Neuralgia and the diseases that resemble it
by Francis Edmund Anstie · English · Gutenberg #37592 · 670,351 chars · public domain (US)
The Project Gutenberg eBook of Neuralgia and the diseases that resemble it
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world 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. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.
Title: Neuralgia and the diseases that resemble it
Author: Francis Edmund Anstie
Release date: October 1, 2011 [eBook #37592]
Most recently updated: January 8, 2021
Language: English
Other information and formats: www.gutenberg.org/ebooks/37592
Credits: 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)
*** START OF THE PROJECT GUTENBERG EBOOK NEURALGIA AND THE 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
Showing first 200,000 characters. Full text: gutenberg.org/ebooks/37592