +must be very careful that we do not mistake the mere reluctance to move +the limb, on account of the painfulness of all movements, for true +paralytic weakness of nerve and muscle. And it is also necessary to bear +in mind, in prolonged cases, the probability that much of the weakness +may have been caused by degeneration of the muscles owing to forced +inaction. Still, there is a class of secondary paralyses that are in no +way to be confounded with such effects as these: for instance, it +occasionally happens, almost in the very first onset of severe sciatic +pain, that the limb hangs absolutely helpless; and in one such case +lately, being struck with the completeness of the loss of power, I +tested the Faradic irritability by directing a sharp current on +comparatively exposed portions of the painful nerve (_e. g._, in the +popliteal space, and behind the head of the fibula), and elicited only +the most feeble contractions, entirely unlike what the same current +evoked in the opposite limb. I regret that I have as yet found it +impossible to carry out a regular inquiry as to the sensibility to the +different currents of motor nerves which are centrally connected with +neuralgic sensory nerves. + +Muscular viscera which are composed of unstriped fibre, like the +intestines, or of a mixture of striped and unstriped, like the heart, +are probably very liable to a secondary paralytic influence from certain +special neuralgiae. It is ascertained that the pain of a certain degree +of severity in the branches of the fifth may absolutely stop the heart's +action for a moment--an effect which is succeeded, usually, by violent +and disorderly pulsations. I have myself once known the operation of +"pivoting" a tooth, which gave frightful pain, cause instantaneous and +most alarming arrest of the heart's motion, which for a minute or two +seemed as if it were going to be fatal. But the variety of visceral +paralysis which is probably far the most frequent is secondary paralysis +of the bladder, from neuralgia in one or other of the pelvic organs, or +of the external genitalia; and next to this comes paralytic distension +of the caecum, colon, or rectum, secondary to various abdominal and +pelvic neuralgic affections. In one instance of acute ovarian neuralgia +that I saw, the paralytic distention of the colon was by far the most +remarkable circumstance, so enormously was it developed; and for some +days after the neuralgia had ceased, and when the flatulence had nearly +disappeared, the intestine remained absolutely torpid. + +4. Convulsive actions of muscles, as every one knows, are very common +complications of neuralgia. In trigeminal neuralgias these may be +observed (according to the division or divisions of the nerve that are +affected) in the proper muscles of the eye, or in those supplied by the +fourth and sixth nerves, or (perhaps only when two or three divisions +of the fifth are neuralgic at once) by the portio dura. It is curious, +however, that those formidable spasmodic affections of the face which +belong to the same order as torticollis and writer's cramp, are not +frequently, if ever, directly associated with trigeminal neuralgia. The +only connection between them seems to be that these peculiar spasmodic +affections are only developed in highly-neurotic families, some of whose +members are almost sure to be found suffering from some form of regular +neuralgia. In severe sciatica it has several times happened to me to see +convulsive action of the flexors, bending the leg spasmodically upon the +thigh. And in a very large proportion of all neuralgias, wherever +situated, attentive observation of the patient during the paroxysms will +detect the existence of local twitching or local spasm of muscles, +though these may be slight in degree. + +Among the convulsive affections must be reckoned convulsive movements +and tonic spasms of various portions of the alimentary canal. Vomiting +is a common example of this; in migraine it is the regular and necessary +climax of attacks which last with severity for a certain time; indeed, +any severe attack of neuralgia involving the ophthalmic division of the +fifth may excite vomiting. Convulsive action of the pharyngeal muscles, +as a complication of pharyngeal or laryngeal neuralgia, occasionally +occurs to such an extent as to render deglutition difficult or +impossible for the time. And I have seen what I do not doubt to have +been a spasmodic condition of the rectum induced by peri-uterine +neuralgia. The genito-urinary organs are also not unfrequently affected +spasmodically in consequence of a neuralgic affection either +peri-uterine or pudendal. I have seen spasmodic stricture of the male +urethra thus produced, and likewise vaginal spasm. + +5. Impairments of sensation, both common and special, are very frequent +attendants of neuralgia. As regards the special sensations, we may first +mention that of touch; this is almost constantly impaired, immediately +before, during, and some little time after a neuralgic paroxysm, in the +skin supplied by the painful nerves. I was first led to make this +observation by my own experience; the skin all round the inner angle of +my right eye is permanently less sensitive to distinctive impressions +than that of the opposite side, and this impairment is always decidedly +greater, and spreads over a larger surface, before, during, and for some +time after, the attacks of pain. More extended observation has convinced +me that a certain amount of bluntness of distinctive skin-sensation +accompanies nearly every neuralgia. As regards the sense of taste, I +have found this decidedly perverted, at the time of an attack, even in +my own case, although the neuralgia never extends into the third branch +of the nerve. It is interesting to notice, in connection with this, +that the epithelium of my tongue has been seen, on one occasion, to be +exaggerated on the side of the neuralgic affection, showing a +probability that there is perturbed function, at any rate of certain +fibres, of the third division. But I have seen much more decided +alteration, indeed temporary entire abeyance of the power to distinguish +between the tastes of different substances, with the affected side of +the tongue, in a case of severe epileptiform tic in which the third +division was strongly affected with neuralgia; and Notta records a +similar instance. As regards vision, besides minor perversions and +disturbances, I have observed more or less complete amaurosis in several +instances of ophthalmic neuralgia; in one case it was absolute, and +lasted, with but slight improvement in the intervals between the +paroxysms, for nearly a month, but disappeared entirely, though somewhat +gradually, after the final cessation of the neuralgia. As regards +hearing, I have noticed serious impairment only in five cases, all of +them of a severe type of trigeminal neuralgia, involving all three +divisions of the nerve. Smell, I have never observed to be more than +doubtfully impaired, except in one case (_vide_ Chapter III), where it +was completely destroyed. + +Common sensation was reported by Notta as affected in only three cases +out of a hundred and twenty-eight; but my own experience has afforded a +much larger proportion of instances in trigeminal neuralgia. Indeed, in +all situations neuralgia appears to me to involve this effect, in the +larger number of instances, in the early stages; later, it is supplanted +in part by great tenderness on pressure in the well known _points +douloureux_, and sometimes the tenderness becomes diffused over a +considerable surface. I agree with Eulenburg in thinking that anaesthesia +is more frequent in sciatica than in other neuralgias. + +6. Secretion is often very notably affected in neuralgia; the phenomena +are necessarily more easily observed in connection with affections of +the trigeminal than of other nerves. In the great majority of cases the +affection is in the direction of increase; at least, the watery elements +of secretion are often poured out in profusion. Thus, profuse +lachrymation is exceedingly common in ophthalmic neuralgia; in a large +number of cases there is also copious thin nasal flux on the affected +side; sometimes, however, the secretion, though copious, is +semi-purulent, or bloody. Increased salivation has been noticed, by a +large number of observers, in neuralgia involving the lower division of +the fifth. In a smaller number of instances, the secondary effect on +secretion is precisely opposite; thus both Notta and myself have +observed complete dryness on the nostril on the affected side in +ophthalmic neuralgia. + +I might expand this chapter on the complications of neuralgia to a very +much greater length; but, as regards the clinical history of these +affections, it is perhaps better not to occupy more time and space. It +will, however, be necessary to return to the consideration of the +subject in connection with Pathology. + +FOOTNOTE: + +[15] Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866. + + + + +CHAPTER III. + +PATHOLOGY AND ETIOLOGY OF NEURALGIA. + + +The pathology and the etiology of neuralgia cannot be considered apart; +they must be discussed together at every step. I do not mean to say that +neuralgia is singular among diseases in this respect; it seems to me +merely a case in which the intrinsic defects of the conventional system +of separating the "causes" of disease from its pathology happen to be +more glaring and more easily demonstrable than usual. + +Neuralgia possesses no "pathology," if by that word we intend to signify +the knowledge of definite anatomical changes always associated with the +disease, in a manner that we can exhibit or exactly describe. It also +possesses no demonstrable causes, if we employ the word "causes" in the +old metaphysical sense. And yet I am very far from admitting, what seems +to be so generally taken for granted, that we know less about the seat, +the nature, and the conditions of neuralgia than of other diseases. On +the contrary, I believe, with all deference to the supporters of the +ordinary opinion, that we know more about neuralgia, in all these +respects, than we do about pneumonia, only our knowledge is not of the +superficial and obvious kind, but requires the aid of reason and +reflection to develop and turn it to account. It has long been a matter +of surprise to me, that even able writers have been content to talk +about this disease (as, indeed, they have been content to speak of many +nervous diseases) with an inexplicable looseness of phraseology. They +speak of its "protean" forms; whereas, in my humble judgment, its forms +are by no means specially numerous. They insist on the mysterious and +unintelligible manner of its outbreaks, remissions and departure; but I +shall try to show that, although, in the investigation of neuralgia, we +are continually stopped in particular lines of inquiry by what seems to +be ultimate facts, susceptible of no further immediate solution, the +channels of information open to us are so unusually numerous as to +enable us to accumulate a mass of information which, upon further +reflection, will be found to furnish the materials of a synthesis of the +disease singularly clear and effective for every practical purpose of +the physician. In one important particular I especially hope to convince +the reader that a large proportion of the mystification as to the +pathology of neuralgia is gratuitous, and the result of great +carelessness in estimating the comparative value of different facts. I +hope to show clearly that, as regards both the seat of what must be the +essential part of the morbid process, and the general nature of the +process itself, we possess very definite information indeed. I expect, +in short, to convince most readers that the essential seat of every true +neuralgia is the posterior root of the spinal nerve in which the pain is +felt, and that the essential condition of the tissue of that nerve-root +is atrophy, which is usually non-inflammatory in origin. This doctrine +seems, at first sight, presumptuous,[16] in the confessed absence or +extreme scarcity of dissections which even bear at all upon the +question. But one source of the extraordinary interest which the +pathology of neuralgia has long possessed for me resides in this very +fact, that I am convinced we can demonstrate the above apparently +difficult theorem by means of pathological observations on the living +subject, taken in conjunction with physiological experiments, and with +only the aid of a very few isolated facts of positive morbid anatomy. I +need hardly say that I am none the less anxious for that further +assurance which we shall one day, perhaps, obtain by means of +greatly-improved processes for microscopic detection of minute changes +in nerve-centres; but, looking to the necessary rarity of opportunities +for post-mortem examinations of the nervous system in any but the most +advanced stages of neuralgias, it will hardly be disputed that, if I am +right in my main position, we are singularly fortunate to be so +unusually independent of the need for this source of information. + +1. The first fact which strikes me as of decided importance is the +position of neuralgia as an hereditary neurosis; and this character of +the disease is so pregnant with significance, that I shall take some +considerable pains to put the fact beyond doubt in the reader's mind. + +There are two series of facts which support the theory of the +inheritance of the neuralgic tendency: (_a_) instances in which the +parent of the sufferer had also been affected with the disease; and +(_b_) instances in which the family history of the patient being traced +out more at large it appeared that, among the members of two or more +generations, while one, two, or more individuals had been actually +neuralgic, other members had suffered from other serious neuroses (such +as insanity, epilepsy, paralysis, chorea, and the tendency to +uncontrollable alcoholic excesses), and, in many instances, that this +neurotic disposition was complicated with a tendency to phthisis. + +(_a_) The question of the direct transmission of neuralgia itself from +the parent seems the easiest of decision, though even this cannot always +be satisfactorily cleared up by the hospital patients, among whom one +collects the largest part of one's clinical materials. However, I have +been at the pains of investigating a hundred cases of all kinds of +neuralgia, seen in hospital and private practice, with the following +results: twenty-four gave distinct evidence that one or other parent had +suffered from some variety of neuralgia; fifty-eight gave a distinctly +negative answer; and eighteen would not undertake to give any answer at +all. Among the twenty-four affirmatives are inserted none in which the +history of the parent's affection did not clearly specify the liability +to localized pain, of intermitting type, but recurring always in the +same situation during the same illness. In three of these twenty-four +instances, the patient stated that both parents had suffered from such +attacks, and, in one of these, it appeared that the grandfather had +likewise suffered. + +(_b_) The question of the tendency of a family, during two or more +generations, to severe neuroses of more or less varying kinds, including +neuralgia, is difficult to work out perfectly, though in a large number +of instances we may get enough information to be very useful. I have +spent much time and trouble in endeavoring to collect such information; +but there are two main difficulties in connection with all such +attempts. From hospital patients you frequently can get no reliable +information whatever respecting any members of the family farther back +than the immediate parents; and, even respecting uncles and aunts and +first cousins, it is often impossible to learn any thing. And when you +get to a higher class of society, especially when you approach the +highest, although the information may exist, it may be withheld, or you +may be purposely mystified. One would doubt beforehand, under these +circumstances of difficulty, whether it would be possible to obtain +affirmative evidence of the neurotic temperament of the families of +neuralgic patients in general; but, in truth, the evidence is so +overwhelming in amount, that more than enough can be obtained for our +purpose. I shall give, first, the results of one special inquiry which, +by the kindness of a patient, I have been able to carry out with more +than usual completeness; it relates to the medical genealogy of a +sufferer from sciatica; the account is fairly complete for four +generations. The great-grandfather was a man of splendid physique (an +only son), who lived very freely, but died an old man. His children were +three sons, one of whom (though strictly temperate) was a man of +eccentric and somewhat violent temper, and suffered from a spasmodic +facial affection. This one, the grandfather of my patient, married a +lady who died of phthisis, and among the ten children she bore him, two +sons died of phthisis, two sons became chronically insane, one son died, +probably of mesenteric tubercular disease (aged fifty-six), two sons are +still alive at very advanced ages, and have always been perfectly +healthy and strong; one daughter died in middle age, it is not certain +from what cause; one daughter lived healthily to the age of eighty, and +then was attacked by facial erysipelas, followed by violent and +intractable epileptiform tic, which clung to her for the remaining four +years of her life; and the remaining daughter, an occasional sufferer +from migraine, died at the age of sixty-seven, almost accidentally, from +exhausting summer diarrhoea. The fourth generation, in this branch of +the family, consisted of thirty-one individuals; of whom seven have died +of phthisis, or scrofulous disease; one from accidental violence, one +from rheumatic fever, one from scarlet fever; and among the surviving +twenty-two one has been insane, but recovered; two are decided +neuralgics; one is occasionally migraineuse, and once had a smart attack +of facial erysipelas, corneitis, and iritis, as the climax to a severe +neuralgic attack; one has been a sufferer from chorea; one has become +phthisical; one developed strumous disease, but has fairly recovered +from it. The remaining fifteen enjoy good health, but are distinguished, +almost without exception, by a markedly neurotic temperament, indicated +by an anxious tendency of mind, quickness of perception, aesthetic taste, +disposition to alternations of impulse and procrastination. Of the young +fifth generation growing up, there have been twenty-five children, of +whom only one has died (from fever), the rest are apparently healthy +(most of them specially so); but, as few have yet reached the age for +the development either of phthisis or of neurotic diseases, the future +of this generation can only be guessed at. [It is unnecessary to trace +the other descendants of the second generation, but I may state that +their medical history, also, strongly supports the theory of inheritance +of the neurotic tendency, and of the influence of an imported element of +phthisis in aggravating the latter.] I suspect that, as regards the +young children now growing up, everything will depend on the care with +which they are fed, and the kind of moral influences brought to bear on +them, two subjects which will be fully dwelt on in the chapter on +Treatment. + +Of less perfect inquiries on the subject of neurotic disposition +inherited by neuralgic patients, I have made a great number, though I +regret to say that I have not attempted the task in the whole number of +those from whom I inquired as to direct inheritance of neuralgia from +their parents. However, in eighty-three cases this was done with all +possible care, and any deficiency of completeness in the results is not +my fault. I shall take first those that were private patients, +twenty-two in number, respecting whom, I may say, that the evidence is +of the best, as far as it goes, since I was better able to discriminate +as to the worth of statements, than in dealing with hospital patients, +and have rejected every case in which the informant did not seem +intelligent enough, or otherwise to have the means, to give a thoroughly +reliable account. + + I. Neuralgia cervico-brachialis; in a lady, aged seventy-one. + Mother suffered from epileptiform facial tic; uncle was + paralyzed; patient herself eccentric to the verge of insanity. + + II. Bilateral sciatica of great severity; in a gentleman, aged + seventy-three. Gout, paralysis, and neuralgia, have been + frequent in the family. + + III. Cardiac neuralgia; in a man, aged twenty-four. Father epileptic + and a drinker; grandfather died of softening of the brain, + aged thirty-eight. + + IV. "Cerebral" neuralgia; in a single lady, aged thirty-eight. + Mother has been insane; first cousin epileptic. + + V. Lumbo-abdominal neuralgia; in a gentleman, aged fifty-two. + Father a drinker; mother insane; maternal grandfather + phthisical. + + VI. Severe neurotic angina pectoris; in a gentleman, aged fifty. + Almost every one of the graver neuroses among patient's near + relations. + + VII. Migraine and cervico-occipital neuralgia; in a young lady, aged + twenty-five. Immediate causes, brain-work, and influence of + cold weather. Father and brother both epileptic; father's + family much affected with neurotic diseases. + + VIII. Sciatica; highly-nervous temperament. Father died insane from + drink; and probably other members of the family also nearly or + quite insane. + + IX. Auriculo-temporal neuralgia; in a married lady, aged + twenty-eight. Father's family markedly phthisical and neuralgic. + + X. Intercostal neuralgia; in a girl (phthisical), aged twenty-four. + Mother and two uncles phthisical; maternal grandfather epileptic + and a drinker. + + XI. Facial neuralgia (third branch trigeminal); in a gentleman, aged + fifty-four, a great whiskey-drinker. Drinking hereditary for + three generations; father died insane; grandfather epileptic; + sister phthisical; two brothers very "eccentric." + + XII. Migraine, severe; in a lady, aged thirty-three. Grief was the + immediate cause. Mother hemiplegic at forty-second year; first + cousin insane; two aunts (maternal) epileptic. + + XIII. Extremely severe sciatica and cervico-brachial neuralgia of the + left side, with singular inflammatory consequences; in a lady, + aged fifty-two. A family history remarkably free from neurotic + diseases and from phthisis. The neuralgia was probably caused + partly by excessive ptyalism, partly by over brain-work. + + XIV. Migraine; in a young lady, aged sixteen; very profuse + menstruation, which had lasted for two years. Family history + very free both from phthisis and neuroses. + + XV. Frontal and nasal neuralgia; in a man. Repeated attacks of + localized facial erysipelas; drinking-habits for some years; + fatal acute insanity in middle age. Father insane, committed + suicide; mother subject of violent epileptiform tic. + + XVI. Angina pectoris (neurotic); spasmodic asthma, twenty years; + facial neuralgia and erysipelas; in a gentleman, aged fifty. + Family medical history scanty and imperfect; but, as far as it + goes, entirely without evidence of either phthisis or neuroses. + + XVII. Neuralgia of testis, immediately caused by local irritation. + Father died of phthisis; paternal uncle epileptic and insane. + +XVIII. Ovarian neuralgia; in a girl, aged twenty-six, liable to + occasional migraine. Mother has suffered sciatica; brother + died of phthisis. + + XIX. Gastralgia; in a man, aged twenty-seven; highly intellectual and + nervous. Family history very free from neuroses; but some + evidence of phthisis, in two previous generations, on mother's + side. + + XX. Sciatica; in a lady, aged sixty; second attack. Ancestors, on + both sides, for some generations, clever, and in several + instances decidedly eccentric, if not insane; much neuralgia + in the family. + + XXI. Migraine; in a young lady, aged seventeen; menstrual + difficulties. No neurotic nor phthisical family history. + + XXII. Sciatica; in a married lady, aged twenty-seven; first pregnancy; + had rheumatic fever and subsequent chorea in childhood. Paternal + uncle epileptic; mother had rheumatic fever and cardiac disease; + paternal grandfather suffered from sciatica late in life. + +No one, I think, can look down the above list and fail to be struck with +the great preponderance of cases in which the general neurotic +temperament plainly existed in the patients' families; and let me add +that, in not a few of these cases, the neuralgia in the individual under +observation might have been easily set down as dependent merely upon +peripheral irritation, which, indeed, plainly did act as a concurrent +cause. + +Fortunately, however, I am not dependent upon my own evidence alone, for +the proofs of the proposition that neuralgia is eminently a development +of hereditary neuroses. The great French alienists, Morel and Moreau of +Tours, some years ago laid the foundations of the doctrine of hereditary +neurosis. They enforced this chiefly with reference to the manner in +which insanity is transmitted through a chain of variously-neurotic +members of a family stock; and Moreau laid special stress on the deeply +interesting connection of the phthisical with the neurotic tendency. +Since then various observers have insisted on the same thing. Of late, +Dr. Maudsley has worked out this subject with great ability, in his work +"On the Physiology and Pathology of Mind," and in his recent "Gulstonian +Lectures;" and Dr. Blandford dwells on it with emphasis in his +interesting "Lectures on Insanity." [Dr. Blandford does not, however, +admit that the phthisical diathesis has any such close and causal +relation with neuroses as has been imagined by some recent pathologists; +and, on the other hand, he points out that phthisis in neurotic +subjects, _e. g._, the insane, must, in a large measure, be considered +the product of the accidentally unhealthy circumstances in which they +pass their lives. In the latter opinion I entirely agree.] Indeed, it +may be taken as a recognized fact, among the more advanced students of +nervous diseases, that hereditary neurosis is an important antecedent of +neuralgia, in at least a very large number of instances. I shall +conclude this part of the argument by stating the general results of my +inquiries respecting sixty-one hospital patients. Of these cases, +twenty-two were migraine, or some other affection of the ophthalmic +division of the fifth nerve; seven were sciatica; two were epileptiform +facial tic; ten were neuralgias affecting chiefly the second and third +divisions of the fifth nerve; three were intercostal neuralgias pure; +one was intercostal neuralgia plus anginoid pain; seven were intercostal +neuralgias with zoster; three were brachial neuralgias; and five were +abdominal neuralgias (hepatic, gastric, mesenteric, etc.) Of +eighty-three hospital and private patients [It must be understood that +the respective numbers do not indicate with any accuracy the relative +frequency of the different neuralgias as seen in my practice. (Sciatica, +_e. g._, was proportionally more frequent.) They represent but a small +part of the neuralgic patients whom I have seen during fourteen years of +dispensary, hospital, and private practice, and they were selected for +inquiry merely because I happened to be able to give the time for the +necessary questions. Every one who knows out-patient practice will +understand how seldom this happened.] I obtained evidence of the +presence, among blood-relations, of the following diseases: Epilepsy, +fourteen cases (eight were examples of migraine); hemiplegia or +paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen +cases; "consumption," eighteen cases; "St. Vitus's dance," four cases. +I am well aware that these figures must be taken with caution, and that +considerable doubt must rest on the accuracy of some of these details, +more especially with regard to "epilepsy," as it was impossible, with +the greatest care, to be sure that this was not given, by mistake, for +hysteria in some cases; and the same may apply to the statement that +relations had suffered from "consumption." The facts are given for what +they are worth, and with the express reservation that their total +reliability is far less than that of the accounts obtained respecting +private patients belonging to the more educated classes. But, in one +respect, viz., as regards drunken habits, it is possible that a truer +estimate is gained from the statements of hospital patients than from +those of private patients, who would usually be more prone to reticence +on such a topic. + +The evidence as to the hereditary character of neuralgia assumes a yet +higher importance when supplemented by the facts respecting the +alternations of neuralgia with other neuroses as the same individuals. +Every practitioner must be aware how frequent is the latter occurrence. +Nothing is more common, for example, than to see insanity developed as +the climax of minor nervous troubles, especially of neuralgia. And there +is one form of neuralgia, the true epileptiform tic, which is intimately +bound up with a mental condition of the nature of melancholia, and even +with the markedly suicidal form of the latter affection. I have lately +had under my care a lady in whom the prodromata of a severe facial +neuralgia were mental; the disturbance commenced with frightful dreams, +and there was great mental agitation even before the pain broke out; +this disturbance of mind, however, continued during the whole period of +the neuralgia, and was relieved simultaneously with the cessation of the +attacks of pain. This is contrary to what happens in some cases; thus, +Dr. Maudsley quotes the case of an able divine who was liable to +alternations of neuralgia and insanity, the one affection disappearing +when the other prevailed. Dr. Blandford has met with several instances +in which neuralgia has been followed by insanity, the pain vanishing +during the mental disturbance, and reappearing as the latter passed +away. And he remarks that, in the transition of a neuralgia (to mental +affection), we may well believe that the neurotic affection is merely +changed from one centre to another, from the centres of sensation to +those of mind. He says that the ultimate prognosis of such cases is bad; +a point to which we shall have to refer again. + +The prominent place which quasi-neuralgic pains hold in the earlier +history of locomotor ataxy is a fact that cannot but engage attention. +In this volume we have not treated these pains as belonging to the truly +neuralgic class, for the very practical reason that they are but +incidents in a most important organic disease, and that in a diagnostic +and prognostic point of view it is necessary to dwell on their +connection with that disease. But, in considering the pathological +relations of neuralgia, it would be improper to omit the consideration +of the pains of locomotor ataxy, which bear a striking semblance to +neuralgic pains. The fact that they are an almost if not quite constant +feature of a disease which is from first to last an atrophic affection +(mainly of the posterior columns of the cord), in which the posterior +roots of the nerves are almost always deeply involved, has a bearing on +our present inquiry too obvious to need further remark. + +Equally important to our investigation is the fact that pains, closely +resembling neuralgia, are not very uncommonly a part of the phenomena of +commencing, and more frequently of receding, spinal paralysis. I have +the notes of three cases of partial recovery from paraplegia, in all of +which the patients remained for years, in one case for nearly twenty +years (ending with death), the victims to a singularly intractable +neuralgia of both lower extremities. In the worst of the cases the +patient was the victim of excessive and continuous labor at literary +work of a kind which hardly exercised the mental powers, but was +extremely exhausting to the general power of the nervous system; he +broke down at about the age of fifty, but dragged on a painful existence +for the long period above mentioned. + +We are also certainly entitled to adduce the example of the so-called +neuralgic form of chronic alcoholism as an instance of the close +relationship of neuralgia to other central neuroses. I refer to those +cases, more common perhaps than is generally admitted, in which pains in +the extremities, often quite resembling neuralgia in their +intermittence, are either superadded to or take the place of the +muscular tremors and general restlessness that are more popularly +considered as the essential nervous phenomena of chronic alcoholic +poisoning. That the pains are usually bilateral, and more diffuse in +their character than those of ordinary neuralgia, is a fact which it is +not difficult to explain by the _modus operandi_ of the cause; but we +shall have more to say on the general relations of alcoholic excess to +neuralgia presently. The pains themselves will be fully described in the +second part of this book, which treats of the affections that simulate +neuralgia; here we need only remark that it is not uncommon for them to +occur interchangeably with true neuralgia in the same person. + +The occasional interchangeability of migraine with epilepsy is a +well-known fact; every practitioner who has seen much of the latter +disease will have seen some cases in which the patient had been liable, +at some point of his medical history, to "sick-headaches" of a truly +neuralgic kind; although it is quite true, as Dr. Reynolds points out, +that the kind of sensorial disorder specially premonitory of the +attacks consists rather in indefinable distressing sensations, than in +actual pain. The genealogical connection between migraine and epilepsy +is, as I have already stated, apparently very close. Such instances as +one mentioned by Eulenburg are rightly explained by him; it is the case +of a girl who suffered at an unusually early age (nine) from migraine; +her mother had been a migraineuse, and her sister was epileptic; the +strong neurotic family tendency is believed by Eulenburg to account for +the appearance of migraine at such a period of life. + +This seems the fitting place to introduce some special remarks on +migraine in its relations to other neuralgias of the head, because +Eulenburg has mentioned and combated my view, according to which +migraine is a mere variety of neuralgia of the ophthalmic division of +the fifth nerve. I call it my view, because, though several other +authors had previously expressed it, I was first lead to entertain it by +observations made before I had studied their works, and especially by +the impressive teaching of my own case, as to which more will be +presently said. Eulenburg, though he fully allows that migraine is a +neuralgia, urges a series of objections to the identification of +migraine with ophthalmic neuralgias; of which objections one, based on +the doctrine of Du Bois Reymond as to the action of the sympathetic in +migraine, must be reserved for consideration when we discuss the general +pathology of the vaso-motor complications of neuralgia. The other +grounds of distinction that he urges are the following: In the first +place, he remarks that the site of the pain is by far less distinctly +referred to definite foci on the outside of the skull than in trigeminal +neuralgia; the patient's sensations very usually lead him to declare +that the pain is in the brain itself. Secondly, he says that the points +douloureux (in Valleix's sense) are almost constantly absent in true +migraine. Thirdly, he specifies the character of the pain in +migraine--dull, boring, straining, etc.--as differing from that of +trigeminal neuralgia, which is ordinarily much more acute and darting. +Fourthly, he notes the long duration of individual attacks of migraine, +and the long intervals (very commonly three or four weeks) between them. +Fifthly, he dwells on the frequent prodromata of migraine referable to +the organs of sense (flashes before the eyes, noises in the ears), or to +the stomach (nausea), or more generally to the reflex functions of the +medulla oblongata (_e. g._, convulsive rigors, excessive yawning, etc.) + +Now, I should have nothing to say against the accuracy of this +description, did it apply merely to the distinctions between +highly-typical cases of the "sick-headache" of the period of bodily +development, and highly-typical cases of the ophthalmic neuralgias which +are commonest in the middle and later periods of life; nor indeed should +I greatly care if it were finally decided that migraine and clavus +should be separated from the true trigeminal neuralgiae, provided the +following points were well impressed on the minds of practitioners. In +the first place, I must insist that in my own experience the great +majority of undoubtedly neuralgic headaches, which subordinate stomach +disturbance, are far less sharply separated than the above description +would allow from the unmistakable trigeminal neuralgias; it is only a +minority of cases that wear this extreme type, and a far larger number +shade imperceptibly away toward the type of ophthalmic neuralgia pure +and simple. And so, again, of the so-called clavus there is every +variety, from a form bordering closely on the migraine type to another, +differing in nothing from an unusually severe ocular and frontal +neuralgia of the fifth, except in the presence of a tremendously painful +parietal focus. But the fact on which I would most particularly insist +is one that was first taught me by my personal experience, viz., that +migraine is, with extraordinary frequency, the primary or youthful type +of a neuralgia which, in later years, entirely loses the special +characters of sick-headache, and assumes those of ordinary frontal +neuralgia, with or without complications. In my own case, the +"sick-headache" character of the affection was strongly marked during +the first two or three years, after which time it gradually but steadily +lost all tendencies to stomach complications, and, what is more, the +type of the recurrence became entirely changed. Yet it is quite +impossible to believe that the malady is now a different one, in any +essential pathological point, from what it was at first; if any disproof +of this were needed, it might be remarked that the singular series of +secondary trophic changes which have complicated my case have been +impartially distributed between the respective periods when the +affection was frankly migraineuse, when it was mixed, and when it was +simply ophthalmic neuralgia (as it is at present;) indeed, some of the +most decided of these trophic complications (orbital periostitis, +corneal ulceration, fibrous obstruction of the nasal duct) occurred +within the period in which every attack of pain, unless I succeeded in +getting to sleep very shortly, ended in violent vomiting. The experience +thus gained has made me very attentive to the past history of those who, +in later life, complain of frontal neuralgia without stomach +complication, and it is surprising to find in how many cases patients, +who at first declare that they never had neuralgia before, on reflection +will recall the fact that they were often "bilious" in their youth; +which "biliousness" turns out to have been regularly preceded by +one-sided headache, and to have been severe in proportion to the +severity and duration of that previous headache. + +I ask the reader to dwell with fixed attention on this fact of the +exclusiveness, or almost exclusiveness, with which the neuralgias of +the anterior part of the head are represented during the period of +bodily development, and especially in the years just succeeding puberty, +by migraine or by clavus. When this fact has thoroughly entered the +mind, we can hardly help joining with it that other and most important +fact already noticed, of the close connection between the predisposition +to migraine and the predisposition to epilepsy, and reflecting further +on the strong tendency which epilepsy likewise shows to infest the +earlier years of sexual life. In view of these things, it is difficult +to avoid the inference that both the epileptic and the neuralgic +affections of this critical period of life are the expression of a +morbid condition of the medulla oblongata, in which the sensory root of +the trigeminus has its origin; and further, that this morbid condition +(tending to explosive and atactic manifestations of nerve-force) must +have its basis in defective nutrition. For, be it remembered, the epoch +of sexual development is one in which an enormous addition is being made +to the expenditure of vital energy; besides the continuous processes of +the growth of the tissues and organs generally, the sexual apparatus, +with its nervous supply, is making by its development heavy demands upon +the nutritive powers of the organism; and, it is scarcely possible but +that portions of the nervous centres, not directly connected with it, +should proportionally suffer in their nutrition, probably through +defective blood-supply. When we add to this the abnormal strain that is +being put on the brain, in many cases, by a forcing plan of mental +education, we shall perceive a source not merely of exhaustive +expenditure of nervous power, but of secondary irritation of centres +like the medulla oblongata, that are probably already somewhat lowered +in power of vital resistance, and proportionably irritable. Let us +suppose, then, that to all these unfavorable conditions there was added +the circumstance that the structure of the medulla oblongata, or of +parts of it, was congenitally weak and imperfect; then surely it would +be scarcely possible for these loci minimae resistentiae to escape being +thrown into that state of weak and disorderly commotion which eminently +favors pain in the sensory, and convulsion in the motor apparatus. + +2. We have so far been mainly considering the relations to the +production of neuralgia of certain conditions of the central nervous +system which indisputably are inherent from birth. Let us now pass quite +to the other extreme, and consider a class of momenta which take a +decided part in producing many neuralgiae, but which are altogether +accidental and factitious, and cannot be included among the necessary +hostile conditions of life. To push the contrast to the utmost, let us +inquire first, what amount of influence in the production of neuralgia +can be given by such a purely "functional" influence as educational +misdirection of intellect and emotion? + +It is somewhat strange, though every one accepts as a mere truism the +maxim that sudden emotional shock may produce almost any degree or +variety of nervous disorder, the slower but far surer influence of +long-continued mental habit is often practically ignored. It cannot, +indeed, be left out of sight as a cause of disorders of the mind itself, +nor are there many who would deny that such diseases as cerebral +softening are, in a considerable number of cases, the premature ending +to a life that has been broken down by harassing work and anxiety. But +what is far less appreciated is the tendency of certain unfortunate +mental surroundings and modes of mental life to produce a generally +neurotic condition, which may express itself in a variety of functional +disorders, among which not the least common is neuralgia. + +I may fairly hope to be acquitted of any predisposition to lay +exaggerated stress on this kind of influence in the production of +neuralgia, considering all that I have said of the importance of that +inevitable cause, the neurotic inheritance, and all that I shall have to +say presently as to the effects of a variety of external influences of a +totally different kind. But I confess that, with me, the result of close +attention given to the pathology of neuralgia has been the ever-growing +conviction that, next to the influence of neurotic inheritance, there is +no such frequently powerful factor in the construction of the neuralgic +habit as mental warp of a certain kind, the product of an unwise +education. This work is not intended as a treatise either on religion or +psychology, and yet it is impossible for me to avoid some few words that +may seem to trench on the province of each: for I believe that there are +certain emotional and spiritual and intellectual grooves into which it +is only too easy to direct the minds of young children, and which +conduct them too often to a condition of general nervous weakness, and +not unfrequently to the special miseries of neuralgia. As regards the +working of the intellect, it is easier to speak in a free and +unembarrassed manner than respecting the other matters. There can be no +doubt that, of intellectual work, that sort which exhausts and harasses +the nervous system is the forced, the premature, and the unreal kind; +and this it is which predisposes, among other nervous maladies, to +neuralgia. It is more difficult to speak the truth about emotional +influences generally, and especially about those which are concerned +with the highest spiritual matters; but I should do wrong were I to +suppress the statement of my convictions on this point. I believe that a +most unfortunate, a positively poisonous influence upon the nervous +system, especially in youth, is the direct result of efforts, dictated +often by the highest motives, to train the emotions and aspirations to a +high ideal, especially to a high religious ideal. It is not the object +that is bad, but the machinery by which it is sought to be attained. In +modern society there are two principal methods which are popularly +employed for this purpose; I shall describe them, by two epithets which +are selected with no offensive intention, as the Conventual and the +Puritan methods of spiritual training. By the former is meant that kind +of education which deliberately dwarfs the nervous energy, with the hope +of preserving the mind from the contamination of unbelief and of sinful +passion. It is a system which is not peculiar to the Roman Church, nor +even to the Christian religion, and it need the less detain our +attention, as its effects, so far as they are evil, are mainly seen in +general nervous and mental enfeeblement, rather than in the outbreak of +explosive nervous disorders, such as convulsion, insanity, or neuralgia. +There are doubtless exceptions to the rule; but that is the rule. It is +far otherwise with the spiritual education which is here called Puritan, +but which is confined to no party in the Church. This is a system which +seeks to purify and exalt the mind, not by enforcing obedience to a +series of spiritual rules for which another mind is responsible, but by +compelling it to a perpetual introspection directed to the object of +discovering whether it comes up to a self-erected spiritual standard. +The reader will understand that I have not the remotest intention to +depreciate either a true and manly self-restraint in obedience to the +direction of "pastors and masters," or an honest watchfulness over one's +own conduct and thoughts. But the lessons which our psychologists are +rapidly learning, as to the evil effects on the brain of an education +that promotes self-consciousness, are sorely needed to be applied to the +pathology of nervous diseases generally, and of neuralgia among the +rest. Common sense and common humanity, when united with the physician's +knowledge, cry out against the system under which religious parents and +teachers subject the feeble and highly mobile nervous systems of the +young to the tremendous strain of spiritual self-questioning upon the +most momentous topics. More especially is such a practice to be +condemned in the case of boys and girls who are passing through the +terrible ordeal of sexual development--an epoch which, as we have +already seen, is peculiarly favorable to the formation of the neurotic +habit, and I must emphatically state my belief that among the +seriously-minded English middle classes, more especially, whose life is +necessarily colorless and monotonous, the mischief thus worked is both +grave and widely spread. + +Perhaps the maximum of damage that can be inflicted through the mind +upon the sensory nervous centres is effected when to the kind of +self-consciousness that is generated by an excessive spiritual +introspection there is added the incessant toil of a life spent in +sedentary brain-work, and checkered with many anxieties, and many griefs +which strike through the affections. Doubtless, such a combination of +morbid mental influences is sufficient of itself to generate the +neuralgic disposition in its severest forms, without any hereditary +neurotic influence, and without any other peripheral irritations; I have +more than one such instance in my mind at this moment. But, if they can +do this, much more can such influences arouse inherent tendencies to +neuralgia; to persons who are predisposed in this manner they are most +highly deleterious. + +3. We come now to the peripheral influences which in a more obvious +manner become factors in the production of neuralgia. Of such influences +there are an immense variety, and the only common quality that can be +predicated of all is the tendency directly to depress the life of the +sentient centre upon which their action impinges. + +If we search among the external influences which contribute to the +production of neuralgia for one that is apparently trivial as to the +amount of material disturbance which it can cause, and yet is very +frequently effective, we may select the agency of cold. The effect of a +continuous cold draught of air impinging on the naked skin for some time +is comparatively frequently seen in the provocation of neuralgic attack: +we say comparatively, because this influence is more frequently +effective than blows, wounds, or temporary irritations of any kind, +applied to the peripheral ends of sensory nerves. But if neuralgia be a +more frequent consequence of cold than of these other influences, a +moment's reflection will show that it is by no means an absolutely +common result. One has only to think of the numerous omnibus-drivers, +engine-drivers, cab-drivers, etc., etc., who pass their whole working +lives in presenting the (more or less) naked expanse of their trigeminal +and their cervico-occipital nerves to every variety of wind, to perceive +that, were this sort of influence very potent in itself, male neuralgic +patients should swarm as thick as bees in our hospital and dispensary +out-patient rooms; which is notoriously quite contrary to the fact. The +same remarks, in both directions, may be applied to the direct influence +of atmospheric moisture, either with or without the effect of wind (of +course I am not speaking of the more recondite effects of damp soil on +the persons who live about it). [Among the hundred patients who formed +the basis of the inquiries mentioned in this work, forty-one accused +external cold of producing the attack, but many of these produced +insufficient evidence that such was the case.] In short, the direct +effects of atmospheric cold would seem to be these. Mere lowness of +temperature goes for something, but not much; [The most marked instance +of the effect of cold, _per se_, that I have seen, was exhibited by a +young lady who was under my care during the past severe winter +(1870-'71). During much of the time she was confined to a +carefully-warmed apartment, on penalty of a violent paroxysm if she left +it.] for about as much, perhaps, as it does in the way of aggravating +all neurotic tendencies. Cold joined with wind is much more powerful. +And the maximum of ill-effect seems reached by very cold wind mingled +with sleet or driving rain, which keeps the skin sodden. But the +conclusion at which I long ago arrived is, that none of these influences +ever take more than a small (though it is sometimes an important) part +in the production of neuralgia; and that in the majority of cases there +is no pretence for supposing that they had the slightest share in its +causation. + +A word or two must be said as to the _modus operandi_ of cold and cold +wind, as these are the most frequent of external, so-called "exciting" +causes. The popular use of such phrases as the latter has an +extraordinary influence in disguising the plain fact, which is, that +these influences operate wholly in the direction of robbing the nerves +of force. The continuous abstraction of heat from the surface, which of +course is materially aided by rapid movement of the air, must +necessitate a readjustment of the distribution of energy, the only +result of which must be to drain the sensory nervous centre of its +reserve of force. But, in fact, there is an experiment, ready performed +to our hands, which may amply satisfy us as to the kind of influence +exerted by cold on superficial nerves, viz., the sensations experienced +in recovering from frost-bite, which has been severe enough to paralyze +the nerves without causing actual gangrene of the tissues. The passage +of the nerves back from temporary death to full functional life is +marked by a half-way stage in which there is agonizing pain. + +4. We must next consider the effects of a class of peripheral influences +which act, where they exist, in a more constant manner than any others; +viz., those in which the trunk or periphery of a sensory nerve either +receives a severe injury, or becomes more or less engaged in +inflammatory processes, or compressed or otherwise damaged by the growth +of tumors or the spread of destructive ulcerations. + +With regard to ordinary nerve-wounds as a cause of neuralgia, we have +already said (_vide_ Chapter II.) nearly as much as it is necessary to +say; we need only here point out that, like the influence of cold +applied to superficial nerves, that of wounds must necessarily be a +depressing one to the centre with which the wounded nerve is connected, +and the resulting neuralgia must be regarded as an expression of impeded +and imperfect nerve-energy, not of heightened nerve-function. The pain +is set up during the process of nerve-healing; that is to say, at a +stage intermediate between those of abolished function and completely +restored function; and there can be little doubt that the obstinacy with +which it is often protracted is due to the slowness with which a wounded +nerve recovers its full functional activity; when once the latter is +completely restored there is an end of neuralgic pain. It is exactly +analogous to the course of events in recovery from freezing. + +There remain for consideration, however, (a) a small class of cases of +nerve-wounds in which the healing process is not simple; but the lesion +is followed by the development of a tumor of the kind denominated true +neuroma. The process consists of hyperplastic changes in the +nerve-fibres; its commonest examples are seen in the extraordinarily +painful swellings that occur on the ends of nerves left in stumps after +amputations; but, in fact, a neuroma of this kind may occur after any +kind of severe nerve-injury, as, _e. g._, a cut from broken glass, the +impaction of foreign bodies, etc. The true neuromata are composed mainly +of nerve-tissue, with a relatively small element of connective tissue: +the nerve-fibres can be traced directly to the nerve-tumor. Besides the +traumatic neuromata which form permanent tumors, incapable of being got +rid of except by actual excision, a minor variety of the same kind of +change has in several cases been known to take place in consequence of +an abiding local irritation from the impaction of a foreign body, on the +removal of which the neuromatoid enlargement completely disappeared. (b) +There are likewise a certain number of cases in which a tumor is +developed from the neurilemma, and does not consist of nervous tissue; +these are distinguished as false neuromata, and may be of various kinds, +the fibromatous and gliomatous being far the most common, but cysts and +cystic tumors also sometimes occurring. + +The case of the neuromata is well worth reflecting upon, in the course +of our endeavors to clear up the Pathology and Etiology of Neuralgia. If +ever we could find a merely peripheral influence which would of itself +be invariably competent to excite neuralgic pains, it would surely be +found in neuroma; but the case is not merely not so, it is strikingly +contrary. Just as wounded and inflamed nerves frequently go through the +whole processes of disease and recovery without once eliciting a +neuralgic pang, so is it with neuromata; they are not unfrequently quite +indolent, and neither excite neuralgia, nor are themselves at all +particularly tender to the touch. And what is most remarkable is, that, +as Eulenburg correctly remarks, among the pseudo-neuromata the kind of +tumor which is most frequently associated with neuralgia is by no means +the dense fibroma or glioma, which might be expected by its mechanical +pressure to excite inevitable neuralgic pain, but the far softer and +more yielding cystic tumors. I do not know how the facts may affect the +reader, but to me they suggest the strongest possible arguments against +the belief that peripheral irritation can of itself produce neuralgia +without the intervention of some centric change. The tendency to such +change (from inherent constitution) in the sensory root of the nerve +must surely be the reason why neuroma causes neuralgia in a given number +of subjects, instead of letting them go scot-free, as it does other +persons. + +The same remarks apply to the result of observations on the effect of +tumors commencing in tissues altogether unconnected with the nerve, and +merely coming to involve it, secondarily, in pressure. It has been often +noted that, among these tumors, fluid-containing cysts and soft +medullary cancers are far more frequently the cause of decided and +distressing neuralgia than the denser and less yielding neoplasms. Of +kinds of tumors that are specially apt to produce severe and even +intolerable neuralgia by the pressure on nerves, it has been remarked +that aneurisms are among the worst: here every pulsation often sends a +dart of agony through the nerve. There is a reason here, however, which +is often left out of sight; not merely is the perpetually varying +pressure specially harassing and exhausting to the nerve, but in many of +these cases there is general arterial degeneration, and the sensory root +of the nerve is exceedingly likely to be very badly nourished. [This +result will be more directly brought about when the aneurism happens to +press on the ganglion of a posterior root.] We pass now to the +consideration of the influence exerted by other great series of +peripheral impressions in the production of neuralgia. These impressions +are connected chiefly with the functions of the digestive and of the +genito-urinary organs, the functions of the eye, and the nutrition of +the teeth. + +To take the least important of these first, I may surprise some readers +by the statement, which I nevertheless make with much confidence, that +irritation of any part of the alimentary canal is, on the whole, a rare +concurrent cause, even in the production of neuralgia. There are, as has +been already fully explained, cases of neuralgia seated in these viscera +themselves (or the plexuses in their immediate neighborhood), although +their number is immensely smaller than that of the neuralgias of +superficial nerves. But it is not at all common--it is even exceedingly +rare--for irritation conveyed from the alimentary canal to take any +important part in setting up neuralgia of a distant nerve, even when +that nerve has close connections, through the centres, with those coming +from the irritated portion of the alimentary canal. Valleix had the +great merit to perceive this, even in the case of neuralgias of the +head, where appearances are so likely to lead the observer to a contrary +opinion. And it is not a little remarkable that this should be the case, +when we consider the close central connections which the vagus, the +great sensory nerve of a large portion of the alimentary canal, has with +the sensory root of the trigeminus. In fact, however, there are certain +peculiar forms of gastric irritation which do react upon the trigeminus; +for instance, a lump of unmelted ice, suddenly swallowed, almost +invariably produces acute pain in the supra-orbital branch of the fifth, +on one side or the other, and occasionally (as in a case cited by Sir +Thomas Watson) in other nerves. But that common dyspeptic troubles at +all frequently or importantly contribute to the production of neuralgia, +I do not for a moment believe: it needs some very powerful irritation, +such as that just mentioned, or as impaction of great masses of scybalae +in the intestines, or severe irritation from worms, to produce such an +effect. + +It is far otherwise with the genito-urinary apparatus; in a large number +of cases, irritations proceeding from these organs do undoubtedly +contribute to the production of neuralgia, though by no means in the +important degree which many authors seem to have assumed. There can be +no doubt, for example, that the irritation of a calculus, either within +the kidney itself, in the ureter, or in the bladder, may set up violent +neuralgia, which for the most part is localized in the branches of the +lumbo-abdominal nerves. The instance of the eloquent Robert Hall is an +example of renal calculus acting in this way: he suffered the most +excruciating agony for years, and was obliged to take enormous +quantities of opium in order to make life endurable. An instance of +calculus impacted in the ureter, in a gentleman somewhat past middle +age, occurred in my own practice; the lumbo-abdominal neuralgia occurred +in frequent paroxysms of dreadful severity; and another case, already +referred to was that of a woman, in whom ovarian neuralgia was +undoubtedly in great part due to the irritation of an impacted calculus +in the ureter. These cases, however, are very rare in comparison with +others in which the peripheral source of the neuralgia is either the +uterus or ovary, or the external genitals. I have no means of +ascertaining, with anything like accuracy, the frequency with which the +internal sexual organs are the starting-point of neuralgia, because the +majority of such cases pass, naturally, to the care of physicians who +practice chiefly in the diseases of women, and consequently not +adequately represented either in my hospital or my private practice; +still, I have seen a good many of these affections, and, though I speak +with the reserve necessitated by the circumstances just named, I am much +inclined to believe that even such powerful centripetal influences as +those of the states of commencing puberty, of pregnancy, of the change +of life, and uterine diseases generally, are very rarely the cause of +true unilateral neuralgia, except in subjects with congenital tendencies +to neuralgia. But in predisposed subjects there can be no doubt that +these influences assist most powerfully in producing the malady. + +Of the power of irritation of the external genitalia to act as a +so-called "exciting cause" of neuralgia, there is abundant evidence. I +would especially call attention to the remarkable monograph of M. +Mauriac, ["_Etude sur les Nevralgies Reflexes symptomatiques de +l'Orchi-epididymite blenorrhagique_" Par C. Mauriac, Medecin de +l'Hospital du Midi. Paris, 1870.] on the neuralgias consecutive to +blenorrhagic orchi-epididymitis, as illustrating this with a force that +was to me, for one, surprising. I shall, perhaps, have further occasion +to these researches; here it will be enough to mention that M. Mauriac's +enormous experience of blenorrhoea and orchitis at the Midi has shown +that, in an exceedingly large number of cases, certainly not less than +four per cent., this combination is followed by reflex neuralgias, of +which a large number are not seated in the genital apparatus, but affect +the track of some distant sensory nerve, through the intermediation of +the spinal centres; and that with these reflex pains there is often +profound general disturbance, including very often an extremely profound +general anaemia. The most frequent kind of these neuralgias is +rachialgia, _i. e._, pain in the superficial posterior branches of +spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and +crural, visceralgic (abdominal), etc.; and besides all these there are +numerous instances of neuralgia in the testis. As to the nervous +"reflection," more hereafter. + +It has surprised me, somewhat, that while M. Mauriac has seen so many +reflex neuralgias set up by orchi-epididymitis, he does not appear to +have noticed cases of trigeminal neuralgia from this source; because, in +the very analogous instance of the peripheral irritation produced by +excessive masturbation, we undoubtedly do frequently get a development +of the tendency to migraine, and also to other forms of neuralgia of the +fifth: moreover the effect of such local irritation can be occasionally +traced with much distinctness in the trigemini, by a tendency to certain +forms of eye-disease without positive neuralgia. This was remarkably +exemplified in a case which was under my care some years ago, and in +which both eyes were greatly damaged by vaso-motor and trophic changes; +partial insanity also supervened with hallucinations of sight and +hearing. + +We come now to one of the most powerful sources of peripheral irritation +tending to set up neuralgia; viz., functional abuse of the eye. This is +one of the very few peripheral influences which occasionally we see +producing neuralgia unaided by hereditary predisposition, or any other +observable cause whatever, and in a far larger number producing it with +the sole aid of more or less defective general nutrition. The latter +occurrence is well exemplified by a case which Mr. Carter sent me the +other day, and which also illustrates (second attack) the effect of the +superaddition of syphilitic taint: + +Matilda W----, aged thirty-three, married, and has three very healthy +children. Comes of a remarkably healthy family, of which she told me the +entire history for three generations, with unusual intelligence and +clearness. No neuroses, properly so-called, in any of her relatives +during all this time. She herself was a very strong and hearty girl +until the age of seventeen; between this date and her marriage, three +years later, she was obliged to work tremendously hard at fine sewing, +by which means she gained a very scanty livelihood. After a +comparatively short period of this work she began to suffer from typical +attacks of migraine, very severe, and recurring every three or four +weeks, but in no particular connection with the menstrual function, +which was normal. On her marrying and ceasing to do needle-work, the +migraine entirely disappeared, and she retained perfect health till the +commencement of 1871. At this time she had suckled a very hearty baby +for ten months, and was not able to furnish such good living as usual. +She was attacked early in January, with violent neuralgia affecting all +three branches of the right fifth, and she the more readily applied for +advice because she soon found that the neuralgia was becoming +complicated with dimness of vision in the eye of the affected side, "as +if she was going to have a cast." Was quite unconscious of ever having +had syphilis. The medical man encouraged to believe that the whole +malady was nervous, and would soon disappear under appropriate remedies, +and gave her quinine, under which treatment she declares that she was +rapidly improving, both as to pain and vision, but that her resources +came to an end, and she could no longer pay for the medicine. She then +neglected herself, and rapidly got worse in all regards, till at last +she was compelled to apply to the South London Ophthalmic Hospital, +whence Mr. Carter sent her to me, on the 6th of April. At this time the +paroxysms were excessively violent and frequent, though brief. On +examination, tender points were found at the supra-orbital notch, at the +infra-orbital foramen; in front of the ear; in the temporal region; in +the parietal region, and the inferior dental region. There was strongly +marked anaesthesia of the skin of the right half of the face, of the +gums, and of the side of the tongue. The teeth were absolutely perfect: +not one spot of caries could be seen. Taste was completely destroyed in +left half of anterior part of the tongue. Smell was totally lost on both +sides, and had been so, the woman declared, from a very early period in +the illness. The right eye showed complete paralysis of the levator +palpebrae and of the external rectus; nearly complete paralysis of the +superior and inferior rectus, rather less marked paralysis of the +internal rectus. Pupil normal, conjunctiva moderately congested, +lachrymation profuse, photophobia partial. The functions of the retina +were perfect. Accommodation was affected in the following degree and +manner. The vision of the affected eye was perfect at long distances, +very imperfect at short distances. With both eyes open she saw every +thing double, but could still count all the bricks in a whitewashed wall +at sixteen feet distant. There was no secondary disturbance of the +stomach whatever. On the first visit she assuredly had no visible +signs, in skin or throat, of syphilis; the perfect health of her +children, and absence of abortions, made syphilis the less probable. But +on her second visit she complained of sore throat, and a week later a +palpably specific sore appeared on the soft palate. She declared, with +apparent sincerity, that it was the first symptom of the kind she had +ever had. The neuralgia rapidly disappeared under thirty grains of +iodide of potassium daily. The lesions of taste and smell disappeared +exactly pari passua with the trigeminal pains. The ocular paralysis +threaten to be much slower in departing. I think we must believe that +this woman contracted syphilis after the birth of her last child. It is +at any rate certain that the migraine of her youth was perfectly +unconnected with syphilis, being as unlike the pains evoked by the +latter as it is possible for two kinds of pain to be. In all probability +she was infected during her last lactation. + +Last among the peripheral influences of sufficient importance to be +specially mentioned as effective factors in the production of neuralgia, +must be mentioned caries of the teeth, and the comparatively rare +accident of the mal-position or abnormal growth of a "wisdom-tooth." It +is an undoubted fact that these things may cause neuralgia even of a +very serious type, and attended with extensive complications; as in Mr. +Salter's cases, already mentioned, of reflex cervico-brachial neuralgia +from carious teeth. Looking to the extreme frequency of caries, however, +as compared with the rarity of true neuralgia (not mere toothache) as a +consequence of it, it is impossible not to suppose that the share of the +carious teeth in the production of such neuralgia must be very small, +compared with that of other influences. + +5. The next influence which we shall mention as undoubtedly very +effective in assisting the production of neuralgia in certain cases is +that of anaemia and mal-nutrition generally; but it is not necessary to +dwell on this at any length. The fact is notorious that severe loss of +blood is always followed by headache; and if there be the least +predisposition to neuralgia, this headache will very commonly take the +form of the severest clavus. And, in like manner, chronic states of +anaemia and of mal-nutrition undoubtedly aggravate every existing +neuralgia, and bring out lurking tendencies to the disease. But I do not +believe that anaemia, or starvation pure and simple, ever generates true +neuralgia by its sole influence. + +6. The question how far, and in what way, the neuralgic tendency is +helped by certain constitutional diatheses, such as rheumatism and gout, +and by certain toxaemiae, such as malaria, alcoholism, lead-poisoning, +etc., is a very much more difficult one than might be supposed from the +off-hand manner in which many writers speak of the "rheumatic," the +"gouty," or the "alcoholic" forms of "neuralgia." We may, however, +simplify it a good deal. In the first place, it seems obvious to me that +the only manner in which alcohol helps the production of true neuralgia +is by its tendency, after long abuse, to produce degeneration of the +nervous centres: it will therefore be considered, shortly, under another +division of the present subject. Lead-poisoning, again, only produces so +highly special a form of neuralgia (if colic be neuralgia at all) that +it need not detain us here. The influence of malaria is, for the most +part, an utter mystery to us, but by so much as we can see it appears +plain that one of the most important features in the disease is a +powerful disturbance of the spinal vaso-motor centres. But the most +interesting consideration that we have to deal with is the question of +the supposed relations of the rheumatic and the gouty diatheses, and the +syphilitic dyscrasia, to the neuralgic tendency. On this point I am +obliged to disagree _in toto_ with the popular view that assigns these +diatheses among the most frequent predisposing causes of neuralgia. + +To take the case of rheumatism first, I am willing to allow that there +are a number of facts which superficially appear to countenance the idea +of a close connection of this disease with neuralgia. But of these facts +a considerable proportion consist only of examples of inflammation of +the nerve-sheath, with a certain amount of effusion within and around +it, occurring in persons who have never shown any symptoms which warrant +the assumption of a general rheumatic diathesis; and these local +phenomena really differ in nothing from many trophic and vaso-motor +changes which have been already described as plainly secondary to +ordinary neuralgia in which there could be no pretence of a rheumatic +pathology except on the slender foundation of a suspicion that the +affection was immediately excited by the influence of cold, which is +really no argument at all. Such patients will be found to have +exhibited, not special rheumatic, but special neuralgic tendencies in +their past history. On the other hand, there undoubtedly are a certain +number of patients who, having previously given signs of a tendency to +generalized rheumatic inflammation of fibrous membranes, are, on some +particular occasion, attacked with similar inflammation extending over a +more or less considerable tract (not a small limited spot) of a nerve +sheath. But so far from agreeing with those who think that this is a +frequent case, my experience teaches me that it is quite exceptional; +nor do I believe that the common opinion could ever have arisen had it +not been for the rage that exists for connecting every disease with a +special diathesis which the profession flatters itself that it +understands. Few persons have taken more pains than myself to ascertain +the frequency with which neuralgic patients show a history of previous +rheumatism, whether in the so-called "fibrous," or in the synovial +form; but it is remarkable how seldom I have found this to be the +case--a result which surprised me, because it happened that I, a +neuralgic subject, had suffered in youth from regular acute rheumatism, +and had fancied that I should discover a close connection between +rheumatism and neuralgia. Eulenburg states that neuralgia caused by cold +more frequently attacks the sciatic nerve than any other, and thinks +that the tendency to sciatica is characteristic of the relations of +rheumatism to sensory nerves. For my own part, I see no reason to call +in the rheumatic diathesis as a _deus ex machina_ to explain the +frequency with which sciatica follows comparatively trifling peripheral +impressions like that of cold. The true reason I believe to be, that +what would have been a slight and trivial neuralgia elsewhere, becomes a +serious affection in the instance of the sciatic nerve, by reason of the +strong muscular pressure end dragging which are always going on in the +thigh in locomotion. I shall return to this subject when speaking of +Treatment. + +As regards the relations, of gout to neuralgia, I can hardly express my +own view better than by quoting the words of Eulenburg:[17] "Much more +doubtful is the influence of gout, which in rare cases, perhaps, +produces neuralgia directly, by means of neuritis, or by the deposit of +tophus-like calcareous concretions in the nerve-trunks. Gout has been +reckoned as a great influence among the causes of superficial neuralgias +(sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but +this influence is more probably only an indirect one, operating through +circulation changes which are often produced by chronic liver-diseases +or by diseases of the heart and vessels, (_e. g._ Valvular diseases and +narrowing of the coronary arteries in angina)." To which I will add this +argument against any close connection of gout with neuralgia, that it is +exceedingly seldom that colchicum effects any decided good, a fact which +is as unlike the relations of colchicum to true gout as any thing could +be. For, whatever may be thought of the advantages or disadvantages, on +the whole, of employing colchicum against gout, at least no one with any +experience will deny that in the immense majority of cases of true gouty +pain, it gives rapid relief to the acute suffering. I doubt if it +ever[18] acts in that way in real neuralgia, though I have occasionally +seen it apparently useful in a more limited way, as will be said +hereafter. + +As regards the relation of the syphilitic dyscrasia to neuralgia, I +agree in general with Eulenburg. "Syphilis," he says, "may be the direct +cause of neuralgia, either by the development of specific gummata in +the nerve-trunks or in the centres, or by arousing chronic irritative +processes in the nerve sheaths, the membranes of the brain and spinal +cord, or, especially, in the bones and periosteum (syphilitic osteitis +and periostitis)." The case of periostitis, however, is a doubtful one: +it may be questioned whether this affection (which will be among the +diseases discussed in Part II. of this work) ever give rise to true +neuralgia. Persons who are, by inheritance, highly predisposed to +neuralgia, may from the mere general lowering of their health produced +by constitutional syphilis, become truly neuralgic simultaneously with, +or subsequently to, the appearance of painful nodes on their bones. And +as regards the whole relations of syphilis to neuralgia, I must, from my +experience, conclude that the former is, after all, but rarely concerned +in the production of the latter. Syphilis has a strong specialty for +producing limited motor paralyses, but a much weaker one for producing +limited affections of the sensory system. + +7. We now come to the discussion of a group of momenta whose influence +in the production of neuralgia is at once very powerful, and of the +highest significance as regards the general pathology of the disease. +These are the degenerative changes of the arterial and capillary systems +which are a part of the normal phenomena of old age, but may occur at +earlier periods of life, in consequence either of certain constitutional +diseases, especially gout, or of special toxic influences on nutrition, +of which persistent alcoholic excess is very far the most important. + +The reader does not need to be told the familiar story of the +degenerative changes in the vessels which, commencing usually some time +during the fifth decenniad, by degrees convert the elastic arterial +coats, and the almost membranous walls of the capillaries, into more or +less rigid tubes; nor does he need to be informed that the tendency of +these changes, as they operate in the great motor and intellectual +centres, is notoriously to produce innutrition of the tissues that +depend for their blood supply on the affected vessels, whence cerebral +softening so commonly results. That analogous changes take place in the +vessels supplying the spinal centres is certain; but it is a remarkable +fact that these do not very commonly produce motor paralysis. What they +do produce is rather a slow enfeeblement both of (spinal) sensation and +motion, but where the process of decay has been prematurely forced, or +the inheritance of neurotic weakness is very marked, the process of +sensorial decay (the decline, that is, of true sensorial function) is +apt to be mingled with pain. That this pain should be localized, often +in a single nerve, is no more surprising than the fact that the +degenerative process itself should vary so greatly in the degree of its +development at one point from that which it shows at others. I have +already insisted (_vide_ Chapter I.) on the marked correspondence +between the period of life in which degenerative changes commence and +progress (the last third, roughly speaking, of a fairly long life), and +that in which the most severe, intractable, and progressively increasing +neuralgias are developed. I must here notice a singular statement of +Eulenburg's, that neuralgia never attacks people who are over seventy. +That statement shows that persons of a greater age than seventy are rare +in this world, and that no such patient happened to come under +Eulenburg's notice; for I have (by mere chance, doubtless) seen several +instances of first attacks occurring after seventy; and almost the worst +case of epileptiform tic I ever saw began when the patient was eighty; +she was a member of a highly neurotic family whose medical genealogy is +given at a previous page. In general terms, it may be said that every +additional year of life after fifty increases the probability that a +neuralgia, should such arise, will be severe and rebellious to +treatment; and in the very aged the cure of such affections is probably +impossible. + +8. This seems the proper place to introduce such facts as have been +observed, and they are very few, that directly illustrate the material +changes occurring in neuralgia. + +Very much the most important of these facts is the history of a +remarkable case recorded by Romberg. ["Diseases of Nervous System," Syd. +Soc. Trans., vol. i.] The patient, a man sixty-five years old at the +time of his death, had suffered for several years from the most violent +and intractable epileptiform trigeminal neuralgia, complicated with +interesting trophic changes of the tissues. Post-mortem examination +showed that the pressure of an internal carotid aneurism had almost +destroyed the Gasserian ganglion of the painful nerve, that the trunk +and posterior root of the nerve were in a state of advanced atrophic +softening, and the atrophic process had extended in less degree to the +nerve of the opposite side. Now, the value of this case is by no means +restricted to the fact that it records the existence of a particular +anatomical change in one example of neuralgia. Its most striking +teaching is the fact that the acutest agonies of neuralgia can be felt +in a nerve, the central end of which is reduced to such a pitch of +degeneration that conduction between centre and periphery must very +shortly have entirely ceased had the patient lived. And hardly less +important is its illustration of the fact that permanent injury to the +ganglion of the posterior root of a spinal nerve impairs the vitality of +the posterior root itself--a fact which has been independently made out +by the physiological researches of Bernard and of Augustus Waller. + +On the other hand, if we examine the tolerably numerous histories of +cases in which the painful nerves have been examined at the apparent +site of pain, we discover nothing to lead us to connect neuralgia +definitely with any one sort of change. Assuredly, for example, local +neuritis is by no means universally, it is probably even not commonly, +present in the early stages of neuralgia; it has also been repeatedly +detected in nerves that had been wholly free from neuralgia; and, on the +other hand, it has been entirely absent in nerves that have been the +seat of the severest pains. Moreover, many facts which have been put +down without reflection, as showing a local peripheral cause for +neuralgia, are at least open to another and, as I believe, truer +explanation; as (_e. g._) in the following remarks of Eulenburg on +mechanical irritations of nerves as causes of neuralgia: "Diseases of +bones are extraordinarily frequently the cause of neuralgias in +consequence of compression or secondary disease, which affects the +branches of nerves passing through canals, foramina, fissures, or over +processes of bone. The appearances which the opportunities of resections +of the trigeminus for facial neuralgia have permitted to be discovered, +have given us valuable information in that direction. Flattening and +atrophy of nerves from periostitis, or from concentric hypertrophy in +narrowed bony canals, have frequently been discovered. The neurilemma at +the narrowed parts was often seen reddened, ecchymosed, infiltrated with +serum, or surrounded with fibrous exudation; occasionally inflammation +had been followed by partial thickening of the neurilemma (fibrous +knots) and turbidity (Trubungen) of the nervous cord at the +corresponding spot. Similar appearances have been noted in other +neuralgias (neuralgia-brachialis, sciatica)." For my own part, I believe +that the above description represents the facts from an erroneous point +of view. True neuralgia, if by that we understand a pain of intermittent +character limited to one or more nerves, is in my experience an +extremely uncommon result of periosteal disease, or of inflammation of +the linings of bony canals; but in a great number of instances such +diseases appear to be set up as the secondary consequence of the +neuralgic process (whatever the essential nature of that may be) going +on in sensory nerves which supply the parts when these inflammations +appear. And it must be remembered that the specimens obtained by +resection of nerves are comparatively few in number, and are taken +universally from old-standing and desperate cases of disease; in short, +from cases which are just in those advanced stages of neuralgia in +which, as has already been amply shown, these secondary inflammations +are almost always present. On the other hand, I have myself had one +opportunity of examining the local condition of an intercostal nerve, +which during life, and quite up to death, had been the site of the most +pronounced neuralgia, which, however, had only existed for a few days. +The patient, a young man, aged twenty-seven, was probably insane, and +had attempted suicide. Not a trace of inflammation, either in the nerve +itself or in any of the tissues to which it was distributed, could be +detected. (This was a case in which I greatly regretted the +impossibility of getting a family history that was at all reliable.) The +spinal cord, unfortunately, could not be examined. And I strongly +believe, from the marked absence of tenderness on pressure which is +almost universally observed in ordinary cases of neuralgia at an early +stage, that primary inflammation of neurilemma, periostem, etc., as a +cause of neuralgia, is altogether exceptional; so much so, that we are +entitled to believe it can never be more than a concurrent, and then not +the most important, cause. + +It is necessary here to inquire, more particularly than we have yet +done, into the nature of the "painful points" first signalized by +Valleix as a distinctive symptom of neuralgia. Very great differences of +opinion have prevailed among subsequent writers, both as to the +frequency and the significance of these points. It may be said, however, +to be now quite settled that the presence of definite points, painful on +pressure, and also corresponding to the foci of severest spontaneous +pain, is far from universal in neuralgia. Upon this point there is +probably no reason to doubt the correctness of Eulenburg's observations +made in the surgical clinic of Greifswald and the polyclinic of the +University of Berlin; he says that he discovered the existence of tender +points in "Valleix's sense," in rather more than half the cases of +superficial neuralgia, but in the rest he could not by any means +discover them. In many other cases, however, he found more indefinite +points of tenderness, not accurately corresponding to nerve-branches, +but affecting individual portions of skin, bone, or joints; the relation +of these to the neuralgic symptoms was difficult of explanation. +Eulenburg lays down the principle that "hyperaesthesia" may depend on +three sorts of causes--(1) On local disease of the peripheral ends of +nerves; (2) on alterations of the psychical centres; and (3) on morbidly +exaggerated conduction in the nerve-trunks themselves; and it is to this +third source that he attributes many of the phenomena of the neuralgic +painful points, and especially their multiplicity, in many cases. The +_locus in quo_ of the mischief which sets up this exaggerated conduction +of sensory impression is, upon this theory, between the psychical centre +and the main point of branching of the nerves; hence a large number of +peripheral nerve-termini might be practically sensitive to touch, +because the mischief, though localized in a comparatively small spot, +might easily affect many bundles of fibres, which diverge widely from +each other in their course. It will be seen presently with what limits +and for what reasons we believe this to be a true theory. But to return +to the question of painful points in Valleix's sense, we must state one +or two facts which seem certain from our own experience, but have not +been adequately recognized, we believe, by others. The first is, that +localized tender spots, accurate pressure on which will set up or +aggravate the neuralgic pain, are not early phenomena, save in +neuralgias of exceptional severity of onset; but that a certain +persistence and severity of neuralgia are always followed by the +formation of one or more true points douloureux. The second fact relates +to the clinical history of migraine. Roughly speaking, it is true, as +Eulenburg states, that, in pure migraine, painful points in Valleix's +sense are not to be found; in place of them we observe, after the +paroxysms have passed away, a more generalized soreness of considerable +tracts of the scalp, forehead, etc., or diffuse tenderness of the +eyeball. But I must here again refer to the fact, first observed in my +own case, and afterward verified in many others, that migraine may be +only the youthful prelude to a regular trigeminal neuralgia attended +with the formation of characteristic localized painful points at a later +period. And the third fact that must be specially mentioned is that the +true Valleix's point, when it has become established for some time, is +not a mere spot of sensitive nerve, but is the scene of trophic changes, +involving hyperaemia and thickening of parts surrounding the nerve. To +give one example, it is quite a frequent thing to find a patch of tender +and sensibly thickened periosteum of irregular shape, but equal +sometimes to a square inch in size, over the frontal bone at and +immediately above the inner end of the eyebrow, in cases where +supra-orbital neuralgia has recurred frequently during some years, +although no such thing was present when the neuralgia first commenced. +In my own case, the bone has become sensibly thickened at that point. + +The general result of such post-mortem and clinical information as can +be had seems clearly to be that positive anatomical changes, either of +nerve-terminals or superficial nerve-branches, are but casual and +infrequent factors in the first production of neuralgia, and, in +particular, it would seem that inflammation of a nerve itself by no +means necessarily produces neuralgic pain, but (far more commonly) +simple paralgesia or anaesthesia of the parts external (peripheral) to +the lesion. The one marked exception to this general proposition is to +be found in the case of the severe and peculiar injuries inflicted on +the trunks of nerves by gunshot-wounds which, as we have seen (from the +American experiences), can produce some of the most dreadful forms of +neuralgia. But the nature of the injury here inflicted is, it must be +remembered, quite different from any thing which either disease or +accident in civil life would produce, save in the most exceptional +instances. For the chief material element in the production of the +neuralgias of ordinary life we are really driven, by exclusion, to the +condition of the posterior roots of special nerves, in some cases, +perhaps, to the (spinal) ganglia on which the nutrition of these roots +probably is considerably dependent. + +With the field thus narrowed for us, it is surely legitimate, in the +necessary scarcity of anatomical records referring directly to the state +of the nerve-roots in ordinary neuralgia, to place great weight on the +facts of a disease like locomotor ataxy, in which the main anatomical +change is a progressive atrophy of the posterior columns which usually +falls with peculiar severity on the posterior nerve-roots, or on the +parts of the gray matter immediately adjoining these, and in which +neuralgia may be said, for practical purposes, to be a constant and most +characteristic phenomenon. If any one desires to see how strikingly the +connection of the neuralgic phenomena with the anatomical-change comes +out, I recommend him to study Dr. Lockhart Clarke's papers on locomotor +ataxy (_vide_ "St. George's Hospital Reports, i." 1866; _Lancet_, June, +10 1865; "Med.-Chir. Soc. Transactions," 1869), or the excellently +reported case by Nothnagel (_Berlin Klin. Wochensch._, 1865). It is +really not too much to say that the only important difference between +the clinical aspect of the pains of locomotor ataxy and those of +ordinary neuralgia is simply such as depends on the fact that the +anatomical change in the former case is bilateral, and usually affects +the roots of several, sometimes of a great many pairs of nerves. I +infer, from a conversation with Dr. Clarke, that he fully recognizes the +force of the analogy, and the great strength of the presumption which it +sets up in favor of an atrophic change of the posterior roots in +neuralgia. + +It may, of course, be urged, against the view that neuralgia depends on +any change analogous to those which occur in ataxy, that quantities of +cases of the former recover speedily, and must be supposed to be either +independent of material change altogether or, at any rate, to have +involved only very trivial anatomical changes, not formidable diseases, +like atrophy of nerve-centres. I find it impossible to admit that this +argument has the slightest force. Are we to suppose that the posterior +nerve-roots alone, of all tissues and organs of the body, are incapable +of minute and partial changes in the direction of molecular death which +may be perfectly recovered from in weeks, months, or even days? I, for +one, cannot doubt, that such changes are of frequent occurrence, in all +parts of the central nervous system, when I can consider the absolute +dependence of these portions of the organism upon a perfect +blood-supply, and the immense number of possible causes of temporary +interference with that source of nutrition. And I can see no probable +difference, except in degree and persistence between the effects on +sensation which would be produced by such a change of the posterior +roots as this, and that which would result from the more serious and +fatally continuous change which is involved in locomotor ataxy. + +9. We come now to a most important but most complex and difficult +portion of the argument respecting the _locus in quo_ of the essential +pathological process (if such there be) in neuralgia; viz., as to the +paths and the character of the so-called "reflex" influences which +intervene in the causation, both of neuralgia itself, and also of the +numerous complications with which we have seen that neuralgia is liable +to be attended. The clinical facts which confront us here, and demand +explanation, are the following: (1) Irritation so called, of sensory +fibres may apparently evoke pains attributed to the site of the +irritation, or to the parts on the peripheral side which are supplied by +the same sensory nerves. (2) Peripheral irritation of a particular +sensory nerve may evoke neuralgic pains in nerves connected with that +irritated only through the spinal centre. (3) Neuralgia in a sensory +nerve may (and almost always does, to some extent) produce secondary +vaso-motor paralyses: these paralyses may affect fibres which run in the +same branch of the nerve as that which is painful, or fibres that run in +another branch of the same nerve, or fibres that run with another +sensory nerve, or the ganglionic chain of the sympathetic itself. (4) In +like secondary manner, neuralgia may produce vaso-motor spasms in any of +the directions just specified; this is usually a short-lived phenomenon, +giving place quickly to paralysis; but Du Bois Reymond's often-quoted +analysis[19] of his own sufferings from migraine seems to show that +spasm-producing irritation of the trunk of the sympathetic may last +during some hours. (5) Neuralgia in a sensory nerve may increase, alter, +or (more rarely) suspend the secretions of glands supplied by fibres +bound up either in the same branch, or in another branch of the same +nerve, or in a different nerve with which it is connected only through +the centre or (possibly) only through a plexus. (6) Neuralgia in a +sensory nerve can produce paralysis of muscles supplied by motor fibres +bound up with the painful branch, or with another branch of the same +nerve, or in muscles supplied by a totally distinct nerve connected only +through the centre. (7) It may produce convulsion and spasms of muscles, +in all the above directions; this usually alternates with great +weakness, or actual paralysis of the same muscles. (8) It may produce +partial or complete loss of common or special sensation in nerve-fibres +that run either with the same branch, or with another branch of the same +nerve. (9) It may produce trophic changes, either in the direction of +simple atrophy or of subacute inflammation with proliferation of +lowly-vitalized tissue (_e. g._, connective) in the parts with which are +supplied with sensation by the painful branches or by other branches of +the same nerve. + +It is necessary to go over again the proof of these facts; they are +given pretty copiously in the chapter on Complications; and could have +been made much more numerous. But the point to which I desire to compel +the reader's attention is the impossibility as it seems of me, of +accounting for the variety and complexity of these phenomena, except by +the supposition that there is in every case of neuralgia a central +change, which is the one most important factor in the producing both of +the pain and of the secondary phenomena. For the result of my experience +is that neuralgia, unless very slight and brief, is never unattended by +these complications and in the great majority of cases involves several +different secondary alterations of function which must (so to speak) +radiate from the central end of the sensory nerve, and from no other +place whatever. And it must be remembered that the most elaborate +"_symptome-complexe_" is found equally in cases where no suggestion of +any peripheral origin of the pain can be made, and in cases where, at +first sight, one might fancy there was a very obvious peripheral cause +for pain. I am quite willing to admit, with Eulenburg and others, that +the evidence, powerful and varied though it be of the relations of +neuralgia to hereditary neuroses, to alcoholic and senile degeneration, +etc., only raises a strong probability that some part of the central +nervous system is the _locus in quo_ of the essential morbid processes +in the majority of neuralgias. But the case stands far otherwise now +that we are able to show, not merely that the majority of neuralgic +patients suffer from such influences as those above mentioned, but that +every variety of neuralgia is liable to be complicated with secondary +affections of the most divergent nerves, the only common meeting-place +of which is in the spinal centre of the painful nerve; and when we find +moreover, that many of these secondary affections can equally be +produced by undoubted atrophic changes (as in ataxy of those same +posterior roots). + +At this point we must introduce a remark relative to the true nature of +so-called "reflex" effects. The word is constantly used, and is also +much abused, as Eulenburg remarks. We all understand, of course, what is +intended by the commonest use of the word: the case of sneezing produced +by the irritation of snuff applied to the peripheral branches of the +fifth nerve in the nose is a stock example. But another application of +the phrase, of much more questionable propriety, is that where it is +employed to designate functional nervous actions, which merely arise +simultaneously with or subsequently to sensory phenomena as to which +there is no proof whatever that they were produced by peripheral +irritation. This particular inaccuracy of customary speech has probably +contributed largely to the inveteracy with which writers on nervous +disease have insisted on assuming a peripheral origin in every case for +neuralgia itself. In the case of sciatica, for example, complicated, +secondarily, with paralysis of the flexors of the limb, it seemed easy +and scientific to speak both of the neuralgia and the paralysis as +"reflex" effects of a local peripheral mischief--gouty, rheumatic, or +the like; and it appears to have been perfectly forgotten by many that +the whole phenomena might be explained by an original morbid action in +the sensory root of the nerve, extending subsequently to the motor root, +without any intervention of peripheral irritation whatever, or under the +influence only of the ordinary peripheral impressions, which, in health, +evoke no painful nor paralytic symptoms. It is by this kind of extension +of a central morbific process, leading to radiation of the perturbing +influence centrifugally along divers nervous paths, that I believe we +must explain the facts observed in complicated cases. + +Take, for example, the following case, which, in its history of +twenty-three years, presents a fair example of a type of trigeminal +neuralgia which I believe to be the rule rather than the exception, +though the trophic changes were somewhat unusually varied and +interesting. The following would be the pathological order of events, +according to the radiation theory: First or true migrainous stage; +failure of nutrition of a portion of the sensory root of the right fifth +nerve within medulla oblongata, lesser degree of the same condition in +the adjoining and closely-connected vagus root (hence supra-orbital +pain, local anaesthesia and vomiting); extension of the morbid process to +the motor root (hence vaso-motor paralysis and secretory and trophic +changes in the cornea, superciliary periosteum, etc). Second period: +recovery, to a large extent, of the nutrition of the posterior root of +the trigeminus, complete recovery of the root of the vagus (hence +alteration of the type of recurrence of the pains, which now occur at +increasingly long intervals, and needed special provocation, _e. g._, +excessive fatigue, to bring them on; hence, also, disappearance of the +stomach symptoms); continuance of the affection of the motor portion of +the nerve (hence, continuance of the tendency to trophic, secretory, and +vaso-motor changes); development of the true points douloureux during +and after the paroxysms, instead of the diffused tenderness following +the old attacks of migraine. Third stage: neuralgic attacks become rare +and comparatively unimportant; tendency to trophic changes greatly +lessened; local anaesthesia persists. Presumption, that the nutrition of +the nerve-centre has nearly recovered itself, but that that centre is +still the _locus minimae resistentiae_ of the central nervous system, +liable to suffer from any cause of general nervous depression. + +Now, in interpreting the above phenomena, as I do, upon the theory of +one essentially uniform nutritive change affecting the fifth nerve +within the medulla oblongata, I shall be met with the following +objections: First, there is the common and superficial difficulty that +pain and paralysis of sensation must be opposite states, and that it is +impossible to refer them both to one and the same pathological process. +I have already in many places given instances how constantly pain and +sensory paralysis interchange in a manner which is totally +incomprehensible except upon the supposition that their physiological +basis is essentially the same; but the most satisfactory evidence, +perhaps, that could possibly be produced on this point is to be found in +the perusal of a group of cases observed by Hippel,[20] and entitled by +him "Anaesthesia of the Trigeminus," the loss of sensation being the most +remarkable feature. The cases are so deeply interesting that I would +gladly transfer them bodily to these pages, but must abstain from want +of space. Suffice it to say here, that, in the first place, the +anaesthesia was accompanied, in every one of these cases, by a most +distinct and typical neuralgia; and, secondly, that trophic changes +occurred which most interestingly (though not with absolute +completeness) reproduced the phenomena observed after complete section +of the trigeminus at the Gasserian ganglion. + +The second objection sure to be raised to the theory of a simple +spreading of a nutritive central change, as the cause of all the +phenomena in such a case as the above, is this: It will be asked how the +process extended itself to the motor root, which, in the case of the +fifth nerve, is removed by a somewhat formidable anatomical distance +from the sensory root. I am, of course, well aware of the latter fact, +and it is an additional reason for selecting neuralgia of the fifth, as +an extra difficult test of the value of my theory. A few words must be +premised, reminding the reader of the physiological anatomy of the +nerve. + +The trigeminus is in all its characters a spinal nerve; but it has +sundry peculiarities both of structure and of connections with other +nerves. Its posterior or sensory root is enormous, and, as Schroder van +der Kolk showed, takes a direction from behind downward and forward, +which is intended to facilitate its numerous and important connections +with the nuclei of other nerves: of these the most notable are its +connections with the vagus, facial, glosso-pharyngeal, and hypo-glossal +nuclei. The motor root, much smaller than the sensory, was shown by +Lockhart Clarke to be traceable as low as the inferior border of the +olivary body, as a column of cells which occupies a situation +corresponding to that of the anterior course of the spinal gray matter. + +As this column passes onward in the medulla oblongata, on a level with +the glosso-pharyngeal nerve, it forms a group of cells of large size. +Besides numerous other connections which it forms, Clarke describes the +motor root as sending processes forward, like tapering brushes or tails +of fibres, in connection with more scattered cells lying in their +course, which may be frequently seen to communicate with the transverse +bundles which traverse the "gray tubercle" and the sensory roots of the +fifth contained therein. In this way the sensory root, though seemingly +much separated from, is really in very direct connection with, the motor +root. + +Now, proofs, which must be considered almost positive, have recently +been adduced to show that the nerve-fibres concerned in those peculiar +alterations in the tissues supplied by the ophthalmic division of the +fifth, which occur in section of the trigeminus, come entirely from the +motor root of the fifth, and form a very small band in the inner or +medial margin of the ophthalmic trunk. The observation of Meissner[21] +goes to show that it is possible (by good luck) to divide the trunk in +such a partial manner as to cut only the inner fibres, and thereby +produce the trophic eye-changes without any anaesthesia, or only the +sensory fibres, and thereby induce anaesthesia without any trophic +changes; and it must be owned that this really affords the only +reasonable explanation of the discrepancy between the experimental +results obtained by Magendie and Bernard; and also the facts of such +cases as those related by Mr. Hutchinson,[22] who in two instances found +that a completely anaesthetic eye recovered perfectly well from the wound +made in a surgical operation. The nature of the nervous influence +(whether ordinary vaso-motor only, or a special trophic function) has +been greatly disputed. Dr. Wegner,[23] from observing the remarkable +group of glaucomatous cases under Horner (of which one has been +related), made experiments, from which he concluded that the +augmentation of intra-ocular pressure in glaucoma was a phenomenon +dependent upon the sympathetic, which was irritated by reflection from +the trigeminus. But the researches of Hippel and Grunhagen, especially +their latest,[24] give a different explanation, excluding the +sympathetic; they found that irritation of the medulla oblongata, in the +neighborhood of the trigeminus root, produced a lasting and very +pronounced augmentation of intra-ocular blood-pressure, an effect which, +they remark, could not depend on irritation of the vaso-motor centre, +since that must produce contraction of the vessels and lowering of the +blood-pressure. They conclude that "the trigeminus contains specific +fibres which possess the property of actively dilating the blood-vessels +of the eye;" and in reference to the secretion of the fluid humors of +the eye, they conclude also that "the trigeminus also plays the part of +an (active) nerve of secretion." + +Of these conflicting opinions I can have no difficulty in at any rate +rejecting that of Wegner; for the clinical phenomena of the +complications attending trigeminal neuralgia, such as they are described +in my last chapter (and could have been described at much greater +length), seem to me utterly to exclude vaso-motor spasm except as a +temporary phenomenon at the commencement of the attacks of acute pain. +Vaso-motor palsy undoubtedly is very often present, in fact every attack +of neuralgia of a certain severity is thus complicated; and there is no +reason to doubt that this paralysis could be caused by lesions within +the medulla. Are we, then, to admit functions of active dilatation of +vessels, and active impulse to secretion in certain fibres of the fifth? +It is necessary at any rate to clear the ground in one respect: it must +not be supposed that I for a moment entertain the idea that there can be +direct active dilatation, _i. e._, that there can be any system of +muscular fibres (and nerve-fibres stimulating them) whose office is to +open the calibre of the vessels; the idea is wildly improbable--in fact +almost inconceivable by any one who reflects on the necessary +machinery--and there is not a single observed anatomical fact to give it +support. If, then, I speak of the possibility of "active" dilatation, it +must be understood that I refer to a theory of "inhibition," which +supposes certain fibres to be gifted with the power of paralyzing or +inhibiting the vaso-motor nerves. It is my duty to speak with all +reasonable reserve on that most difficult _quaestio vexata_, the +existence of special inhibiting systems of nerves, and the extent to +which a double series of opposed nervous actions is generalized in the +body; but it is impossible to avoid the subject altogether, and I offer +the following remarks, with deference, to our professional +physiologists. The strongest instances of the apparent inhibiting action +are probably afforded by the _nervi erigentes_, as shown by Loven, the +cardiac depressor, by Ludwig and Cyon, and the splanchnics (upon the +intestine), by Pfluger. But there is not a single one of these examples +that has not been challenged by experimenters of repute. Thus the theory +of the distinctive restraint-action of the splanchnics upon the +intestine, and of the vagus upon the heart, has been especially +controverted by Piotrowski, who, indeed, rejects the whole theory of +special inhibitory nerves.[25] And, from another point of view, Mr. +Lister long ago attacked the views of Pfluger, maintaining that it was +possible to produce exactly opposite effects through the medium of the +very same nerves, according as the experimental irritation applied to +them was weak or strong. To Dr. Handfield Jones[26] this seems a still +unanswerable objection to the inhibitory theory. And in the remarkably +able and judicial summary of the "Physiology and Pathology of the +Sympathetic or Ganglionic System,"[27] by Dr. Robert T. Edes, a less +decided but still tolerably strong acquiescence is given to Mr. Lister's +criticisms of this theory. Personally, I must express very strongly the +distrust (which is probably felt by many others) of doctrines which +assert an exact opposition between the functions of any two nerves, on +the basis of an observation that the same apparent effects may be +produced by section of the one and galvanization of the other; both +processes seem far too pathological, and too remote from the conditions +of ordinary vitality, to admit of any such absolute deductions from +their results. + +In the present state of our information I am inclined to explain all the +congestive complications of trigeminal neuralgia on the basis of +vaso-motor paralysis. And I further believe that the cause of that +paralysis is a direct extension of the original morbid process from the +sensory root to the motor, affecting the origin of fibres in the latter, +which are destined to govern the calibre as ocular and facial vessels. +These fibres I suppose it is that Meissner succeeded in dividing when he +partially cut the trigeminus, and got nutritive and vascular changes +without anaesthesia. + +There must be more than this, however, to account for the whole of the +trophic phenomena; for there is a great body of evidence to show that +mere vaso-motor paralysis does not produce any phenomena of such an +actively morbid kind as those we are endeavoring to explain. The +phenomena on the side of secretion might indeed be possibly explained by +vaso-motor paralysis. [It must be remembered that I am speaking of such +augmented secretion as is seen in neuralgia. I agree with Prof. +Rutherford (Lectures on Experimental Physiology, Lancet, April 29, 1871) +that it is difficult thus to explain the effects of galvanization of the +chorda tympani on the submaxillary gland.] Consisting as they do (a), in +the great majority of cases, of a mere outpour of what seems little more +than the aqueous part of the secretion, and (b) in a few cases of +arrested secretion, a phenomenon otherwise by no means unfamiliar as the +result of sudden, passive engorgement of glands. But the mere cessation +of vaso-motion will not account for such facts as the rapid and +simultaneous development of erysipelatous inflammation, of corneal +clouding and ulceration, of iritis and glaucoma, of nutrition-changes in +hair and mucous membrane. I must, for the present, be content to believe +it probable that there is a special set of efferent fibres in the +trigeminus, emanating from the motor-root, whose office it is in some +unknown way to preside over the equilibrium of molecular forces in the +tissues to which the nerve is distributed; trophic nerves, in fact, +though not active dilators of blood-vessels. + +It seems to me that, without enlarging further on this almost endless +topic, I should be justified in assuming that I had shown the very high +probability that the common starting-point both of the neuralgia and of +its vaso-motor secretory, and trophic complications, was in the sensory +root of the trigeminus. But the argument is greatly strengthened when we +consider the fact that loss of peripheral common, and also tactile +sensation, to a greater or less degree, is constantly observed to occur +simultaneously with the pain and with the other complications. When we +observe a patient suffering from racking supra-orbital and ocular +neuralgia, and discover that at the very same period the skin round the +eye is markedly insensitive to impressions, except in the _points +douloureux_, what can we rationally suppose, except that both pain and +insensibility are the result of one and the same influence, which +radiates from the sensory centre? + +Nor are we likely to reach a different conclusion, if we test the matter +by the consideration of a rarer, but still sufficiently common kind of +case, such as I have described in Chapter I., in which a very strong +peripheral influence (traumatic) produces neuralgia, accompanied by +vaso-motor and secretory phenomena, and by anaesthesia, but not in the +district of the painful nerve, but in the territory of a quite different +nerve. How can we doubt, in the case, _e. g._, of a trigeminal neuralgia +thus complicated, the exciting cause of which was a wound of the ulnar +nerve, that the morbid influence, traveling inward from the lesion, +would have passed without any special consequences (as happens in +thousands of such nerve-wounds), had it not, in its passage along the +medulla, encountered a _locus minoris resistentiae_ in the roots of the +trigeminus? It seems impossible to account for the phenomena on any +other theory. [Eulenburg says, in reference to my reported cases of the +kind: "_Solche Falle begunstigen in hohem Grade die Annahme +pradisponirender Momente, die in der ursprunglich schwacheren +Organisation einzelner Abschnitte des centralen Nerven-apparates +beruhen._" _Op. cit._, p. 56.] + +It is necessary, in the next place, to consider a very important +question, how far irritation can pass over from one nerve to another, +without reflection through a spinal centre, solely in virtue of a +connection through the medium of a nervous plexus. The case which +apparently presents such phenomena in the most unmistakable way is that +of _angina pectoris_. + +The site to which the essential heart-pain is referred in this disease +is probably the cardiac, or this and the aortic plexus; in a +comparatively small number of cases the pain does not extend farther. +But much more frequently it spreads in various directions, and we have +to account for its presence (_a_) in intercostal nerves, (_b_) cervical +nerves, (_c_) nerves springing from the brachial plexus. + +Before we inquire into the mechanism by which this extension of the pain +takes place, we ought in strictness to ask ourselves whether the +essential heart-pain is felt only in the spinal sensory branches, or +whether the sympathetic fibres are themselves capable of feeling pain. +The latter supposition, notwithstanding all that has been argued in its +favor from the supposed analogies of the pain of colic, gall-stone, +etc., seems to me very doubtful. It would appear more probable that both +the latter pains, and also those of angina, are really connected with +branches either of the vagus or of other spinal nerves. And there is no +need to invoke the sympathetic as a sensory nerve, to account either for +the essential heart-pain of angina, or for its extension into arm, +chest-wall, and neck. For the plexus cardiacus receives spinal branches, +both from the vagus and also (through the medium of the sympathetic +ganglia of the neck) from the whole length of the cervical and the +uppermost part of the dorsal cord-centres. And, in this way, it would +seem quite possible intelligibly to account for the pain radiating into +intercostal, cervical, and brachial nerves, merely by extension of a +morbid process essentially seated in the cord. Usually, however, one +sees it explained not in this way, but by the inter-communications that +exist outside the spine, between the branches from the cervical ganglia +and the lower cervical and upper dorsal nerves; and the pain in the arm +is especially explained by the connection (outside the spinal canal) of +the inferior cervical ganglion, on the one hand with the lower cervical +nerves, which go to the brachial plexus, and, on the other hand, with +the heart itself. There remains to be explained, however, the singular +tendency of the arm-pain to be one-sided (this happens in at least four +cases out of five); and this explanation seems to me insuperably +difficult, on the theory that the transference of morbid action to the +brachial nerves takes place through external anastomoses. It appears +greatly more probable that angina is essentially a mainly unilateral +morbid condition of the lower cervical and upper dorsal portion of the +cord; liable of course to be seriously aggravated by such peripheral +sources of irritation as would be furnished by diseases of the heart, +and especially by diseases of the coronary arteries; the latter +affection probably involving constant mechanical irritation of the +cardiac and the aortic plexuses. It is noteworthy that the arm-pain is +sometimes (I do not know how often) accompanied by vaso-motor paralysis +in the limb; this phenomenon could also certainly be more easily +accounted for on the supposition of radiation from a spinal vaso-motor +centre (to which the morbid process had extended from a posterior +nerve-root) than on that of communication between painful sensory nerves +and vaso-motor nerves; through either of the plexuses independently of +the spinal centres. + +In truth, I suspect that, whatever part the plexuses, with their +reenforcing ganglionic cells, may play during physiological life, they +are not often the channels of mutual pathological reaction of one kind +of nerve with another. It would be possible to argue this even more +strongly in the case of trigeminal neuralgias; but I must not +unnecessarily expand this already too lengthy discussion. + +From the varied considerations which have now been adduced, the reader, +unless I altogether miscalculate the value of the facts, will probably +have arrived at the following conclusions: (1) That the assumption of a +positive material centric change as the essential morbid event in +neuralgia is almost forced upon us; (2) that, whereas the morbid +process, if centric, is _a priori_ infinitely more likely to be seated +in the posterior root of the painful nerve, or the gray matter +immediately connected with it, than anywhere else; so, again, the +assumption of this locality will explain, as no other theory could +explain, the singular variety of complications (all of them nearly +always unilateral, and on the same side as the pain) which are apt to +group themselves around a neuralgia; and some of which are very seldom +absent in neuralgia of any considerable severity. To this we may +certainly add that it is extremely probable that the vast majority of +neuralgic patients inherit the tendency to this localized centric +change; in support of this we may finally mention two considerations +derived from the sex and the ages most favorable to neuralgia. Eulenburg +saw a hundred and six cases of neuralgia of all kinds, of which +seventy-six were in women and only thirty in men; my own experience is +very similar; namely, sixty-eight women and thirty-two men out of a +hundred hospital and private patients. The strong connection between the +hysteric and the neuralgic temperament in women, and the great +preponderance of women among neuralgics, strengthen in no small degree +the probability of inherent tendencies to unstable equilibrium as a very +common predisposing factor in neuralgia. And, on the subject of age, I +need only recall what I have said so strongly about the coincidence of +neuralgia with particular epochs in life, as affording evidence of the +most powerful kind that neuralgics are, save in exceptional instances, +persons with congenitally weak spots in the nervous centres, which break +down into degeneration, temporary or permanent, under the strains +imposed by one or other of the physiological crises of the organism, or +the special physical or psychical circumstances which surround the +patient's life. + +Having thus decidedly expressed my belief in the essential material +participation of the nerve-centre in neuralgia, it remains for me to +discuss two points: first, as to the character of the material change in +the nerve-root, and next, as to the extent to which mere peripheral +influence, without special inherited tendencies, may suffice to set this +process going. + +The morbid change in the nerve-centre is probably, in the vast majority +of cases, an interstitial atrophy, tending either to recovery, or to the +gradual establishment of gray degeneration, or yellow atrophy, of +considerable portions of the whole of the posterior root, and the +commencement of the sensory trunk as far as the ganglion. + +It is probable, however, that in a certain number of cases, the atrophic +stage may be preceded by a process of genuine inflammation, and that +this inflammation is centripetally produced in consequence of +inflammations of peripheral portions of the nerve. The considerations +which make this probable are chiefly derived from the analysis of cases +in which a more or less chronic, but severe, visceral disorder has been +followed by so-called reflex paralysis, but in which neuralgic +phenomena, have been conspicuous. In reference to this subject I +recommend to the reader's attention the very interesting paper on +"Reflex Paralyses" by Prof. Leyden, of Konigsberg.[28] He is immediately +commenting upon a case in which dysenteric affection of the bowel were +followed by the symptoms of myelitis, attended with febrile +exacerbations, and also with severe pains in the region of the sacrum, +in the course of the dorsal intercostal nerves of the right side, and in +the knees, and semi-paralytic weakness of the lower extremities, and +with pains between the shoulder-blades and the left arm. Leyden +discusses the doctrine of reflex paralyses in general, starting from +the cases of urinary paraplegia brought forward by Stanley, in 1835, and +tracing the growth of opinion through the phases represented by Graves, +Henoch, and Romberg, by Valentine and Hasse, then by Pfuger, and other +professors of the inhibitory doctrine; by Brown-Sequard (in his +well-known, and now very generally discredited, theory of spasm of the +vessels in the nervous centres), by Jaccoud in the "Erschopfung" +(exhaustion) theory, down to the more careful and reliable researches of +Levisson on the temporary reflected paralyses induced by experimental +squeezing of the kidney or uterus of animals; and then gives the history +of the more recent doctrine of a positive material change in the cord +centripetally introduced. Gull[29] (1856) may be said to have +inaugurated the new doctrine of a morbid process transmitted along the +pelvic nerves to the cord, and causing material changes there. +Remak,[30] on the other hand, suggested a material change operating in +the opposite direction; _a neuritis descendens_, starting in the very +nerves (within the pelvis) which showed the paralysis in the +extremities. The symptoms are supposed by him to be distinctive, +inasmuch as there is both violent pain in the nerves of the soles of the +feet, and also tenderness of the same. On the other hand, Remak said +that myelitis, with neuritis, might be the origin of paraplegia and +simultaneous palsy of bladder and rectum. The theory of neuritis +descendens was supported by Kussmaul,[31] in the record of a case where +disease of the bladder was complicated with pelvic inflammation, +atheromatous degeneration of the arteries, and consequent fatty +degeneration of the sciatic nerves, causing direct paraplegia. We return +to the centripetal theory of urinary paralysis with Leyden's own cases, +published in 1865; of three patients with urinary paraplegia, two died, +and the existence of a secondary (centripetal) myelitis seems to have +been established, and by all analogy it must have existed in the third +case, which recovered. The only puzzle and doubt that ensued was caused +by the fact that there was an absence of neuritis in the different +nerves themselves; though it seemed plain that the starting point of the +myelitis was at the entrance of these nerves into the cord. This mystery +seemed to be cleared up by the important experiments of Tiesler, ("Ueber +Neuritis" Konigsberg, 1860) a pupil of Leyden's. This observer excited +local traumatic inflammation in the sciatic nerve of rabbits and dogs; +the rabbit became paraplegic and died three days afterward. At the site +of the artificial irritation there was a localized formation of pus, and +there was a second similar formation within the vertebral canal at the +point where the posterior roots of the sciatic enter the cord; but +there was no neuritis of the intervening portion of the nerve. + +Upon this and similar evidence is based the modern doctrine of a +neuritis migrans, with centripetal tendencies, upon which it is supposed +that a very large proportion, at least, of the urinary, dysenteric, and +uterine paraplegias, miscalled "reflex," depend; and it is clear that +the application of the word "reflex" in such a case is a grave abuse, +tending to produce such confusion of thought and error in practice. In +relation to the subject of our own inquiry--neuralgia--it is obviously +of the highest consequence to investigate the question whether +peripheral irritations, analogous to those which produce urinary +paraplegia, are at all frequently the cause of the changes in the +posterior roots which produce true neuralgia; for of course an +inflammation may be the beginning of an atrophy which may presently +exhibit no distinction whatever from one of which the origin was +altogether non-inflammatory. I think that there is strong reason for +thinking that this is not at all frequently the case. In the first +place, all the evidence that exists respecting these centripetal +inflammations of the cord is opposed to the idea that, save in the +rarest instances, the inflammatory process limits itself to one small +segment of the cord. Secondly, the description of the pains that have +usually accompanied such inflammations of the cord is considerably +different from the strictly localized, frankly intermittent character of +a true neuralgia; in fact, all we know of the history of myelitis +(except when complicated with a large amount of meningitis) forbids us +to suppose that severe pain would be an immediate symptom. But, thirdly, +a far more important objection to the theory of an origin in localized +centripetal myelitis, the result of a neuritis migrans, is the rarity of +motor paralysis as an early symptom, instead of which we ought to find a +very distinct history of decided paralysis (much more decided than those +secondary paralyses which actually do occur in some neuralgias) of the +muscles supplied by the anterior roots of the painful nerve, in every +case in which such a peripheral origin could be assumed. Again, the +totally feverless commencement of neuralgias, a character which is +maintained throughout the progress of the milder cases, is entirely +opposed to the idea of a direct connection between myelitis and +neuralgia. The superficial appearance of pyrexia is sometimes given by a +local vaso-motor paralysis, which makes the neuralgic part, after a long +bout of pain, hot and red; but of general pyrexia there is nothing. + +Taking every thing into consideration, one is inclined to say that there +is a probability that in a very limited number of cases peripheral +irritation does cause actual limited myelitis, which escapes recognition +at the time, but which issues in an atrophy, the subjective expression +of which is actual neuralgic pain. We may well ask ourselves, also, +whether there is not some likelihood that a peripheral irritation, which +stops short of producing an actual neuritis migrans capable of +centripetally exciting a myelitis, may not, by a lower degree of +centripetal irritation, give a bias toward certain forms of +non-inflammatory atrophy in cells of posterior nerve-roots which are +congenitally of weak organization. I am inclined to believe strongly +that this does occur. For example, I should explain thus the majority of +the peripheral cases of ciliary neuralgia, migraine, etc., that we meet +with in poor young needle-women, especially the hypermetropic, who, at +an age when they can ill afford the strain, work so constantly and +strenuously at an occupation which fearfully taxes the eye. + +I would also go farther, and express the opinion that peripheral +influences of an extremely powerful and continuous kind, where they +occur with one of those critical periods of life at which the central +nervous system is relatively weak and unstable, can occasionally set +going a non-inflammatory centric atrophy which may localize itself in +those nerves upon whose centres the morbific peripheral influence is +perpetually pouring in. Even such influences as the psychical and +emotional, be it remembered, must be considered peripheral--that is, +they are external to the seat and centre of the neuralgia. And there are +probably few practitioners of large experience who have not seen a +patient or two in whom the concurrence of some unfortunate psychical +with some other noxious peripheral influence, the whole taking place at +some critical period of life (especially in the years between puberty +and marriage), seems to have totally deranged the general balance of +nervous forces, and induced morbid susceptibilities and morbid +tendencies to some particular neurosis. It is a comparatively frequent +thing, for example, to see an unsocial solitary life (leading to the +habit of masturbation), joined with the bad influence of an unhealthy +ambition, prompting to premature and false work in literature and art. +The bad peripheral influence of constant fatigue of the eyes in study +may so completely modify a young man's constitution as to make a wreck +of him in a very few years, changing him from the state of habitual and +conscious health to that of chronic neurosis of one sort or another. +And, though it is doubtless on persons with congenital tendencies to +nervous diseases that such a combination of bad influences produces its +most serious effects, yet there unquestionably are a few persons in whom +they appear to entirely generate the neurotic constitution. I have +already touched upon the part that misdirected psychical influences, +especially religious and other forms of emotional excitement, may play +in this unfortunate perversion of the natural and healthy nervous +functions, more especially in youth; and need only add, here, that +perhaps the most fatal combination of all the bad influences is the +melancholy union of highly-strained religious sentiment with peripheral +sexual irritation, which is, unfortunately, a too common phenomenon +under certain systems of education. The most frequent neurotic +consequences of the class of influences which have now been referred to +are probably neuralgia--in the form either of migraine, of nervous +angina, or of sciatica--or else asthma. + +But, if the combination of several such centripetal influences may +generate the neurosis unaided, even a single one of them operating +powerfully for a long period may produce most serious consequences in +those who are hereditarily predisposed. The influence of prolonged +fatigue of the eyesight, independently of any special intellectual or +emotional strain, was strongly illustrated in my own case about three +years ago. I was then engaged upon a piece of scientific writing which +demanded no great intellectual effort, but was being done against time, +and by working, night after night, many hours by gas-light. My neuralgic +(trigeminal) attacks came on with great severity, accompanied by +vertiginous sensations of so alarming a kind as to make me fear the +invasion of some serious brain-mischief. I broke off all work, and went +to the sea-side, but was greatly disappointed to find, for the first few +days, that the symptoms were not in the least mitigated. The mystery was +soon explained. The weather had been such as to confine me a good deal +to the house, and, thinking it would do no harm, I amused myself with +reading newspapers and novels. At last I suspected that the use of my +eyes in reading was altogether mischievous; I desisted from reading any +thing, and in forty-eight hours every symptom had vanished. + +Among peripheral influences of a more mechanical kind there is one cause +of neuralgia, the force of which has been variously estimated, but which +some authors rate as very important, viz.: the influence of the +pressure, and especially of the varying pressure, of blood-vessels, or +other hollow viscera, upon the trunks of the nerves. We must set aside +one such action which is undoubtedly very powerful, as essentially +differing from the others; I mean the pressure of dilated blood-vessels, +especially aneurisms, when this happens to be exerted upon the ganglion +of the sensory trunk. Here there can be no doubt of the mischief; for +the pressure, if at all severe, gradually destroys the life of the +ganglion, upon which, as was proved by Waller, the nutrition of the +posterior nerve-root hangs with very intimate dependence, and the +pulsations of the vessel seem greatly to aggravate both the irritation +and the centripetal tendency to atrophy. In short, it is plain that such +lesion of a ganglion may be the whole and sufficient cause of a +neuralgia of the most desperate and incurable kind. It is another matter +when we are asked to believe that the mere varying pressure of +intestines, in different states of fullness, or plexuses of pelvic veins +liable to temporary congestions, can so affect the sciatic nerves as to +set up neuralgia. Considering the extreme frequency of cases in which +such momenta must be partially coming into operation, especially in +women--a frequency altogether out of proportion to that of sciatica--I +cannot admit the probability that this influence is more than an +occasional and very secondary factor, and that only in cases where the +disposition to neuralgia is uncommonly strong. + +A sufficiently complete explanation of my theory as to the pathology and +etiology of neuralgia has now been given, although the subject might be +elaborated at far greater length; and I hope it will be apparent to the +reader that the view now advocated is at once important, and also +vouched for by strong evidence. I claim for it that the whole argument +shall be taken together, for it is a case of cumulative proof; every +link must be weighed and tested, before the remarkable strength of the +chain can be felt. And it may fairly be said that, if the proof of a +definite kind of material change in a definite organ, as the essential +factor in neuralgia, has been established upon reasonable grounds, an +important step has been taken toward removing a serious opprobrium and +difficulty in practical medicine. Although the true neuralgias are not +among the most frequent of human diseases, they form a class of enormous +practical importance, for they are sufficiently common to be sure to +occur in considerable numbers in the practice of every medical man, and, +both from the suffering which they inflict, and the rebelliousness which +they often show to treatment, they are among the gravest sources of +anxiety which the practitioner is likely to encounter. There are +probably few disorders which so often occasion mortification and loss of +professional credit to the physician. The helplessness which men, who do +not enjoy special opportunities of seeing those diseases with frequency, +so often show in dealing with them, is largely caused by the extreme +timidity and vagueness with which the standard treatises on medicine +deal with the question of their pathology; and a very unfair advantage +has thus been given to the specialists, who, by the mere force of +opportunity, and continual blind "pegging away" in an entirely empiric +manner, have acquired a certain rude skill in the treatment of these +maladies which enables them to outshine practitioners who often have far +more in them of the veritable _homme instruit_ as regards general +scientific education and habits of mind. It will be evident, as a mere +abstract proposition, that the enunciation of a reasonable pathology of +the disease, and the sweeping away of a mass of unmeaning phrases about +"mysterious functional affections" and the like, must be a distinct gain +to practitioners of plain common-sense and good general knowledge, to +whom neuralgia is merely one of a vast number of different diseases +among which their attention and study are divided. And I hope that, in +the further remarks on Diagnosis, Prognosis, and Treatment, yet to be +made, the value of clear pathological ideas of disease will be brought +more practically and clearly into view. [The reader will find, at the +end of Part I. of this volume, a note which contains a brief discussion +on the "Erschopfung" theory of Jaccoud, and the doctrines of Dr. +Handfield Jones respecting inhibition, with which I thought it best not +to encumber the text of the present chapter.] + +FOOTNOTES: + +[16] Eulenburg, to whose excellent work ("Lehrbuch der functionellen +Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to +refer, has partly misunderstood the drift and scope of my argument, a +misfortune which I owe to the impossibility of giving, in the "System of +Medicine," more than the briefest and most superficial sketch, both of +my ideas and of the facts on which they rest. + +[17] _Op. cit._, p. 60. + +[18] This opinion is somewhat stronger than that expressed in my article +in the "System of Medicine." I can only say it is the result of much +increased experience. + +[19] _Journal de la Physiologie, v._ + +[20] "Ernaehrungsstoerungen der Augen bei Anaesthesie des Trigeminus." +Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f. +Ophthalm. Band. xiii. + +[21] Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from +independent sources, of the truth of Meissner's views. His own +observation only proved half the case; but he quotes an observation of +Buttman's in which the exact converse of his own experience happened, +the external fibres being affected without the inner band, and +anaesthesia without trophic changes being the result. Moreover, Schiff +(Gaz. hebdom., 1867) obtained experimental results (in operating on cats +and rabbits) which coincide with Meissner's. + +[22] London Hospital Reports, vol. iii., p. 305. + +[23] Wegner, loc. cit. + +[24] Archiv f. Ophthalm., xv., 1. + +[25] "Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware +whether Piotrowski has at all altered his opinions since the +(subsequent) observations of Ludwig and Cyon upon the "depressor" nerve. + +[26] "Functional Nervous Disorders." Churchill, 2d edit., 1870. + +[27] "Prize Essay of the New York Academy of Medicine." New York: Wood & +Co., 1869. + +[28] Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex +Lahmungen," von E. Leyden. Leipzig, 1870. + +[29] "Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856. + +[30] Wurzburg. Med. Zeitsch., iv., 56-64. + +[31] Med. Cent. Ztg. 21, 1860. + + + + +CHAPTER IV. + +DIAGNOSIS AND PROGNOSIS OF NEURALGIA. + + +_Diagnosis._--This subject is much simplified and shortened, in regard +to our present purpose, by the plan of the present work, which, by +separately describing (in Part II.) the other disorders which resemble +neuralgia, and are liable to be confounded with it, avoids the necessity +for stating here the negative diagnosis of neuralgia itself. We are only +concerned here to give a clear picture of the positive signs which it is +necessary to verify before we can suppose disease to be neuralgia. The +special modes of searching for these are interesting, and in some +respects peculiar; + +(1) The first and most essential characteristic of a true neuralgia is, +that the pain is invariably either frankly intermittent, or at least +fluctuates greatly in severity, without any sufficient and recognizable +cause for these changes. + +(2) The severity of the pain is altogether out of proportion to the +general constitutional disturbance. + +(3) True neuralgic pain is limited with more or less distinctness to a +branch or branches of particular nerves; in the immense majority of +cases it is unilateral, but when bilateral it is nearly always +symmetrical as to the main nerve affected, though a larger number of +peripheral branches may be more painful on one side than on the other. + +(4) The pains are invariably aggravated by fatigue or other depressing +physical or psychical agencies. + +The above are characteristics which every genuine neuralgia possesses, +even in its earliest stages; if they be not present, we must at once +refer the diagnosis to one or other of the affections described in Part +II. of this work. + +Supposing the above symptoms to be present, we expect to find-- + +(5) In by far the largest number of instances that the patient has +either previously been neuralgic, or liable to other neuroses, or that +he comes of a family in which the neurotic disposition is well marked. +Failing this, we are strongly to doubt the neuralgic character of the +malady, unless we detect that there has been-- + +(6) A poisoning of the blood by malaria (but this very rarely causes +neuralgia, save in the congenitally predisposed); or-- + +(7) A powerfully operating or very long-continued peripheral irritation +centripetally directed upon the sensory nucleus of the painful nerve; +which irritation may be (_a_) "functional," as where the eye has been +persistently and severely over-strained and trigeminal pain results, or +a sudden severe shock has been received; or, (_b_) coarsely material, as +where inflammation, ulceration, etc., of surrounding tissues involve the +periphery of the painful nerves in a perpetually morbid action, or +chronic but profoundly depressing psychical influences; or-- + +(8) A constitutional syphilis. In this case there will either be marked +syphilitic local affection of the trunk of a nerve, or if, as is more +common, the syphilitic change is in the nerve-centre, there will most +likely be other syphilitic centric mischiefs, leading to scattered motor +or vaso-motor paralyses, characteristic modifications of special +sense-functions, etc. + +If the neuralgia be of some standing and a certain degree of severity, +there will inevitably be found-- + +(9) Some of the fixed tender points of Valleix, in such situations as +have been described in Chapter I.; and-- + +(10) Secondary affections (_a_) of secreting glands, or (_b_) vaso-motor +nerves; or (_c_) of nutrition of tissues; or secondary localized +paralyses of muscles, or localized anaesthesia of a somewhat decided +though not complete kind, as described in Chapter II.; any one or any +number of these various complications may be present. + +I must insist that the above picture includes only the essentials for a +diagnosis of neuralgia; if the painful affection will not answer to the +conditions therein included, we have no right to call it a neuralgia--it +belongs, for every practical purpose, to some other category of disease. +Let me add one more essential characteristic, which is, that the pain +begins and assumes its characteristic type before any other of the +phenomena appear, with the single and partial exception of anaesthesia. + +There are some special modes of diagnosis of the varieties of +neuralgia, developed of late years, that require notice here; they are +chiefly the result of the researches of Moriz Benedikt. + +As regards the quality of the pain, Benedikt says that the curve of +intensity has an intimate relation to the _locus in quo_ of the +neuralgia (_i. e._, whether in the periphery, trunk, or roots). An +inflammatory irritation set up at the periphery of a nerve (by a +joint-inflammation, for instance) produces a continuous pain; the same +kind of irritation, attacking a nerve-trunk (_e. g._, in the bony +canals), produces a paroxysmal pain; an inflammation spreading from the +vertebrae to the nerve-roots or the cord-centres produces momentary +lancinating pains. The latter characteristic he supposes to be +especially characteristic of the centrally-produced neuralgias; and I +may observe, as so far confirmatory of this idea, that this is +especially the character of the pains in locomotor ataxy. There are +sundry special cases to be considered, however: thus, Benedikt himself +remarks that the pain set up by the pressure of a pulsating aneurism is, +from the nature of things, lancinating from moment to moment. +Eulenburg,[32] moreover, says that Benedikt's tests of the locality of +the primary mischief only hold good under the following circumstances: +(1) When the irritability and the exhaustibility of the nerves are in a +normal condition during the neuralgia; (2) when the irritation that +calls forth the paroxysm is either identical with the original cause of +the disease, or at least operates upon the same spot. The two +conditions, however, do not concur. The irritability and exhaustibility +may be sometimes excessive in neuralgias, sometimes normal, and perhaps, +in certain cases, beneath the normal standard; by which means the form +of the curve of intensity must be considerably modified. Moreover, the +irritation that provokes an attack may from the periphery attack the +primary seat of the disease, even when this is central, on account (says +Eulenburg) of exaggerated conductivity of the nerves (his second +cause[33] of "hyperaesthesia"), as is, in fact, very frequently the case. +He also thinks the distinction between paroxysmal and lancinating pains +too indefinite to serve as a sufficiently reliable basis of diagnosis, +especially considering the endless _nuances_ of the form which the pain +is apt to take. I agree with Eulenburg upon this point; and am +convinced, from my own observations, that such a distinction as that +between lancinating and paroxysmal pains is illusory, [I have taken some +pains to investigate the character of the pains, not only in neuralgia, +but in locomotor ataxy. It is true that the lancinating character +predominates, on the whole, in the latter disease; but there are great +differences in different individuals, and even in the same patient at +various times, which plainly depend on subjective influences. Compare +for instance, Dr. Headlam Greenhow's report on an ataxic patient, with a +report on the same man by Dr. Buzzard and myself. ("Trans. Clin. Soc.," +vol. i., 1868, pp. 152-162.)] the two kinds being frequently found +alternate in the same case. The only useful distinction, in my opinion, +is Benedikt's first one: he is probably right in saying that, where such +an affection as an inflamed joint forms the source of peripheral +irritation that immediately provokes a neuralgia, the pain is apt to be +unusually continuous. + +The extent to which the pain of neuralgia spreads into different termini +of the same nerve has been made the basis of distinctions as to the seat +of the original mischief. For example, it has been said that pain in the +mental branch of the third division of the trigeminus, which does not +invade the auriculo-temporal branch, can hardly depend on an irritation +operating on the trunk of the inferior dental; it must be distinctly +peripheral, or else it must act upon limited portions of the central +origin of the fifth nerve. But the fact seems rather to be that, whether +the neuralgia was excited by lesions at the periphery, in the +nerve-trunk, or in the centre, it is equally possible that either a +small or a large part of the peripheral expanse of the nerve may become +the seat of the pain: this almost necessarily follows from the entire +independence of individual fibres in nerves. + +As regards the evidence afforded by the motor, vaso-motor, and trophic +complications, there is this very positive diagnostic value in +them--that they enable us to say, with greater assurance than we could +otherwise do, that the disease is a real neuralgia. But, the only +evidence that they afford as to the situation of the mischief is, that +they uniformly point to the central end of a particular nerve; and +accordingly I have already shown, in the chapter on Pathology, that the +attentive study of these very complications furnishes us with some of +the most powerful arguments upon which rests my theory that in neuralgia +there is always centric mischief. What share in the production of the +malady, in any given case, has been taken by the centric disease, and +what if any by a peripheral irritation, the existence of these +complications in no way helps us to determine; far less does it enable +us to localize a peripheral lesion which may have acted as a concomitant +cause; on the contrary, I believe that there is no more fertile source +of erroneous judgment on this very point, than some of these +complications, especially the vaso-motor and trophic. I suspect that it +has happened, in hundreds of instances, that a localized congestion or +inflammation, which is a mere secondary phenomenon, produced in the +centrifugal manner already so fully explained, has been taken for the +veritable _fons et origo_ of the malady: hence the neuralgia has been +confidently reckoned as one peripherally produced, and, what is even +worse, the whole energy of treatment has been directed to a mere +outlying symptom, under the idea that the primary source of mischief was +being attacked. + +The application of electricity as a test of the nature of a neuralgia +has been employed by Benedikt,[34] who lays down certain laws as the +result of his researches. He says that (_a_) in idiopathic peripheral +neuralgias the nerves are not sensitive to the current; (_b_) in +neuralgias dependent on neuritis or hyperaemia of the nerve-sheath there +is general electric tenderness of the nerve; (_c_) in cases where the +pain has been set up by morbid processes in tissues surrounding the +nerve, there is electric tenderness only at the site of these changes. I +may, in general terms, express concurrence in these statements; but I +must add that, as diagnostic rules they apply only to the early stages +of neuralgia; for the occurrence of secondary complications may and does +altogether change the condition of electric sensitiveness. It need +hardly be said that the above remarks on diagnosis apply for the most +part only to the superficial neuralgias, which, however, include an +immense majority of the cases of neuralgias. The diagnosis of visceral +neuralgias is, it need hardly be said, in most cases, a far more +difficult and complicated matter. In these diseases we have often little +more to guide us, in the actual symptoms, than (_a_) the intermittence +of the pain, and (_b_) the absence of commensurate constitutional +disturbance, especially the complete freedom from sense of illness in +the intervals between the pains. We shall be obliged to rely greatly on +such historical facts as the presence or absence of neurotic tendencies +in the patient and his family; the possibility of his having been +exposed to blood-poisoning (_e. g._, from malaria or chronic alcoholic +excess, or extreme over-smoking); the circumstance that he has been +habitually overworked, or greatly exposed to agitating psychical +influences; perhaps that he has been subject to a combination of several +of these morbific momenta. To say truth, the diagnosis of visceral +neuralgias must, at the best of times, be a difficult and anxious +matter, and we can hardly ever thoroughly satisfy ourselves until we +have procured some decided results from treatment; fortunately, however, +it happens tolerably often that we can do this, and sometimes in a very +striking way. + +_Prognosis._--The prognosis of neuralgia varies exceedingly, according +to the form and situation of the disease, and many other considerations. +There are, of course, in the first place, certain neuralgias in which +the prospect is perfectly hopeless as to cure; such are the cases in +which the nerve is involved in a continuously growing tumor (especially +within a rigid cavity, like the skull), or a slow but persistent +ulcerative process. + +Supposing, however, that the case is none of these, the very first +prognostic consideration is that of age. + +Of the neuralgias of youth, the majority either disappear altogether +after a first attack, or recur a certain number of times during some +years, the neuralgic tendency either disappearing or becoming greatly +mitigated when the process of bodily consolidation is over. In another +group the neuralgic tendency is never lost, but the form of the attacks +changes, and there is far less spontaneity in the manner of their +production. It is exceedingly common to see delicate boys and girls +between puberty and the age of eighteen or twenty, attacked with typical +migraine, which recurs regularly every three or four weeks for perhaps +two or three years, then ceases to occur at regular periods, then loses +the tendency to stomach complication; and, by the age of twenty-five or +somewhat later, has left, as its only relic, a tendency to attacks of +ophthalmic neuralgia, which come on when the patient is excessively +fatigued, or encounters the close air of a theatre, or undergoes an +unusual strain of mental excitement or anxiety, etc.; but which never +come on without some such special provocation. So, again, there is a +variety of sciatica which belongs mainly to the period between puberty +and the twenty-fifth to thirtieth year, and which seems really to +belong, pathologically, to the age of unsettled and irregular sexual +function, the tendency to it usually disappearing after the patient has +settled down happily in married life. Ovarian and mammary neuralgia have +very commonly a similar history. + +On the other extreme we find the neuralgias of the period of bodily +decay: these are of very bad prognosis. A neuralgia which first develops +itself after the arteries and capillaries have begun to change decidedly +in the direction of atheroma is extremely likely, even if apparently +cured for a time, to recur again and again, with ever-increasing +severity, and to haunt the patient for the remainder of his days. It +therefore becomes exceedingly important, in a prognostic point of view, +to assure ourselves as soon as possible whether this arterial +degeneration has decidedly commenced; and for this purpose I am in the +habit of insisting to pupils on the great importance of sphygmographic +examination for all neuralgic patients who have passed the middle age. +Where we get the evidence which is furnished by the formation of a +distinctly square-headed radial pulse-curve, even though there be no +palpable cord-like rigidity of superficial arteries, we are bound to be +exceedingly cautious of giving a favorable prognosis. + +In women the period of involution of the sexual apparatus forms a crisis +which, in regard to neuralgias, is of great prognostic importance. On +the one hand, if the general vital status be good, and the arterial +system fairly unimpaired, we may look to the completion of the process +of involution as a probable time of deliverance from neuralgic troubles +that have hitherto beset a woman; we know that she will probably suffer +a temporary aggravation of her pains, but we hope to see her lose them +altogether. On the other hand, if it should happen that she enters on +the period of sexual involution with her general nutrition considerably +impaired and her arterial system decidedly invaded by atheroma, it is +only too likely that neuralgias recurring now, or attacking her for the +first time, will assume the worst and least manageable type. + +Of almost or quite equal importance with the question of the +physiological age of the patient is that of his personal and family +history with regard to the tendency to neuralgia and to other severe +neuroses. Upon this subject I have dwelt so very fully in other parts of +this work, that it is merely necessary here to repeat, that the balance +of chances is most heavily swayed to the bad side by all evidence +tending to prove congenital neurotic tendencies in the patient and vice +versa. + +Of prognostic hints that are to be gathered from our knowledge of the +immediate causes of the attack, there are none so valuable as those +which we gather from the detection of a malarial or a syphilitic factor +in the production of the malady. In the former case, we hope to cure the +patient either with quinine or arsenic, with almost magical certainty +and rapidity; in the latter, we expect an almost equally brilliant +result from iodide of potassium. + +The particular nerve in which the neuralgia is seated does not so +decidedly influence the prognosis, according to my experience, as is +stated by some authors; nevertheless, there are differences of this +kind. For instance, sciatica, though by no means so frequently a mild +and trifling complaint as Eulenburg would make it to be, is certainly, +on the whole, more curable than the trigeminal neuralgias taken as a +group. I, however, cannot share Eulenburg's opinion as to the rarity of +a central cause for sciatica, nor his consequent explanation of its more +frequent curability; the latter I explain by the fact that it is +possible far more completely to remove the concomitant causes in +sciatica than in trigeminal neuralgia. By simply keeping a sciatic +patient in the prone posture, shielded from cold and from pressure on +the nerve, we have it in our power to remove nearly all peripheral +sources of irritation; but in trigeminal neuralgia there are many +influences, particularly psychical ones, which cannot be shut out, and +which will continue to act with disastrous effect in many cases. With +all this, however, we see a sufficiently large number of incurable +sciaticas, on the one hand, and of severe trigeminal neuralgia cured on +the other. It is only the genuine epileptiform tic, occurring in +subjects whose arterial system is an advanced stage of degeneration, +that stands out clearly and unmistakably pre-eminent among neuralgias +for rebelliousness to treatment of every kind. + +FOOTNOTES: + +[32] _Op. cit._, pp. 65, 66. + +[33] Idem, p. 8. + +[34] "Elektrotherapie." Wien, 1868. + + + + +CHAPTER V. + +TREATMENT OF NEURALGIA. + + +I now approach what is really the most difficult portion of my task; +for, although it would be easy enough to write copiously on the +treatment of neuralgia, it is extremely difficult to keep a just medium +between the opposite extremes of undue meagreness and of useless +profusion of detail in the handling of this subject. There are also +difficulties connected with the present uncertain and transitional state +of opinion, even among high authorities, as to the value of particular +remedies, and even of large groups of remedial agents, altogether there +has been more hesitation in my mind as to this part of the present work +than about any other, and the present chapter has been rewritten more +than once. I mention this only to account for what there may very likely +be found in it--an imperfect literary style such as too commonly marks +work which has been repeatedly patched and corrected. At the same time, +it should be said that my hesitation does not apply to the main +principles of treatment which will be recommended below; it proceeds +rather from the fear of seeming to ignore from carelessness modes of +treatment which are still much used, but which I have really rejected, +because, after full trial, they appeared to me valueless. Space is, +after all, limited, and a complete account of all the remedies for +neuralgia in vogue, in English and Continental clinics, would of itself +fill a large volume. + +The treatment of neuralgia may be divided into four branches: (1) +Constitutional remedies; (2) narcotic-stimulant remedies; (3) local +applications; (4) prophylaxis. + +1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_) +anti-toxic, and (_c_) medicinal tonic. + +(_a_) The importance of a greatly-improved diet for neuralgic patients +is a matter which is more fully appreciated by the English school of +medicine than by either the French or the German; it has, for instance, +very much surprised me to notice the almost entire silence of Eulenburg +on this topic. For my part, the opinions expressed three years ago[35] +on this matter have only been modified in the direction of increasing +certainty; I have learned by further experience that the principle is +even more extensively applicable than I had supposed. + +That neuralgic patients require and are greatly benefited by a nutrition +considerably richer than that which is needed by healthy persons, is a +fact which corresponds with what may be observed respecting the chronic +neuroses in general; and it gives me much satisfaction to point out this +position of neuralgia as belonging to this large class of disorders, not +merely by its pathological affinities, but by its nutritive demands. In +a very excellent and suggestive paper by Dr. Blandford[36] it is stated, +as the result of a large experience in mental and other nervous +disorders, that the greater number of chronic insane and hypochondriacal +cases, as well as neuralgic patients, are remarkably benefited by what +might seem at first sight almost a dangerously copious diet. +Occasionally it happens that the patients discover this by the teaching +of their own sensations, and the apparent excesses in eating which some +epileptic and hypochondriacal persons habitually commit are looked on by +many practitioners as the mere indications of a morbid _bulimia_ which +represents no real want, but only the craving of a perverted sensation +which ought to be interfered with and allayed rather than encouraged. It +is now many years since I began to doubt the justice of this opinion; +the particular instance which called my attention to it being that of +epilepsy, of which disease I saw a considerable number of cases, within +a short period of time, that were distinguished by the presence of +enormous appetite for food; and I finally came to the conclusion that, +so far from this symptom being of evil augury, and likely to lead to +mischief, it is, with certain limitations, a most fortunate occurrence. +It is hardly necessary to say that over-eating, such as produces +dyspepsia and distention of a torpid intestine with masses of faeces, may +distinctly aggravate the convulsive tendency; but the truth is that, +with a little careful direction and management of the unusual appetite, +these bulimic patients can in most cases be allowed to satisfy their +desires without harm of this kind following; a larger portion of food +really gets applied to the nutritive needs of the body, and the nervous +system unmistakably benefits thereby, the tendency to atactic disorder +being visibly held in check. + +That which I have thus observed in the case of epilepsy, and which Dr. +Blandford more particularly affirms concerning chronic mental diseases +and the large number of neuroses that hover on the verge of insanity, +has been most distinctly verified in my experience of the treatment of +neuralgia. It is, unfortunately, by no means a frequent occurrence that +the sufferer from this malady is inclined to eat largely, but the few +patients of this type that I have seen were, in my judgment, distinctly +the better for it. Far more common in neuralgia is a disposition of the +patient to care little for food, to become nice and dainty, and in +particular to develop an aversion--partly sensational and partly the +result of morbid fear about indigestion--for special articles of diet. +Dr. Radcliffe pointed out the special tendency of neuralgics to neglect +all kinds of fat; partly from dislike, and partly because they believe +it makes them "bilious;" and I have had many occasions to observe the +correctness of this observation. In fact, by the time patients have +become sufficiently ill with neuralgia to apply to a consulting +physician, they have already, in the great majority of cases, got to +reject all fatty foods, and have cut down their total nutriment to a +very sufficient standard. Young ladies suffering from migraine are +especially apt to mismanage themselves, to a lamentable extent, in this +direction: this is natural enough, because the stomach disorder seems to +them the origin of the pain, instead of being, as it is, a mere +secondary consequence of the neurosis. But it is not only the sufferers +from sick-headache in whom we find this tendency to insufficient eating, +especially of fat; not to mention that all severe pain usually tends to +disorder appetite and make it fastidious, there is nearly always some +wiseacre of a friend at hand, ready to suggest that neuralgia is +something very like gout, that gout is always aggravated by good living, +and, _ergo_, that the patient should be "extremely cautious as to diet;" +the end of which is that the poor wretch becomes a half-starved +valetudinarian, but, so far from his pain getting better, it steadily +becomes worse. I cannot too strongly express the benefits that I have +seen accrue, in the most various kinds of neuralgic cases, from +persistent efforts to remedy this state of things, and to convert the +patient from a valetudinarian to a hearty eater; and I wish particularly +to say that this success has always been most marked when I have from +the first insisted on fat forming a considerable element of the food. +Cod-liver oil is the form in which I much prefer to give it, if this be +possible; there can be no mistake about the relatively greater power of +this than of any other fatty matter, I believe simply from its great +assimilability. But the very cases in which we most urgently desire to +give fat are often those in which the patient's fantastic stomach openly +revolts at the idea of the oil; we must then try other fats; and we +should go on trying one thing after another--butter, plain cream, +Devonshire cream, even olive or cocoanut oil (though these are the +poorest things of the sort we can use)--till we get the patient well +into the way of taking a considerable, if possible a decidedly large, +daily allowance of fat, without provoking dyspepsia. It is surprising +what can be done in this way by perseverance and tact, and it is no less +striking to observe the good effects of the treatment. Nothing is more +singular than to see a girl, who was a peevish, fanciful, and really +very suffering migraineuse, brought to a state in which she will eat +spoonful after spoonful of Devonshire cream, and at the same time lose +her headaches, lose her sickness, and develop the appetite of a +day-laborer; and, though such very marked instances as this are +uncommon, they do sometimes occur, and a minor but still important +degree of improvement is very frequent. + +As for the _modus operandi_ of the fatty food, there is no certainty. +Dr. Radcliffe believe it acts as a direct nutrient of the nervous +centres; and I also cannot help feeling that there is some evidence in +favor of this idea. But, whether this be so or not, there is another +kind of action of fat that is more simple and obvious; namely, it seems +to be certain that the enrichment of the diet by fat greatly assists the +assimilation of food in general, and thus the patient's nutrition is +altogether improved. + +It is not merely, however, by increasing any one element of food that we +should seek to enrich the diet of neuralgics, but rather by such a +steady and persistent effort as Dr. Blandford describes, to increase the +total quantity of nutriment to perhaps as much as one-third more than +the patient would probably have taken in health. To those who from +prejudice are incredulous of the propriety of this method, I would say, +"Try it, and I venture to say your incredulity will disappear." More +especially I would urge the great importance of this system in modifying +the nervous status of very young, and also of aged, sufferers from +neuralgia; it is the indispensable basis of a sound treatment for such +patients. + +This seems the proper place for such remarks as must be made upon the +function of alcohol in neuralgia; for, though this agent is a true +narcotic when given in large doses, it is not under that aspect that I +can recommend its use in neuralgia at all. I have written so much on +this subject lately, that I shall here content myself with an emphatic +repetition of my protest against the use of alcoholic liquors as direct +remedies for pain. They ought only to be given, in neuralgia, in such +moderate doses, with the meals, as may assist primary digestion without +inducing any torpor, or flushing of the face, or artificial +exhilaration. I cannot too expressly reprobate the practice of +encouraging neuralgics, especially women, to relieve pain and depression +by the direct agency of wine or spirit; it is a system fraught with +dangers of the gravest kind. + +(_b_) The anti-toxic remedies include agents addressed to the +modification of a special condition of the blood and tissues induced by +the presence of morbid poisons, of which syphilis, malaria, and (more +doubtfully) gout and rheumatism, are the representative examples. + +Of syphilitic neuralgia the treatment may be summed up in a few words: +Give iodide of potassium in doses rapidly increased up to a daily +quantum of twenty to thirty grains. If this fails, give one-twelfth of a +grain of bichloride of mercury thrice daily. + +Of malarial neuralgia I can only speak from such a limited experience +that I am by no means in a position to give an exhaustive account of the +treatment. Quinine is, of course, the remedy that should first be tried; +and, as the paroxysms are usually regular in their recurrence, I prefer +to give the drug after the plan which is, I think, incontestably the +best in ordinary ague--_i. e._, to administer one large dose (five to +twenty grains) about an hour before the time when the attack is +expected. With a few exceptions the malady, unless it had taken very +deep root before we were consulted, will yield to a few doses given in +this way; after the morbid sequence has been thus interrupted, it will +be proper to continue the action of quinine in smaller and more frequent +doses, given for three or four weeks continuously. For the comparatively +rare cases in which quinine fails, the prolonged use of arsenic +(Fowler's solution, five to eight minims three times a day), especially +with the simultaneous employment of cod-liver oil, is to be recommended. + +The part which gout may play in inducing neuralgia is, as I have already +said, a far more doubtful question than the popular medical traditions +assume it to be; and treatment directed to gout as a cause is an +extremely uncertain affair. The direct relief of neuralgic pain by the +administration of colchicum, for example, is, in my experience, a very +rare occurrence, even where the gouty diathesis is unmistakably present; +and, on the other hand, the depressed vitality which gouty neuralgics +usually show in a marked degree, renders it very doubtful whether the +relief of the pain may not be too dearly purchased at the cost of the +general lowering effects of colchicum. It is probable that neuralgia +occurring in gouty subjects is more safely, and equally effectually, +treated upon general principles. At the same time it may be admitted +that, in the subordinate function of an adjuvant to the aperients which +it is sometimes advisable to give, small doses of the acetic extract of +colchicum seem to possess some value. + +The question of treatment addressed to a supposed rheumatic element in +neuralgia will, of course, be differently judged according to the +respective ideas of various practitioners as to the pathological +affinities of the two diseases; and the reader already knows that I +believe these affinities to be different in kind from what is generally +believed. The utmost that I should concede is, that in a certain very +limited number of cases the peripheral factor in neuralgia is an +inflammation of the nerve-sheath, or surrounding tissues, which forms +part of a chain of phenomena of local fibrous inflammations in different +parts of the body. Iodide of potassium, in five or ten grain doses +three times a day, is the proper treatment for such cases. I have never +found alkalies do any direct good to the pain. + +(_c_) The medicinal tonic variety of constitutional treatment is more +especially represented by the use of iron and arsenic in cases where +poverty of the blood seems to exist in a marked degree, and by the +administration of certain tonics--quinine, phosphorus, strychnia, and +zinc--which are supposed to exert a specially restorative influence upon +the nervous tissues. + +The use of quinine as an anti-malarial agent has been already referred +to; its employment in non-malarial cases is of much more restricted +scope and benefit. Experience has taught me to agree in general with the +opinion of Valleix, that it is a very unreliable agent; the one marked +exception to this being the case of ophthalmic neuralgias. What the +reason may be I cannot in the least say, but it is a fact that quinine +does benefit these neuralgias, in cases where there is no room for +suspicion of malaria, with a frequency which is very much greater than +in the treatment of the painful affections of any other nerve in the +body. The quantity given should be about two grains three times a day. + +The preparations of phosphorus which I have employed in the treatment of +neuralgia are the phosphuretted oil, the hypophosphite of soda (five to +ten grains three times a day), and pills of phosphorus (according to Dr. +Radcliffe's recommendation) containing one-thirtieth of a grain, given +twice or thrice daily. Either of the two last will do all that +phosphorus can do, but its utility is not very extensive or reliable. I +have found it to do most good in cases where there was a high degree of +anaesthetic complication. + +Preparations of zinc have, in my hands, done no particular good, +although I have tried them in all manner of doses. + +Strychnia, on the other hand, is a remedy which I have learned to prize +much more highly during the last few years than previously. Its most +decided efficacy has been shown in some of the visceralgiae, especially +gastralgia, and (to a less extent) angina pectoris. Its internal use for +these complaints is best effected by giving doses of five to ten minims +of tincture of nux-vomica three times a day; but a method which I have +several times employed with good effect is the subcutaneous injection of +very small doses of strychnia (one-eightieth to one-fiftieth of a grain) +twice daily. For the superficial neuralgias, on the other hand, I +generally administer one-fortieth of a grain, with ten or fifteen minims +of tincture of sesquichloride of iron, by the stomach, three times a +day; this is a very powerful prophylactic remedy to prevent the +recurrence of the attacks when once the sequence of them has been broken +through by other means. + +Of iron generally, as a remedy in anaemic cases, I have only to remark +that, in order to get its full benefits, it is necessary to use large +doses. I give the saccharated carbonate in twenty-grain doses twice or +three times a day. + +But of the sesquichloride of iron I am inclined to say something more; +it has seemed to me that, besides its effects on the blood, it has a +marked and direct influence upon the nervous centres, which is different +from anything which one observes in the action of other preparations of +iron. It is certain that the action of sesquichloride of iron, in those +cases of chlorosis which are distinguished by profound nervous +depression, is something quite peculiar; and the effect which it +produces in the anaemic neuralgias, more especially of young women, is +equally remarkable. I cannot help alluding here to the striking effects +which large doses of the tincture, as recommended by Dr. Reynolds, +produce in acute rheumatism; the severest pain is often checked within +twenty-four hours after the commencement of this treatment. Both in this +disease and in neuralgia, I employ the old-fashioned tincture: if given +alone it should be used in large doses (thirty or forty minims three +times a day); but an excellent combination is that, already mentioned, +of ten-minim doses of this tincture with one-fortieth of a grain of +strychnia. There is something in the revivifying effects of this mixture +that is quite peculiar. I have very lately employed it in the case of a +gentleman, aged thirty-five, who was the subject of frontal neuralgia +complicated with paralysis of the internal rectus, and who was decidedly +anaemic, and greatly depressed and worried in mind by the consciousness +of his inability to overtake professional work which had accumulated +upon him. This patient improved with great rapidity, and in the course +of three weeks lost, not merely his neuralgia, but also his strabismus, +almost entirely; but he then got into a condition which, though not of +permanent importance, was sufficiently undesirable to make me mention it +here, especially as I have seen the same thing in more than one patient +besides him. It is a peculiar state of restlessness during the day and +sleeplessness at night, without any positive exaltation of reflex +excitability such as one used to see from strychnia in the days when +mischievously large doses of that drug were very commonly given, and +patients used to complain of decided twitchings and startings of the +limbs. It is clearly not a strychnia effect pure and simple, nor an iron +effect only; it is a _tertium quid_ compounded of the actions of both +drugs. + +The direct effects of arsenic in the improvement of the quality of the +blood seem to me incontestable; and its use for this purpose in anaemic +neuralgias is certainly something over and above its special neurotic +action. No one, who has employed it much in the cases of anaemic children +suffering from chorea after rheumatism, can have failed to observe its +frequently striking influence upon blood-formation even long before the +nervous ataxia is materially reduced. The misfortune is, however, that +we possess no indications by which to judge beforehand whether we may +reckon on its most favorable action in any given (non-malarious) case, +with certain special exceptions. In angina pectoris it has a most direct +effect, which is rarely altogether missed, and is sometimes surprising: +the cases in which it succeeds best are those distinguished by anaemia, +but we may well suppose, from its remarkable action upon other neuroses +of the vagus, that it is something more than an action on the +blood-making process which produces such powerful effects in allaying +the tendency to recurrence of the paroxysms. My attention was called to +its action in this disease chiefly by the remarkable case published by +Philipp;[37] this was a purely neurotic angina, but one of the severest +type, and the influence of arsenic was very striking. Since that time I +have employed it in several cases, and, after trying various forms of +administration, I conclude that nothing is better than Fowler's +solution, in doses of three minims (gradually increased, if the remedy +be well tolerated, up to eight or ten) three times a day. Unfortunately, +there are some neurotic patients who cannot bear arsenic, the +irritability of their alimentary canal is such that the drug always +provokes vomiting, or diarrhoea, or both; this was the case with one +of my patients, in whose case I had allowed myself to hope for the very +best results from arsenical treatment. But where the patient tolerates +it--and usually he tolerates it extremely well--the prolonged use of +arsenic seems really to root out the anginoid tendency, or at least to +confine it to the more trivial and manageable manifestations. I believe +that in at least three patients, I have so completely broken down a +succession of cardiac neuralgic attacks as to substitute for them a mere +remnant of a tendency to "tightness at the chest" after any severe +bodily exertion or mental emotion. It might be a question, in cases +where the stomach does not tolerate the ordinary administration of the +agent, whether it would not be worth while to try the effect of +subcutaneous injection (two to four minims of Fowler), or inhalation of +the smoke of arsenical cigarettes. But, in truth, it is not certain that +even in this case we escape the characteristic effects of the drug upon +those persons who are abnormally sensitive to it. + +A remarkable instance of the beneficial influence of arsenic occurred in +the case of a woman, aged forty-six, the solitary example of severe +angina in a female that I have ever seen. [It is by no means uncommon, +however, to see the milder forms of cardiac neuralgia in women; the +remarkable statistics of Forbes, quoted in Chapter I., must certainly +have been taken exclusively from cases of the severest type of the +disease.] This was a hospital patient, who had always suffered much +from hysteria, and from childhood had been liable to hemicranic +headache; she had entered on the period of "change" at the time the +attacks began, but menstruation, though irregular, still continued, and, +in fact, did not cease till four years later, long after the anginal +attacks had been subdued. The patient had been attacked for the first +time at the end of a heavy day's washing; she dropped on the ground with +the sudden agony and faintness, and thought she should "never come to +life again." The paroxysms returned five times within the next month, +though not always so severely as on the first occasion; but the poor +woman lived in a constant state of terror. On the occasion of her second +visit to me, she had a most severe attack in the waiting-room at the +hospital: being called to her I found her very nearly pulseless, +gasping, and with the kind of complexion which is so suggestive of +approaching death. She was recovered by a large dose of ether. It was a +rather uncommon feature in this case that the pain was only at and +around the lower end of the sternum, except that occasionally it shot +along the sixth intercostal space. The employment of Fowler's solution +(in doses gradually mounting to twenty-one minims daily) for six months +completely eradicated the anginal tendency; the proof that it was a real +therapeutic effect was given by the result of an attempt to leave the +medicine off at the end of eight weeks' treatment; the patient +immediately began to suffer again. When she really left off, at the end +of six months' treatment, she had had no tendency to heart-pang for more +than a month, and, besides this, looked quite another creature in her +improved vitality and vigor. Yet the menstrual troubles went on, and the +function was not finally suppressed for a long time afterward. + +I suspect, however, that the most frequent successes with arsenic will, +after all, be made in the cases of more or less anaemic male patients who +are attacked with the neurotic form of angina in the midst of a career +(as is especially the case with some professional careers) that implies +not merely incessant labor, but great anxiety of mind. The drug does +little good, however, if not positive harm, in that form of angina +pectoris minor which is not the result purely of these causes, but of +these, or some of these, plus the morbid action of the alcoholic excess, +to which the patient has fled in order to relieve mental harassment and +the fatigue that comes from overwork, especially overwork at tasks that +are not congenial to his natural disposition; there is usually in such +cases a heightened irritability of the alimentary canal, which is almost +sure to cause arsenic to disagree: the really useful treatment is +quinine for the first few days, and then, when the stomach will bear it, +cod-liver oil in increasing doses, up to a large daily amount given for +a long time together. + +On the whole, arsenic, from its singularly happy combination of powers +as a blood-tonic, a special stimulant of the nervous system, and withal +as a special opposer of the periodic tendency, must be regarded as one +of the most powerful weapons in the physician's hands, and (although it +seems to act best in the neuralgias of the vagus and of the fifth) there +is a possibility of its proving the most effective remedy in almost any +given case which may come before us. + +2. The narcotic-stimulant treatment for neuralgia includes some of the +most powerful remedies for the disease which we possess. These remedies +have very different properties, but they all agree in this, that in +small doses they appear restorative of nerve-function--in large doses +depressors of the same. + +Four very different types, at least, of narcotic-stimulant drugs are +useful in neuralgia: (_a_) There is the opium type, by which pain is +very directly antagonized, and, besides this, sleep is also directly +favored. (_b_) There is the belladonna type, by which pain is also much +relieved, though with far greater certainty in some regions than in +others (_e. g._, much the most powerful effect is seen in cases of pelvic +visceralgia), but sleep is by no means so certainly or directly produced +as by opium. (_c_) There is the chloral type, which is almost purely +hypnotic; it is represented almost solely by chloral itself, which is +resembled by scarcely any other drug. (_d_) There is bromide of +potassium, which stands alone for its powerful action on the cerebral +vaso-motor nerves, and which is useful in neuralgia simply by its power +to check psychical excitement directly (through the circulation) and +indirectly (through the production of sleep). + +(_a_) Opium and the remedies that resemble it are, for the treatment of +neuralgia, fully represented by the hypodermic use of morphia, which is +the only kind of opiate treatment that ought ever to be employed, save +in very exceptional instances. The great reasons for the preference of +the subcutaneous administration over the gastric are, the economy of the +drug which it affects and the much smaller degree of disturbance of +digestion which it causes. The hypodermic injection of morphia, if +conducted on correct principles, enables us, when necessary, to repeat +the dose a great number of times with but little loss of the effect, and +consequently with a much smaller rate of progressive increase of the +quantity required; and the absence of depressive action on digestion +enables us to carry out simultaneously that plan of generous nutrition +which has already been shown to be so important a part of treatment. +Indeed, the case is hardly expressed with sufficient strength, when we +say that hypodermic morphia is usually harmless to the digestive +functions; for in a great number of instances it will be found actually +to give an important stimulus both to appetite and digestion; and the +patient, who without its aid could hardly be persuaded to take food at +all, will not unfrequently eat a hearty meal within half an hour after +the injection. + +The remarkable effects of hypodermic morphia have, however, caused it to +be rashly and indiscriminately used, and so much harm has been done in +this way that it is necessary to be exceedingly careful in the rules +which we lay down for its employment. Upon these grounds I must hope to +be excused if, in order to render this work complete, I repeat a good +deal of what I have already said in other places. In the first place, I +shall speak of the mode of administration, and then of the dose. + +As regards the mode of administration, I prefer the use of a solution of +five grains of acetate of morphia to the drachm of distilled water; if +the acetate be a good specimen, this will dissolve easily (and keep some +time without precipitation) without the use of any other solvent. With a +solution of this strength we require nothing elaborate in the form of +the syringe; a simple piston arrangement does well; only it is advisable +that the tube shall have a solid steel triangular point, and a lateral +opening. As regards the place of injection, I must repeat the +opinion[38] which I have already published, that Mr. Hunter's plan of +injection at an indifferent spot is, in the great majority of instances, +fully as effective as the local injection would be; nevertheless, there +is one consideration which in some cases may properly induce us to adopt +the latter plan. Very nervous and fanciful patients will sometimes be +much more readily brought to allow the operation when it seems to go +directly to the affected spot, when they would be sufficiently +incredulous of the benefits of an injection performed at a distance to +indulge their dislike of incurring pain by refusing to submit to it. And +there is one class of cases in which it is likely that there are real +physical advantages in the local injection; in instances of old-standing +neuralgia with development of excessively tender "points," which are +also the foci of the severest pain, it will sometimes be advisable to +inject into the subcutaneous tissue at these points. There is undeniable +reason for thinking that the sub-inflammatory thickening of tissues +around a certain point of nerve delays the transit of the morphia into +the general circulation, and enables it to act more directly and +powerfully on the nerve, which it thus renders insensitive to external +impressions; an important respite is thus gained, during which the +nerve-centre has time to recover itself somewhat. At the same time it +must be remarked that this immediate injection of a tender point is apt +to be exceedingly painful, and it may be absolutely necessary to apply +ether-spray before using the syringe. In early stages of neuralgia, +before the formation of distinct tender points, there is no advantage +whatever (except the indirect one above mentioned) in the local +injection. And, on the other hand, it is often of great consequence not +to run the chance of disfiguring such a part as the face, the neck, +etc., when the injection can easily be done over the deltoid, or in the +leg, or in some other part which even in women is habitually covered by +the dress. + +The dose to be employed is an exceedingly important matter, and one as +to which practitioners are still very often injudicious. We ought never +to commence with a larger dose than one-sixth of a grain; but very often +as little as one-twelfth of a grain will give effective relief, and in +not very severe cases it is well worth while to try this smaller +quantity. When no larger quantity than one-sixth of a grain is employed +we commonly observe no narcotic effects, _i. e._, there is no +contraction of pupil, no heavy stupor, and, although the patient very +often falls asleep, on waking he does not experience headache, nor is +his tongue foul. I cannot too strongly express the opinion that it is +advisable by all means to content ourselves with this degree of the +action of hypodermic morphia, unless it fails to produce a decided +impression on the pain. But in very severe cases our small doses will +fail; and then, rather than allow the patient to continue having severe +paroxysms unchecked, we must frankly admit the necessity of using a +narcotic dose from one-quarter to one-half of a grain, according to +circumstances. Whatever actual dose be employed, it is important not to +repeat it with unnecessary frequency; once a day in the milder, and +twice a day in the more severe cases, will be all that is advisable, +save in very exceptional cases: the point being to administer it as +quickly as possible after the commencement of an exacerbation. If by +these means we can prevent the patient having any severe pains during a +period of several days, we often give time to the affected nerve to +recover itself so completely, especially with the aid of other measures +to be presently mentioned, that the tendency to neuralgia is completely +broken through, and we can drop the injections, either at once or by +rapid diminution of the dose, and thereafter treat the case merely with +tonics, and with the precautionary measures to be dwelt upon under the +heading of Prophylaxis. But, if we have been driven to the use of +distinctly narcotic doses, and these do not very speedily break the +chain of neuralgic recurrence, it will not do to continue to rely upon +hypodermic morphia; it will be best to try some of the local remedies +(blistering, galvanism) with it. If this combination fails, we should +then try the effect of atropine, the sulphate of which, hypodermically +injected, fully represents for all useful purposes the mydriatic class +of narcotics. + +(_b_) The commencing hypodermic dose of atropine should be one-one +hundred and twentieth grain; it is not often that so small a quantity +will do any good, but it is necessary to use this agent with great +precaution, as we occasionally meet with subjects in whom extremely +small doses provoke most uncomfortable symptoms of atropism, as dry +throat, dilated pupil, delirium, and scarlet rash. Commonly we shall +find ourselves obliged to increase the dose to one-sixtieth, +one-fiftieth, or one-thirtieth of a grain; and in a very few cases it +may be necessary to go even as high as the one-sixteenth or one-twelfth. +In my experience such instances are excessively uncommon; and I cannot +but suppose that the practitioners who use the high doses frequently +must inject in such a manner as to fail to get the whole dose taken up. +[Absolutely inexplicable to me is the statement of the illustrious +Trousseau--that hypodermic remedies are "less active" (!) than gastric +remedies--except on his hypothesis.] + +The most remarkable effects that I have seen from hypodermic atropia +were obtained in cases of peri-uterine neuralgia, especially +dysmenorrhoeal neuralgia. Speaking generally of atropine, it must +undoubtedly be counted far inferior to morphia as a speedy and reliable +reliever of neuralgic pain, but for all pelvic neuralgias it appears to +me on the whole to surpass morphia. And besides this, in other +neuralgias, where opiates altogether disagree (as with some subjects +they do), it is not uncommon to find that atropia acts with +exceptionally good effect. And to some extent I am inclined to confirm +Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does +so more permanently than morphia. + +There is another special use of hypodermic atropine which I have not +seen mentioned by any one but myself, but which is probably very +important, namely, in ophthalmic neuralgia where acute iritis, or +especially glaucoma, seems coming on. I may be mistaken, but I believe +that in three cases I have succeeded, by prompt injection of sulphate of +atropine (one-sixtieth to one-fortieth of a grain), in saving a +neuralgic eye from damage, and possibly from destruction, from impending +glaucoma. + +(_c_) The class of cases for which merely hypnotic remedies are of much +value is limited; nevertheless, in the milder kinds of migraine and +clavus, especially when they have been brought on or are kept up by +mental worry or hysterical excitement, these remedies will sometimes +prove very useful. In former days, before we knew chloral, I used to +employ camphor for this purpose; three or four grains being administered +every two hours: and in hysterical hemicrania of a not very severe type +this not unfrequently produced a short sleep, from which the patient +awoke free from the pain. But chloral infinitely transcends in value any +agent of this kind that was known before. Perfectly valueless for the +really severe neuralgias, it is of the greatest possible use as a +palliative in migraine and clavus, where the great object, for the +moment, is to get the patient to sleep. A single dose of twenty to +thirty grains will often effect our object: it may be repeated in two +hours if sleep has not been induced; it should be given as soon as the +pain has at all decidedly commenced. + +And here I wish to make some special remarks on the subject of +"palliation," and the relation it bears to "cure." Nothing is more +common than to read serious admonitions, in medical works, about the +folly of trusting to remedies which only palliate for the moment but +leave the root of evil untouched; and, of course, there is a certain +respectable modicum of the fire of truth behind all this orthodox smoke. +In the case of neuralgia, however, it is most important to understand +that mere palliation, that is, stopping of the pain for the moment, may +be either most useful or highly injurious, according to the way in which +it is done. The unnecessary induction of narcosis for such a purpose, +doubtless, is most reprehensible; but if it were possible simply to +produce sleep from which the patient should awake refreshed, without any +narcotic effects, then, certainly, that sort of palliation must be good. +That is precisely what the judicious use of chloral does; and I may +mention, as resembling though not equalling it, the action of Indian +hemp, which has been particularly recommended by Dr. Reynolds. From +one-fourth to one-half of a grain of good extract of cannabis, repeated +in two hours if it has not produced sleep, is an excellent remedy in +migraine of the young. It is very important, in this disease, that the +habit of long neuralgic paroxysms should not be set up; and if the first +two or three attacks are promptly stopped, by the induction of sound, +non-narcotic sleep, we may get time so to modify the constitution, by +tonics and general regimen and diet, as to eradicate the neuralgic +disposition, or at least reduce it to a minimum. But I would decidedly +express the opinion that such remedies as either opium or belladonna are +mostly unsuited to this purpose. If the migraine of young persons does +not yield to chloral, to cannabis, or to muriate of ammonia (in twenty +or thirty grain doses), it will not be advisable to ply the patient with +any remedies of the narcotic-stimulant class, but to trust to tonic +regimen and the use of galvanism. + +The mention of muriate of ammonia, which, for migraine and clavus and +the milder forms of sciatica, not unfrequently proves useful in stopping +the violence of a paroxysm and enabling the patient to get some +refreshing sleep, leads me to notice that not only may a variety of the +milder narcotic-stimulants be employed in this way, but the external +stimulus of heat to the extremities (very hot pediluvia) greatly +assists the action of any such remedies; especially if mustard-flour be +added, so that a mild vapor of mustard rises with the steam and is +inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is +to give twenty grains of chloral, and make the patient plunge his feet +in very hot mustard-and-water and breathe the steam. He can hardly fail +to fall asleep for a longer or shorter time, and awake free from pain. + +(_d_) The use of bromide of potassium in neuralgia is a subject of great +importance, and which requires much attention and discrimination. In +common with, I dare say, many others, I made extensive trial of this +agent when it first began to be much talked of, but was so much +disappointed with its effects in neuralgias, that at one time I quite +discarded it in the treatment of those affections. Renewed experience +has taught me however, that, though its use is restricted, it is +extremely effective if given in appropriate cases and in the right +manner. For the great majority of neuralgias it is quite useless, and, +what is more, proves often so depressing as indirectly to aggravate the +susceptibility of the nervous system to pain. The conditions, _sine quis +non_, of its effective employment seem to be the following: The general +nervous power, as shown by activity of intelligence, and capacity of +muscular exertion and the effective performance of co-ordinated +movements, must be fairly good, find the circulation must be of at least +average vigor; the patient must not have entered on the period of +tissue-degeneration. Among neuralgics who answer to this description, +those who will benefit by the bromide are chiefly subjects--especially +women--in whom a certain restless hyperactivity of mind and perhaps of +body also, seems to be the expression of Nature's unconscious resentment +of the neglect of sexual functions. That unhappy class, the young men +and young women of high principle and high mental culture to whom +marriage is denied by Fate till long after the natural period for it, +are especial sufferers in this way and for them the bromide appears to +me a remedy of almost unique power. But I wish it to be clearly +understood that it is not to the sufferers from the effects of +masturbation that I think the remedy specially applicable: on the +contrary, it is rather to those who have kept themselves free from this +vice, at the expense of a perpetual and almost fierce activity of mind +and muscle. The effects of solitary vice are a trite and vulgar story; +there is something far more difficult to understand and at the same time +far more worth understanding in the unconscious struggles of the +organism of a pure minded person with the tyranny of a powerful and +unsatisfied sexual system. It is in such cases, which it heeds all the +physician's tact to appreciate, that it is sometimes possible to do +striking service with bromide of potassium; but it will be necessary to +accompany the treatment with strict orders as to generous diet, and, +very likely, with the administration of cod-liver oil. + +Having decided that bromide of potassium is the proper remedy, we must +use it in sufficient doses. Not even epilepsy itself requires more +decidedly that bromide, to be useful, shall be given in large doses. It +is right to commence with moderate ones (ten to fifteen grains), because +we can never tell, beforehand, that our patient is not one of those +peculiar subjects in whom that very disagreeable phenomenon--bromic +acne--will follow the use of large doses. But we must not expect good +results till we reach something like ninety grains daily. Let me add +that it is not so far as I know, by reducing any "hyperaesthesia" of the +external genitals, of which the patient is aware, that the remedy acts; +I have not seen such a nexus of disease and remedy in these cases. + +3. Local Measures.--The external remedies which may be applied for the +treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_) +paralyzers of peripheral sensory nerves; (_c_) remedies adapted to +diminish local congestion; (_d_) remedies adapted to diminish arterial +pulsation; (_e_) electricity; (_f_) mechanical means of protection. + +(_a_) Among the skin-stimulants blisters hold the highest place as a +remedy for neuralgia; indeed the assertion of Valleix, that they are the +best of all remedies, is still not very wide of the truth. They are by +no means universally applicable, and the degree to which their action +should be carried varies materially in different forms of the disease, +but they are of the greatest possible service in a large number of +instances. + +It is possible to view the action of blisters in neuralgia in more than +one way. When applied in such a manner as to vesicate decidedly, and +especially if kept open and suppurating for some time, they cause +considerable pain of a different kind from that of neuralgia itself and +the mental effect of this, operating as a diversion of the patient's +thoughts from his original trouble, may be thought to assist in breaking +the chain of nervous actions by which he is made to feel neuralgic pain. +There may be something in this, but I confess that I do not believe this +kind of effect goes for much in genuine neuralgia. It is rather in the +pain of hypochondriasis, and the so-called spinal irritation (to be +described in the second part of this work), that such an action of +blisters proves useful. + +Another action of blisters, which some authors hold to be perhaps the +most effective portions of their agency, is that which is produced by +the drain of fluid, specially when they are kept open, by which means a +kind of depletion is set up, and the morbid irritation that causes the +nerve pain removed. I cannot at all assent to this view. In the first +place, I believe that any one who has large experience of blistering in +neuralgia will ultimately come, as Valleix did, to believe that +prolonged drain from a blister is rarely or never useful, and that a far +better plan is that of so-called flying blisters, renewed at intervals +if necessary. The most genuine successes that I have procured from +blistering have certainly been got in this way. But I should go further, +and say that the prolonged drain and the peculiar kind of chronic +irritation produced by a suppurating blistered surface can very +decidedly aggravate a neuralgia; this is more especially the case when +the blister is applied immediately over the focus pain. + +The view which I am strongly convinced alone explains the beneficial +action of blisters is that which supposes them to act as true stimulants +of nerve-function. In order that this effect shall be produced, it will +be necessary that the skin-irritation be either produced at some +distance from the seat of the greatest pain, or that, if applied in that +spot, it shall be comparatively mild in degree. And accordingly, I have +been led, in my observations to apply the blister at some distance from +the focus of pain. An indifferent point, however, will not do--there +must be an intelligible channel of nervous communication between the +irritated portion of skin and the painful nerve. This object is +accomplished by placing the blister as close as may be to the +intervertebral foramen from which the painful nerve issues; the effect +of this is probably a stimulation of the superficial posterior branches, +which is carried inward to the central nucleus of the nerve. I must say +that the results which I have derived from this plan of treatment have +been far more satisfactory than those which I used to obtain when I +habitually applied the vesication as near as might be to the focus of +peripheral pain; and I think that this result tallies well with the idea +that the essential mischief in neuralgia consists in an enfeebled +vitality of the central end of the posterior root. An exceedingly +interesting confirmation of this idea as to its _modus operandi_ has +been afforded me by the fact that not merely neuralgic pain, but also +trophic and inflammatory complications attending it, have been sensibly +relieved, in several cases that I have seen, by this mode of reflex +stimulation. This has been particularly the case in herpes zoster, where +the process of inflammation and vesiculation has been very promptly +checked by the application of a tolerably powerful blister by the side +of the spine at the proper level; and I am gratified to mention that Dr. +J. K. Spender, of Bath, pointed out this fact[39] at a time when he had +only seen my statement that the pain could be relieved in this way. In +the case of the trigeminus, the same kind of reflex stimulation is most +effectively obtained by applying the blister over the branches of the +cervico-occipital, at the nape of the neck; and it is remarkable what +powerful effects are sometimes thus produced, even in cases that wear +the most unpromising aspect. For example, in the desperate epileptiform +tic of old age, I have more than once seen a complete cessation of +suffering, which lasted for a very long time--so long, in fact, as to +make me hope against hope that it might never return. I do not now +entertain any such expectations from this remedy; still, its value is +very great. + +There are curious differences between the effects of blistering in +trigeminal or intercostal neuralgia and in sciatica. On the whole, it +would appear that blistering in the neighborhood of the spine is less +frequently effective in the latter, and we sometimes, after failing with +this method, obtain immediate success by two or three repetitions of the +flying blister, somewhere over the trunk of the nerve, especially just +outside the sciatic notch. I have one lady patient in whom this series +of phenomena has several times been observed; and I have seen it occur +in a particular attack, in other patients, in whom, nevertheless, on +another occasion the spinal blistering has been promptly effective. + +I consider blistering of the posterior branches to be an important, and +usually an essential, element in the treatment of all cases of sciatica +in the middle period of life which have reached some severity and lasted +long enough to become complicated with decided secondary affections. + +In all cases where blistering is employed it is advisable to adopt the +simultaneous use of hypodermic morphia or atropine; this combination of +remedies is exceedingly powerful. + +Lastly, it must be said of blistering, that, on the whole, it is a +remedy not well fitted to be applied to aged subjects; and in its +severer forms it should never be applied to patients who are greatly +prostrated in strength. For it must be borne in mind that the remedy may +miss its aim of relieving the neuralgia, in which case it is necessary +to remember, more accurately than many practitioners appear to do, what +a very serious element of misery and prostration will be introduced into +the case by the vesication itself. + +I am not convinced that any of the other forms of severe skin-irritation +(_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to +such a degree as to produce not the anaesthetic but the irritant effects) +are of any particular value; if blistering failed, I should not expect +to see them succeed. + +A milder degree of skin-stimulation is represented by rubefacient +liniments of various kinds, which may be briskly rubbed into the skin +along the track of the painful nerve, without any danger of producing +vesication. Among this class I continue to prefer chloroform diluted, +with six or seven parts of chloroform, to any other; in the milder forms +of neuralgia, especially in young persons and first attacks, it is +surprising how frequently the paroxysm may be greatly relieved, if not +arrested. Still, this can only be regarded as the merest palliative; and +in severer cases such applications are useless. Occasionally, when +chloroform-liniment has failed, a mustard plaster will do good. + +The mildest degree of skin-stimulation is represented by the continuous +application of moist warmth, which is best effected by the simple +application of moistened spongio-piline; so far as I have observed, +however, it is rather in cases of myalgia than in true neuralgia that +this does good; in the latter it is probably little more than a mere +protector against cold. + +(_b_) A variety of agents can be employed with the object of temporarily +interrupting the conductivity of the painful nerve; by this means a +period of rest is obtained during which the centres--sensory and +psychical--have time to regain a juster equilibrium, and the habit of +pain is, _pro tanto_, broken through. + +There is one agent of this class which for general purposes I do not +think is worth retaining on our list of sensory paralyses--namely, cold. +Cold, to be of any value, ought to be of the degree which is represented +by ice allowed to melt slowly in contact with the skin; and for the +majority of neuralgias this is decidedly inferior to other remedies that +can be applied by painting or inunction. The one case in which ice is +supremely useful is in neuralgia of the testis; here I make no doubt +that it is almost, if not quite, the most useful remedy we can employ, +although of course other means must be taken to modify the neuralgic +temperament. It should be applied the moment an attack comes on. + +Far more useful, in neuralgias generally, is the external application of +aconite or of veratrine. Aconite may be employed in the milder or the +stronger form; in the former case, we simply paint the ordinary tincture +on the skin over the painful nerves (avoiding any cracks or sores); in +the latter, we rub in an ointment containing one grain of the best +hydrate of aconitine to the drachm of lard, about twice a day, and to +such an extent as to maintain complete numbness of the parts +continuously, for two, three, or four days. I do not believe that this +will ever, by itself, cure a true neuralgia of any considerable +severity; but I have more than once known its intervention, at a crisis +in treatment when it seemed that other remedies might fail, produce a +striking change in the progress even of a very bad case. + +A milder, but still very useful form of the same kind of action, is +produced by veratrine-ointment. I would recommend, however, as a rule, +that it be employed, at any rate at first, of weaker strength than that +recommended in the Pharmacopoeia, for with some persons it is easy to +pass the anaesthetic, and to enter on the irritant, action of veratrine +upon the skin. This leads me to give a caution that should properly +have come earlier, when I was speaking of skin-stimulants. In aged +subjects, especially, we rather frequently meet, in neuralgia, with a +specially irritable state of the skin, even although there may be at the +same time some loss of common and tactile sensation; and the +practitioner must be warned against the danger of producing an amount of +skin-irritation which will fearfully annoy his patient. I speak +feelingly, having by such an indiscretion lost the richest patient who +ever favored my consulting-room with his presence! + +The inunction of mild veratrine-ointment is extremely useful, as an +adjunct to other treatment, in migraine and supra-orbital neuralgias of +suckling women, and of chlorotic girls. I have also seen it do much good +in mammary neuralgia. + +The last division of the subject of paralyzing agents in the treatment +of neuralgia includes the surgical operations for division or resection +of a painful nerve. Upon this question there is much difficulty in +speaking decidedly. I admit at once, of course, that surgical +interference is evidently indicated when, along with decided and +intractable neuralgic pain, there is plain evidence either of the +existence of a neuromatous tumor, or the presence of a foreign body +impacted, or a tight cicatrix pressing upon a nerve. I admit, also, +though with much greater qualifications, that carious teeth may need to +be extracted before we can cure a neuralgia; but even here I should put +in the decided caveat that we must consider whether the system is in a +state to bear the shock, and that in any case we probably ought to +mitigate the effects of the operation by performing it under chloroform. +And I need hardly tell any one, who is familiar, either practically or +from reading, with the subject, that thousands of carious teeth have +been extracted from the mouths of neuralgic patients, not only without +benefit, but with the effect of distinctly aggravating the disease. And +I am yet more doubtful as to the advisability of such surgical +procedures as the division or the resection of a piece of the painful +nerve. Theoretically, as the reader will understand from the strong +opinion I have given as to the mainly central origin of neuralgias, I +never could anticipate that such a procedure would be more than +temporarily successful; on the contrary, the mischief in the central end +of the nerve remaining, I should suppose that the trying process of the +reunion of the nerve (which always takes place) would be almost +certainly attended with a revival of the neuralgia, too probably in an +aggravated form. The only two cases of excision of a piece of the nerve, +that I have ever seen, completely answered to this anticipation. In +common fairness, however, I must admit that there is a large amount of +evidence on the other side. Neuralgias of the trigeminus are pretty +nearly the only cases in which the proposal of neurotomy or neurectomy +ought to be entertained; in mixed nerves the inconvenience of the +muscular paralyses that would follow would be usually too serious to +allow of our incurring them. But resection of painful branches of the +trigeminus has been performed in a great number of instances, more +especially by German surgeons, with results that merit our attention; +the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be +especially referred to. On the other hand, with the exception of simple +division of the nerve, which can be subcutaneously performed, and is a +trivial proceeding (but has very short-lived effects), these operations +are by no means without danger, especially when they are pushed to such +a length as the opening of bony canals, and the resection of +considerable portions of bone in order to get sufficiently far toward +the centre, and fatal results have in more than one case followed. Above +all, we can never too seriously reflect on the most interesting case of +Niemeyer's reported by Wiesner,[40] in which the most formidable +operations of this kind have been performed, in an apparently desperate +case of epileptiform facial tic, and in which, after all, the +application of the constant current painlessly effected an infinitely +greater amount of good than had been done by all those severe and +painful surgical manipulations. I think it is impossible, after this, +not to conclude that neurectomy ought never to be even thought of except +as a last resort, in cases of extreme severity, after other measures had +been patiently tried and had decisively failed. + +(_c_) Of remedies that are intended to relieve local congestion, I must +speak with very doubtful approbation. Leeches or scarifications are, I +think, very seldom of value. The only remedy that has sometimes seemed +to do good is local compression, and, after all, it is quite as likely +that this acts by anaesthetizing the nerve as by reducing congestion. + +(_d_) Remedies that interfere mechanically with arterial pulsation are +of considerable value where they can be effectively applied. I have +already pointed out the specially aggravating effect of the +momentarily-repeated shocks of arterial pulsation upon neuralgic pain. +Where, then, it is possible, effectively to control an artery pretty +near to the point where it divides into the branches that lie close to +the painful part of the nerve, it is always worth while to try the +experiment. But such a measure as the compression of the carotid in +trigeminal neuralgia is of very doubtful propriety; I suspect the +consequent anaemiation of the brain more than does away with any benefit +that might be mechanically produced. And any attempt to interfere with +the general arterial circulation by cardiac depressants is not to be +permitted for an instant. + +(_e_) We enter now upon a most important subject, the treatment of +neuralgia by electricity. It is necessary to exercise much caution in +speaking upon this topic, and, as I shall have to express somewhat +decided opinions, I may be excused for referring to the circumstances +under which I have arrived at my present stand-point upon this question. +I can hardly be accused of having, with any very rash haste, espoused the +cause of medical electricity in the therapeutics of pain, as any one will +see who cares to turn to my article on Neuralgia[41] written only three +years ago. At that time I had already been studying the subject for a +considerable period, but was so convinced of the multitude of +opportunities for fallacy that beset the student of electro-therapeutics, +that I was unwilling to state more than the minimum of what I hoped and +believed might be affected by this mode of treatment. Since that time I +have become more fully acquainted with the researches of foreign +observers, and, with the help of their indications, have been able to +apply myself more fruitfully to my personal inquiries into the matter. +The result is, that I am now able to speak with far greater assurance of +the positive value of electricity as a remedy for neuralgic pain. I shall +make bold to say that nothing but the general ignorance of the facts can +account for the extraordinary supineness of the mass of English +practitioners with regard to this question. + +In the first place, I have arrived at a decided conviction that Faradic +electricity is of little or no value in true neuralgias, and that the +cases which are apparently much benefited by it will invariably be +found, on more careful investigation, to belong to some other category. + +On the effect of frictional electricity I have had such very small +experience that I cannot venture to speak with any confidence, and the +accounts that I have heard from others whose experience is much larger +have not led me to attribute much importance to this agent. If I am to +judge at all, I should say it merely acts as a skin-stimulant, and is, +in that capacity, inferior to many other simpler and more facile +applications. + +Very different is the verdict of experience as regards the effects of +the constant current; here the results which I have obtained have been +so remarkable that even now I should distrust their accuracy, were it +not that they are in accord with the general result which (among minor +discrepancies) may be gathered, we may fairly say, from all the more +important researches that have lately been carried out in Germany. The +constant current, as I now estimate it, is a remedy for neuralgia +unapproached in power by any other, save only blistering and hypodermic +morphia, and even the latter is often surpassed by it in permanence of +affect; while it is also applicable in not a few cases where blistering +would be useless or worse. + +The English medical profession has not as yet adequately appreciated the +necessity for great care in the choice of apparatus and the mode of +application of electricity. It is all-important, however, and especially +in the case of applying galvanism for the relief of pain. The first +quality that must be absolutely required in a battery, that is to be +used for this purpose, is that it shall deliver its current with as +little as possible variation of tension, in fact that it shall be +constant, and not merely continuous; a vast majority of all the various +galvanic apparatus that have been used have been merely the latter, and +have consequently been almost valueless for the relief of pain. Such are +Pulvermacher's chains, the voltaic piles made with elements of metallic +gauze, Cruickshank's battery, and many others that have been used. A +sufficiently constant current may be obtained from either of the +following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's. +For hospital use, the Daniell battery (in Muirhead's modification, or +with the form of cells introduced by Siemens-Halske) is perhaps the most +desirable; but for private practice it is worth while to sacrifice +something of the superior constancy which we gain in the Daniell battery +for the sake of comparative portability. All purposes which we aim at in +the electric treatment of neuralgia may be sufficiently obtained by the +use either of the Bunsen battery (zinc-carbon, excited by dilute +sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc +and platinized silver, excited by dilute sulphuric acid), as in the +highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It +must be remarked that, for the purpose of treating neuralgia, we shall +never need to employ more than fifteen, or at the utmost twenty, cells +of either of these batteries. Both the Stohrer's Bunsen and the modified +Smee of Weiss are made so that the elements are not immersed in the +exciting fluid until the moment when the battery is going to be used; a +simple mechanism at once throws the battery into or out of gear. In this +way, destruction of the elements is minimized; and either of these two +batteries may be used for from three to six months without any renewal, +supposing the average work done to be one or two daily seances. If the +battery is worked harder, it will require more frequent revivification. +I strongly recommend London practitioners to deliver themselves from all +care and trouble about the repair of their batteries, by making an +agreement with the manufacturers to inspect and set them in order at +stated intervals. The country practitioner, on the other hand, will do +well to familiarize himself with the process of renewing the acid, of +cleaning the plates, of amalgamating the zinc, etc.; in fact, to make +himself independent of the manufacturer in every thing short of an +actual renewal of the elements, when that becomes necessary. For all +further details respecting the above-named, and other batteries, I must +refer the reader to systematic works on medical electricity.[42] I must +now pass on to the various modes of application, and the cautions to be +observed. + +It is, in the first place, necessary to say, that all the best observers +coincide in the statement that the use of a current intense enough to +produce actual pain or severe discomfort is never to be thought of in +the treatment of true neuralgias; such practice will infallibly do harm. +Only such a current is to be employed as produces merely a slight +tingling, and (on prolonged application) a slight burning sensation, +with a little reddening of the skin at the negative electrode. This +being the case, it is perhaps not unnatural for those who have not had +practical experience, to suspect that an application which causes so +little palpable perturbation is devoid of any positive influence at all. +Such skepticism will certainly not survive any tolerably lengthened +observation of the actual facts; but, as some persons may be deterred by +this _prima-facie_ view of the case from making any fair trial of the +current, it may be worth while, here, to allude to the unmistakable +physical effects which similarly painless constant currents are +repeatedly observed to produce in cases of motor-paralysis attended with +a wasted condition of muscles. Those who have had experience of the +treatment of such cases know that it is a by no means infrequent thing +to see both muscles and nerves aroused from a state of complete +torpidity, and brought into a condition in which the Faradic current, +quite powerless before, is again able to excite powerful contractions, +while, at the same time, the bulk of the muscles has increased most +sensibly. These, surely, are sufficient indications of a positive action +of the painless constant current; and such facts have now been recorded, +in multitudes, by most competent observers. + +The next maxim of first-rate importance is that the applications of the +current should be made at regular intervals, and at least once daily; in +most instances, this is enough, but occasionally it will be found useful +to operate twice in the day. The matter of regularity is, I find, of +great consequence, and it will not do to intermit the galvanism +immediately on the occurrence of a break in the neuralgic attacks: it +should be continued for some days longer. + +The length of sittings is a point as to which there is considerable +difference of opinion between various authorities; but my own +experience coincides with that of Eulenburg, that from five to ten, or, +at the utmost, fifteen minutes, is almost the range of time. + +Closely connected with the question of the length of sittings, is that +of the continuity with which the current is to be applied. I have seen +the best results, on the whole, from passing a weak current, without any +breaks, for about five minutes. But, where there are several foci of +intense pain, it will often be advisable to apply the current to each of +these, successively, for three or four minutes. + +The places to which the electrodes should be applied vary much according +to the nature of the case. + +Benedikt's rule, that the application of electricity, to be useful, must +be made to the seat of the disease, is undoubtedly true; but it is +capable of being applied in a somewhat different manner from that which +he recommends in particular cases, the difference being due to the view +of the pathology of neuralgia which is taken in this work. That view is, +that the essential _locus morbi_ is always in the posterior nerve-root +(and usually in that portion of the root which is within the substance +of the cord), and that the peripheral source of irritation, if any, is +only of secondary--though sometimes of considerable--importance. Hence +the main object, in electrization, would seem to be to direct the +influence of the current upon the posterior nerve-root. This may, +however, be done in different ways, according to the situations in which +we place the electrodes, and the direction in which we send the current. + +There are, as yet, very considerable differences of opinion among +electro-therapeutists as to the principles which should govern us, both +in the localization of the effect and the direction of the current. +Benedikt, for example, recommends that the current should be directed +toward the supposed seat of the mischief. Thus, if we suppose a +neuralgia to depend on morbid action within the spinal cord, then we may +galvanize the spine, taking care to make the current come out through +any vertebra over which we detect tenderness. If we suppose the seat of +the disease to be in the nerve-root in the mere ordinary sense of the +word, then we apply the positive pole to the vertebra opposite the +highest nerve-origin that can be concerned, and we stroke the negative +pole down by the side of the spinous processes, some forty times in +succession. The proportion of cases of idiopathic neuralgia in which +this treatment succeeds is, according to Benedikt, very large. In other +cases, he sends the current from the cord to the apparent seat of pain. + +On the other hand, Althaus[43] tells us that, whether the application +be central or peripheral, it is the positive pole, alone, which should +be applied to the part which we intend to affect: and that the +application of the negative pole in this situation is rather likely to +do harm than good, as proving too exciting. Eulenburg, also, says that +in general the positive pole should be applied to the seat of the +disease, the negative on an indifferent spot, or on the peripheral +distribution of the nerve. + +It is, however, very doubtful to me whether, in the majority of cases, +the direction of the current makes any considerable difference in its +effects, provided only that the stream is fairly directed so as to +include the _locus morbi_ in the circuit, and care is taken to apply it +with sufficient persistence and with not too great intensity. Upon this +point I am glad to be able to cite the authority of Dr. Reynolds, whose +experience is very large. This author, while admitting that in theory +the "direct" and the "inverse" currents would seem likely to have +different effects, declares that in practice this does not prove to be +the case, either in the instance of pain of nerve or of spasm of muscle. +Dr. Buzzard, also, in relating a very striking case (which I had the +advantage of personally observing) before the Clinical Society, +particularly mentioned that the direct and the inverse currents had a +precisely similar effect in relieving the pain. The patient suffered +from severe and probably incurable cervico-brachial neuralgia; the poles +were placed, respectively, on the nape of the neck and in the hand of +the affected limb, and whether the positive was on the nape and the +negative in the hand, or _vice versa_, the effect was the same. Very +striking remission of the pain was always produced, and the immunity +from suffering sometimes lasted for a considerable time, while no other +plan of treatment seemed to have more than the most momentary effect. + +My own experience tells the same story very decidedly, for I have on +very many occasions obtained great benefit, both by the direct and by +the inverse currents, in the same patient. I shall here relate a few +instances: + +CASE I.--A married woman, aged forty-eight, whose menstrual periods had +ceased quietly some six years previously. She was, on the whole, a +healthy person, but had suffered from migraine in her youth, and came of +a neurotic family. She was attacked with severe cervico-brachial +neuralgia, which resisted all treatment for nearly three months, and, on +her then trying a month's change of air and absence from medication, +became worse than ever. The constant current was applied, from ten (and +afterwards fifteen) cells of Weiss's battery, daily for twenty-four +days, the pain vanished finally at the end of thirteen days, and the +accompanying anaesthesia and partial paralysis disappeared before the +treatment was concluded. In this case the negative pole was applied by +the side of the three lower cervical vertebrae, and the positive was +applied, successively, to three or four different parts of the most +intense peripheral pain. + +CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the +leg. Galvanization (twenty cells Daniell), from the anterior tibial +region to the spine was found invariably to cut short the pain. I now +reversed the current; the effect was the same. After ten sittings I +suspended the treatment, as there had been no attack for three days; but +a week later the neuralgia returned in full fury. I resumed +galvanization from periphery to spine; after twelve more sittings the +attacks had become rare and slight. I continued treatment for eight days +longer, during the whole of which time there was no pain. It had not +recurred when I saw her fifteen months afterward. + +CASE III.--H. G., a footman, aged twenty-three, applied to me at +Westminster Hospital, with neuralgia of the first and second divisions +of the right trigeminus, of six weeks' standing. The right eye was +bloodshot and streaming with tears, the skin of the right side of the +nose and right cheek was anaesthetic, the right levator palpebrae was +partially paralyzed. Hypodermic injections of morphia proved only very +temporarily beneficial. After a fortnight's treatment with this and with +flying blisters to the nape of the neck and the mastoid process, I +commenced the use of the constant current daily (ten cells, Weiss). The +first application (positive on nape, negative on infra-orbital foramen) +stopped the pain, and procured fourteen hours' immunity. On the next day +I reversed the current; the pain stopped after three minutes' +galvanization; it did not recur for four days, during which time, +however, I continued the daily use of the direct current. On the sixth +day of treatment the patient came to me with a somewhat severe paroxysm, +almost limited to the ophthalmic division; it was accompanied by +spasmodic twitchings of the eyelid, and copious effusion of altered +Meibomian secretion, looking like pus. Galvanization from supra-orbital +foramen to nape stopped the pain in five minutes. The next day the +patient presented himself, quite free from pain, which had not returned; +the conjunctiva was clear, and there was no visible Meibomian secretion. +Inverse galvanization was continued for ten days; but no recurrence of +the pain took place. The cure was permanent three months later. + +On the contrary, we sometimes see complete failure of the current to +affect any good whatever; and in these cases the reversal of the current +has not, so far, appeared to me to make any particular change in the +result. Such was the case with a patient whose history I detailed (along +with that of Case I.) to the Clinical Society. She was an ill-fed and +overworked unmarried needle woman, aged thirty; the neuralgia was a most +violent double occipital pain, with foci, on each side, where the great +occipital nerves become superficial. The current was passed daily, for +some days, from one focus to another (necessarily passing through the +nerve-roots and the spinal cord), and the positions of the conductors +were occasionally reversed; this not succeeding, the current was applied +altogether to the spine, the negative pole being placed on the highest +cervical vertebrae, but no good effect was produced after a treatment, +altogether, of sixteen days. + +Notwithstanding these, and a good many similar facts that could be +adduced, I should hesitate to go so far as to say that there is never +any importance in the direction of the current. In old-standing cases, +where there are well-marked _points douloureux_ that are exceedingly +sensitive, I have found that the application of the positive pole, +successively, on the most tender points, the negative being placed on +the spine opposite the point of origin of the nerve, has had a more +beneficial effect than any other mode of application. + +There are very considerable differences, both as to the best manner of +galvanization, and also as to the chances of doing good with it, in the +case of neuralgias of different nerves; and, on the whole, I find +Eulenburg's conclusions on this matter very just. He indicates sciatica +as the affection which is by far the most curable by the constant +current; he says that many cases are cured in from three to five +sittings, while others require as many weeks, or even months of +treatment; and that a total absence of benefit is only seen in rare +cases dependent on central causes, or on diseases which are irremovable +(like malignant pelvic tumors). On the other hand, he reports that +intercostal neuralgia has never been materially benefited by +galvanization in his hands. With regard to ordinary trigeminal +neuralgias, he speaks strongly of the current as a palliative, but very +doubtfully of its power to cure, in genuine and severe cases. In +cervico-brachial neuralgia he speaks of it as dividing with hypodermic +morphia the whole field of useful treatment, in the majority of cases. +In cervico-occipital neuralgia he says it rarely does much good. I shall +return to Eulenburg's estimate of its utility in migraine, presently. +Let me here say that I am inclined to indorse everything in the +above-detailed statements, excepting that I should place a considerably +higher estimate on the curative powers of the current in ordinary +trigeminal neuralgias. The remedy, like every other, will doubtless fail +in a considerable number of those very bad cases which occur in the +degenerative period of life; but if anyone desires to see the proof of +the power it sometimes exerts, even in extreme cases, he should study +the two most remarkable cases treated by Prof. Niemeyer, of Tubingen, +and reported by Dr. Wiesner.[44] The patients were respectively aged +sixty-four and seventy-four, and the duration of the neuralgia had been +respectively five and twenty-nine years; in both the pain was of the +severest type, and in both the success was most striking. In one of them +every possible variety of medication, and several distinct surgical +operations for excision of portions of the affected nerve, had been +quite vainly tried. The cases are altogether among the most interesting +facts in therapeutics that have ever been recorded. Dr. Russell Reynolds +has also told me of a case under his own care, in which a lady, who had +been the victim, for twenty years, of an extremely severe neuralgia of +the ophthalmic division of the fifth, which attacked her daily, and had +caused great injury to her general health and nutrition, was not merely +benefited, but the affection absolutely removed, at any rate for a long +period, by a single application of the current. I have personally seen +no such remarkable cases as these but I have had some extremely severe +cases under my care in which the effect of the current was to arrest the +pain in a few applications, and procure a remission for several days, or +even weeks. And I have had several slighter cases which were as much +cured, to all appearance, as any disease can be, by any remedy. + +As a general rule, neuralgia of the limbs requires to be treated with a +more powerful current than neuralgia of the face (twenty cells instead +of ten). In the latter case, indeed, it is necessary to be exceedingly +cautious (commencing with five cells), since a current of high power has +been known to produce most serious effects upon the deeper-seated +organs; the retina has been permanently paralyzed, by too strong a +current applied on the face, and still graver dangers attend the +incautious use of galvanization of the brain or of the sympathetic, of +which we have now to speak. + +Galvanization of the brain is a remedy chiefly employed in true +migraine, and is certainly very effective in that disease. I have not +found it useful to apply the current in the long axis of the cranium, +but transmitted from one mastoid process to the other it has proved most +useful; and I am glad to find that my experience on this point coincides +with that of Eulenburg. But the use of this remedy is highly perilous in +careless hands. In working with either Daniell's or Weiss's battery, it +is necessary to use at first only three or four cells, and to increase +the number only with the greatest caution. The sittings should never +last more than half a minute; but the slightest giddiness should make us +stop even sooner. On the other hand, the applications ought to be made +daily, and usually twice a day. Ten cells (Daniell or Weiss) is the +utmost that will ever be required, few patients will bear so much; and, +apart from the possibility of more serious mischief, there is nothing +which annoys and frightens patients more seriously than the sudden and +intense vertigo which over-galvanization of the brain may induce. + +Even more ticklish than the galvanization of the cerebral mass is +galvanization of the sympathetic. I am not going to raise here the vexed +question in physiological electricity as to the possibility of a +galvanization the effects of which shall be accurately limited to the +sympathetic. The fact is unquestionable, that very powerful and peculiar +effects, utterly unprocurable in any other way, can be produced by +placing one pole on the superior cervical ganglion (just behind and +below the angle of the jaw) and the other on the manubrium sterni. This +is a mode of galvanization which has been highly praised, more +especially by Remak, and after him by Benedikt, but it has yielded +rather disappointing results in neuralgia in my hands. Either I have not +observed any distinct effect at all, or, if a current even a very little +too strong were applied, I have repeatedly seen most uncomfortable, and +sometimes very alarming, symptoms. I shall not easily forget a patient +who applied at the Westminster Hospital, suffering from a severe form of +facial neuralgia, and who was persuaded to come to my house and have his +sympathetic galvanized. I used only twenty cells of Daniell, but the +current had not been applied more than a few seconds when the patient +fell on the floor, and remained in a state of half swoon for a +considerable time. I allude to this and other less dangerous accidents +that I have seen follow galvanization of the sympathetic, not with the +view to prove that the method is useless in trigeminal neuralgia--I +should certainly hesitate to say that, considering the large amount of +respectable evidence in its favor--but I think that it is a procedure +requiring the utmost caution, and meantime I have not personally found +it nearly so useful as the methods already described. + +There are sundry special applications of galvanism to particular forms +of neuralgia which require a few words of notice. Of electrical +treatment in regular angina pectoris I have had no experience; and in +the one case of intercostal neuralgia, complicated with quasi-anginal +attacks, in which I applied the constant current to the spine and the +cardiac region, in the direction of the affected intercostal nerve, no +effect was produced. I shall, however, mention the experience of +Eulenburg, as he is a sober and dispassionate writer on the effects of +electric treatment in general. He says he believes that in the proper +use of the constant current we shall discover the chief, possibly the +only direct, remedy for angina; and he describes the apparently +favorable results he has already obtained in three or four cases. The +current was from thirty cells; the positive pole was placed on the +sternum (broad electrode), the negative on the lower cervical vertebrae. +The alternative method which Eulenburg suggests, but has not, so far, +put in practice, is direct galvanization of the sympathetic and vagus +in the neck. + +The application of the constant current in neuralgic affections of the +larynx and pharynx is of most indisputable service; the experience of +Tobold[45] upon this point is fully borne out by my own, as far as it +goes. In many cases it will be sufficient to place the positive pole +(from fifteen cells Weiss) on the pomum Adami, and the negative on the +nape of the neck, and to keep up a continuous current for five or ten +minutes daily; but in some cases the direct application of the current +to the pharynx or larynx may be required; in such, a modification of Dr. +Morell Kackenzie's laryngeal conductor will be found useful. [I shall +have occasion, in Part II., to notice the superior action of +Faradization in mere hysteric throat-pain, as distinguished from true +neuralgia.] + +Neuralgia of the testicle can be best treated, if galvanism be thought +necessary, by immersing the whole scrotum in a basin of salt and water, +in which the positive pole is placed: the negative pole is to be placed +on the upper lumbar vertebrae; the current should be from fifteen cells +Weiss, and the application should last continuously for ten minutes. In +neuralgia of the urethra, I should be inclined to adopt a plan, +mentioned to me by Dr. Buzzard, of attaching one conductor to an +ordinary silver catheter introduced into the urethra, and placing the +other pole upon the perinaeum. + +Neuralgia of the neck of the bladder I have found to be materially +relieved by the constant current from twenty cells passed through from +pubis to perinaeum; the sittings being rather long. I have also, on one +occasion, tried the introduction of a proper _porte-electricite_, +insulated, except at the tip; but the result was not superior to that +obtained in the other way. + +As a general rule, it may be said that electricity, like other local +measures which tend to concentrate the patient's attention on the parts, +is only to be applied to the genital organs as a last resort. This is, +of course, especially true in the neuralgias of these organs in women. + +In concluding what will doubtless seem to some English readers an +over-long and over-favorable estimate of the employment of galvanism in +neuralgias, I must carefully guard myself against the supposition that I +consider it a remedy to be applied in all cases, or likely to meet with +uniform success, even in the forms of the disease to which it is most +appropriate. It is a weapon which I seldom employ in the first instance, +for many reasons; the principal of which is the costliness of the +proceeding to the patient. Either the physician must personally +administer the remedy, daily, often for a considerable period, or he +must make the patient provide himself with an expensive battery; and in +the latter case there is, after all, the unsatisfactory consideration +that the application (even after the most careful directions have been +given) will perhaps be unskilfully and inefficiently made. On the other +hand, it is not desirable to delay the employment of galvanism too long, +if other remedies have been fairly tried; and the practitioner will do +well to remember the distinctions above laid down as to the varieties of +neuralgia in which it is specially likely to prove decidedly and quickly +beneficial. More especially in sciatica it would really, with our +present knowledge, be a decided neglect of duty were we to allow the +disease to run any considerable length without giving the constant +current a thorough trial. [I can only briefly refer, here, to the novel +mode of galvanization introduced by Dr. Radcliffe, and based upon his +ingenious theory, according to which the true effects of the voltaic +current upon nerve are the result of the charge of free electricity +which it sets up, and not of the current directly. The reader will find +the whole argument elaborately worked out in Dr. Radcliffe's recent work +on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be +enough to say, here, that the object to be attained, according to this +view, is to replace the neuralgic nerve in its healthy physiological +state, by charging it with free positive electricity. The manner in +which this is done is as follows: In a case, _e. g._, of +cervico-brachial neuralgia, we place the positive pole as near as may be +to the central origin of the affected nerve; the negative pole is held +in the hand of the same side, which is immersed in a basin of warm salt +and water. In this same basin is another electrode, the wire from which +is put in communication with the earth--most conveniently by putting it +in contact with a gas-pipe. The patient, and the battery, ought properly +to be insulated. The result of this arrangement is, that the free +negative electricity is carried off by the earth-wire, and the limb +remains charged with free positive electricity. I have had no sufficient +experience of this method to give any opinion of its merits, but the +inventor thinks it decidedly superior to the ordinary modes of applying +the constant current.] + +(_f_) The last kind of local remedies for neuralgia of which we have to +speak are those by which we seek to mitigate the paroxysm by thoroughly +excluding the air from the site of apparent pain. These are chiefly of +value in those cases where a distinct inflammation (herpetic or +erysipelatoid), or an unusual degree of sensitiveness on pressure, etc., +has become developed around the superficial branches of the neuralgic +nerve. Very much the best agent of this kind with which I am acquainted +is the flexible collodion; in neuralgic herpes and erysipelas the effect +of this application, conjoined with the hypodermic injection of morphia +(preferably in the immediate neighborhood), is of the greatest possible +service in mitigating the pain. In herpes it has this further special +advantage, that it prevents the occurrence of sores after the vesicles +fall, an accident which otherwise will sometimes happen, and which very +much increases the severity and intractability of the consecutive +neuralgic pain. + +4. Lastly, we have to speak of prophylactic measures, which really ought +never to be thought of as a separate matter, but always as an essential +and most important part of the treatment of neuralgia. The prophylaxis +of neuralgia is divisible into (_a_) measures for preventing the +development of the neuralgic habit in those who may be supposed to have +a predisposition to it; (_b_) measures between the paroxysms; (_c_) +measures to be adopted after the attacks have ceased. + +(_a_) The measures that should be taken to avert neuralgia, in those who +may be reasonably assumed to be predisposed to it, have scarcely +received any consideration at the hands of systematic writers; yet this +is a most important subject. The persons in question are children who +belong to families known to be infected with tendencies to neurotic +diseases, or persons whose daily occupations submit them to peculiarly +strong predisposing influences of an external kind. The hostile +influences that should be avoided, or at any rate compensated, are of +several kinds: (1) Psychical; (2) defects of nutrition; (3) +mismanagement of the muscular system; (4) sexual irregularities; (5) +over-fatigue of the special senses, and insufficiency of sleep, +especially the latter; (6) unhealthy atmosphere and climate. + +(1) The psychical influences which must be especially avoided, if we +would avert the formation of the neuralgic habit, form a large and +somewhat indefinite group, which it is doubtless difficult to deal with +satisfactorily. The matter is, however, highly important, and the +attempt must be made. And there are, at any rate, some leading +principles that I feel justified in laying down with confidence. + +We shall best commence the inquiry by directing our attention once more +to the fact, so often insisted upon in this work, that the large +majority of neuralgic patients carry in them the seeds of their malady +from their birth. It has been amply proved that every child born of a +family that has shown strong tendencies to insanity, epilepsy, +paralysis, etc., etc., ought to be looked on as a neurotic subject, and +as a potential sufferer from neuralgia. It has been shown that such +children will be exposed, even under favoring external circumstances, to +the danger of neuralgia at certain important stages of their +physiological history. The earliest of these critical periods is marked +by the occurrence of puberty; and it is not till this time that +psychical influences, as such, come to have any serious bearing on the +formation of the neuralgic habit. Mischief may, indeed, be done to the +brain and the general nervous system, by injudicious mental training, at +a far earlier period; but this mischief, serious or even fatal as it may +be, usually takes some other form than that of neuralgia. It will be +necessary, here, to reflect a little upon certain features of the +childish mind, in order that we may rightly estimate the kind of +influence which puberty exerts upon it. + +A very young child is selfish, in the purely animal sense; it is +greedily acquisitive, and its selfishness is unchecked by any sense of +shame. With later childhood there comes a sense of right and wrong, and +a sensitiveness to shame, which check this tendency; still it is the +exception rather than the rule to find any great capacity of +self-abnegation in young school-boys. But a moderately healthy-minded +child, up to the age of puberty, is only acquisitively selfish; he is +not self-centered in the sense of dwelling upon his own mental state, +and reflecting upon the nature of his motives and feelings. It is with +the age of puberty that self-consciousness begins to be a feature in the +mind of the young, and its appearance marks the entrance of a dangerous +element into the character. It is an inevitable stage in mental growth, +and, if wisely dealt with, is ultimately productive, not of evil, but of +good; but it is more perilous to some children than to others, and it is +especially fraught with danger to those whose nervous centres are, by +inheritance, weak and unstable in whole or in parts. The mental antidote +to its possible evil effects is to be found in a vigorous (but not +excessive) training of the mind in studies which shall be as far as +possible external, and the discouragement of all tendencies to +introspection. I would venture to express the decided opinion that the +common idea, that close study injures the young, is only true in a +modified sense. It is, however, unquestionably the fact, that hasty and +imperfect cram-work does very seriously impair the stability of the +brain and the nervous system in young people; there is a spurious +excitement about this kind of learning (especially when it is mainly +competitive, and directed to the gaining of prizes and medals) which +must be injurious. But I think it is quite ridiculous to suppose that, +in this country, the actual amount of intellectual labor undergone by +boys and girls at school is sufficient to do harm, were it only regular +and systematic, and carried out in a conscientious manner; on the +contrary, though I think that the total daily period occupied in study +ought not to exceed some six or seven hours, I believe that the +insisting on strenuous diligence during school hours, and the +maintenance of a high standard as to the quality of the work exacted, is +all on the side of nervous health. But, an even more serious and +difficult matter than the regulation of the amount of intellectual work +to be done is, the question how we are to deal with the unfolding +emotional instincts of the boy or girl who has reached the age of +puberty. It is useless to ignore this side of the mental life; it will +assert itself either for good or for evil. At the risk of seeming to +meddle with matters that belong to the school-master rather than to the +physician, I would urge very strongly that a portion of the training be +deliberately directed to a serious study of one or other of the fine +arts--to that one, whether poetry, painting, sculpture, or music, to +which the boy or the girl instinctively leans. I am aware that there is +a prejudice among parents that the study of the fine arts renders young +people idle and indifferent to other branches of education and other +duties of life. I believe that this only applies to the miserably +inefficient way of teaching these subjects which prevails at present in +all but a few English schools; and that, in truth, a thorough knowledge +of the principles of either music or painting, and a real study of the +best masters, would be sure to prevent the development of that lazy, +conceited manner, and that neglect of other duties, which no doubt +unfavorably distinguish a good many of the young ladies and gentlemen +who dabble a little in music, or painting, or versification. We want the +German rather than the English type of training, we want the acquirement +of sound knowledge of the principles of music (at any rate) to be made +so common that the accidental possession of two pennyworth of +superficial accomplishment in that line shall not enable young ladies +and gentlemen to give themselves airs in society. The truth is, that the +young people who make music or painting an excuse for idleness +respecting other matters are invariably imposters even in that which is +their own supposed _forte_. On the other hand, the serious study of art, +a certain definite portion of time being set apart for it, and +thoroughness being insisted upon, is, I believe, an admirable vent for +the emotional effervescence of commencing sexual life; and I no less +firmly believe that the things that are usually substituted for it are +intensely pernicious. I have already, in the chapter on Pathology, +remarked on the mischief which is often done by the anxiety of religious +parents to make their children (usually somewhere about this perilous +time of puberty) experience the emotional struggle which is believed to +end in a change of heart and principles. I need, therefore, only now +repeat the expression of my intense conviction that the results of this +process, as seen by the physician to occur within that mental region +where the emotions and the organic nervous system come into closest +relations, are simply disastrous. It is not my business to suggest the +proper alternative to a mode of spiritual training which I think +deleterious; I can only intimate, in the most general way, my belief +that a calm and systematic training in the simplest principles of duty +and religion is greatly more suitable to the immature mind and brain of +youth than any strong emotional excitement on such topics. But if +ill-regulated spiritual emotion of a religious kind be a dangerous thing +for young persons in the most serious crisis of bodily development, far +more decidedly pernicious is the spurious excitement of feeling which is +directed to lower and often most unworthy objects. The increasing +precocity of boys and girls, in their familiarity with the most +objectionable aspects of passion and intrigue, is steadily fed, in the +present day, by a system that allows them, too often, unlimited access +to light literature which (as is strikingly the case with many novels of +our day) is at once devoid of true literary and artistic merit and at +the same time replete with sensational incident of a vulgarly exciting +kind. The same degrading tendency is very distinctly to be noted in the +character of the dramatic and other public exhibitions which are most +popular at the present day; the main characteristics being, bad art, and +thinly-veiled sensuality, all the more pernicious for being veiled at +all. It would be a hundred times better that a boy, or even a girl, +should study the frank and outspoken descriptions to be found in +Shakespeare or Fielding, with all their occasional coarseness, than that +they should enervate their minds with the sickly trash that is most +current and most popular at the present day, in theatre and circulating +library. + +(2) The defects of nutrition that assist the development of the +neuralgic tendency are often the consequence of a system which, it is to +be hoped, is to a large extent becoming effete, but which, nevertheless, +survives in sufficient vigor and extent to demand express reprobation. +It was till lately the general, and it is still a too common practice, +to keep children and young persons on a very insufficient allowance of +the most important elements of food; the state of things in this +respect, both in public and private schools, in the first half of the +present century, is a lasting reproach to the medical practitioners of +those days, who scarcely lifted a finger to amend it, even when they did +not expressly approve it, under the influence of absurd theories about +the dangers of excessive "grossness of blood." It is indeed amazing +that, with the palpable fact staring them in the face, of the rapid and +incessant additions to tissues which are being made by children and +young people, medical men should have failed to perceive the necessity +for supplies of food practically unlimited except by the capacity of +digestion. Yet this seems hardly ever to have been thought of, and the +unfortunate results seem scarcely to have been noticed, except when they +led to emaciation or consumptive disease. But the effects were perhaps +even more disastrous where, with a maintenance of a fair amount of +muscular nutrition, there was only a little dyspepsia, and perhaps some +slight tendency to nervousness, to show that anything was wrong. The +children who were born of strong and healthy parents, may have suffered +comparatively little from this regimen as regards their nervous system, +but those who were born of neurotic ancestors undoubtedly suffered +extensively. The crisis of puberty was, in such ill-nourished children, +too frequently the signal for an explosion of epilepsy, chorea, or +neuralgia; and too often the mischief was yet further increased by a +most injudicious medical treatment, including a deterioration rather +than an improvement in the already insufficient dietary system. At the +present day, however, we may fairly hope that common sense is +prevailing, so as to put an end to this mischief as regards the children +of the upper and middle classes. Unfortunately, with the poor a similar +ill-nourishment of the young is too often inevitable, and the +consequences are constantly to be traced in enfeeblement of the nervous +system, of which neuralgia is a pretty common result. + +It cannot be too frequently repeated that for those children, more +especially those who come of nervous families, any considerable error in +this direction has a fatal tendency to awaken the disposition to nervous +disease. At every step of the infancy, childhood, and youth of such +persons, the most generous allowance of the more nutritive elements of +food is of the first importance. At the same time I am entirely opposed +to the practice of giving stimulants to any considerable extent, or +indeed to any extent, save in exceptional instances. Good meat, bread, +milk, butter, fruit, and vegetables, are really the efficacious means of +fortifying the nervous system against the impending dangers. With +hospital out-patients, for whom we cannot command such diet, our best +course, whenever they show signs of deficient nutrition, will be the +steady administration of cod-liver oil for a long period. + +(3) The true and proper training of the muscular system is among the +most important means of antagonizing the tendency to the development of +the neuralgic habit. It is a great mistake to suppose that over-training +in athletics of any kind is of use; but the systematic employment of +means which tend to make the muscular system hardy and efficient is of +very great benefit. The parents of children who may be supposed by +inheritance to possess a tendency to neuralgia would do well to study +such a methodical series of directions as those which are given by Mr. +Maclaren, in his excellent work on physical training. I suspect that the +benefit of judicious gymnastics is wrought in two ways: first, by its +improving circulation and general nutrition, including the nutrition of +the nervous centres; and, secondly, that it gives the nervous centres an +education, so to speak, by the variety of difficult co-ordinative +movements over which it trains those centres to preside. But +unquestionably the matter is a science, not a mere rude art, and +requires to be studied as such. + +(4) Of unspeakable importance to the object of averting the formation +of the neuralgic habit is the prevention of sexual irregularities in the +young. Under this heading is included a large and various group of +influences; of these the first that requires notice is the prevention of +precocious sexual stimulation, whether by talk or by acts, which may +precipitate the occurrence of puberty at an unnaturally early age. I +know very well how difficult it is to devise any scheme which really +would effectively control and antagonize the worst mischief of schools; +but it is at least a duty to say here, that no experienced physician can +doubt that such a scheme must be found, if we are ever to hope for a +healthier race of children and of young men and women, and if we are to +break down one of the most potent of the influences that go to the +production and maintenance of the neurotic disposition. I would be +clearly understood not to suppose for a moment, either that this sort of +cause is usually at work in the production of neuralgia in the young, or +that of itself it is sufficient to produce the disease; but I would say, +for certain, that on children of nervous families such influences act +with disastrous energy; and, moreover, that where we see signs, in a +neuralgic young person, of that general form of bad health which is +connected with precocious puberty, we may be nearly certain that such +influences have actually been at work. At all cost, and by all +conceivable means, all children, but most especially the delicate and +nervous ones, ought to be shielded from the risk of this occurring. + +Another form of sexual irregularity which can be counted as a +contributor to the formation of the neuralgic habit is menstrual +irregularity, especially at the commencement of sexual life. By far the +most mischievous in this way is menorrhagia of the young. I have seen +exceedingly severe and intractable neuralgia set up by it. As regards +the influence of simple amenorrhoea, I am by no means clear: it seems +pretty nearly as likely that the deficient excretion (when not dependent +on mechanical cause) is a mere sign of the general weakness which also +predisposes to the neuralgia, as that the neuralgia is in any way the +direct consequence of the amenorrhoea. + +Leucorrhoea, especially when profuse and long-continued, is a much +more indisputable factor in many neuralgias. It is a point of real +importance to put an end promptly to such a discharge, if it exists, and +the usual remedies--cold bathing, mild astringent injections, +etc.--should be at once prescribed. + +Dysmenorrhoea, a painful menstruation, when not dependent on a purely +mechanical cause, affords a strong example of neuralgia connected with +sexual difficulty; but there is every reason to think that the neuralgia +is the primary and not the secondary affection. The only effective +prophylaxis, therefore, is the adoption of such general measures as will +raise the whole tone of nervous health. It often happens that marriage +completely cures the tendency to these attacks. + +(5) Insufficiency and irregularity as to the allowance of sleep are +potent influences in developing neuralgia in those who are hereditarily +predisposed. It is needless to say a single word to prove the imperative +need of the young for periodical and prolonged repose from the conscious +actions of the nervous system. Full ten hours of sleep in the +twenty-four, for boys and girls who are at or near the period of +puberty, is an absolute necessity if we would prevent any existing +irritability of the nervous system from developing into the fully-formed +neurotic temperament. Indeed, I believe that, for all young people (but +especially girls) up to the age of twenty-five, this allowance is not +the least beyond what is necessary: only the need is most pressing at, +and just before, the development of the sexual organs. Of course a much +larger allowance of sleep is necessary in actual infancy: from seven to +twelve we may be content if we get nine hours clear sleep; but during +the two or three years preceding puberty we should insist upon ten +hours, at any rate for children who possess the nervous temperament. + +(6) Impurity of the atmosphere in which they habitually or daily reside +must be carefully shunned for young children, especially for the +nervous. The kind of dull and diffused headache which children often +complain of, after study for some time in a close, ill-ventilated +school-room, is very likely (if the bad influence be continued for a +number of years) to develop itself, at puberty, into a regular migraine. +Purity of air in the school-room must therefore be scrupulously provided +for; and the same thing must be attended to as regards the sleeping +rooms. + +Of the climatic influences we may speak in a few words. Besides the +avoidance of distinctly malarial districts, and also of places where, +although there is no distinct ague, there is a prevalence of neuralgic +or even of so-called "rheumatic" complaints, it is necessary very +carefully to shun damp soils, and places where there is a great deal of +harsh and cold wind. Mere lowness of average temperature is not in +itself a strong predisposer to neuralgia, at any rate if guarded against +by abundant food and the use of such clothes as will prevent children +from ever feeling chilly and depressed. But damp and harsh winds are +actively bad; and when joined to habitual or frequent lowness of +temperature, they constitute very unfavorable surroundings for the +nervous systems of delicate children. + +(_b_) We come now to the prophylaxis which is to be adopted in the +intervals of the paroxysms when neuralgia has been actually set up. This +consists essentially in three things: (1) Physiological rest, as perfect +as possible, of the affected parts; (2) protection from cold; (3) +protection from sunlight; (4) avoidance of injurious mental emotions. + +(1) The maintenance of physiological rest, to the greatest extent that +is possible, is an absolute necessity, if we would shield a nerve, which +has lately been attacked with neuralgia, from fresh paroxysms. The most +evident illustrations of this fact are afforded by those neuralgic +affections in which it is most difficult to adopt this precaution. Thus +the greatest embarrassment from this cause is met with in the case of +sciatica; a mild case is often converted into one of great severity and +intractability because the patient, in the early stages, either cannot +or will not maintain the recumbent posture. So, too, though in less +marked degree, the cure of cervico-brachial neuralgia is often greatly +impeded by the difficulty of maintaining complete rest of the limb. +Again, in neuralgia affecting the third division of the fifth, the +movements of mastication and of speech are a terrible hinderance to the +progress of recovery; and it often becomes necessary, in severe cases, +to prescribe absolute silence, and even to feed the patient exclusively +with such liquid or semi-liquid food as shall require no efforts of +chewing. + +(2) Preservation from external cold is highly important. When a nerve of +the arm, or leg, or trunk, is affected, warm flannel under-clothing +ought immediately to be adopted. The patient who has been suffering from +cervico-occipital neuralgia should for some time, in anything but quite +summer weather, never go out without wearing a warm comforter round the +neck. The sufferer from facial neuralgia should for some time after the +cessation of actual attacks never face wind without wearing a thick +veil. + +(3) Exposure to bright light must be scrupulously avoided by sufferers +from ophthalmic neuralgia. The affection known as "snow-blindness" is +really a neuralgia, with vaso-motor complications, produced by the glare +of light reflected from snow; and one of the severest attacks of +neuralgia which I personally ever experienced was provoked in this way. +Even the comparatively slighter, but for an Englishman unusual, glare of +sunlight which one meets with during the first days of a Continental +holiday, in wandering about towns made up of clean white stone or +whitewashed houses, is enough to provoke an attack, unless the eyes are +carefully guarded with colored glasses. + +(4) It is scarcely necessary, after what has been already said, to +insist upon the absolute necessity of mental quietude, as far as this +can be obtained. This precaution is more or less important in all +neuralgic affections; but in migraine and in other trigeminal neuralgias +it is almost of more consequence than any other prophylactic measure; +and in angina pectoris it is so essential that adoption or neglect of it +may easily turn the scale between life and death. All forms of abdominal +visceral neuralgia, also, are greatly affected by emotion, and passion +or strong excitement of any kind must be scrupulously shunned if the +neuralgic habit is to be broken through. Unfortunately, it too often +happens that the mental surroundings of the patient cannot be so changed +as to enable us to carry out this kind of prophylaxis effectually; and +neuralgic cases of this class are among the severest trials of the +physician's tact and skill, and too frequently defy his efforts. + +(_c_) The precautionary measures which are to be adopted, after the +neuralgic habit has apparently been fairly broken through, in order to +prevent the patient from sliding again into the old vicious groove, can +hardly be defined with exactness though their general character will be +readily gathered from the picture of the clinical history and pathology +of the disease which has been exhibited at large in this work. They +mainly consist in the avoidance of severe, and especially of unequal, +strains upon bodily or mental powers; and in redoubled carefulness in +these respects at those natural crises in the life of the organism which +have been shown to exercise so important an influence upon the neuralgic +tendency. To a certain extent, also, but with much precaution, we may +attempt to modify the peripheral sensibility by what is commonly called +a hardening regimen. Thus, with great care, and proceeding in a very +gradual manner, we may by degrees accustom the patient to a larger +amount of exposure to free air, and even at last to rough weather, so +that in the end he may become less sensitive to some of the commonest +immediately exciting causes of neuralgia. If one were to construct an +advancing scale of such measures, one might arrange them something like +this: First, in-door gymnastics, and gentle horse-exercise for out-door +work, in fine weather only; then horse-exercise alternated with +pedestrianism, sea-bathing in warm weather; and, finally, we should try +to reach a stage at which the patient can well endure a ten or fifteen +miles' walk or ride every day, and be comparatively careless about the +weather. In reaching this latter stage I have seen some patients helped, +in an extraordinary degree, by the frequent use of the Turkish bath, +followed by douche. Upon this latter subject I beg to offer some +remarks, which are the result of pretty careful and extensive study of +the effects of the Turkish bath in a variety of chronic nervous +diseases. I believe it to be a very great mistake to suppose that, +either in rheumatism or in true neuralgia, the process of the bath +should be prolonged to such an extent as is commonly done. Instead of +the usual slow heating process, gradually carried to a point at which +excessive sweating occurs, I believe that the really scientific is the +following: The patient should as quickly as possible get into the +hottest atmosphere he intends to expose himself to, which should never +be more than about 170 deg. Fahr. He should stay in this place just long +enough to get thoroughly hot, and, with the assistance of a glass or so +of water drunk, throw himself into a free but gentle perspiration. He +should then be rapidly shampooed, exposed to the spinal douche for two +or three minutes, and then pass to the cooling-room. Let him beware of +too long dawdling in the latter place, and let him avoid smoking there. +It is a positively dangerous thing to cool one's self quite down to the +normal heat, still more so to induce the slightest chilliness; the body +should be still in a universal glow when one issues into the street. +Over and over again I have proved upon myself that it is the beneficial +method, whereas the prolonged use of the bath, the production of very +copious sweating, and above all a lengthened cooling process, most +seriously exhaust the nervous energy. + +There are certain special considerations as to the habits of life that +require a word or two. I need say nothing more to enforce the views +already put forward as to the necessity of copious supplies of food. I +need only refer to what I have already said about the decidedly +mischievous tendency of anything like habitual excess in the use of +alcohol, merely adding a special caution against such indulgence during, +and particularly toward, the end of the period of sexual activity. There +is one more topic upon which something must be said, namely, the extent +to which sexual intercourse should be allowed. Speaking of neuralgia +generally (excluding neuralgic affections of the sexual organs +themselves), it may decidedly be said that the regular and moderate +exercise of the function, during the natural period of sexual life, is +beneficial; but that excess is always dangerous, and that the +continuance of sexual intercourse, after the powers naturally begin to +wane, is extremely pernicious in its tendency to revive latent +tendencies to neuralgia. As regards neuralgias of the sexual organs, it +is very difficult to speak positively; and yet I believe that (once the +neuralgic habit broken through by other means) it is very desirable that +the patient should live according to the laws of normal physiological +life. + + +NOTE I. + +ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE. + +The following cases must be now added to those recorded in my list of +private patients whose family history has been ascertained with reliable +accuracy. + +CASE I. is that of a gentleman, aged forty-seven, the subject of +lumbo-abdominal neuralgia: no history of nervous disease in the family; +his mother, however, was of a "nervous" temperament. + +CASE II.--A gentleman, aged sixty-four, suffering from angina. His +family nervous history is fearful. On the father's side it is not +possible to get a clear account. But on the maternal side there has been +a strong tendency to insanity and suicide; and in the patient's own +generation one brother committed suicide from insanity, and one sister +is still alive, insane. An interesting fact is, that the mother's family +have shown an extraordinary proclivity to erysipelas. + +CASE III.--The young gentleman, whose single but extremely severe attack +of angina is previously described, comes of a family in whom the +tendency to neuralgia is undoubtedly very strongly inherited. His father +is frequently and very severely _migraineux_, and in early life suffered +cardiac symptoms not unlike his son's. A brother was also liable to +attacks of true migraine between puberty and the age of twenty-one. + +CASE IV.--On the other hand, a case of angina which I saw in the +country, last year, occurred in a gentleman, aged fifty, whose family +presented no traceable neurotic history. But the damage inflicted upon +his nervous system by various external influences was quite +extraordinary. In some way or other he got some attacks of migraine at +the age of fifteen or sixteen; for these he was treated with bleeding, +and with a most savage antiphlogisticism generally. From that time he +never got free of the neuralgic tendency. He used to have not only +facial, but intercostal neuralgia; for this last he was repeatedly bled, +under the idea that it was pleurisy. Added to all this he habitually did +an immense deal of brain-work in his study, and for years had performed +clerical duties of the most exacting and exhausting character. It is not +much wonder that these combined circumstances had sufficed to generate +the neurotic temperament. + + +NOTE II. + +THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD. + +In the present transitional state of opinion concerning the mode in +which the phenomena are produced that are popularly known under the name +of "reflex paralysis," I cannot pass without notice the doctrines of +these two observers. The reader will have perceived that, as regards the +secondary paralytic symptoms observed in neuralgias, I explain the +phenomena mainly on the theory of a process which is central, and not +peripheral, in origin. And, even where, as in some few instances, it +seems possible that the starting-point was an organic affection of some +viscus, we must always consider the possibility that the link between +this and the neuralgia and paralyses was a neuritis migrans travelling +inward to the sensory centre, and from that passing over to motor +centres and thus producing paralysis; or that, without the intervention +of any truly inflammatory process, the continual impressions streaming +in upon the cord from the original seat of organic disease may damage +the nutrition of the sensory nerve-root, producing a partial atrophy, +and that this process may extend to the motor root. + +It remains, however, to inquire whether the influence of powerful +peripheral agencies may not, in a purely "functional" manner, disable +the nerve-centres for a time, causing paralysis with or without +neuralgia. The main supporters of such a doctrine are Dr. Handfield +Jones[46] and M. Jaccoud.[47] + +Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to +spasm of the vessels in the nerve-centres, and we need not repeat his +arguments on that head, because it seems to be generally felt that the +vascular spasm theory will not account for the facts. Jones believes +that the state produced in the nerve-centre by the peripheral influence +is one of paresis from shock-depression, and that from the sensory +centre this state can communicate itself to motor and vaso-motor +centres, though commissural fibres. He does not believe in the existence +of a special inhibitory portion of the nervous system: he believes that +an impression may prove stimulating when it is mild, or paralyzing when +it is strong; and that any afferent nerve may convey either the one +influence or the other to the centres and thus produce secondary +stimulus or secondary paralyses in various efferent nerves. Jones has +the distinguished merit of being one of the first authors distinctly to +perceive that pain must rank on the same level with paralysis: hence he +sees nothing unintelligible in the communication of paralysis to a motor +centre from a sensory centre that was in the state which the mind +interprets as pain. + +The _theorie d'epuisement_ of Jaccoud (Erschopfungs-theoric) also denies +the possibility of Brown-Sequard's idea of prolonged spasm of the +vessels of the centres. It imagines that powerful peripheral excitements +exhaust the irritability of the nerve, and through that of the centres, +and induce a state of unimpressibility--analogous to that which exists +in a nerve or nerve-centre, which is included in the circuit of a +constant current. The nervous force is wasted, and, until an opportunity +of repose is afforded to the centre, the faculty of impressibility +cannot again revive. + +I must say that of these two theories I decidedly incline to that of +Handfield Jones (though I imagine that in reality the cases are +extremely rare, if there be any, in which the change in the centres is +really only functional and non-organic), I prefer the idea of +paralyzing shock to that of exhaustion from over-excitement, from a +consideration of the nature of that form of peripheral influence which +has been specially mentioned by authors as competent to produce this +sort of "reflex" affections, namely, intense and persistent cold. It +seems to me a mere abuse of words to speak of this as an agent that +could exhaust the nerve by over-stimulation; it must surely exhaust it +in a much more direct manner than this, namely by the direct physical +agency of withdrawing heat from the nerve, and spoiling its physical +texture, _pro tanto_. If such an effect as that which must thus be +produced on the nerve, and through it on the centre, is to be looked on +as a case of over-stimulated function, then, it seems to me, there is no +meaning in language, and no possibility of attaining to clear ideas on +the subject of nervous influence. + + +NOTE III. + +ARSENICAL TREATMENT OF VISCERALGIAE. + +Since writing the above chapter on the Treatment of Neuralgia, I have +had two fresh and very striking examples, in private practice, of the +power of arsenic to break the morbid chain of nervous actions in angina +pectoris. + +The first example was that of a medical man, aged seventy-five, in whom +a neuralgia, originally malarial in origin, and of some years' duration, +had fixed itself for some time in the fifth and sixth left intercostal +spaces, and of late had become complicated with anginoid attacks of an +unmistakable character, though not of the highest degree of severity. +The case certainly seemed very unpromising, looking at the patient's age +and the consequent high probability that there was much arterial +degeneration. However, the use of Fowler's solution (five minims three +times a day) was commenced and steadily pushed. The anginoid attacks +rapidly diminished in frequency and at the end of ten days' time were +entirely gone, and after one month of treatment he still had no return +of them, although they had previously been of daily occurrence. It is a +curious fact, whether a mere coincidence or not I cannot say, that, some +few days after the anginoid attacks ceased, he began to experience +somewhat severe pains, rheumatic in feeling, but unattended with heat or +swelling, in the elbows, wrists, and fingers, symmetrically. This has +nearly disappeared, but he is still free from angina. There is no +discoverable heart-lesion in this patient. + +The other case was that of a fine old man of sixty-four, who, but for +some few slight attacks of gout, a few small calculi, and a troublesome +prostatic affection, had always enjoyed remarkably good health, until +about five months ago, when he began to notice tightness across the +chest, etc., when he walked uphill. About a fortnight before he came to +me, he was seized with very violent and alarming paroxysms of pain +across the chest and running down both arms, extreme intermittence +of pulse, and a sense of impending dissolution. The attack had recurred +daily, at the same hour (6 P. M.), ever since; besides which there was +an abiding sense of uneasiness in the cardiac region, and a +consciousness that the least excitement or exertion would bring on the +paroxysm. I put the patient on five minims of Fowler, three times a day, +with directions to take ether when the paroxysms came. At the end of the +first week there was already much improvement, the paroxysms having been +both less frequent and less severe. At the end of a fortnight's +treatment he reported that there had been nothing like a paroxysm for +the last eight days, although there was still a good deal of uneasiness +from time to time. The hour at which the attack was expected passed by +absolutely without a trace of angina. It remains to be seen how long +this improvement will last, but the altered state of things, and +particularly the suddenness of the change, cannot be overlooked, and has +very much struck the patient himself. It is now six weeks since he had +any paroxysm. + +It becomes more and more apparent that arsenic is generally applicable +to neuroses of the vagus. In asthma, I have long held it to be the most +powerful prophylactic tonic that we possess. It is also an excellent +remedy in gastralgia; although I have rather dwelt (in the text of this +work) on the action of strychnia in this disease, I would not omit my +testimony to arsenic. Dr. Leared has related some exceedingly +interesting cases bearing on this point. (See _British Medical Journal_, +November 23 and 30, 1867.) + + +NOTE IV. + +INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT. + +Dr. Reynolds pointed out to me the exceedingly curious fact, which I have +several times verified, that the constant current, in relieving facial +neuralgia, not unfrequently disperses, almost instantaneously, the brown +skin-pigment that has collected in the painful region; _e. g._, near the +orbit. + + +NOTE V. + +THE ACTUAL CAUTERY. + +A remedy for inveterate neuralgia which of late years I had almost +discarded--the actual cautery--has quite recently yielded me very good +palliative results in two cases. Its omission from the text of the +chapter on Treatment was an accident due to the effect of habit in +making one, half unconsciously, reckon this remedy as a +"counter-irritant." The longer I practise, however, the more decidedly I +am convinced that the actual cautery, if properly applied, does not act +as an irritant at all; and this fact was sufficiently in my mind, when +writing of irritant remedies, to make me omit the cautery from that +section. I should have inserted it under the heading of remedies that +interrupt the conductivity of nerves, and thus give the centres +temporary rest. The only useful way to apply it is, to make an iron +white hot, and very lightly brush the skin over so as to make an eschar +not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is +the best for the purpose, but I have made the flat-iron cautery serve +very well. + +FOOTNOTES: + +[35] Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.) + +[36] Practitioner, vol. iv., 1870. + +[37] Berlin. klin. Wochensch., 1865. + +[38] In a paper on the "Hypodermic Use of Remedies," in the +_Practitioner_ of July, 1868, I gave the reasons for this opinion in +full; and I see no reason to alter any thing I then said. + +[39] Practitioner, vol. iv. + +[40] Berlin. klin. Wochensch., 17, 1868. + +[41] "System of Medicine," vol. ii. + +[42] The English reader may consult Althaus ("A Treatise on Medical +Electricity," second edition, Longmans), or Meyer ("Medical +Electricity," translated by Hammond: Trubner & Co.) + +[43] "A Treatise on Medical Electricity," second edition, Longmans. + +[44] _Op. cit._ + +[45] Berlin. klin. Wochensch., 22, 1865. + +[46] _Op. cit._ + +[47] "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris, +1864. + + + + +PART II. + +DISEASES THAT RESEMBLE NEURALGIA. + + + + +CHAPTER I. + +MYALGIA. + + +Of all the diseases which superficially resemble neuralgia, none are so +likely to be confounded with it, on a cursory glance, as myalgia. More +careful inquiry, however, furnishes, in nearly all cases, ample means +for distinguishing between the two affections. + +Myalgia is an exceedingly painful affection, and it is also much more +common than was formerly supposed. It is to Dr. Inman that we +undoubtedly owe the demonstration of the frequent occurrence of this +malady, and the facility with which it may be mistaken for other, and +sometimes much more serious, diseases, with very disastrous results. At +the same time, I must express the opinion that this ingenious author has +decidedly exaggerated the importance of this local disease at the +expense of an unjust depreciation of the frequency and significance of +other painful disorders which have their origin within the nervous +system. + +Myalgia proper includes all those affections which are severally known +as "muscular rheumatism" (for the muscles generally), and "lumbago," +"pleurodynia," etc. (according to locality). It is essentially pain +produced in a muscle obliged to work when its structure is imperfectly +nourished or impaired by disease. + +The clinical history of the different varieties of myalgia absolutely +requires this key for its interpretation; otherwise, the appearance of +the sufferers from different kinds of myalgia is so widely dissimilar +that we should be exceedingly likely to miss the important features of +treatment, which must be applied to them all in common. Nothing, for +instance, can be more strikingly unlike than the appearance of the +pallid, stunted, under-nourishment cobbler who complains of epigastric +myalgia, and that of the ruddy and muscular navvy who suffers from acute +lumbago, or the similarly plethoric-looking country commercial +traveller, who has been driving in his gig against wind and rain, and +complains of violent aching pains in one or both shoulders; yet one and +all of these individuals are suffering from precisely the same cause of +pain, viz., a temporarily crippled muscle or set of muscles which has +been compelled to work against the grain. Why this state of things +should invariably be interpreted as sensation in the form of acute pain +never absent, but severely aggravated by every movement of the affected +part, is a matter beyond our powers of explanation, we must accept it as +an ultimate fact for the present. + +There is scarcely any need to describe the pain of myalgia, since almost +every one has suffered either from lumbago, or from a stiff neck +produced by cold. The pain is essentially the same in all cases; it is +an aching actually felt either in or toward the tendinous insertions of +the affected muscles, and sharply renewed by every attempted contraction +of those muscles. The variations in the character and severity of the +pains are really entirely due to the greater or the less opportunity for +physiological rest which the muscle can obtain. Thus the most obstinate +and the most severe, kind of myalgic pain is undoubtedly that of +pleurodynia--pain in the intercostal muscles and their fibrous +aponeuroses--a fact which depends on the incessant movements which these +muscles are compelled to perform in the act of respiration. And next to +this in severity and obstinacy are myalgias of the great muscles which +are incessantly engaged in maintaining, by their accurately opposed +contraction, the erect position of the spinal column and of the head. +This rate of proportional frequency and severity, however, must be taken +as strictly relative; _i. e._, it is correct upon the supposition that +the different sets of muscles were equally worked and that the state of +nutrition was equal in the different parents. It is otherwise when the +conditions are reversed. Thus, the unfortunate cobbler or tailor, who +sits for long hours in one cramped and bent posture, is continuously +exerting his recti abdominales (probably suffering from an +under-nutrition common to all his tissues) to a degree perfectly +abnormal, and out of all proportion to the functional work he is getting +out of any other part of his muscular system. The consequence is, that +he comes to us complaining of acute epigastric, and sometimes pubic, +pain, rising to agony when he assumes his ordinary sitting posture, and +only reduced to any thing moderate by the most complete extension of the +whole trunk in the supine posture. + +There is no need to dilate at greater length upon the varieties in the +symptoms of myalgia, according as it affects one or another part of the +body. We must consider, briefly the different kinds of cause that +produce it. The immediate source of the pain being, as we have seen, the +sense of embarrassment in a muscle obliged to contract when unfit for +the work, we have to ask what are the remoter causes that can produce +this special unfitness for the work of contraction. They are three: +(_a_) Overlabor pure and simple (_i. e._, in proportion to the existing +bulk and quality of the muscle); (_b_) cold, and especially damp cold, +producing a semi-paralyzing effect on the vaso-motor nerves, and causing +congestion and sometimes a little effusion among the fibres or within +the sheath of the muscle; (_c_) fatty degeneration of muscle which is +exposed to inevitable and incessant work. Either of these conditions may +so disable the muscle that its unavoidable contractions will set up the +myalgic state. + +Undoubtedly however there is something further, in the shape of a +natural predisposition not yet understood, which makes some patients so +much more liable to suffer myalgic pain as a consequence of this sort of +influences than other persons are. I am in no condition to decide what +the nature of this predisposition is; I feel sure it is heightened by an +inherited or acquired gouty taint, but I have seen it in people whom +there is no reason to suspect of gouty tendencies. It appears to have no +connection with true rheumatism. + +Still after all that can be said, myalgia remains a disease chiefly of +local origin, and depending for nine-tenths of its causation upon a +derangement between the balance of work and nutrition in the muscle. + +As regards the diagnosis of myalgia from neuralgia, which is a very +important matter, the following are the main points that we should +recollect: + + _Neuralgia._ _Myalgia._ + + Follows the distribution of a Attacks a limited patch or + recognizable nerve or nerves. patches that can be identified + with the tendon or aponeurosis + of a muscle which, on inquiry, + will be found to have been hardly + worked. + + Goes along with an inherited or As often as not occurs in persons + acquired nervous temperament, with no special neurotic + which is obvious. tendency. + + Is much less aggravated, Is inevitably, and very severely, + usually, by movement than aggravated by every movement of + myalgia is. the part. + + Is at first accompanied by no Distinguished from the first, by + local tenderness. localized tenderness on pressure + as well as on movement. + + Points douloureux, when Tender points correspond to + established at a later stage, tendinous origins and insertions + correspond to the emergence of of muscles. + nerves. + + Pain not materially relieved by Pain usually completely and always + any change of posture. considerably relieved by full + extension of the painful muscle + or muscles. + +The treatment of myalgia is not only satisfactory in itself, but often +affords, in its results, a very desirable confirmation of diagnosis. + +For a very large number of cases, all that is required is (_a_) to put +and keep the affected muscle in a position of full extension, which is +only to be changed at somewhat rare intervals; (_b_) to cover the skin +all over and round it with spongio-piline, so as to maintain a perpetual +vapor-bath; (_c_) on the subsidence of the acutest pain and tenderness, +to complete the treatment by one or two Turkish baths, to be taken in +the manner that I have recommended by speaking of the prophylaxis of +neuralgia. + +When treatment such as this cures a pain which was greatly aggravated by +muscular movement, we may be sure that pain was myalgic and not +neuralgic. + +The pain, however, is not unfrequently rebellious to such simple +remedies as these, more especially when (as in pleurodynia) we are not +able to enforce complete physiological rest of the part. When this is +the case, we shall find the internal use of twenty and thirty grain +doses of muriate of ammonia by far the most effective remedy. In the +first very acute stage of a severe case it may be advisable to inject +morphia hypodermically; but this is seldom necessary. The +muriate-of-ammonia treatment may be usefully accompanied by prolonged +gentle frictions, three or four times a day, with a weak chloroform +liniment. + +When there is visibly a very great deficiency in the general nutrition, +we shall often fail to obtain a cure until we have remedied this defect; +and accordingly, in the majority of cases of half-starved and overworked +needle-women, cobblers, tailors, and the like, who present themselves in +the out-patient room, I accompany the above-named treatment with the +steady administration of cod-liver oil for three or four weeks or more. + +There is one remedy for this pain which I have myself seen used in only +a few cases, but which I believe promises exceedingly well for the +treatment of obstinate myalgia; viz., acupuncture. I have not even +mentioned it as a remedy for neuralgia, for I believe it to be totally +useless in true cases of that disease, whether applied in the simple +form or in that of galvano-puncture. I think very differently of its use +in myalgia; and I venture to believe that it is entirely to cases of +this disease that the exceedingly interesting observations of Mr. T. P. +Teale, in a recent number of the _Lancet_, apply. Where (after the usual +remedies for myalgia have been applied) we are unable to get rid of a +deep-seated and fixed muscular pain, I believe it to be excellent +practice to plunge two or three long needles deeply into the muscle near +its tendinous attachment. + + + + +CHAPTER II. + +SPINAL IRRITATION. + + +I retain this phrase, not because it is an absolutely good one, but +because it has become so familiar that it is difficult to dispense with +it. We have taken a useful step, however, in separating the true +neuralgias from the somewhat indefinite group of diseases to which this +title has been given. I think the reader who has carefully studied Part +I. of this work will not deny that the latter disorders present a very +clear and definite common outline which distinguishes them essentially +from the vaguer affections to be described under the present heading. + +Spinal irritation, in my sense, includes all those conditions in which, +without any special mental affection, and without any single nerve being +definitely affected, there are sensations varying between mere cutaneous +tenderness, often of a large and irregular surface, and acute pain +approaching neuralgia in character, together with fixed tenderness of +certain vertebrae on deep pressure. A very large majority of the +phenomena are such as would be popularly included (now that they are +known not to be of an inflammatory character) under the term +"hysterical." That unhappy word crosses our path at every turn in a most +embarrassing manner, and yet it can hardly at present be said that we +could afford to do without it. + +The more typical cases of so-called "hysterical hyperaesthesia" present +the following phenomena: Along with the general symptoms of the +hysterical temperament (tendency to causeless depression, variable +spirits, sensation of globus, semi-convulsive attacks terminated by the +discharge of a great quantity of pale, limpid urine) there is commonly a +marked superficial tenderness of the surface everywhere, and an +exaggeration of reflex irritability. The general tenderness is so far +merely cutaneous that deep pressure is ordinarily borne better than the +lightest finger-touch. But besides this there are usually one or several +spots in which the tenderness is more profound and genuine. There is +almost sure to be some point in the spinal column where firm pressure +not merely evokes a complaint of pain, but also induces secondary +objective phenomena connected with distant organs, such as nausea and +vomiting when the cervical vertebrae are tender, severe gastric pain when +the dorsal vertebrae are tender, etc. In such cases there is not only +spinal tenderness, but very usually also a well-marked tenderness in the +epigastrium and the left hypochondrium, the _trepied hysterique_ of +Briquet. The reader must, however, be warned that the whole of these +three tender points may be merely myalgic, and it is necessary very +carefully to observe whether local movements do or do not seriously +aggravate the pain in them. And, on the other hand, the spinal tender +point may be merely the "point apophysaire" of a true neuralgia which +exhibits no other symptoms of the so-called hysteric constitution. + +The kind of hysteria that is joined with the existence of fixed tender +spots in definite points of the vertebral column is not commonly +distinguished by the occurrence of cutaneous anaesthesia; but those +writers are certainly wrong in saying that such a combination never +takes place. I have seen examples of the most marked union of the two +classes of symptoms in the same person. + +These cases of so-called spinal irritation with general hysteric +manifestations are very commonly attended with paroxysmal pains that +approach true neuralgia in character. Nor is it to be denied that we +sometimes meet with the combination of general hysteria, spinal +tenderness in definite points (with secondary spasmodic or paralytic +phenomena always following pressure exerted on the latter), and true +neuralgia limited to one nerve. But the more typical spinal irritation +cases are merely complicated with a tendency to vague pains which are +shifting both in character and position, not with definite unilateral +neuralgia always haunting the same nerve and exhibiting more or less of +the same type. In fact, as far as one can judge in the absence of any +precise information as to the condition of the nervous centres in such +cases, it would seem likely that the ordinary cases of spinal irritation +differ from the true neuralgias chiefly in this--that the injury, or +inherited weakness of organization, or both, which is at the root of the +malady, is at once slighter in degree, and spread over a larger tract of +the nervous centres, than that which produces a true neuralgia. I +believe that Dr. Radcliffe is right in supposing it to be probable that +a blow or other injury to the back producing general spinal shock, is +the original but unsuspected cause of a large proportion of these cases. +One of the most perfect examples of spinal irritation that I have ever +seen (and which also contrasts keenly with the commoner hysteric +affections on the one hand, and the true neuralgiae on the other) was +that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds, +and Dr. Bridge. This young lady was a most intelligent person, and not +in the slightest degree inclined to the apathy and idleness so often +seen in hysterical people. She had received what was thought at the time +to be a very slight contusion in a railway collision, in which, however, +her sister, who was in the same carriage, had been severely injured. She +nursed this sister assiduously, and it was not till three or four months +later that her own health began to fail seriously; but she then became +anaemic and extremely depressed. About six months after the accident it +was quite casually discovered that there was a spot over the lowest +cervical vertebra, pressure on which gave her exquisite pain and a +sensation of extreme nausea; and the very curious observation was made +that such pressure instantaneously produced extinction of the right +pulse, the left pulse remaining unaltered. In this case it cannot be +doubted that a serious shock had been communicated to a lateral segment +of the cord involving chiefly the vaso-motor nerve fibres, in which +probably some decided material lesion had been gradually set up; and +besides this there was probably slighter damage to the spinal cord +generally, as there was great general feebleness of movement, though no +actual paralysis of the limbs. + +Along with the phenomena of fixed spinal tenderness, without distinct +neuralgia of any particular nerve, we not unfrequently observe the +development of more or less decided tenderness of some of the internal +surfaces of the body. I have recently had under my care a young woman in +whom a very tender point was developed over the second cervical +vertebra, and who suffered from such persistent tenderness of the whole +posterior part of the pharynx, that I was for some time seriously +apprehensive of the existence of spinal caries and post-pharyngeal +abscess. The general character of her symptoms, however, induced me to +hope that the case was one of spinal irritation merely, and the event +proved that this was the case, for under the use of iron and small doses +of strychnia she recovered completely in about three weeks. In another +patient who came under my care about twelve months ago, there was +extraordinary sensitiveness of the gastric mucous membrane, causing +exquisite pain after she had eaten almost any thing: there was only +occasional vomiting, however, and there had never been any haemorrhage, +so that the evidence for gastric ulcer, which I otherwise inclined to +think existed, was insufficient. I discovered that pressure on the third +or the fourth dorsal vertebra gave great pain, and produced a strong +inclination to vomit; this made it probable that the affection was +spinal, and accordingly all treatment addressed to the stomach was +abandoned. Flying blisters to the neighborhood of the painful spinal +points quickly relieved all the symptoms. + +Another distressing class of symptoms, which is very commonly observed +in connection with these cases of spinal irritation, is that of abnormal +arterial pulsations: I am not sure whether even severe neuralgia +produces more distress than does this pulsation. I have repeatedly seen +abnormal pulsation of the carotids in connection with fixed +tender-points over the cervical or the upper dorsal vertebrae; and still +more commonly pulsation of the abdominal aorta in connection with +tenderness over one or two of the upper dorsal vertebrae. Spasmodic cough +and spasmodic dyspnoea frequently accompany tenderness of points in +the upper half of the spinal column; and in one instance I have seen +pressure on the lowest cervical vertebrae produce a paroxysm which looked +alarmingly like angina pectoris. A case of singularly prolonged and +obstinate spasmodic hiccough which came under my notice was +distinguished by the presence of a fixed tender spot over the third +dorsal vertebra. + +Prolonged spastic contraction of voluntary muscles, going on, sometimes +for weeks, and even months, is a phenomenon that has often been +observed; it may attack the arm only, or may affect all the limbs, and +the muscles of the trunk and of the neck: it is for the most part +symmetrical, but is occasionally unilateral. It begins in the +extremities, and is very commonly limited to them; it is much more +gentle than tetanic spasm, and is also painless, or nearly so; but the +contraction is often strong enough to resist very vigorous efforts at +artificial extension. + +Paralyses, both of bowel and bladder, have been recorded among the +occasional phenomena of spinal irritation with fixed tender points; but +I cannot say that I have ever seen such an occurrence. On the whole, I +must say that by far the most frequent phenomena of spinal irritation +that I have seen have been somewhat diffuse cutaneous or mucous +tenderness and irritability (without acute pain) and the presence of +tormenting arterial throbbings; also a marked tendency to aggravation of +some symptoms, especially the gastric, when firm pressure is made upon +the tender spinal points. For a further and fuller account of the +phenomena of spinal irritation I may refer the reader to the able +article of Dr. Radcliffe,[48] and the work of the brothers Griffin, +already quoted; adding the suggestion, however, that both these +authorities, and especially the Griffins, appear to me not to draw a +sufficiently clear distinction between the class of cases that I have +been attempting to describe and the true neuralgias. + +After what has been said, there is no need to draw out a formal list of +the points of diagnosis between spinal irritation and neuralgia. It must +be admitted, moreover, that the two forms of diseases have a strong +connection in the fact that they are each of them most frequently +developed in the descendants of neurotic families. It is by the more +generalized character of the symptoms, and the absence of the tendency +to perpetual recurrence of paroxysmal pain in one definite nerve, that +spinal irritation is mainly distinguishable from true neuralgia. I may +add that there is a marked distinction, also, in the results of +treatment. + +The treatment of spinal irritation is, it must be confessed still in an +unsatisfactory position; and I believe that a good deal of unnecessary +discouragement has been occasioned to physicians by their failures to +cure supposed neuralgias which really belonged to the spinal irritation +class. I would assuredly by no means assert that genuine neuralgia is +not frequently intractable, or even incurable; but it is certainly much +more curable than spinal irritation; and for this reason, mainly as I +believe--that there is much more possibility of aiming our remedies at +the actual seat of the disease. On the other hand, in spinal irritation +we are confused and distracted with a variety of phenomena for which +even the most subtle analysis will frequently fail to trace a common +origin. It is true that the existence of definite tender spots in the +spine apparently suggests a strictly local application of remedies; and +it true also that medication based upon this fact is sometimes very +effective; but this is, in my experience, only an occasional result, and +the practitioner who trusts to local measures will frequently be +disappointed. And, on the other hand, the general tonic treatment, and +the use of special medicines, like quinine and arsenic, or the +hypodermic injection of morphia oratropia, have nothing like the +extensive utility in the treatment of spinal irritation that they +possess in that of true neuralgia. Of internal remedies, by far the most +useful in my hands have been sesquichloride of iron with small doses of +strychnia, and the milder vegetable bitters, especially calumba. + +There is one special phase, however, of spinal irritation which is very +amenable to the direct, treatment, viz., cutaneous and mucous +tenderness. Whatever the "hyperaesthetic" part is within reach, so that +we can apply Faradization, we can almost certainly eradicate the morbid +sensibility very quickly. The secondary current of an electro-magnetic +or volta-electric induction apparatus is to be employed; the conductors +should be of dry metal and the negative one, which is to be applied to +the painful surface, should be in the form of the wire brush. The +positive pole is to be placed on some indifferent spot, and the negative +is to be stroked briskly backward and forward over the sensitive skin, a +pretty strong current being employed. The process is painful so much so +that it will often be advisable, with delicate patients, either to +administer chloroform or to inject morphia subcutaneously before the +Faradization. A very few daily sittings of four or five minutes length +will generally remove the morbid tenderness completely. Where the tender +part is within one of the cavities, at the rectum, bladder, vagina, or +pharynx, we must of course use a solid negative conductor of appropriate +form, and must content ourselves with applying it steadily to one point +after another of the sensitive surface. + +The fact that Faradization proves so remarkably useful, in these cases +of spinal irritation with diffuse cutaneous or mucous tenderness, is in +itself a strong diagnostic between this sort of affection and the true +neuralgiae, which, as I have stated are seldom benefited, and are often +made worse, by the interrupted current, though the constant current +frequently mitigates or cures them. + +Sometimes where it is not possible to apply the remedy directly to the +sensitive surface, we may nevertheless do great good by sending the +interrupted current through it. Thus, in gastric sensitiveness connected +with spinal tenderness in the upper dorsal region, I have seen very +great relief afforded by sending a current from the positive pole, +placed on the tender vertebrae, to a broad, negative conductor placed on +the epigastrium. And similarly, I have seen an acutely sensitive +condition of the neck of the bladder greatly soothed by the passage of a +current from a painful lumbar vertebra to the perinaeum immediately +behind the scrotum. + +Undoubtedly, however, the more serious cases of spinal irritation will +yield only (if they yield at all) to a prolonged treatment in which very +skilful use is made of general hygienic measures, and especially of +morbal influences. As the brothers Griffin long ago pointed out, +although rest is useful in the early stages of this malady, if the +disease does not quickly yield to this and to appropriate tonic +medication, and perhaps local applications to the spine, it will not do +to keep the patient recumbent and confined to the house; on the contrary +at whatever cost of immediate discomfort, he (or she for these patients +are by far the most frequently females) must be roused up, and persuaded +or compelled to take out-door exercise, and if possible to travel, and +divert the mind by complete change of scene. When such expensive +remedies are out of the question, it seems better that patients, even +seemingly very feeble, should take to their ordinary avocations in life +again, and fight down the tendency to invalidism. But of course, the +decision on such a point must rest with the tact and judgment of the +practitioner in each individual case, for there are, doubtless, +instances in which the attempt to carry out such a plan, even +moderately, would break down the remaining strength, and make matters +worse than they were before. + +In the worse case of spinal irritation that I ever saw, that of a young +lady, aged twenty-eight, there were pronounced anaemia and general +feebleness, the true hysteric _trepied_ of tender points, painful +irritability of the stomach, which baffled all medical advisers and +resisted almost every possible form of tonic and nervine medicines, +counter-irritation to the spine, and, in fact every thing that one dared +attempt with so feeble-looking a patient, but at once cleared up and was +quite cured after marriage. And there can be no question that a very +large proportion of these cases in single women (who form by far the +greater number of subjects of spinal irritation) are due to this +conscious or unconscious irritation kept up by an unsatisfied sexual +want. In some patients there cannot be a doubt that this condition of +things is indefinitely aggravated by the practice of self abuse; but it +would be most unjust to think that this is a necessary element in the +causation; on the contrary, it is certain that very many young persons +(women more especially) are tormented by the irritability of the sexual +organs without having the least consciousness of sensual desire, and +present the sad spectacle of a _vie manquee_ without ever knowing the +true source of the misery which incapacitates them for all the active +duties of life. It is a singular fact, that in occasional instances one +may even see two sisters inheriting the same kind of nervous +organization, both tormented with the symptoms of spinal irritation, and +both probably suffering from repressed sexual function, but of whom one +shall be pure-minded and entirely unconscious of the real source of her +troubles, while the other is a victim to conscious and fruitless sexual +irritation. + +I have already causally alluded to the danger of mistaking mere myalgia +for spinal irritation and must again enforce this consideration upon the +reader. Myalgic tender points in the region of the spine are common +enough; and it would be easy without careful attention, to mistake them +for the deeper-seated vertebral tenderness which is truly characteristic +of spinal irritation. Hence the utmost care must be taken to ascertain +the true history of the commencement of the disorder whether it +succeeded to great and long continued fatigue of particular sets of +muscles, and whether it is specially aggravated by contractions of those +muscles, and relieved by their full extension. The differences of +treatment which depend on the diagnosis are too obvious to need dwelling +upon. + +The question of administering remedies with the direct intention of +procuring sleep, for patients suffering from spinal irritation, often +becomes an important and a very difficult one. It is, for the most part, +highly objectionable to commence the use of such remedies; and yet +sleeplessness is a very distressing symptom with many patients, and is, +of course in itself exhausting and deleterious. For as long as we +possibly can, we should content ourselves with efforts to produce sleep +by the timely administration of nourishment. The same general rule of a +very generous (though not very stimulating) diet to be enforced as +carefully as in the case of sufferers from neuralgia. But it is +especially advisable in spinal irritation; that the patient should take +some food shortly before bedtime; and it is well, also to place food +within reach at the bedside, so that if he wakes up he may take some. +If, however, we are absolutely driven to employ hypnotics, we must +commence with the very mildest. The popular remedy of a pillow stuffed +with hops will sometimes suffice; and a better way of administering the +volatile principle of hops is to scatter a few hops on hot water in an +inhaler, and let the patient breathe the steam. Hot foot-baths, with +mustard, are also very useful. If these fail, chloral, in moderate doses +is probably the best and safest remedy, and, with care not to give too +much, we may go on using the same dose without increase for a good many +times. + +FOOTNOTE: + +[48] Reynolds's "System of Medicine," vol. ii., Art. "Spinal +Irritation." + + + + +CHAPTER III. + +THE PAINS OF HYPOCHONDRIASIS. + + +There is perhaps nothing, in the whole range of practical medicine, more +difficult to seize with clear comprehension, and picture to the mind +with accuracy, than the group of pseudo-neuralgiae which belong to the +domain of hypochondriasis. They are among the most indefinable, and at +the same time the most intractable, of nervous affections. + +To understand what hypochondriac pains are, we must first be familiar +with the general character of the hypochondriacal temperament, for the +pains are only a subordinate and ever-varying phenomena of the general +disease. + +Hypochondriasis is not insanity, if by insanity we mean intellectual +perversion dependent mainly or entirely on the state of the higher +nervous centres. But it is closely allied to insanity in its phenomena, +only that these are, as it were, manifested in a scattered form, +unequally distributed over the whole central nervous system, and +especially affecting the spinal sensory centres. And its radical +relationship to true insanity is strongly indicated by the fact that the +sufferers from hypochondriasis are nearly, if not quite, always members +of families in which distinct insanity has shown itself; indeed, more +often than not, of families which have been strongly tainted in this +way. In the majority of instances there are psychical peculiarities of a +marked kind which accompany or precede the development of the abnormal +sensations which form the especial torment of hypochondriacs. Without +apparent cause, they begin to evince a heightened self-feeling and an +anxious concentration of their thoughts upon the state of one or more of +their bodily organs. Or it may be that, before any such definite bias is +given to their thoughts, they simply become less sociable and more +self-centred, and are subject to fits of indefinite and inexplicable +depression, or at least to great variability of spirits. But before long +they begin to experience definite morbid sensations, most commonly +connected with the digestive organs, and very often accompanied by +positive derangement of digestion of an objective character; such as +flatulence, sour eructation, spasmodic stomach-pain, etc. Along with +these phenomena, or soon afterward (and not unfrequently before the +patient has acquired that intensity of morbid conviction of his having +some special disease which is afterward so marked a peculiarity of his +mental state), he very often becomes the subject of the kind of pains +which it is the special purpose of this chapter to describe. + +The pains of hypochondriasis, when they assume any more definite form +than that of mere dyspeptic uneasiness, present many analogies with +neuralgia. They are not, usually, periodic in any regular manner, but +they have the same tendency to complete intermission, and they +frequently haunt some one or more definite nerves for a considerable +period of time. Of all nerves that are liable to this kind of affections +the vagus is undoubtedly the most susceptible; hypochondriac patients +very frequently complain of pseudo-anginoid and pseudo-gastralgic pains; +next in frequency are nervous pain in the region of the liver, or in the +rectum or bladder. The main distinctions by which they are separable +from true neuralgia are two: in the first place, the character of the +pain nearly always is more of the boring or burning kind than of the +acutely darting sort which is most usual in true neuralgia; and, +secondly, the influence of mental attention in aggravating the pain is +far more pronounced than in the latter malady; indeed, it is often +possible, by merely engaging the patient in conversation on other +topics, to cause the pain to disappear altogether for the time. But in +hypochondriasis it is not often that we are left, for any long time, to +these means of diagnosis only; the special character of the disease is +that the morbid sensations shift from one place to another, in a manner +that is quite unlike that of the true neuralgias. The patient who to-day +complains of the most severe gastralgia, or liver-pain, will to-morrow +place all his sufferings in the cardiac region, or in the rectum, or +will complain of a deep fixed pain within his head; and these changes +are often most rapid and frequent. Frequently there are also peculiar +skin sensations, which usually approach formication in type, and these, +like the pains, are apt to shift with rapidity from one part of the body +to another. Later on in the disease, especially in those worst cases +which approach most closely to the type of true insanity, there are +often hallucinations of a peculiar and characteristic nature, such as +the conviction of the patient that he has some animal inside him gnawing +his vitals, that he is made of glass and in constant danger of being +broken, and a variety of similar absurdities. In short, it is not the +fully-developed cases of hypochondriasis that need puzzle us, these are +usually distinct enough; but the earlier and less characteristic stages +in which pain may be nearly the only symptom that is particularly +prominent. + +In hypochondriasis, as in hysteria, there is often great sensitiveness +of the surface; and, as in hysteria, this sensitiveness is found to be +very superficial, so that a light touch often hurts more than firm, deep +pressure. As in hysteria, too, the tenderness is a phenomenon so greatly +affected by the mind, that, if we can divert the patient's attention for +a moment, he will let us touch him anywhere, without noticing it at all. + +It is a marked peculiarity of hypochondriasis that it is far more common +in men than in women; a relation which is precisely the opposite to that +which rules in neuralgia. Hypochondriasis is also pre-eminently a +disease of adult middle life; it is scarcely ever seen in youth, except +as the result of excessive masturbation acting on a temperament +hereditarily predisposed to insanity. + +The results of treatment frequently assist our diagnosis in difficult +cases. Almost any medicine will relieve the pains of the hypochondriac +for a time, and it is generally far easier to do him good, temporarily, +than it is to relieve a neuralgic patient; but, _en revanche_, every +remedy is apt to lose its affect after a little while. The only chance +of producing permanent benefit in hypochondriasis is by the judicious +combination of remedies that remove symptoms (especially dyspepsia, +flatulence, etc.), which mischievously engage the patient's mind, with +general tonics, and, above all, which such alterations in the patient's +habits of daily life as take him out of himself and compel him to +interest himself in the affairs of the world around him. And, after all, +our best efforts will frequently lead to nothing but disappointment. + +It is notoriously the fact that hypochondriasis especially affects the +rich and idle classes; but it would be a great mistake to suppose that +it never attacks the poor or the hard-worked: only, in the latter +instances, it apparently needs, for it development, the existence of +strong family tendencies to neurotic disease, and especially to +insanity. Among the numerous debilitated persons who attend the +out-patient rooms of our hospitals we every now and then encounter as +typical a case of hypochondriasis as could be found even among the rich +and gloomy old bachelors who haunt some of our London clubs. I have one +such patient under my care now, who has been a repeated visitor at the +Westminster Hospital during many years: he has had pseudo-neuralgic +pains nearly everywhere at different times; but his most complaint has +been of pain in the groin and scrotum of the right side. The existence +of what seemed, at first, like the tender points of lumbo-abdominal +neuralgia, at one time led me to believe it was a case of that +affection; but I was soon undeceived by finding that the tenderness did +not remain constant to the same points, but shifted about. This man has +professed, by turns, to derive benefit from nearly all the drugs in the +Pharmacopoeia; but the only remedies that have done him good, for +more than a day or two at a time, have been valerian and assafoetida, +with the prolonged use of cod-liver oil. He will never be really cured; +and I suspect that the secret of his maladies is an inveterate habit of +masturbation acting on a nervous system hereditarily predisposed to +hypochondriasis. + +Sometimes it happens that the starting-point of hypochondriac pains, +simulating neuralgia, is a blow, or other bodily injury acting on a +predisposed nervous system. Another of my patients at the Westminster +Hospital was a policeman, who had received a severe kick in the groin; +he suffered pains which at first seemed to wear all the characters of +true neuralgia in the pudic nerve, but afterward shifted to other places +and exhibited all the intractability of hypochondriasis; the patient +also developed the regular appearance and the characteristic +hallucinations of the latter disease. On the last occasion when I saw +him, he struck me as likely to become really insane, in the melancholic +form; and the probability is that the casualty which he suffered was +only accidentally the starting-point of a malady which was inherent in +him since birth, and would have been developed, in any case, at some +period of his life. + + + + +CHAPTER IV. + +THE PAINS OF LOCOMOTOR ATAXY. + + +Considering the vast amount that has been written about this disease +during the last few years, it might be thought superfluous for me to +give any description of its general features. But it unfortunately +happens that there is still great divergence of opinion among +authorities as to the true limitation of the group of cases that can +properly be ranked under this title, and, indeed, as to the propriety of +employing the title at all. The phrase ataxie locomotrice progressive, +as every one knows, was applied by Duchenne de Boulogne to a class of +cases which really only form a subdivision of the group known under the +older title of _tabes dorsalis_ and the most advanced German +pathologists maintain that the old word was better, and that Duchenne +was altogether wrong in making the one symptom, ataxy of locomotion, the +bases of a new phraseology;[49] more especially as his theory as to the +seat of the morbid changes was undoubtedly erroneous. + +In this country, however, there is as yet no disposition to give up the +phrase locomotor ataxy, and it only remains to define with sufficient +care the class of cases to which the word is here meant to apply. The +disease is understood to depend upon a degeneration of the spinal cord, +of which the following description is given by Lockhart Clarke:[50] "In +true locomotor ataxy, the spinal cord is invariably altered in +structure. Its membranes, however, are sometimes apparently unaffected, +or affected only in a slight degree; but generally they are much +congested, and I have seen them thickened posteriorly by exudations, and +adherent, not only to each other, but to the posterior surface of the +cord. The posterior columns, including the posterior nerve-roots, are +the parts of the cord which are chiefly altered in structure. This +alteration is peculiar, and consists of atrophy and degeneration of the +nerve fibres to a greater or less extent, with hypertrophy of the +connective tissue, which give to the columns a grayish and more +transparent aspect; in this tissue are embedded a multitude of corpora +amylacea. Many of the blood vessels that travel the columns are loaded +or surrounded to a variable depth by oil-globules of various sizes. For +the production of ataxy, it seems to be necessary that the changes +extend along a certain length, from one to two inches of the cord. The +posterior nerve-roots, both within and without the cord, are frequently +affected by the same kind of degeneration, which sometimes extends to +the surface even of the lateral columns, and occasionally along the +edges of the anterior. Not unfrequently the extremity of the posterior +cornua, and even deeper parts of the gray substance, are more or less +damaged by areas of disintegration. The morbid process appears to travel +from centre to periphery, that is, from the spinal cord to the posterior +roots. In the cerebral nerves, on the contrary, the morbid change seems +to travel in the opposite direction, that is, from the periphery toward +the centres. From the optic nerves it has been found to extend as far as +the corpora geniculata, but seldom as far as the corpora quadrigemina. +With the exception of the fifth, seventh, and eighth pair, all the +cerebral nerves have occasionally been found more or less altered in +structure." + +The symptoms which occur in cases in which the above are the morbid +appearances found after death are (roughly speaking) as follows:[51] "A +peculiar gait, arising from want of co-ordinating power in the lower +extremities, a gait precipitate and staggering, the legs starting hither +and thither in a very disorderly manner, and the heels coming down with +a stamp at each step." + +No true paralysis in the lower extremities or elsewhere. Characteristic +neuralgic pains, erratic paroxysmal in the feet and legs chiefly--pains +of a boring, throbbing, shooting character, like those caused by a sharp +electric shock. + +More or less numbness, in the feet and legs chiefly, in all forms of +sensibility, excepting that by which differences of temperature are +recognized. + +Frequent impairment of sight or hearing, one or both. + +Frequent transitory or permanent strabismus or ptosis, one or both. + +No very obvious paralysis of the bladder or lower bowel. + +No necessary impairment of sexual power. + +No tingling or kindred phenomenon. + +No marked tremulous, convulsive, or spasmodic phenomena. + +No marked impairment of muscular nutrition and irritability. + +No impairment of the mental faculties. + +Occasional injection of the conjunctivae, with contraction of the pupils. + +The probable limitation of the distinctive phenomenon of locomotor ataxy +(the want of co-ordinating motor power) to the lower extremities. + +The above description includes all the necessary facts for the +recognition of the disease, except one, namely, that the use of the +eyesight is always needed in order to prevent the patient from falling +during progression; and is usually necessary even to enable him to stand +upright without falling. + +The pains of locomotor ataxy are early phenomena in most cases, and they +are usually present, more or less, throughout the course of the disease. + +They are often preceded by strabismus, with or without ptosis; the +strabismus, is usually accompanied by amblyopia. It may happen, however, +that neuralgic pains are, for a considerable time, the only noticeable +phenomena; or they may be attended with a certain amount of anaesthesia. + +The most frequent type of the pains is lancinating or stabbing; they are +like violent neuralgias occurring successively in various nerves; +shifting about from one to another. Sometimes it will happen that the +pain remains fixed to one particular nerve for hours together; but it +never continues long without showing the characteristic tendency to move +about. Most commonly our diagnosis is soon assisted by the occurrence of +a greater or less degree of ataxy. But, even before the setting in of +definite atactic symptoms, the shifting character of the pains, and the +development of a very noticeable amount of anaesthesia, together with the +absence of anything like positive motor paralysis, will have given us +the necessary clew. + +The effect of treatment, or rather its want of effect, usually affords +powerful assistance in distinguishing the pains of locomotor ataxy from +those of true neuralgia. Even where the pain has been fixed for some +hours in a single nerve, and has been stopped by some powerful remedy +(such as hypodermic morphia), it will be apt speedily to recur, and +frequently in some quite distant nerve. + +Locomotor ataxy is a disease affecting chiefly the male sex, and +occurring in the immense majority of cases between the thirty-fifth and +the fiftieth year. + +Not merely is it strictly limited to individuals who belong to families +with neurotic tendencies, but it is itself frequently seen to occur in +several members of the same family, and sometimes of the same +generation. When, therefore, we meet with neuralgic pains of the +shifting type above described, it is very important at once to make +careful inquiries whether any members of the family have suffered from +symptoms of ataxy going on to a fatal result. Otherwise, we might be the +more readily deceived into the idea that the pains were merely +neuralgic, because the symptoms of the disease are not unfrequently +provoked by such causes as fatigue and exposure to cold or wet, which +are also very ordinary exciting causes of true neuralgia. + +FOOTNOTES: + +[49] The most complete and careful work of the German school, on this +subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin, +1867.) + +[50] _Lancet_, June 10, 1865. (Comment on a case of Dr. J. Hughlings +Jackson's.) + +[51] Radcliffe, in "Reynolds's System of Medicine," vol. ii. + + + + +CHAPTER V. + +THE PAINS OF CEREBRAL ABSCESS. + + +Cerebral abscesses is, fortunately, a rare disease; but the very fact of +its rarity makes the resemblance of the pain it causes to that of +neuralgia the more likely to lead us into serious errors. We are apt to +forget the possibility of suppuration of the brain on account of its +infrequence. + +Pain in the head is present as an early symptom of abscess in the brain +in a large proportion of cases in which there is pain at all. [Of +seventy-five cases of cerebral abscess analyzed by Gull and Sutton +(Reynolds's "System of Medicine," vol. ii.), pain was a symptom in +thirty-nine, and most frequently an early symptom.] Many cases are +recorded in which it preceded every other morbid sign by a considerable +period. It is usually more or less paroxysmal, often strikingly so; in +the latter case, it bears a great similarity to neuralgia. On the other +hand, it sometimes takes the shape of a fixed burning sensation, much +less resembling neuralgia. The situation of the pain by no means always, +nor even usually, corresponds to the situation of the cerebral abscess; +on the contrary, abscess in the cerebellum has often caused pain +referred to the anterior part of the head, and so on. So long as the +disease remains characterized only by pain, more or less, of a +paroxysmal character, the diagnosis must be very uncertain; but in the +great majority of cases certain more distinctive symptoms soon become +superadded; either convulsions (sometimes hemiplegic), vertigo, coma, +paralysis, vomiting, or a combination of some of these. + +In the stage in which there is as yet no conspicuous symptom but severe +pain, the diagnosis of cerebral abscess from neuralgia must rest on the +following points of contrast: + + _Cerebral Abscess._ _Neuralgia of Head._ + + Often occurs secondarily to caries Rarely appears before puberty. + of internal ear, and purulent + discharge the result of scarlet + fever, measles, etc., in + childhood. + + Frequently follows a blow or Comparatively seldom caused by + injury. blow, or other external + injury or caries of bone. + + No true "points douloureux." If severe, soon presents, in most + cases, the "points douloureux." + + Usually the pain does not Intermissions of pain complete, + completely intermit. and of considerable length. + + Pain often excruciating from a Pain usually not very violent at + very early period. first. + + Pain often limited in situation, Pain superficial; follows + seems deep-seated, though, as distribution of recognizable + often as not, it has no relation nerve-branches belonging to + to the site of the abscess. the trigeminus or the great + occipital. + + No well localized vaso-motor or Usually there are lachrymation, + secretory complications. congestion of conjunctiva, or + other vaso-motor and secretory + complications, such as are + described in Chapter III. + + Very rare in old age; then Severe and intractable neuralgia + usually traumatic. is commonest in the + degenerative period of life. + + Relief from stimulant narcotics Relief from opium, etc., is much + very transitory. more considerable and + permanent. + +The only case of cerebral abscess that I have personally seen, in which +the above points of distinction would have been insufficient, was that +of a boy of sixteen, in whom the only discoverable symptom, for nearly +three months, was pain, very strongly resembling ordinary migraine, +recurring not oftener than once in ten days or a fortnight, lasting for +some hours at a time, and nearly always ending in vomiting, and +disappearing after sleep. At the end of the three months, acute pain in +the left ear set in, and this was followed, soon, by right hemiplegia, +coma, and death. It was then discovered, although it had formerly been +denied, that the boy had suffered from discharge from the left ear, +following a febrile attack which had been marked by sore-throat, and +followed by desquamation of the cuticle--evidently scarlet fever. In all +cases of severe pain in the head, it is a golden rule to inquire most +carefully as to the possible existence, present or past, of discharge +from the ear, or other signs of caries of the temporal bone; and, even +if no positive history of this kind be given, we should still regard +with great suspicion any case in which there has been scarlet fever +followed by deafness. + + + + +CHAPTER VI. + +PAINS OF ALCOHOLISM. + + +A very important class of pains, which are occasionally confounded with +true neuralgias, are those which occur in certain forms of chronic +alcoholism. The diagnosis of their true nature is a matter of the utmost +consequence, and the failure to recognize them for what they are may +have very disastrous results. It is a curious fact that this consequence +of chronic alcoholic poisoning has been entirely overlooked by some of +the best known writers on that affection; it has, however, been +described by Mr. John Higginbottom, and also by M. Leudet. + +It must be clearly understood that the pains of which we are now to +speak are not among the common consequences of chronic excess in drink. +The affections of sensation which most usually occur in alcoholism take +the shape either of anaesthesia, or of this combined with anomalous +feelings partaking more or less of the character of formication. Chronic +drinking has also a tendency, in its later stages, when the nutrition of +the nervous centres has been considerably impaired by the habit, to set +up true neuralgia, of a formidable type, in subjects who are +hereditarily predisposed to neuroses. But the affection of which I now +speak may occur at any stage except the very earliest, and, though often +severely painful, is essentially different both in its seat and in its +general characters, from neuralgia proper. + +The earliest symptoms from which the patient usually suffers in these +cases are insomnia, and intense depression of spirits, which, however, +is not incompatible, indeed is frequently combined, with a morbid +activity and restlessness of thought. There is generally marked loss of +appetite, but often there is none of the morning nausea so +characteristic of the common forms of alcoholism. Nor is there, +ordinarily, any special unsteadiness of the muscular system. The pains +are usually first felt in the shoulder and down the spine; but as the +case progresses they especially attack the wrist and ankles; and it is +in these latter situations that I have found them to be most decidedly +complained of. Their similarity to neuralgia consists (_a_) in their +somewhat paroxysmal character; (_b_) in their frequently recurring at +about the same hour of the day, most commonly toward night; and (_c_) in +their special aggravation by bodily and mental fatigue. + +Their differences from neuralgia are--(_a_) that they never follow the +course of a recognizable single nerve; (_b_) that they are nearly always +present in more than one limb, and usually in both halves of the body, +at the same time; and (_c_) especially, that they are far less promptly +and effectually relieved by hypodermic morphia than are the true +neuralgias; indeed, opiates very frequently only slightly alleviate the +pain, while they excite and agitate the patient and render sleep +impossible. On the contrary, a large dose of wine or brandy will never +fail to procure temporary comfort and induce sleep, at least until the +patient reaches an advanced stage of the disorder, and is, in fact, on +the verge of delirium tremens. + +I am not quite sure that I am right in believing that there is a special +physiognomy for this form of chronic alcoholism, and yet I am much +inclined to believe that there is. All the patients whom I have seen +suffering with it have presented a peculiar brown sallowness of face, +and a general harsh dryness of the skin, which has usually lost its +natural clearness, not only in the face, but even more remarkably in the +hands, which are so dark-colored as to appear as if they were dirty. +There is usually considerable leanness of the limbs, and, though the +abdomen may be somewhat prominent, this does not seem to depend much on +the presence of fat, but rather on relaxation of the abdominal muscles, +and sometimes flatulent distention of the stomach and intestines. The +hands are usually hot, sometimes quite startlingly so. + +Some of the patients suffer, besides the pains in the limbs (which they +often describe as resembling the feeling of a tight band pressing +severely around the ankles or wrists), from frequent or occasional +attacks of genuine hemicrania; such a combination is to me always a +suspicious sign, and induces me immediately to direct my attention to +the possibility of chronic alcoholic poisoning. Otherwise, the +limb-pains are often spoken of as resembling rheumatism, but there is no +swelling of joints, and usually no decided tenderness of the painful +parts. The patient has usually a particular worn and haggard appearance, +complains of intense fatigue after the most moderate muscular exertion, +and is usually utterly indisposed to physical exercise even though the +mind, as already said, may display a feverish activity. + +So far as I have seen, the subjects of this affection are by far the +most frequently women; and I am inclined to attribute this +predisposition of the sex not to inherent peculiarities of female +organization, but to the fact that a much larger proportion of +intemperate women than of intemperate men indulge in secret excess. They +never get drunk, probably, but they fly to the relief of alcohol upon +every trivial occasion of bodily or mental distress; and this habit may +have been going on for years before it comes to be suspected by their +friends or their medical attendant. Meantime, they have been more or +less looked upon, and have looked upon themselves as, "debilitated" and +"neuralgic" subjects, and have come, either with or without mistaken +medical advice, to consider free stimulation as the proper treatment for +the very ailments which have been produced by their own unfortunate +habits. I cannot avoid the expression of the misgiving, that imperfect +diagnosis, and consequent erroneous prescription, have done great harm +in many such cases. It has happened to me no less than three times +within the last six months to be called to lady patients, all suffering +from alcoholism induced by a habit of taking stimulants for the relief +of so-called neuralgic pain; and in the most distressing of these the +mischief had been greatly aggravated by a prescription of brandy, based +on the erroneous idea that the pains were truly neuralgic. I have +already protested against this kind of medication, even in cases that +are truly neuralgic in character; but it is doubly mischievous where +given for a state of things which actually depends on alcoholic excess. + +It is undoubtedly very difficult, sometimes, to elicit the truth, even +in cases where we may entertain considerable suspicion that alcoholic +excesses are the real cause of the pains which the patient calls +neuralgic; more especially where the patient is aware that he or she is +taking an amount of alcohol which is seriously damaging to health. And +it is therefore necessary to look out for every possible additional help +to our diagnosis. Besides the cardinal features of the disease--the +insomnia, loss of appetite, foul breath, haggard countenance, and pains +encircling the limbs near the joints rather than running longitudinally +down the extremities there are certain moral characteristics of the +patient that often tells a significant tale. The drinker, especially if +a woman, is shifty, voluble, and full of plausible theories to account +for this and the other phenomenon. It will be well to try the effects of +a somewhat sudden though not uncourteous remark, to the effect that the +diet should be strictly unstimulating. If this be introduced with some +abruptness, in the course of a conversation not apparently leading to +it, the patient's manner will not unfrequently betray the truth; while, +if our suspicions are groundless, we shall also probably perceive that, +in the unconscious, or frankly surprised, expression of the countenance. +We may sometimes derive crowning proof of the existence of alcoholic +excess by cautious questions which at least reveal the fact that the +patient suffers from spectral hallucinations; this is a far commoner +occurrence in chronic alcoholism than is generally supposed; it needs to +be inquired for with great tact, but, when established beyond doubt, and +joined to insomnia and the peculiar foul breath, is of itself sufficient +to establish a positive diagnosis of alcoholic poisoning. + +The results of treatment, in true neuralgia and in alcoholic pains, +respectively, establish an important difference between these +affections. In the former malady, for instance, the hypodermic injection +of morphia always produces striking palliative, and very often curative +effects. In alcoholic pains this remedy either affords only trifling +relief, or more commonly aggravates the malady by increasing the general +nervous excitement; and the only true treatment is at once to suspend +all use of stimulants, to administer quinine, and to insist upon a +copious nutrition. If any hypnotic must be employed, let it be chloral, +or bromide of potassium with cannabis Indica. It will be well also to +put the patient upon a somewhat lengthened course of cod-liver oil. +There is one special symptom from which the chronic alcoholist often +suffers acutely, namely a hypersensitiveness to cold; for this I found +the use of Turkish bath two or three times a week, for three or four +weeks, very useful in one case that was under my care. It will be +important to insist that the patient shall take the bath only after that +shorter method which I have described in speaking of the prophylaxis of +true neuralgia. + + + + +CHAPTER VII. + +THE PAINS OF SYPHILIS. + + +Syphilis, as has already been shown in Part I. of this work, may excite +true neuralgia in subjects already predisposed to the latter. The case +of Matilda W., previously given, is an example. The pains, however, +which are now to be described, are those which occur in the ordinary +course of a constitutional syphilitic infection, and have nothing to do +with neuralgia proper, from which they should be carefully +distinguished. + +There are two varieties of syphilitic pains proper, which are quite +distinct. The first kind is represented by the so-called _dolores +osteocopi_, which occur in the early stages of the constitutional +affection, coincidently with, or just before, the secondary +skin-eruptions. The second kind are those which occur in the tertiary +stage, and are the immediate precursors of the formation of periosteal +nodes. + +It is the first of these varieties of syphilitic pains which is least +commonly confounded with neuralgia. The pain is referred to the +superficial bones, of which those most frequently attacked are the +forehead, sternum, clavicle, ulna, and tibia, pretty much those selected +for the growth of nodes at a later stage of the disease. Besides the +bones, the shoulders, elbows, and nape of the neck are attacked +sometimes simultaneously, sometimes successively. The pains are readily +controlled by proper treatment; if untreated, their course is very +uncertain. When they manifest themselves at the outset of the disease, +they usually cease when the cutaneous eruption is fairly out. Commonly, +there is no swelling or heat at the painful places; but, when the pains +are very severe, nodes now and then form at this early period.[52] + +These early syphilitic pains, in their violent aching character, and +their intermittence, occasionally resemble true neuralgia very closely; +but they are usually distinguished from it by their symmetrical +disposition and by their attacking several bones at once. Moreover, they +nearly always show the peculiarity of being distinctly aggravated by the +warmth and repose of bed even if they be not altogether absent (as is +not unfrequently the case) when the patient is up and moving about. A +typical case of this kind is not so likely to be confounded with +neuralgia as with rheumatism; but we occasionally meet with cases in +which the pains are localized in a manner much more resembling the +former. Thus I have met with several instances in which a patient, +entirely unconscious (or professing to be unconscious) of having been +syphilized, complained of violent pain in one tibia, recurring every +night at a certain hour, and at first undistinguishable from that +variety of sciatica in which the pain is principally felt in this +situation, especially as it was relieved by firm pressure, just as +neuralgia is in the early stages. And in one remarkable case, which came +under my care at Westminster Hospital, the resemblance to clavus was +most misleading: + +H. A., aged nineteen, worker in a laundry, presented herself on account +of a violent pain in the right parietal region, recurring three times +daily with great regularity. The first two attacks occurred in the +day-time, the third, which was always the severest, woke her out of +sleep about midnight; the pain of this last was so agonizing that on +more than one occasion she had become delirious. The girl (whose +respectable appearance was against the notion of syphilis) was very +anaemic; not, however, with the tint either of anaemic from haemorrhage, or +with that of chlorosis, exactly. It was rather a dirty sallowness of +skin; but the gums and the conjunctivae were exceedingly bloodless, and +she complained of almost constant noises in the head. Menses scanty but +regular. There was a soft anaemic bruit with the first sound at the base +of the heart. Having failed to make any impression on the pains with +iron and with muriate of ammonia in large doses, I was led to observe +the fact that there was no diffuse soreness of the scalp, such as very +commonly occurs in clavus, in the intervals of the pains, and the mere +fact that there was this unusual circumstance in the case led me to +reconsider the diagnosis thoroughly. In order to be sure of not omitting +a point, I inquired, though without any expectation of an affirmative +answer, as to the possibility of syphilitic disease; the girl at once +confessed to having had sores, and examination detected a papular rash +about the shoulders and back and on both thighs. Small doses of mercury +greatly relieved the pain within a week, and cured it in less than three +weeks; and it was very remarkable that the anaemia, which had obstinately +refused to yield to iron, improved at once as the mercury began to +relieve the pains. The eruption disappeared simultaneously. + +It is the later pains of syphilis, however, that are most frequently +confounded with neuralgia, and occasionally with very disastrous +results. These pains, which are the precursors of the formation of true +nodes, frequent the same localities as those affected by the earlier +pains; they may exist in considerable severity for days, or even for +many weeks, before any node-formation can be detected. The situation in +which, of all others, they are likely to be mistaken for neuralgia is +the scalp or face, especially when a single spot is affected on one +side, and in the situation of one of the usual foci of trigeminal or +occipital neuralgia. I have personally known the mistake to be made with +syphilitic affections causing pain, respectively, in the superciliary +region, in the malar bone, the jaw near the mental foramen, and the +parietal eminence. + +The possibility of mistaking tertiary syphilitic pain for neuralgia is +fraught with such grave dangers, that we ought to be constantly and most +vigilantly on the watch against it. But most especially is this the case +when the pain is situated in some part of the cranium, as the parietal +or temporal eminences, the mastoid process, or the prominences of the +occipital bone. For it must be remembered that the same process, which +forms syphilitic nodes upon the external surface of bones, or within +bony canals, can produce them on the lining membrane of the skull, with +most serious consequences, should the symptoms be neglected or +misunderstood. + +The pains produced by nodes upon the internal surface of the cranium are +usually of a very intense character, and are mostly continuous, though +aggravated from time to time, especially at night. Where syphilitic +inflammation is diffused over a considerable portion of the meninges, it +is certain very quickly to produce symptoms which can hardly fail to +apprise us of the gravity of the affection; there will be decided and +rapidly increasing impairment of memory, and general cloudiness of +intellect, tending toward complete imbecility, the special senses will +be greatly interfered with or lost, and muscular paralysis will be +developed. But in the case of a more limited syphilitic affection of the +dura mater, pain, of the kind already described, may be for some days +the only very noticeable symptom. The following is an instance: + +J. E., aged forty-seven, a street and tavern singer, applied to me +(November 14, 1861), on account of severe pain in the right temporal +region, which had on the whole the character of neuralgia, though rather +more continuous than such pain usually is. He said that it commenced on +the 10th, without any particular provocation that he knew of, and that +it had hardly left him at all from that moment. It kept him awake at +night, and that circumstance seemed to account sufficiently for a very +worn and depressed look which he presented; he was otherwise a +robust-looking man, and at first denied having suffered from any +previous illness. The pain always came to a climax about one o'clock, A. +M., waking him out of his first sleep in agony, and allowing him little +rest for the remainder of the night; toward morning he would drop to +sleep for an hour or so. There was no particular tender point, +corresponding to any recognized neuralgic focus, yet the pain was +limited most strictly to a spot that might be covered with two +finger-points. There was no lachrymation nor conjunctival congestion, +and nothing to remark in any way about either eye. The patient was +ordered quinine in large doses, in the belief that the pain was +neuralgic. On the following day he reported himself a trifle better, +though still suffering greatly; and on the afternoon of that day there +was an almost complete intermission of the pain for several hours; but +it returned severely at the usual nocturnal period. On the 16th, at 10 +A. M., he came to my house looking exceedingly ill, but the only +additional symptom that I could detect was a small droop of the right +eyelid. He was subcutaneously injected with one-fourth of a grain of +morphia and sent home, where he immediately fell into a heavy sleep that +lasted till bedtime. He awoke, undressed himself without feeling much +pain, and got to bed; after an hour or so of dozing he was awakened by +the pain, which was exceedingly severe. On the 17th he called on me in +the morning, and I at once perceived that the ptosis of the right eyelid +was much greater, and the right pupil was much dilated and insensitive, +and the external rectus was paralyzed; the man also wore a look of +stupidity, and answered questions with an apparent mental effort. I now +cross-questioned him more closely; and also explored the tibiae and other +superficial bones: on the sternum a distinct though not very advanced +node was found. Upon this he was induced to confess that he had suffered +from chancre three years and a half previously, and subsequently had +"blotches" on the skin, which had quickly disappeared under treatment, +of which all that could be learned was, that it was fluid medicine and +did not make his mouth sore. He was immediately ordered to take two +grains of calomel in pill, with a little opium, every four hours. He had +only taken one dose when I was sent for to him, and found him in an +epileptiform convulsion, in which the left side of the body was almost +exclusively affected; the convulsions recurred several times during the +next twenty-four hours, and in the intervals he remained almost +completely unconscious. The mercurial treatment was pushed, in the form +of calomel-powders placed on the tongue. On the evening of the 18th he +began to recover consciousness, and then had a little natural sleep; the +next morning, at 10 A. M., he was found to be fully conscious, had had +no return of convulsions, but the left arm and leg, especially the +latter, were almost entirely powerless; the parietal headache had +vanished; the gums were slightly tender; the third and sixth nerves of +right side were completely paralyzed. Mercurial treatment was very +gently continued, so as to keep the patient on the borders of ptyalism +for the next three or four days; and he was then put on full doses of +iodide of potassium. The pain never recurred; the left extremities +recovered power rapidly; but it was six weeks before the ocular +paralyses were completely well. + +Late in the autumn of 1865 I was sent for hastily one evening to see +this same man, and found him totally unconscious and apparently again +hemiplegic, but now on the right side. He was miserably wasted, and +covered with a rupious eruption; I was informed that he had been leading +a most debauched and drunken life for some time past, and that, after +looking extremely ill, and apparently half imbecile for a week or two +past, he had suddenly fallen down unconscious in the street a few hours +before I saw him. He remained deeply comatose, and died the next +morning; no _post mortem_ could be obtained. + +The true neuralgias in which syphilis only plays the part of secondary +factor, and which have been referred to in Part I. of this work, may +depend for their exciting cause on local syphilitic processes, affecting +either the peripheral distribution, the main trunk or the central origin +of a sensory nerve; but I have pointed out the fact that, whatever the +reason may be, syphilis does but rarely attack the central portions of +individual sensory nerves, in comparison, with the frequency with which +it attacks individual motor (cranial) nerves. But without any neuralgic +predisposition at all, and without any limitation of the syphilitic +process to a particular sensory nerve, the latter may become neuralgic +in consequence of being involved in extensive intracranial or +intra-spinal syphilitic mischief. The trigeminus is liable to suffer in +this way from spreading syphilitic processes about the base of the +brain; and my own impression is, that the cause of the neuralgic pain in +some such cases is the extension of the mischief to the vertebral artery +of the affected side, leading to interfering with the nutrition of the +trigeminal nucleus in the medulla. A very interesting case is reported +by Dr. Hughlings Jackson (who has done so much to acquaint us with +syphilitic affections of cerebral arteries) in vol. iv. of the "London +Hospital Reports," pp. 318-321. The patient was a woman, aged +twenty-seven, and the initial symptoms of the malady which destroyed her +life were violent trigeminal neuralgic pains on the right side: +subsequently she had complete paralysis of the fifth, and of the sixth, +seventh, and eighth nerves of the right side. After death the right +vertebral artery was found engaged in the mass of syphilitic deposit; it +must be added, however, that the (superficial) origin of the fifth nerve +was itself softened, opposite the pons. Another mode in which syphilitic +disease very probably causes neuralgia of the fifth, in a certain number +of cases, is by injuring the Gasserian ganglion, upon the integrity of +which (according to Waller's general law concerning the ganglia of +posterior nerve-roots) the nutrition of the sensory root of the +trigeminus materially depends. I have seen an example (as I cannot but +suppose) of this sequence of morbid events; the evidence appears +sufficiently complete, although I was unable to obtain a _post mortem_ +examination: + +W. M., a house painter, of extremely dissipated habits, but who had +never suffered either from distinct symptoms of alcoholism, nor from any +affection traceable to lead-poisoning. In March, 1867, he applied to me +on account of neuralgic pain, affecting chiefly the right eyeball, but +also darting along the course of the frontal nerve of that side; after a +short time it extended also into the infra-orbital nerves. He bore +several scars of tertiary ulcers about the nose and forehead, and made +no secret of having suffered from chancre six or seven years before, and +from subsequent secondary and tertiary symptoms. I was consequently not +at all surprised at his developing severe iritis (right) after he had +been a fortnight under my care, although I had from the first given +large doses of iodide of potassium; but I was not prepared for the +extensive processes of destruction which followed, notwithstanding that +I immediately commenced mercurial treatment, and applied atropine. I +remarked that while the inflammation of the iris proceeded with great +violence, the cornea was also much more severely affected than is +usually the case in syphilitic iritis; in fact, the changes closely +resembled those which have been noted after section of the fifth at the +Gasserian ganglion, and at the date of the patient's death (seventeen +days from the commencement of the iritis) a corneal ulcer was on the +point of perforating. For the first three or four days after the iritis +set in, the neuralgic pains went on augmenting in intensity, and +extended into all three divisions of the fifth; there was a copious +discharge from the right nostril. Almost suddenly, on the fourth day, +the pains abated and then ceased, and it was now evident that the whole +surface of the right half of the face was completely anaesthetic. Two +days later a dark-red patch appeared on the cheek, and in the course of +the next two days this ulcerated, the ulcer presenting a somewhat livid +appearance, and exuding a sanious discharge; at the same time, +superficial ulcers appeared on the right side of the tongue, and +coalesced to form one large sore. The sores both on cheek and tongue +assumed more and more a gangrenous appearance, and on the sixteenth day +from the commencement of iritis there was considerable loss of substance +in both these situations. On the evening of this day (the patient having +become extremely depressed and much emaciated) general epileptiform +convulsions set in, and followed each other rapidly; in a few hours coma +supervened, and the patient sank the next day. No _post mortem_ could be +obtained; but it seems extremely probable, from the above history, that +the Gasserian ganglion was early involved in the syphilitic +inflammation, and that the neuralgia and subsequent anaesthesia, the +iritis, and the other trophic lesions, were due to the injury inflicted +upon it. + +The treatment of syphilitic pains will, in doubtful cases, often give us +valuable assurance of the correctness of our diagnosis. Where the +disease is extensively diffused, we may fail to do any good; but, in +cases where the syphilitic mischief is limited to a small portion of the +meninges, we may often arrest it. In all merely suspicious cases, where +the pain is thus limited, it will be well to use iodide of potassium +tentatively--forty to sixty grains daily. But, where the pains are very +severe and continuous, and there is danger to the integrity of the eye, +or threatenings of a paralytic attack are observed, it is better not to +trust to anything short of mercury, used in such a manner as just to +stop short of absolute ptyalism. In very bad cases, like the last one +narrated, we may fail to produce any good effect, but, where the +specific treatment is commenced in good time, we may not unfrequently +succeed in arresting the symptoms with a rapidity that assures us of the +correctness of the diagnosis of syphilis. + +FOOTNOTE: + +[52] Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153. + + + + +CHAPTER VIII. + +PAINS OF SUBACUTE AND CHRONIC RHEUMATISM. + + +So firmly is the idea of an essential connection between rheumatism and +neuralgia implanted in the popular mind, and, indeed, in the minds of a +certain portion of the medical profession, that the two complaints are +continually confounded. In the great majority of instances, the mistake +made is that of calling neuralgia a "rheumatism." But the opposite error +occasionally occurs, and a patient is styled "neuralgic" who is really +suffering from chronic rheumatism. + +As true neuralgia is an essentially localized disease, there can be no +excuse for mistaking for it the more typical cases of chronic +rheumatism, in which a number of different joints, muscles, or tendons, +are affected, more especially in the advanced stages, when the +characteristic fixed contractions of the limbs and extremities have +occurred. But there are a few cases in which, either with or without a +previous history of acute rheumatism, one, or perhaps two, joints begin +to suffer vague pains, which after a little time begin to shoot down the +course of the limb, and are aggravated from time to time in a manner +which superficially much resembles neuralgia; and when the malady has +reached a certain intensity the pains may be so much more severely felt +in the longitudinal axis of the limb than in the immediate neighborhood +of a joint, that the patient forgets that in reality they commenced +either within a joint (as the elbow or hip), or in the fibrous +structures immediately outside it. Certain localities are much more +frequently the seat of this kind of affection than other parts of the +body; thus it occurs, perhaps in nine-tenths of the cases, in the +neighborhood either of the shoulder (especially involving the insertions +of the deltoid and triceps muscles), of the elbow (particularly +affecting the tendinous insertions of the muscles on the internal aspect +of the forearm), or the hip (extending to the aponeuroses on the outer +and back part of the thigh): in all these cases there is a considerable +superficial resemblance to true neuralgic pains. Nevertheless, the +diagnosis need not present any serious difficulties after the earliest +stages; for there soon arises a very diffuse and acute tenderness of the +parts, and usually an amount of generalized swelling, which, though it +may not be readily detectable by the eye, is sensible enough to the +touch. Movement of the parts is also very painful; but usually not with +the acute and agonizing pain which occurs in myalgia. + +It is, however, upon signs which are of a more general character that we +ought chiefly to rely for diagnosis. The fact that the patient has +previously experienced a genuine attack of acute rheumatism, though of +some value, is by no means to be taken as a conclusive argument that the +present attack is of a rheumatic nature. The really important matter is, +that whether the patient has or has not suffered acute rheumatism before +the occurrence of the subacute or chronic form, the latter will always +be attended by more or less of the specific constitutional disturbance +of rheumatism. I would carefully abstain from the assumption that +rheumatism is originally dependent on a blood-poisoning, a theory which +I believe to be most doubtful and very probably false; but there is, +nevertheless, a truly specific character about the general phenomena in +acute rheumatism, and I maintain that similar though less-marked +phenomena are always to be seen even in the mildest and least acute +forms of rheumatism. Thus there will be, invariably, more or less of the +peculiar sallow anaemia, together with red flushing of the cheeks when +the pain is at the worst; and there will be a certain amount of the oily +perspiration which makes the faces of rheumatic patients look shiny and +greasy. No doubt these characteristics will sometimes be very slightly +developed, but I believe that attentive observation will always discover +them in any case which is genuinely rheumatic. One case, in particular, +which has been under my care, very strongly impresses me with the value +of these diagnostic signs, where otherwise the symptoms are obscure: + +L. P., aged thirty-one, single, a printer by trade, applied to me, +January, 1863, suffering from what I at first decidedly thought was +cervico-brachial neuralgia, the pain having followed exposure to cold +and wet, situated in the lower part of the neck, the shoulder, elbow and +inner side of the right arm, and existing nowhere else. The character of +the pain was described as at least remittent, if not distinctly +intermittent. The pulse was not more than 78; the tongue was thickly +coated with white fur, but the man did not complain of thirst, and there +were no evident signs of fever. As the pains had only existed for about +a fortnight, it appeared an excellent case for cure by the hypodermic +injection of morphia; and, accordingly this was used in quarter-grain +doses twice a day. After about ten days an attempt was made to do +without the morphia, but the pains returned, worse than before, and +meantime the tongue had remained uniformly coated, and was now very +yellow; the appetite was bad, and there was some increase in frequency +of pulse. It now struck me, for the first time, that the man presented, +in a slight degree, the sallow and red tint and oily features of a +rheumatic patient; it was now found that sweat and urine were distinctly +acid. Acting on this idea, I administered five grains of iodide of +potassium, and thirty grains of bicarbonate of potassium, four times +every twenty-four hours, after giving a moderate saline aperient. The +result was manifest improvement within twenty-four hours, and almost +complete relief of the pain within three or four days (the urine never +becoming distinctly alkaline, however.) As the attack subsided, the oily +appearance of the skin disappeared, and the rheumatic tint was replaced +by mere ordinary pallor, which the patient lost after taking a short +course of steel. + +At the time this case occurred to me, I was not aware of the importance, +in doubtful instances, of looking to the temperature; but subsequent +experience has convinced me that in every truly rheumatic case, however +limited in extent, there is a real, though it may be a small, rise of +temperature. The thermometer will be found to mark from 99-1/4 deg. to 100 deg. +Fahr., and this, joined with the appearances above mentioned, and a +strong acidity of urine, will be sufficient to distinguish the complaint +as rheumatic; and the striking effect of such remedies as iodide with +bicarbonate of potash, followed up with sesquichloride of iron, in full +doses, helps still further to distinguish the cases from true +neuralgias. Since the introduction of the full doses of the +iron-tincture in the treatment of acute rheumatism, I have had the +opportunity of treating two of these cases of subacute rheumatism in the +same manner, viz., with the iron from the first, and the results have +been most satisfactory in every way. These cases were independent of a +much larger number, treated in the same way, in which the symptoms of +rheumatism were more generalized and more severe. + + + + +CHAPTER IX. + +PAINS OF LATENT GOUT. + + +Pains which are connected with a chronic and more or less latent form of +gout not unfrequently receive the designation "neuralgic," and are +treated upon that erroneous theory of their pathology. I have already +endeavored to show that there is by no means that intimate causal +relation between gout and neuralgia which is very commonly assumed to +exist: true neuralgia is, I believe, only caused in an indirect and +secondary manner by the gouty condition setting up changes of the +blood-vessels, which precipitate the occurrence of the neuralgic malady, +to which the patient was otherwise predisposed from birth. But the +common idea, both without and within the profession, seems to be that +neuralgia is only one expression, and that a quite common one, of the +gouty habit. Nevertheless, with strange inconsistence, the kind of truly +gouty pains of which I am now speaking are constantly treated upon a +special plan, upon the supposition that they are neuralgic. + +There are six situations in which gouty pains are apt to be developed in +a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2) +more indefinitely within the cranium; (3) in the stomach, simulating +gastralgia; (4) in the chest, simulating angina pectoris; (5) in the +dorsum of the foot, simulating neuralgia of the anterior tibial nerve; +(6) in a somewhat diffuse manner about the hip and back of thigh, +simulating sciatica. + +It is not really a common thing to find such cases very difficult of +diagnosis, provided that the possibility of their occurrence has been +carefully noted; for the gouty habit has a number of slight +manifestations which are usually enough to discover it even when its +more decided symptoms are entirely wanting. + +Thus, in the first place, it will be almost invariably found, on +inquiry, that the patient has always been intolerant of beer and of +sweet wines. Also, he has been liable (either after a single large +excess in eating or a prolonged course of a diet too highly animalized +in proportion to the amount of exercise taken) to attacks of general +malaise, with or without uneasiness, just short of decided pain, about +the metacarpo-phalangeal joint of the great-toe, and ending after a few +hours or days with a free discharge of uric acid. Less frequently, but +still very often, it will be found that he has some deposit of lithate +of soda (chalk-stone) in some situation where its presence does not +necessarily arrest attention; Dr. Garrod has shown how often these +little tophi are found in the cartilage of the ear. Careful examination +will sometimes detect their presence in the sclerotic of the eye. But in +doubtful cases it would be always well to make a cautious trial of +colchicum, which, if the case be gouty, will nearly always produce an +amount of relief sufficient to confirm the diagnosis of gout. At least, +this rule holds goods for the external forms; but in the case of the +supposed gouty pseudo-angina it is far best to trust to opium, as +colchicum may prove too depressing to a heart which may quite possibly +be already the subject of organic disease. My own impression is, that it +was these cases of gouty heart-pain, which are not true angina at all, +that procured for opium its high reputation for relieving the latter +disease, a reputation which is by no means confirmed by my own +experience, since I have found that drug enormously inferior to +stimulants like ether in its power to relieve genuine angina. + +Lastly, if there be no other possibility of making ourselves certain +whether there is or is not a gouty taint at the bottom of the +quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the +serum of the blood to a search for uric acid (thread-test). + + + + +CHAPTER X. + +COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION. + + +Colic, or painful half spasm, half paralysis of the large intestines, is +the best example of a kind of spasmodic pains to which some authors +accord the name of neuralgia, as it seems to me without good reason. +They appear to be quite independent of the operation of the neurotic +temperament, and to be caused entirely by the operation of some local +irritant, or narcotic irritant, upon the muscular fibres of the viscus. +In the case of colic this influence is most frequently and most +powerfully exerted by lead, which undoubtedly becomes locally deposited +in chronic poisoning with that metal; at other times it is produced by +the irritation of indigestible food passing along the alimentary canal. + +That there may be such a thing as enteralgia, of really neuralgic +character, I do not deny; on the contrary, so far as regards the rectum, +I have myself seen such a case. But true neuralgia of the large bowel is +exceedingly uncommon; what goes by the name is usually either colic from +local irritation of the viscus; or a mere hysterical hyperaesthesia of +the lining membrane, which is one of the occasional phenomena of spinal +irritation; or else it is a case of neuralgia of the abdominal wall, +such as is included in the description of "lumbo-abdominal neuralgia," +in Part I. of this work. + +There is no occasion to describe minutely the symptoms of so familiar a +disease as lead-colic, or as colic from irritation by indigestible food, +when they occur in their typical forms. In the former case the marked +constipation which ushers in the attack of pain, and the peculiar +greenish-yellow sallowness nearly always seen in the countenance, ought +to be sufficient to direct examination to the gums (for the blue line) +and inquiry as to any possible impregnation of the system with lead, +owing either to the nature of the patient's occupation, or to some +accidental entry of the poison into the drinking-water, or its +inhalation from the walls of newly-painted rooms, etc. In the latter +case, the fact that the attack of colic was shortly preceded by a meal, +either of obviously indigestible food, or too copious in quantity and +heterogeneous in kind, or too hastily eaten without sufficient +mastication, supplies a clew. + +But there are a few cases representing minor degrees of either of these +kinds of colic, that are much less easy to diagnose distinctly. + +Lead-poison sometimes enters the system continuously, for a long period, +but in proportions too minute to produce the effects which we identify +as an attack of lead-colic. I believe that for the production of the +latter complaint it is necessary that the poisoning shall be +sufficiently intense completely to paralyze a considerable piece of +bowel, thus altogether hindering peristalsis, or, rather, making the +peristaltic acts of the non-paralyzed portions above worse than +fruitless. But there is a minor degree in which it may happen that the +local affection (owing, I believe, to a less extensive deposit of lead +in the bowel) does not reach the decidedly paralytic stage; the state +then is one of irregular and painful spasm of individual fibres (quite +possibly intermingled with paralysis of a few others), and the practical +result is irregularity of evacuation--now diarrhoea, and again +constipation--and the frequent recurrence of twinges of pain that are +easily mistaken for abdominal neuralgia. Such symptoms as these are +nearly always found to have occurred, if proper inquiry be made, in +those examples of chronic lead-poisoning in which the toxic process goes +on to the development of epilepsy, or marked symmetrical paralysis of +the wrist-extensors, without the patient having ever suffered an attack +of ordinary colic. In these slow and insidious cases the constitutional +affection may not have reached the height at which the complexion and +general aspect of the patient suggests metallic poisoning: and the case +may present very neuralgia-like features. The absence of the _points +douloureux_ is not, as we have seen, conclusive against neuralgia in its +early stages. It is therefore an excellent rule, in all cases of chronic +recurrent spasmodic pain in the abdomen, especially in men, to +investigate the possibilities of lead-poisoning; and, if the slightest +suspicious appearance of the gums be found, this track of inquiry must +be followed up exhaustively before we abandon the idea. The absence of +all special neurotic history in a patient's family should increase our +suspicions respecting pains of this character that continue with an +obstinacy which makes it unlikely they are due to improper food. + +Pains of abdominal irritation are, however, without doubt produced in +some cases by unsuspected faults of diet, and may even recur in such a +quasi-periodic manner as to strongly suggest the idea of neuralgia in +the lumbo-abdominal nerve. One special variety of this happens, I +believe, much more often than is thought. A patient will habitually take +considerable quantities of some article of food which he does not +readily digest, but which is not at all acutely irritant: under these +circumstances a simple accumulation is apt to take place in the colon, +especially at the top of the ascending colon, the top of the descending +colon, or just above the sigmoid flexure, or else in the caecum. The +result of accumulation in the last of these places is not unfrequently +typhlitis and perityphlitis, this part of the bowel having (for some +reason) a special tendency to inflammation. Deposits in the other +localities named are rarely the cause of inflammation, but they very +frequently give rise to violent pain, which is exceedingly apt to be +taken for the pain either of gall-stone, of renal calculus, or else of +some abdominal neuralgia. In cases, therefore, where there is any +possibility that accumulation is the cause of pain, it is highly +desirable to commence with a dose of castor-oil and laudanum, followed +up, if needful, by the administration of a large warm-water enema, given +through an O'Beirne's tube. The most violent and recurrent attacks of +pain in the renal region, the flank, the abdomen, or the groin, will +sometimes be instantly cured by such means, sufficiently proving the +non-neuralgic character of the complaint. + +I have elsewhere explained that the impaction of a renal or an hepatic +calculus, in the ureter or the ductus choledochus, may set up a true +neuralgia in persons with the requisite congenital predisposition. The +passage of renal or hepatic calculi may give rise to symptoms falsely +suggesting neuralgia, which require just to be mentioned here. But there +is no need to dwell much upon the diagnosis, for the passage of renal or +hepatic calculi has always attendant symptoms and features of +constitutional history, which ought to preserve the physician from +mistake. The sensation of constriction, of nausea and vomiting, the +faintness approaching to collapse, the persistent and constantly +increasing severity of the pain up to the moment at which mechanical +relief occurs, to say nothing of other phenomena, are distinctive to the +skilled observer, and, when taken in conjunction with the history of +past attacks, if any, will always prevent mistakes. In the few cases +which might still be doubtful it will be well to try the effect of a +relaxing dose of chloroform, which, in the case of calculus, will often +put an end to the paroxysm at once and finally. + + + + +CHAPTER XI. + +DYSPEPTIC HEADACHE. + + +A final word or two must be given to the distinction between neuralgia +of the head and an affection so utterly different that it is surprising +that they should be so frequently confounded. One constantly hears +medical men speak of "sick headache" (migraine) as if it were the same +thing as headache from indigestion; and, unfortunately, they often treat +migraine upon this confused and erroneous notion, doing no little +mischief thereby. + +But, although migraine, already amply described, is entirely independent +of the state of digestion, and its stomach-phenomena are purely +secondary to the affection of the fifth nerve, there is a kind of +headache really dependent on imperfect digestion. The sufferers from +these headaches are dyspeptics whose stomach troubles are the result of +chronic gastric catarrhal inflammation. (In the acute form of gastric +catarrh there are even more severe headaches; but the general symptoms +of the disorder are too marked to allow us to mistake the case for +neuralgia complicated with secondary stomach disturbance.) The patients +in question have frequently passed so gradually into the dyspeptic +condition as to have become accustomed to it, and inclined to forget +that the stomach was the organ which first gave them annoyance. The +headaches, which occur from time to time, are either frontal or (more +frequently) occipital in position, and they are usually quite evenly +bilateral; still, there is not enough uniformity of difference between +them and true migraine, in this respect, to enable us to establish a +decided diagnosis upon it. This much may be said, however: that the pain +is rarely or never seated in one parietal region, as is frequently the +case with migraine and with clavus. The patient suffers very strikingly, +in almost every case, from languor and a feeling of inability to exert +himself; and has also much aching pain in the limbs, and usually a pain +(sometimes very severe) in the scapular region. The tongue may vary a +good deal in appearance, especially as regards the degree of general +redness; but it always has enlarged papillae, most prominent toward the +tip, and more or less thick furring at the back, and reaching forward, +in some cases, nearly to the tip, to which the "strawberry" aspect is +then confined. The headache is frequently joined with nausea, but never +with absolute vomiting, unless the stomach has been provoked with a meal +that gives it more trouble than usual. The desponding frame of mind +which this kind of dyspeptics always exhibit distinguishes them, in most +cases, quite sufficiently (together with the unwholesome complexion, the +appearance of the tongue, and the great complaints of general malaise +and aching and feebleness of the limbs) from the victims of migraine, +who are often persons of bright spirits and lively intelligence in the +intervals of their attacks; but, above all, there is nothing of the +regular and characteristic sequence of events which distinguishes the +attacks of migraine. The attacks are not periodic, but nearly always +depend on some chance dietary indiscretion, or other imprudence, which +has visibly aggravated the stomach irritation. And, when the pain does +come on, it has no uniform tendency to go on intensifying for some hours +and culminate in vomiting, followed by sleep, after which the patient is +free. On the contrary, the digestive disturbance is the provocation, and +the pain itself is of a heavy character, with a sense of tension or +fulness, and it does not go on intensifying in a regular manner, up to a +climax, but hangs about in a dull, tormenting way, and frequently is +just as bad after sleep as it was before. The diagnosis of these +headaches from neuralgic headache is not really difficult; it only +requires the use of a fair amount of caution in observation. It would, +however, be exceedingly advantageous that the word "sick-headache" +should be dropped altogether, and that migraine should always be called +by that name (or "megrim," if you will), and that headaches really +proceeding from chronic catarrhal disease of the stomach should be +called "dyspeptic" headaches. The present state of nomenclature does +much to perpetuate a confusion of ideas which ought not to exist any +longer, and which leads to much practical mischief. + + * * * * * + +Transcriber's Notes: + +Punctuation and spelling errors fixed. Variant spellings and +hyphenations changed when there is a clear majority. Other unusual +spellings retained. + +Discrepancies in headings and outline labels repaired. In some cases, +this required adding headings implied but not present in the original, +to agree with headings that were present. + +Table of Contents, Part 1, Chapter IV: original reads "DIAGNOSIS AND +PROGRESS OF NEURALGIA." "PROGRESS" has been corrected to "PROGNOSIS" as +shown in the Chapter heading. + +P. 51, "but her mensural troubles" changed to "but her menstrual +troubles". + +P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat." +"Chim." is typo for "Chir." as in footnote just above. + +P. 96, "investigation of neralgi" changed to "investigation of +neuralgia". + +P. 105, "genealogical connection between migraine and epilepsy": in all +reviewed copies of this 1882 edition, original shows "aological" with 4 +or 5 spaces in front of it, an apparent printer error. However, in the +1872 edition, the entire sentence reads as presented here. + +P. 206, "I have already causually" changed to "I have already causally". + + + + + +End of the Project Gutenberg EBook of Neuralgia and the Diseases that +Resemble it, by Francis E. 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