Neuralgia and the diseases that resemble it

by Francis Edmund Anstie

CHAPTER I.

MYALGIA.

Of all the diseases which superficially resemble neuralgia, none are so likely to be confounded with it, on a cursory glance, as myalgia. More careful inquiry, however, furnishes, in nearly all cases, ample means for distinguishing between the two affections.

Myalgia is an exceedingly painful affection, and it is also much more common than was formerly supposed. It is to Dr. Inman that we undoubtedly owe the demonstration of the frequent occurrence of this malady, and the facility with which it may be mistaken for other, and sometimes much more serious, diseases, with very disastrous results. At the same time, I must express the opinion that this ingenious author has decidedly exaggerated the importance of this local disease at the expense of an unjust depreciation of the frequency and significance of other painful disorders which have their origin within the nervous system.

Myalgia proper includes all those affections which are severally known as "muscular rheumatism" (for the muscles generally), and "lumbago," "pleurodynia," etc. (according to locality). It is essentially pain produced in a muscle obliged to work when its structure is imperfectly nourished or impaired by disease.

The clinical history of the different varieties of myalgia absolutely requires this key for its interpretation; otherwise, the appearance of the sufferers from different kinds of myalgia is so widely dissimilar that we should be exceedingly likely to miss the important features of treatment, which must be applied to them all in common. Nothing, for instance, can be more strikingly unlike than the appearance of the pallid, stunted, under-nourishment cobbler who complains of epigastric myalgia, and that of the ruddy and muscular navvy who suffers from acute lumbago, or the similarly plethoric-looking country commercial traveller, who has been driving in his gig against wind and rain, and complains of violent aching pains in one or both shoulders; yet one and all of these individuals are suffering from precisely the same cause of pain, viz., a temporarily crippled muscle or set of muscles which has been compelled to work against the grain. Why this state of things should invariably be interpreted as sensation in the form of acute pain never absent, but severely aggravated by every movement of the affected part, is a matter beyond our powers of explanation, we must accept it as an ultimate fact for the present.

There is scarcely any need to describe the pain of myalgia, since almost every one has suffered either from lumbago, or from a stiff neck produced by cold. The pain is essentially the same in all cases; it is an aching actually felt either in or toward the tendinous insertions of the affected muscles, and sharply renewed by every attempted contraction of those muscles. The variations in the character and severity of the pains are really entirely due to the greater or the less opportunity for physiological rest which the muscle can obtain. Thus the most obstinate and the most severe, kind of myalgic pain is undoubtedly that of pleurodynia—pain in the intercostal muscles and their fibrous aponeuroses—a fact which depends on the incessant movements which these muscles are compelled to perform in the act of respiration. And next to this in severity and obstinacy are myalgias of the great muscles which are incessantly engaged in maintaining, by their accurately opposed contraction, the erect position of the spinal column and of the head. This rate of proportional frequency and severity, however, must be taken as strictly relative; i. e., it is correct upon the supposition that the different sets of muscles were equally worked and that the state of nutrition was equal in the different parents. It is otherwise when the conditions are reversed. Thus, the unfortunate cobbler or tailor, who sits for long hours in one cramped and bent posture, is continuously exerting his recti abdominales (probably suffering from an under-nutrition common to all his tissues) to a degree perfectly abnormal, and out of all proportion to the functional work he is getting out of any other part of his muscular system. The consequence is, that he comes to us complaining of acute epigastric, and sometimes pubic, pain, rising to agony when he assumes his ordinary sitting posture, and only reduced to any thing moderate by the most complete extension of the whole trunk in the supine posture.

There is no need to dilate at greater length upon the varieties in the symptoms of myalgia, according as it affects one or another part of the body. We must consider, briefly the different kinds of cause that produce it. The immediate source of the pain being, as we have seen, the sense of embarrassment in a muscle obliged to contract when unfit for the work, we have to ask what are the remoter causes that can produce this special unfitness for the work of contraction. They are three: (a) Overlabor pure and simple (i. e., in proportion to the existing bulk and quality of the muscle); (b) cold, and especially damp cold, producing a semi-paralyzing effect on the vaso-motor nerves, and causing congestion and sometimes a little effusion among the fibres or within the sheath of the muscle; (c) fatty degeneration of muscle which is exposed to inevitable and incessant work. Either of these conditions may so disable the muscle that its unavoidable contractions will set up the myalgic state.

Undoubtedly however there is something further, in the shape of a natural predisposition not yet understood, which makes some patients so much more liable to suffer myalgic pain as a consequence of this sort of influences than other persons are. I am in no condition to decide what the nature of this predisposition is; I feel sure it is heightened by an inherited or acquired gouty taint, but I have seen it in people whom there is no reason to suspect of gouty tendencies. It appears to have no connection with true rheumatism.

Still after all that can be said, myalgia remains a disease chiefly of local origin, and depending for nine-tenths of its causation upon a derangement between the balance of work and nutrition in the muscle.

As regards the diagnosis of myalgia from neuralgia, which is a very important matter, the following are the main points that we should recollect:

Neuralgia.	Myalgia.
Follows the distribution of a recognizable nerve or nerves.	Attacks a limited patch or patches that can be identified with the tendon or aponeurosis of a muscle which, on inquiry, will be found to have been hardly worked.
Goes along with an inherited or acquired nervous temperament, which is obvious.	As often as not occurs in persons with no special neurotic tendency.
Is much less aggravated, usually, by movement than myalgia is.	Is inevitably, and very severely, aggravated by every movement of the part.
Is at first accompanied by no local tenderness.	Distinguished from the first, by localized tenderness on pressure as well as on movement.
Points douloureux, when established at a later stage, correspond to the to the emergence of nerves.	Tender points correspond to tendinous origins and insertions of muscles.
Pain not materially relieved by any change of posture.	Pain usually completely and always considerably relieved by full extension of the painful muscle or muscles.

The treatment of myalgia is not only satisfactory in itself, but often affords, in its results, a very desirable confirmation of diagnosis.

For a very large number of cases, all that is required is (a) to put and keep the affected muscle in a position of full extension, which is only to be changed at somewhat rare intervals; (b) to cover the skin all over and round it with spongio-piline, so as to maintain a perpetual vapor-bath; (c) on the subsidence of the acutest pain and tenderness, to complete the treatment by one or two Turkish baths, to be taken in the manner that I have recommended by speaking of the prophylaxis of neuralgia.

When treatment such as this cures a pain which was greatly aggravated by muscular movement, we may be sure that pain was myalgic and not neuralgic.

The pain, however, is not unfrequently rebellious to such simple remedies as these, more especially when (as in pleurodynia) we are not able to enforce complete physiological rest of the part. When this is the case, we shall find the internal use of twenty and thirty grain doses of muriate of ammonia by far the most effective remedy. In the first very acute stage of a severe case it may be advisable to inject morphia hypodermically; but this is seldom necessary. The muriate-of-ammonia treatment may be usefully accompanied by prolonged gentle frictions, three or four times a day, with a weak chloroform liniment.

When there is visibly a very great deficiency in the general nutrition, we shall often fail to obtain a cure until we have remedied this defect; and accordingly, in the majority of cases of half-starved and overworked needle-women, cobblers, tailors, and the like, who present themselves in the out-patient room, I accompany the above-named treatment with the steady administration of cod-liver oil for three or four weeks or more.

There is one remedy for this pain which I have myself seen used in only a few cases, but which I believe promises exceedingly well for the treatment of obstinate myalgia; viz., acupuncture. I have not even mentioned it as a remedy for neuralgia, for I believe it to be totally useless in true cases of that disease, whether applied in the simple form or in that of galvano-puncture. I think very differently of its use in myalgia; and I venture to believe that it is entirely to cases of this disease that the exceedingly interesting observations of Mr. T. P. Teale, in a recent number of the Lancet, apply. Where (after the usual remedies for myalgia have been applied) we are unable to get rid of a deep-seated and fixed muscular pain, I believe it to be excellent practice to plunge two or three long needles deeply into the muscle near its tendinous attachment.

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CHAPTER II.

SPINAL IRRITATION.

I retain this phrase, not because it is an absolutely good one, but because it has become so familiar that it is difficult to dispense with it. We have taken a useful step, however, in separating the true neuralgias from the somewhat indefinite group of diseases to which this title has been given. I think the reader who has carefully studied Part I. of this work will not deny that the latter disorders present a very clear and definite common outline which distinguishes them essentially from the vaguer affections to be described under the present heading.

Spinal irritation, in my sense, includes all those conditions in which, without any special mental affection, and without any single nerve being definitely affected, there are sensations varying between mere cutaneous tenderness, often of a large and irregular surface, and acute pain approaching neuralgia in character, together with fixed tenderness of certain vertebræ on deep pressure. A very large majority of the phenomena are such as would be popularly included (now that they are known not to be of an inflammatory character) under the term "hysterical." That unhappy word crosses our path at every turn in a most embarrassing manner, and yet it can hardly at present be said that we could afford to do without it.

The more typical cases of so-called "hysterical hyperæsthesia" present the following phenomena: Along with the general symptoms of the hysterical temperament (tendency to causeless depression, variable spirits, sensation of globus, semi-convulsive attacks terminated by the discharge of a great quantity of pale, limpid urine) there is commonly a marked superficial tenderness of the surface everywhere, and an exaggeration of reflex irritability. The general tenderness is so far merely cutaneous that deep pressure is ordinarily borne better than the lightest finger-touch. But besides this there are usually one or several spots in which the tenderness is more profound and genuine. There is almost sure to be some point in the spinal column where firm pressure not merely evokes a complaint of pain, but also induces secondary objective phenomena connected with distant organs, such as nausea and vomiting when the cervical vertebræ are tender, severe gastric pain when the dorsal vertebræ are tender, etc. In such cases there is not only spinal tenderness, but very usually also a well-marked tenderness in the epigastrium and the left hypochondrium, the trepied hysterique of Briquet. The reader must, however, be warned that the whole of these three tender points may be merely myalgic, and it is necessary very carefully to observe whether local movements do or do not seriously aggravate the pain in them. And, on the other hand, the spinal tender point may be merely the "point apophysaire" of a true neuralgia which exhibits no other symptoms of the so-called hysteric constitution.

The kind of hysteria that is joined with the existence of fixed tender spots in definite points of the vertebral column is not commonly distinguished by the occurrence of cutaneous anæsthesia; but those writers are certainly wrong in saying that such a combination never takes place. I have seen examples of the most marked union of the two classes of symptoms in the same person.

These cases of so-called spinal irritation with general hysteric manifestations are very commonly attended with paroxysmal pains that approach true neuralgia in character. Nor is it to be denied that we sometimes meet with the combination of general hysteria, spinal tenderness in definite points (with secondary spasmodic or paralytic phenomena always following pressure exerted on the latter), and true neuralgia limited to one nerve. But the more typical spinal irritation cases are merely complicated with a tendency to vague pains which are shifting both in character and position, not with definite unilateral neuralgia always haunting the same nerve and exhibiting more or less of the same type. In fact, as far as one can judge in the absence of any precise information as to the condition of the nervous centres in such cases, it would seem likely that the ordinary cases of spinal irritation differ from the true neuralgias chiefly in this—that the injury, or inherited weakness of organization, or both, which is at the root of the malady, is at once slighter in degree, and spread over a larger tract of the nervous centres, than that which produces a true neuralgia. I believe that Dr. Radcliffe is right in supposing it to be probable that a blow or other injury to the back producing general spinal shock, is the original but unsuspected cause of a large proportion of these cases. One of the most perfect examples of spinal irritation that I have ever seen (and which also contrasts keenly with the commoner hysteric affections on the one hand, and the true neuralgiæ on the other) was that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds, and Dr. Bridge. This young lady was a most intelligent person, and not in the slightest degree inclined to the apathy and idleness so often seen in hysterical people. She had received what was thought at the time to be a very slight contusion in a railway collision, in which, however, her sister, who was in the same carriage, had been severely injured. She nursed this sister assiduously, and it was not till three or four months later that her own health began to fail seriously; but she then became anæmic and extremely depressed. About six months after the accident it was quite casually discovered that there was a spot over the lowest cervical vertebra, pressure on which gave her exquisite pain and a sensation of extreme nausea; and the very curious observation was made that such pressure instantaneously produced extinction of the right pulse, the left pulse remaining unaltered. In this case it cannot be doubted that a serious shock had been communicated to a lateral segment of the cord involving chiefly the vaso-motor nerve fibres, in which probably some decided material lesion had been gradually set up; and besides this there was probably slighter damage to the spinal cord generally, as there was great general feebleness of movement, though no actual paralysis of the limbs.

Along with the phenomena of fixed spinal tenderness, without distinct neuralgia of any particular nerve, we not unfrequently observe the development of more or less decided tenderness of some of the internal surfaces of the body. I have recently had under my care a young woman in whom a very tender point was developed over the second cervical vertebra, and who suffered from such persistent tenderness of the whole posterior part of the pharynx, that I was for some time seriously apprehensive of the existence of spinal caries and post-pharyngeal abscess. The general character of her symptoms, however, induced me to hope that the case was one of spinal irritation merely, and the event proved that this was the case, for under the use of iron and small doses of strychnia she recovered completely in about three weeks. In another patient who came under my care about twelve months ago, there was extraordinary sensitiveness of the gastric mucous membrane, causing exquisite pain after she had eaten almost any thing: there was only occasional vomiting, however, and there had never been any hæmorrhage, so that the evidence for gastric ulcer, which I otherwise inclined to think existed, was insufficient. I discovered that pressure on the third or the fourth dorsal vertebra gave great pain, and produced a strong inclination to vomit; this made it probable that the affection was spinal, and accordingly all treatment addressed to the stomach was abandoned. Flying blisters to the neighborhood of the painful spinal points quickly relieved all the symptoms.

Another distressing class of symptoms, which is very commonly observed in connection with these cases of spinal irritation, is that of abnormal arterial pulsations: I am not sure whether even severe neuralgia produces more distress than does this pulsation. I have repeatedly seen abnormal pulsation of the carotids in connection with fixed tender-points over the cervical or the upper dorsal vertebræ; and still more commonly pulsation of the abdominal aorta in connection with tenderness over one or two of the upper dorsal vertebræ. Spasmodic cough and spasmodic dyspnœa frequently accompany tenderness of points in the upper half of the spinal column; and in one instance I have seen pressure on the lowest cervical vertebræ produce a paroxysm which looked alarmingly like angina pectoris. A case of singularly prolonged and obstinate spasmodic hiccough which came under my notice was distinguished by the presence of a fixed tender spot over the third dorsal vertebra.

Prolonged spastic contraction of voluntary muscles, going on, sometimes for weeks, and even months, is a phenomenon that has often been observed; it may attack the arm only, or may affect all the limbs, and the muscles of the trunk and of the neck: it is for the most part symmetrical, but is occasionally unilateral. It begins in the extremities, and is very commonly limited to them; it is much more gentle than tetanic spasm, and is also painless, or nearly so; but the contraction is often strong enough to resist very vigorous efforts at artificial extension.

Paralyses, both of bowel and bladder, have been recorded among the occasional phenomena of spinal irritation with fixed tender points; but I cannot say that I have ever seen such an occurrence. On the whole, I must say that by far the most frequent phenomena of spinal irritation that I have seen have been somewhat diffuse cutaneous or mucous tenderness and irritability (without acute pain) and the presence of tormenting arterial throbbings; also a marked tendency to aggravation of some symptoms, especially the gastric, when firm pressure is made upon the tender spinal points. For a further and fuller account of the phenomena of spinal irritation I may refer the reader to the able article of Dr. Radcliffe,[48] and the work of the brothers Griffin, already quoted; adding the suggestion, however, that both these authorities, and especially the Griffins, appear to me not to draw a sufficiently clear distinction between the class of cases that I have been attempting to describe and the true neuralgias.

After what has been said, there is no need to draw out a formal list of the points of diagnosis between spinal irritation and neuralgia. It must be admitted, moreover, that the two forms of diseases have a strong connection in the fact that they are each of them most frequently developed in the descendants of neurotic families. It is by the more generalized character of the symptoms, and the absence of the tendency to perpetual recurrence of paroxysmal pain in one definite nerve, that spinal irritation is mainly distinguishable from true neuralgia. I may add that there is a marked distinction, also, in the results of treatment.

The treatment of spinal irritation is, it must be confessed still in an unsatisfactory position; and I believe that a good deal of unnecessary discouragement has been occasioned to physicians by their failures to cure supposed neuralgias which really belonged to the spinal irritation class. I would assuredly by no means assert that genuine neuralgia is not frequently intractable, or even incurable; but it is certainly much more curable than spinal irritation; and for this reason, mainly as I believe—that there is much more possibility of aiming our remedies at the actual seat of the disease. On the other hand, in spinal irritation we are confused and distracted with a variety of phenomena for which even the most subtle analysis will frequently fail to trace a common origin. It is true that the existence of definite tender spots in the spine apparently suggests a strictly local application of remedies; and it true also that medication based upon this fact is sometimes very effective; but this is, in my experience, only an occasional result, and the practitioner who trusts to local measures will frequently be disappointed. And, on the other hand, the general tonic treatment, and the use of special medicines, like quinine and arsenic, or the hypodermic injection of morphia oratropia, have nothing like the extensive utility in the treatment of spinal irritation that they possess in that of true neuralgia. Of internal remedies, by far the most useful in my hands have been sesquichloride of iron with small doses of strychnia, and the milder vegetable bitters, especially calumba.

There is one special phase, however, of spinal irritation which is very amenable to the direct, treatment, viz., cutaneous and mucous tenderness. Whatever the "hyperæsthetic" part is within reach, so that we can apply Faradization, we can almost certainly eradicate the morbid sensibility very quickly. The secondary current of an electro-magnetic or volta-electric induction apparatus is to be employed; the conductors should be of dry metal and the negative one, which is to be applied to the painful surface, should be in the form of the wire brush. The positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backward and forward over the sensitive skin, a pretty strong current being employed. The process is painful so much so that it will often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the Faradization. A very few daily sittings of four or five minutes length will generally remove the morbid tenderness completely. Where the tender part is within one of the cavities, at the rectum, bladder, vagina, or pharynx, we must of course use a solid negative conductor of appropriate form, and must content ourselves with applying it steadily to one point after another of the sensitive surface.

The fact that Faradization proves so remarkably useful, in these cases of spinal irritation with diffuse cutaneous or mucous tenderness, is in itself a strong diagnostic between this sort of affection and the true neuralgiæ, which, as I have stated are seldom benefited, and are often made worse, by the interrupted current, though the constant current frequently mitigates or cures them.

Sometimes where it is not possible to apply the remedy directly to the sensitive surface, we may nevertheless do great good by sending the interrupted current through it. Thus, in gastric sensitiveness connected with spinal tenderness in the upper dorsal region, I have seen very great relief afforded by sending a current from the positive pole, placed on the tender vertebræ, to a broad, negative conductor placed on the epigastrium. And similarly, I have seen an acutely sensitive condition of the neck of the bladder greatly soothed by the passage of a current from a painful lumbar vertebra to the perinæum immediately behind the scrotum.

Undoubtedly, however, the more serious cases of spinal irritation will yield only (if they yield at all) to a prolonged treatment in which very skilful use is made of general hygienic measures, and especially of morbal influences. As the brothers Griffin long ago pointed out, although rest is useful in the early stages of this malady, if the disease does not quickly yield to this and to appropriate tonic medication, and perhaps local applications to the spine, it will not do to keep the patient recumbent and confined to the house; on the contrary at whatever cost of immediate discomfort, he (or she for these patients are by far the most frequently females) must be roused up, and persuaded or compelled to take out-door exercise, and if possible to travel, and divert the mind by complete change of scene. When such expensive remedies are out of the question, it seems better that patients, even seemingly very feeble, should take to their ordinary avocations in life again, and fight down the tendency to invalidism. But of course, the decision on such a point must rest with the tact and judgment of the practitioner in each individual case, for there are, doubtless, instances in which the attempt to carry out such a plan, even moderately, would break down the remaining strength, and make matters worse than they were before.

In the worse case of spinal irritation that I ever saw, that of a young lady, aged twenty-eight, there were pronounced anæmia and general feebleness, the true hysteric trepied of tender points, painful irritability of the stomach, which baffled all medical advisers and resisted almost every possible form of tonic and nervine medicines, counter-irritation to the spine, and, in fact every thing that one dared attempt with so feeble-looking a patient, but at once cleared up and was quite cured after marriage. And there can be no question that a very large proportion of these cases in single women (who form by far the greater number of subjects of spinal irritation) are due to this conscious or unconscious irritation kept up by an unsatisfied sexual want. In some patients there cannot be a doubt that this condition of things is indefinitely aggravated by the practice of self abuse; but it would be most unjust to think that this is a necessary element in the causation; on the contrary, it is certain that very many young persons (women more especially) are tormented by the irritability of the sexual organs without having the least consciousness of sensual desire, and present the sad spectacle of a vie manquee without ever knowing the true source of the misery which incapacitates them for all the active duties of life. It is a singular fact, that in occasional instances one may even see two sisters inheriting the same kind of nervous organization, both tormented with the symptoms of spinal irritation, and both probably suffering from repressed sexual function, but of whom one shall be pure-minded and entirely unconscious of the real source of her troubles, while the other is a victim to conscious and fruitless sexual irritation.

I have already causally alluded to the danger of mistaking mere myalgia for spinal irritation and must again enforce this consideration upon the reader. Myalgic tender points in the region of the spine are common enough; and it would be easy without careful attention, to mistake them for the deeper-seated vertebral tenderness which is truly characteristic of spinal irritation. Hence the utmost care must be taken to ascertain the true history of the commencement of the disorder whether it succeeded to great and long continued fatigue of particular sets of muscles, and whether it is specially aggravated by contractions of those muscles, and relieved by their full extension. The differences of treatment which depend on the diagnosis are too obvious to need dwelling upon.

The question of administering remedies with the direct intention of procuring sleep, for patients suffering from spinal irritation, often becomes an important and a very difficult one. It is, for the most part, highly objectionable to commence the use of such remedies; and yet sleeplessness is a very distressing symptom with many patients, and is, of course in itself exhausting and deleterious. For as long as we possibly can, we should content ourselves with efforts to produce sleep by the timely administration of nourishment. The same general rule of a very generous (though not very stimulating) diet to be enforced as carefully as in the case of sufferers from neuralgia. But it is especially advisable in spinal irritation; that the patient should take some food shortly before bedtime; and it is well, also to place food within reach at the bedside, so that if he wakes up he may take some. If, however, we are absolutely driven to employ hypnotics, we must commence with the very mildest. The popular remedy of a pillow stuffed with hops will sometimes suffice; and a better way of administering the volatile principle of hops is to scatter a few hops on hot water in an inhaler, and let the patient breathe the steam. Hot foot-baths, with mustard, are also very useful. If these fail, chloral, in moderate doses is probably the best and safest remedy, and, with care not to give too much, we may go on using the same dose without increase for a good many times.

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CHAPTER III.

THE PAINS OF HYPOCHONDRIASIS.

There is perhaps nothing, in the whole range of practical medicine, more difficult to seize with clear comprehension, and picture to the mind with accuracy, than the group of pseudo-neuralgiæ which belong to the domain of hypochondriasis. They are among the most indefinable, and at the same time the most intractable, of nervous affections.

To understand what hypochondriac pains are, we must first be familiar with the general character of the hypochondriacal temperament, for the pains are only a subordinate and ever-varying phenomena of the general disease.

Hypochondriasis is not insanity, if by insanity we mean intellectual perversion dependent mainly or entirely on the state of the higher nervous centres. But it is closely allied to insanity in its phenomena, only that these are, as it were, manifested in a scattered form, unequally distributed over the whole central nervous system, and especially affecting the spinal sensory centres. And its radical relationship to true insanity is strongly indicated by the fact that the sufferers from hypochondriasis are nearly, if not quite, always members of families in which distinct insanity has shown itself; indeed, more often than not, of families which have been strongly tainted in this way. In the majority of instances there are psychical peculiarities of a marked kind which accompany or precede the development of the abnormal sensations which form the especial torment of hypochondriacs. Without apparent cause, they begin to evince a heightened self-feeling and an anxious concentration of their thoughts upon the state of one or more of their bodily organs. Or it may be that, before any such definite bias is given to their thoughts, they simply become less sociable and more self-centred, and are subject to fits of indefinite and inexplicable depression, or at least to great variability of spirits. But before long they begin to experience definite morbid sensations, most commonly connected with the digestive organs, and very often accompanied by positive derangement of digestion of an objective character; such as flatulence, sour eructation, spasmodic stomach-pain, etc. Along with these phenomena, or soon afterward (and not unfrequently before the patient has acquired that intensity of morbid conviction of his having some special disease which is afterward so marked a peculiarity of his mental state), he very often becomes the subject of the kind of pains which it is the special purpose of this chapter to describe.

The pains of hypochondriasis, when they assume any more definite form than that of mere dyspeptic uneasiness, present many analogies with neuralgia. They are not, usually, periodic in any regular manner, but they have the same tendency to complete intermission, and they frequently haunt some one or more definite nerves for a considerable period of time. Of all nerves that are liable to this kind of affections the vagus is undoubtedly the most susceptible; hypochondriac patients very frequently complain of pseudo-anginoid and pseudo-gastralgic pains; next in frequency are nervous pain in the region of the liver, or in the rectum or bladder. The main distinctions by which they are separable from true neuralgia are two: in the first place, the character of the pain nearly always is more of the boring or burning kind than of the acutely darting sort which is most usual in true neuralgia; and, secondly, the influence of mental attention in aggravating the pain is far more pronounced than in the latter malady; indeed, it is often possible, by merely engaging the patient in conversation on other topics, to cause the pain to disappear altogether for the time. But in hypochondriasis it is not often that we are left, for any long time, to these means of diagnosis only; the special character of the disease is that the morbid sensations shift from one place to another, in a manner that is quite unlike that of the true neuralgias. The patient who to-day complains of the most severe gastralgia, or liver-pain, will to-morrow place all his sufferings in the cardiac region, or in the rectum, or will complain of a deep fixed pain within his head; and these changes are often most rapid and frequent. Frequently there are also peculiar skin sensations, which usually approach formication in type, and these, like the pains, are apt to shift with rapidity from one part of the body to another. Later on in the disease, especially in those worst cases which approach most closely to the type of true insanity, there are often hallucinations of a peculiar and characteristic nature, such as the conviction of the patient that he has some animal inside him gnawing his vitals, that he is made of glass and in constant danger of being broken, and a variety of similar absurdities. In short, it is not the fully-developed cases of hypochondriasis that need puzzle us, these are usually distinct enough; but the earlier and less characteristic stages in which pain may be nearly the only symptom that is particularly prominent.

In hypochondriasis, as in hysteria, there is often great sensitiveness of the surface; and, as in hysteria, this sensitiveness is found to be very superficial, so that a light touch often hurts more than firm, deep pressure. As in hysteria, too, the tenderness is a phenomenon so greatly affected by the mind, that, if we can divert the patient's attention for a moment, he will let us touch him anywhere, without noticing it at all.

It is a marked peculiarity of hypochondriasis that it is far more common in men than in women; a relation which is precisely the opposite to that which rules in neuralgia. Hypochondriasis is also pre-eminently a disease of adult middle life; it is scarcely ever seen in youth, except as the result of excessive masturbation acting on a temperament hereditarily predisposed to insanity.

The results of treatment frequently assist our diagnosis in difficult cases. Almost any medicine will relieve the pains of the hypochondriac for a time, and it is generally far easier to do him good, temporarily, than it is to relieve a neuralgic patient; but, en revanche, every remedy is apt to lose its affect after a little while. The only chance of producing permanent benefit in hypochondriasis is by the judicious combination of remedies that remove symptoms (especially dyspepsia, flatulence, etc.), which mischievously engage the patient's mind, with general tonics, and, above all, which such alterations in the patient's habits of daily life as take him out of himself and compel him to interest himself in the affairs of the world around him. And, after all, our best efforts will frequently lead to nothing but disappointment.

It is notoriously the fact that hypochondriasis especially affects the rich and idle classes; but it would be a great mistake to suppose that it never attacks the poor or the hard-worked: only, in the latter instances, it apparently needs, for it development, the existence of strong family tendencies to neurotic disease, and especially to insanity. Among the numerous debilitated persons who attend the out-patient rooms of our hospitals we every now and then encounter as typical a case of hypochondriasis as could be found even among the rich and gloomy old bachelors who haunt some of our London clubs. I have one such patient under my care now, who has been a repeated visitor at the Westminster Hospital during many years: he has had pseudo-neuralgic pains nearly everywhere at different times; but his most complaint has been of pain in the groin and scrotum of the right side. The existence of what seemed, at first, like the tender points of lumbo-abdominal neuralgia, at one time led me to believe it was a case of that affection; but I was soon undeceived by finding that the tenderness did not remain constant to the same points, but shifted about. This man has professed, by turns, to derive benefit from nearly all the drugs in the Pharmacopœia; but the only remedies that have done him good, for more than a day or two at a time, have been valerian and assafœtida, with the prolonged use of cod-liver oil. He will never be really cured; and I suspect that the secret of his maladies is an inveterate habit of masturbation acting on a nervous system hereditarily predisposed to hypochondriasis.

Sometimes it happens that the starting-point of hypochondriac pains, simulating neuralgia, is a blow, or other bodily injury acting on a predisposed nervous system. Another of my patients at the Westminster Hospital was a policeman, who had received a severe kick in the groin; he suffered pains which at first seemed to wear all the characters of true neuralgia in the pudic nerve, but afterward shifted to other places and exhibited all the intractability of hypochondriasis; the patient also developed the regular appearance and the characteristic hallucinations of the latter disease. On the last occasion when I saw him, he struck me as likely to become really insane, in the melancholic form; and the probability is that the casualty which he suffered was only accidentally the starting-point of a malady which was inherent in him since birth, and would have been developed, in any case, at some period of his life.

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CHAPTER IV.

THE PAINS OF LOCOMOTOR ATAXY.

Considering the vast amount that has been written about this disease during the last few years, it might be thought superfluous for me to give any description of its general features. But it unfortunately happens that there is still great divergence of opinion among authorities as to the true limitation of the group of cases that can properly be ranked under this title, and, indeed, as to the propriety of employing the title at all. The phrase ataxie locomotrice progressive, as every one knows, was applied by Duchenne de Boulogne to a class of cases which really only form a subdivision of the group known under the older title of tabes dorsalis and the most advanced German pathologists maintain that the old word was better, and that Duchenne was altogether wrong in making the one symptom, ataxy of locomotion, the bases of a new phraseology;[49] more especially as his theory as to the seat of the morbid changes was undoubtedly erroneous.

In this country, however, there is as yet no disposition to give up the phrase locomotor ataxy, and it only remains to define with sufficient care the class of cases to which the word is here meant to apply. The disease is understood to depend upon a degeneration of the spinal cord, of which the following description is given by Lockhart Clarke:[50] "In true locomotor ataxy, the spinal cord is invariably altered in structure. Its membranes, however, are sometimes apparently unaffected, or affected only in a slight degree; but generally they are much congested, and I have seen them thickened posteriorly by exudations, and adherent, not only to each other, but to the posterior surface of the cord. The posterior columns, including the posterior nerve-roots, are the parts of the cord which are chiefly altered in structure. This alteration is peculiar, and consists of atrophy and degeneration of the nerve fibres to a greater or less extent, with hypertrophy of the connective tissue, which give to the columns a grayish and more transparent aspect; in this tissue are embedded a multitude of corpora amylacea. Many of the blood vessels that travel the columns are loaded or surrounded to a variable depth by oil-globules of various sizes. For the production of ataxy, it seems to be necessary that the changes extend along a certain length, from one to two inches of the cord. The posterior nerve-roots, both within and without the cord, are frequently affected by the same kind of degeneration, which sometimes extends to the surface even of the lateral columns, and occasionally along the edges of the anterior. Not unfrequently the extremity of the posterior cornua, and even deeper parts of the gray substance, are more or less damaged by areas of disintegration. The morbid process appears to travel from centre to periphery, that is, from the spinal cord to the posterior roots. In the cerebral nerves, on the contrary, the morbid change seems to travel in the opposite direction, that is, from the periphery toward the centres. From the optic nerves it has been found to extend as far as the corpora geniculata, but seldom as far as the corpora quadrigemina. With the exception of the fifth, seventh, and eighth pair, all the cerebral nerves have occasionally been found more or less altered in structure."

The symptoms which occur in cases in which the above are the morbid appearances found after death are (roughly speaking) as follows:[51] "A peculiar gait, arising from want of co-ordinating power in the lower extremities, a gait precipitate and staggering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step."

No true paralysis in the lower extremities or elsewhere. Characteristic neuralgic pains, erratic paroxysmal in the feet and legs chiefly—pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock.

More or less numbness, in the feet and legs chiefly, in all forms of sensibility, excepting that by which differences of temperature are recognized.

Frequent impairment of sight or hearing, one or both.

Frequent transitory or permanent strabismus or ptosis, one or both.

No very obvious paralysis of the bladder or lower bowel.

No necessary impairment of sexual power.

No tingling or kindred phenomenon.

No marked tremulous, convulsive, or spasmodic phenomena.

No marked impairment of muscular nutrition and irritability.

No impairment of the mental faculties.

Occasional injection of the conjunctivæ, with contraction of the pupils.

The probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities.

The above description includes all the necessary facts for the recognition of the disease, except one, namely, that the use of the eyesight is always needed in order to prevent the patient from falling during progression; and is usually necessary even to enable him to stand upright without falling.

The pains of locomotor ataxy are early phenomena in most cases, and they are usually present, more or less, throughout the course of the disease.

They are often preceded by strabismus, with or without ptosis; the strabismus, is usually accompanied by amblyopia. It may happen, however, that neuralgic pains are, for a considerable time, the only noticeable phenomena; or they may be attended with a certain amount of anæsthesia.

The most frequent type of the pains is lancinating or stabbing; they are like violent neuralgias occurring successively in various nerves; shifting about from one to another. Sometimes it will happen that the pain remains fixed to one particular nerve for hours together; but it never continues long without showing the characteristic tendency to move about. Most commonly our diagnosis is soon assisted by the occurrence of a greater or less degree of ataxy. But, even before the setting in of definite atactic symptoms, the shifting character of the pains, and the development of a very noticeable amount of anæsthesia, together with the absence of anything like positive motor paralysis, will have given us the necessary clew.

The effect of treatment, or rather its want of effect, usually affords powerful assistance in distinguishing the pains of locomotor ataxy from those of true neuralgia. Even where the pain has been fixed for some hours in a single nerve, and has been stopped by some powerful remedy (such as hypodermic morphia), it will be apt speedily to recur, and frequently in some quite distant nerve.

Locomotor ataxy is a disease affecting chiefly the male sex, and occurring in the immense majority of cases between the thirty-fifth and the fiftieth year.

Not merely is it strictly limited to individuals who belong to families with neurotic tendencies, but it is itself frequently seen to occur in several members of the same family, and sometimes of the same generation. When, therefore, we meet with neuralgic pains of the shifting type above described, it is very important at once to make careful inquiries whether any members of the family have suffered from symptoms of ataxy going on to a fatal result. Otherwise, we might be the more readily deceived into the idea that the pains were merely neuralgic, because the symptoms of the disease are not unfrequently provoked by such causes as fatigue and exposure to cold or wet, which are also very ordinary exciting causes of true neuralgia.

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CHAPTER V.

THE PAINS OF CEREBRAL ABSCESS.

Cerebral abscesses is, fortunately, a rare disease; but the very fact of its rarity makes the resemblance of the pain it causes to that of neuralgia the more likely to lead us into serious errors. We are apt to forget the possibility of suppuration of the brain on account of its infrequence.

Pain in the head is present as an early symptom of abscess in the brain in a large proportion of cases in which there is pain at all. [Of seventy-five cases of cerebral abscess analyzed by Gull and Sutton (Reynolds's "System of Medicine," vol. ii.), pain was a symptom in thirty-nine, and most frequently an early symptom.] Many cases are recorded in which it preceded every other morbid sign by a considerable period. It is usually more or less paroxysmal, often strikingly so; in the latter case, it bears a great similarity to neuralgia. On the other hand, it sometimes takes the shape of a fixed burning sensation, much less resembling neuralgia. The situation of the pain by no means always, nor even usually, corresponds to the situation of the cerebral abscess; on the contrary, abscess in the cerebellum has often caused pain referred to the anterior part of the head, and so on. So long as the disease remains characterized only by pain, more or less, of a paroxysmal character, the diagnosis must be very uncertain; but in the great majority of cases certain more distinctive symptoms soon become superadded; either convulsions (sometimes hemiplegic), vertigo, coma, paralysis, vomiting, or a combination of some of these.

In the stage in which there is as yet no conspicuous symptom but severe pain, the diagnosis of cerebral abscess from neuralgia must rest on the following points of contrast:

Cerebral Abscess.	Neuralgia of Head.
Often occurs secondarily to caries of internal ear, and purulent discharge the result of scarlet fever, measles, etc., in childhood.	Rarely appears before puberty.
Frequently follows a blow or injury.	Comparatively seldom caused by blow, or other external injury or caries of bone.
No true "points douloureux."	If severe, soon presents, in most cases, the "points douloureux."
Usually the pain does not completely intermit.	Intermissions of pain complete, and of considerable length.
Pain often excruciating from a very early period.	Pain usually not very violent at first.
Pain often limited in situation, seems deep-seated, though, as often as not, it has no relation to the site of the abscess.	Pain superficial; follows distribution of recognizable nerve-branches belonging to the trigeminus or the great occipital.
No well localized vaso-motor or secretory complications.	Usually there are lachrymation, congestion of conjunctiva, or other vaso-motor and secretory complications, such as are described in Chapter III.
Very rare in old age; then usually traumatic.	Severe and intractable neuralgia is commonest in the degenerative period of life.
Relief from stimulant narcotics very transitory.	Relief from opium, etc., is much more considerable and permanent.

The only case of cerebral abscess that I have personally seen, in which the above points of distinction would have been insufficient, was that of a boy of sixteen, in whom the only discoverable symptom, for nearly three months, was pain, very strongly resembling ordinary migraine, recurring not oftener than once in ten days or a fortnight, lasting for some hours at a time, and nearly always ending in vomiting, and disappearing after sleep. At the end of the three months, acute pain in the left ear set in, and this was followed, soon, by right hemiplegia, coma, and death. It was then discovered, although it had formerly been denied, that the boy had suffered from discharge from the left ear, following a febrile attack which had been marked by sore-throat, and followed by desquamation of the cuticle—evidently scarlet fever. In all cases of severe pain in the head, it is a golden rule to inquire most carefully as to the possible existence, present or past, of discharge from the ear, or other signs of caries of the temporal bone; and, even if no positive history of this kind be given, we should still regard with great suspicion any case in which there has been scarlet fever followed by deafness.

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CHAPTER VI.

PAINS OF ALCOHOLISM.

A very important class of pains, which are occasionally confounded with true neuralgias, are those which occur in certain forms of chronic alcoholism. The diagnosis of their true nature is a matter of the utmost consequence, and the failure to recognize them for what they are may have very disastrous results. It is a curious fact that this consequence of chronic alcoholic poisoning has been entirely overlooked by some of the best known writers on that affection; it has, however, been described by Mr. John Higginbottom, and also by M. Leudet.

It must be clearly understood that the pains of which we are now to speak are not among the common consequences of chronic excess in drink. The affections of sensation which most usually occur in alcoholism take the shape either of anæsthesia, or of this combined with anomalous feelings partaking more or less of the character of formication. Chronic drinking has also a tendency, in its later stages, when the nutrition of the nervous centres has been considerably impaired by the habit, to set up true neuralgia, of a formidable type, in subjects who are hereditarily predisposed to neuroses. But the affection of which I now speak may occur at any stage except the very earliest, and, though often severely painful, is essentially different both in its seat and in its general characters, from neuralgia proper.

The earliest symptoms from which the patient usually suffers in these cases are insomnia, and intense depression of spirits, which, however, is not incompatible, indeed is frequently combined, with a morbid activity and restlessness of thought. There is generally marked loss of appetite, but often there is none of the morning nausea so characteristic of the common forms of alcoholism. Nor is there, ordinarily, any special unsteadiness of the muscular system. The pains are usually first felt in the shoulder and down the spine; but as the case progresses they especially attack the wrist and ankles; and it is in these latter situations that I have found them to be most decidedly complained of. Their similarity to neuralgia consists (a) in their somewhat paroxysmal character; (b) in their frequently recurring at about the same hour of the day, most commonly toward night; and (c) in their special aggravation by bodily and mental fatigue.

Their differences from neuralgia are—(a) that they never follow the course of a recognizable single nerve; (b) that they are nearly always present in more than one limb, and usually in both halves of the body, at the same time; and (c) especially, that they are far less promptly and effectually relieved by hypodermic morphia than are the true neuralgias; indeed, opiates very frequently only slightly alleviate the pain, while they excite and agitate the patient and render sleep impossible. On the contrary, a large dose of wine or brandy will never fail to procure temporary comfort and induce sleep, at least until the patient reaches an advanced stage of the disorder, and is, in fact, on the verge of delirium tremens.

I am not quite sure that I am right in believing that there is a special physiognomy for this form of chronic alcoholism, and yet I am much inclined to believe that there is. All the patients whom I have seen suffering with it have presented a peculiar brown sallowness of face, and a general harsh dryness of the skin, which has usually lost its natural clearness, not only in the face, but even more remarkably in the hands, which are so dark-colored as to appear as if they were dirty. There is usually considerable leanness of the limbs, and, though the abdomen may be somewhat prominent, this does not seem to depend much on the presence of fat, but rather on relaxation of the abdominal muscles, and sometimes flatulent distention of the stomach and intestines. The hands are usually hot, sometimes quite startlingly so.

Some of the patients suffer, besides the pains in the limbs (which they often describe as resembling the feeling of a tight band pressing severely around the ankles or wrists), from frequent or occasional attacks of genuine hemicrania; such a combination is to me always a suspicious sign, and induces me immediately to direct my attention to the possibility of chronic alcoholic poisoning. Otherwise, the limb-pains are often spoken of as resembling rheumatism, but there is no swelling of joints, and usually no decided tenderness of the painful parts. The patient has usually a particular worn and haggard appearance, complains of intense fatigue after the most moderate muscular exertion, and is usually utterly indisposed to physical exercise even though the mind, as already said, may display a feverish activity.

So far as I have seen, the subjects of this affection are by far the most frequently women; and I am inclined to attribute this predisposition of the sex not to inherent peculiarities of female organization, but to the fact that a much larger proportion of intemperate women than of intemperate men indulge in secret excess. They never get drunk, probably, but they fly to the relief of alcohol upon every trivial occasion of bodily or mental distress; and this habit may have been going on for years before it comes to be suspected by their friends or their medical attendant. Meantime, they have been more or less looked upon, and have looked upon themselves as, "debilitated" and "neuralgic" subjects, and have come, either with or without mistaken medical advice, to consider free stimulation as the proper treatment for the very ailments which have been produced by their own unfortunate habits. I cannot avoid the expression of the misgiving, that imperfect diagnosis, and consequent erroneous prescription, have done great harm in many such cases. It has happened to me no less than three times within the last six months to be called to lady patients, all suffering from alcoholism induced by a habit of taking stimulants for the relief of so-called neuralgic pain; and in the most distressing of these the mischief had been greatly aggravated by a prescription of brandy, based on the erroneous idea that the pains were truly neuralgic. I have already protested against this kind of medication, even in cases that are truly neuralgic in character; but it is doubly mischievous where given for a state of things which actually depends on alcoholic excess.

It is undoubtedly very difficult, sometimes, to elicit the truth, even in cases where we may entertain considerable suspicion that alcoholic excesses are the real cause of the pains which the patient calls neuralgic; more especially where the patient is aware that he or she is taking an amount of alcohol which is seriously damaging to health. And it is therefore necessary to look out for every possible additional help to our diagnosis. Besides the cardinal features of the disease—the insomnia, loss of appetite, foul breath, haggard countenance, and pains encircling the limbs near the joints rather than running longitudinally down the extremities there are certain moral characteristics of the patient that often tells a significant tale. The drinker, especially if a woman, is shifty, voluble, and full of plausible theories to account for this and the other phenomenon. It will be well to try the effects of a somewhat sudden though not uncourteous remark, to the effect that the diet should be strictly unstimulating. If this be introduced with some abruptness, in the course of a conversation not apparently leading to it, the patient's manner will not unfrequently betray the truth; while, if our suspicions are groundless, we shall also probably perceive that, in the unconscious, or frankly surprised, expression of the countenance. We may sometimes derive crowning proof of the existence of alcoholic excess by cautious questions which at least reveal the fact that the patient suffers from spectral hallucinations; this is a far commoner occurrence in chronic alcoholism than is generally supposed; it needs to be inquired for with great tact, but, when established beyond doubt, and joined to insomnia and the peculiar foul breath, is of itself sufficient to establish a positive diagnosis of alcoholic poisoning.

The results of treatment, in true neuralgia and in alcoholic pains, respectively, establish an important difference between these affections. In the former malady, for instance, the hypodermic injection of morphia always produces striking palliative, and very often curative effects. In alcoholic pains this remedy either affords only trifling relief, or more commonly aggravates the malady by increasing the general nervous excitement; and the only true treatment is at once to suspend all use of stimulants, to administer quinine, and to insist upon a copious nutrition. If any hypnotic must be employed, let it be chloral, or bromide of potassium with cannabis Indica. It will be well also to put the patient upon a somewhat lengthened course of cod-liver oil. There is one special symptom from which the chronic alcoholist often suffers acutely, namely a hypersensitiveness to cold; for this I found the use of Turkish bath two or three times a week, for three or four weeks, very useful in one case that was under my care. It will be important to insist that the patient shall take the bath only after that shorter method which I have described in speaking of the prophylaxis of true neuralgia.

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CHAPTER VII.

THE PAINS OF SYPHILIS.

Syphilis, as has already been shown in Part I. of this work, may excite true neuralgia in subjects already predisposed to the latter. The case of Matilda W., previously given, is an example. The pains, however, which are now to be described, are those which occur in the ordinary course of a constitutional syphilitic infection, and have nothing to do with neuralgia proper, from which they should be carefully distinguished.

There are two varieties of syphilitic pains proper, which are quite distinct. The first kind is represented by the so-called dolores osteocopi, which occur in the early stages of the constitutional affection, coincidently with, or just before, the secondary skin-eruptions. The second kind are those which occur in the tertiary stage, and are the immediate precursors of the formation of periosteal nodes.

It is the first of these varieties of syphilitic pains which is least commonly confounded with neuralgia. The pain is referred to the superficial bones, of which those most frequently attacked are the forehead, sternum, clavicle, ulna, and tibia, pretty much those selected for the growth of nodes at a later stage of the disease. Besides the bones, the shoulders, elbows, and nape of the neck are attacked sometimes simultaneously, sometimes successively. The pains are readily controlled by proper treatment; if untreated, their course is very uncertain. When they manifest themselves at the outset of the disease, they usually cease when the cutaneous eruption is fairly out. Commonly, there is no swelling or heat at the painful places; but, when the pains are very severe, nodes now and then form at this early period.[52]

These early syphilitic pains, in their violent aching character, and their intermittence, occasionally resemble true neuralgia very closely; but they are usually distinguished from it by their symmetrical disposition and by their attacking several bones at once. Moreover, they nearly always show the peculiarity of being distinctly aggravated by the warmth and repose of bed even if they be not altogether absent (as is not unfrequently the case) when the patient is up and moving about. A typical case of this kind is not so likely to be confounded with neuralgia as with rheumatism; but we occasionally meet with cases in which the pains are localized in a manner much more resembling the former. Thus I have met with several instances in which a patient, entirely unconscious (or professing to be unconscious) of having been syphilized, complained of violent pain in one tibia, recurring every night at a certain hour, and at first undistinguishable from that variety of sciatica in which the pain is principally felt in this situation, especially as it was relieved by firm pressure, just as neuralgia is in the early stages. And in one remarkable case, which came under my care at Westminster Hospital, the resemblance to clavus was most misleading:

H. A., aged nineteen, worker in a laundry, presented herself on account of a violent pain in the right parietal region, recurring three times daily with great regularity. The first two attacks occurred in the day-time, the third, which was always the severest, woke her out of sleep about midnight; the pain of this last was so agonizing that on more than one occasion she had become delirious. The girl (whose respectable appearance was against the notion of syphilis) was very anæmic; not, however, with the tint either of anæmic from hæmorrhage, or with that of chlorosis, exactly. It was rather a dirty sallowness of skin; but the gums and the conjunctivæ were exceedingly bloodless, and she complained of almost constant noises in the head. Menses scanty but regular. There was a soft anæmic bruit with the first sound at the base of the heart. Having failed to make any impression on the pains with iron and with muriate of ammonia in large doses, I was led to observe the fact that there was no diffuse soreness of the scalp, such as very commonly occurs in clavus, in the intervals of the pains, and the mere fact that there was this unusual circumstance in the case led me to reconsider the diagnosis thoroughly. In order to be sure of not omitting a point, I inquired, though without any expectation of an affirmative answer, as to the possibility of syphilitic disease; the girl at once confessed to having had sores, and examination detected a papular rash about the shoulders and back and on both thighs. Small doses of mercury greatly relieved the pain within a week, and cured it in less than three weeks; and it was very remarkable that the anæmia, which had obstinately refused to yield to iron, improved at once as the mercury began to relieve the pains. The eruption disappeared simultaneously.

It is the later pains of syphilis, however, that are most frequently confounded with neuralgia, and occasionally with very disastrous results. These pains, which are the precursors of the formation of true nodes, frequent the same localities as those affected by the earlier pains; they may exist in considerable severity for days, or even for many weeks, before any node-formation can be detected. The situation in which, of all others, they are likely to be mistaken for neuralgia is the scalp or face, especially when a single spot is affected on one side, and in the situation of one of the usual foci of trigeminal or occipital neuralgia. I have personally known the mistake to be made with syphilitic affections causing pain, respectively, in the superciliary region, in the malar bone, the jaw near the mental foramen, and the parietal eminence.

The possibility of mistaking tertiary syphilitic pain for neuralgia is fraught with such grave dangers, that we ought to be constantly and most vigilantly on the watch against it. But most especially is this the case when the pain is situated in some part of the cranium, as the parietal or temporal eminences, the mastoid process, or the prominences of the occipital bone. For it must be remembered that the same process, which forms syphilitic nodes upon the external surface of bones, or within bony canals, can produce them on the lining membrane of the skull, with most serious consequences, should the symptoms be neglected or misunderstood.

The pains produced by nodes upon the internal surface of the cranium are usually of a very intense character, and are mostly continuous, though aggravated from time to time, especially at night. Where syphilitic inflammation is diffused over a considerable portion of the meninges, it is certain very quickly to produce symptoms which can hardly fail to apprise us of the gravity of the affection; there will be decided and rapidly increasing impairment of memory, and general cloudiness of intellect, tending toward complete imbecility, the special senses will be greatly interfered with or lost, and muscular paralysis will be developed. But in the case of a more limited syphilitic affection of the dura mater, pain, of the kind already described, may be for some days the only very noticeable symptom. The following is an instance:

J. E., aged forty-seven, a street and tavern singer, applied to me (November 14, 1861), on account of severe pain in the right temporal region, which had on the whole the character of neuralgia, though rather more continuous than such pain usually is. He said that it commenced on the 10th, without any particular provocation that he knew of, and that it had hardly left him at all from that moment. It kept him awake at night, and that circumstance seemed to account sufficiently for a very worn and depressed look which he presented; he was otherwise a robust-looking man, and at first denied having suffered from any previous illness. The pain always came to a climax about one o'clock, a. m., waking him out of his first sleep in agony, and allowing him little rest for the remainder of the night; toward morning he would drop to sleep for an hour or so. There was no particular tender point, corresponding to any recognized neuralgic focus, yet the pain was limited most strictly to a spot that might be covered with two finger-points. There was no lachrymation nor conjunctival congestion, and nothing to remark in any way about either eye. The patient was ordered quinine in large doses, in the belief that the pain was neuralgic. On the following day he reported himself a trifle better, though still suffering greatly; and on the afternoon of that day there was an almost complete intermission of the pain for several hours; but it returned severely at the usual nocturnal period. On the 16th, at 10 a. m., he came to my house looking exceedingly ill, but the only additional symptom that I could detect was a small droop of the right eyelid. He was subcutaneously injected with one-fourth of a grain of morphia and sent home, where he immediately fell into a heavy sleep that lasted till bedtime. He awoke, undressed himself without feeling much pain, and got to bed; after an hour or so of dozing he was awakened by the pain, which was exceedingly severe. On the 17th he called on me in the morning, and I at once perceived that the ptosis of the right eyelid was much greater, and the right pupil was much dilated and insensitive, and the external rectus was paralyzed; the man also wore a look of stupidity, and answered questions with an apparent mental effort. I now cross-questioned him more closely; and also explored the tibiæ and other superficial bones: on the sternum a distinct though not very advanced node was found. Upon this he was induced to confess that he had suffered from chancre three years and a half previously, and subsequently had "blotches" on the skin, which had quickly disappeared under treatment, of which all that could be learned was, that it was fluid medicine and did not make his mouth sore. He was immediately ordered to take two grains of calomel in pill, with a little opium, every four hours. He had only taken one dose when I was sent for to him, and found him in an epileptiform convulsion, in which the left side of the body was almost exclusively affected; the convulsions recurred several times during the next twenty-four hours, and in the intervals he remained almost completely unconscious. The mercurial treatment was pushed, in the form of calomel-powders placed on the tongue. On the evening of the 18th he began to recover consciousness, and then had a little natural sleep; the next morning, at 10 a. m., he was found to be fully conscious, had had no return of convulsions, but the left arm and leg, especially the latter, were almost entirely powerless; the parietal headache had vanished; the gums were slightly tender; the third and sixth nerves of right side were completely paralyzed. Mercurial treatment was very gently continued, so as to keep the patient on the borders of ptyalism for the next three or four days; and he was then put on full doses of iodide of potassium. The pain never recurred; the left extremities recovered power rapidly; but it was six weeks before the ocular paralyses were completely well.

Late in the autumn of 1865 I was sent for hastily one evening to see this same man, and found him totally unconscious and apparently again hemiplegic, but now on the right side. He was miserably wasted, and covered with a rupious eruption; I was informed that he had been leading a most debauched and drunken life for some time past, and that, after looking extremely ill, and apparently half imbecile for a week or two past, he had suddenly fallen down unconscious in the street a few hours before I saw him. He remained deeply comatose, and died the next morning; no post mortem could be obtained.

The true neuralgias in which syphilis only plays the part of secondary factor, and which have been referred to in Part I. of this work, may depend for their exciting cause on local syphilitic processes, affecting either the peripheral distribution, the main trunk or the central origin of a sensory nerve; but I have pointed out the fact that, whatever the reason may be, syphilis does but rarely attack the central portions of individual sensory nerves, in comparison, with the frequency with which it attacks individual motor (cranial) nerves. But without any neuralgic predisposition at all, and without any limitation of the syphilitic process to a particular sensory nerve, the latter may become neuralgic in consequence of being involved in extensive intracranial or intra-spinal syphilitic mischief. The trigeminus is liable to suffer in this way from spreading syphilitic processes about the base of the brain; and my own impression is, that the cause of the neuralgic pain in some such cases is the extension of the mischief to the vertebral artery of the affected side, leading to interfering with the nutrition of the trigeminal nucleus in the medulla. A very interesting case is reported by Dr. Hughlings Jackson (who has done so much to acquaint us with syphilitic affections of cerebral arteries) in vol. iv. of the "London Hospital Reports," pp. 318-321. The patient was a woman, aged twenty-seven, and the initial symptoms of the malady which destroyed her life were violent trigeminal neuralgic pains on the right side: subsequently she had complete paralysis of the fifth, and of the sixth, seventh, and eighth nerves of the right side. After death the right vertebral artery was found engaged in the mass of syphilitic deposit; it must be added, however, that the (superficial) origin of the fifth nerve was itself softened, opposite the pons. Another mode in which syphilitic disease very probably causes neuralgia of the fifth, in a certain number of cases, is by injuring the Gasserian ganglion, upon the integrity of which (according to Waller's general law concerning the ganglia of posterior nerve-roots) the nutrition of the sensory root of the trigeminus materially depends. I have seen an example (as I cannot but suppose) of this sequence of morbid events; the evidence appears sufficiently complete, although I was unable to obtain a post mortem examination:

W. M., a house painter, of extremely dissipated habits, but who had never suffered either from distinct symptoms of alcoholism, nor from any affection traceable to lead-poisoning. In March, 1867, he applied to me on account of neuralgic pain, affecting chiefly the right eyeball, but also darting along the course of the frontal nerve of that side; after a short time it extended also into the infra-orbital nerves. He bore several scars of tertiary ulcers about the nose and forehead, and made no secret of having suffered from chancre six or seven years before, and from subsequent secondary and tertiary symptoms. I was consequently not at all surprised at his developing severe iritis (right) after he had been a fortnight under my care, although I had from the first given large doses of iodide of potassium; but I was not prepared for the extensive processes of destruction which followed, notwithstanding that I immediately commenced mercurial treatment, and applied atropine. I remarked that while the inflammation of the iris proceeded with great violence, the cornea was also much more severely affected than is usually the case in syphilitic iritis; in fact, the changes closely resembled those which have been noted after section of the fifth at the Gasserian ganglion, and at the date of the patient's death (seventeen days from the commencement of the iritis) a corneal ulcer was on the point of perforating. For the first three or four days after the iritis set in, the neuralgic pains went on augmenting in intensity, and extended into all three divisions of the fifth; there was a copious discharge from the right nostril. Almost suddenly, on the fourth day, the pains abated and then ceased, and it was now evident that the whole surface of the right half of the face was completely anæsthetic. Two days later a dark-red patch appeared on the cheek, and in the course of the next two days this ulcerated, the ulcer presenting a somewhat livid appearance, and exuding a sanious discharge; at the same time, superficial ulcers appeared on the right side of the tongue, and coalesced to form one large sore. The sores both on cheek and tongue assumed more and more a gangrenous appearance, and on the sixteenth day from the commencement of iritis there was considerable loss of substance in both these situations. On the evening of this day (the patient having become extremely depressed and much emaciated) general epileptiform convulsions set in, and followed each other rapidly; in a few hours coma supervened, and the patient sank the next day. No post mortem could be obtained; but it seems extremely probable, from the above history, that the Gasserian ganglion was early involved in the syphilitic inflammation, and that the neuralgia and subsequent anæsthesia, the iritis, and the other trophic lesions, were due to the injury inflicted upon it.

The treatment of syphilitic pains will, in doubtful cases, often give us valuable assurance of the correctness of our diagnosis. Where the disease is extensively diffused, we may fail to do any good; but, in cases where the syphilitic mischief is limited to a small portion of the meninges, we may often arrest it. In all merely suspicious cases, where the pain is thus limited, it will be well to use iodide of potassium tentatively—forty to sixty grains daily. But, where the pains are very severe and continuous, and there is danger to the integrity of the eye, or threatenings of a paralytic attack are observed, it is better not to trust to anything short of mercury, used in such a manner as just to stop short of absolute ptyalism. In very bad cases, like the last one narrated, we may fail to produce any good effect, but, where the specific treatment is commenced in good time, we may not unfrequently succeed in arresting the symptoms with a rapidity that assures us of the correctness of the diagnosis of syphilis.

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CHAPTER VIII.

PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.

So firmly is the idea of an essential connection between rheumatism and neuralgia implanted in the popular mind, and, indeed, in the minds of a certain portion of the medical profession, that the two complaints are continually confounded. In the great majority of instances, the mistake made is that of calling neuralgia a "rheumatism." But the opposite error occasionally occurs, and a patient is styled "neuralgic" who is really suffering from chronic rheumatism.

As true neuralgia is an essentially localized disease, there can be no excuse for mistaking for it the more typical cases of chronic rheumatism, in which a number of different joints, muscles, or tendons, are affected, more especially in the advanced stages, when the characteristic fixed contractions of the limbs and extremities have occurred. But there are a few cases in which, either with or without a previous history of acute rheumatism, one, or perhaps two, joints begin to suffer vague pains, which after a little time begin to shoot down the course of the limb, and are aggravated from time to time in a manner which superficially much resembles neuralgia; and when the malady has reached a certain intensity the pains may be so much more severely felt in the longitudinal axis of the limb than in the immediate neighborhood of a joint, that the patient forgets that in reality they commenced either within a joint (as the elbow or hip), or in the fibrous structures immediately outside it. Certain localities are much more frequently the seat of this kind of affection than other parts of the body; thus it occurs, perhaps in nine-tenths of the cases, in the neighborhood either of the shoulder (especially involving the insertions of the deltoid and triceps muscles), of the elbow (particularly affecting the tendinous insertions of the muscles on the internal aspect of the forearm), or the hip (extending to the aponeuroses on the outer and back part of the thigh): in all these cases there is a considerable superficial resemblance to true neuralgic pains. Nevertheless, the diagnosis need not present any serious difficulties after the earliest stages; for there soon arises a very diffuse and acute tenderness of the parts, and usually an amount of generalized swelling, which, though it may not be readily detectable by the eye, is sensible enough to the touch. Movement of the parts is also very painful; but usually not with the acute and agonizing pain which occurs in myalgia.

It is, however, upon signs which are of a more general character that we ought chiefly to rely for diagnosis. The fact that the patient has previously experienced a genuine attack of acute rheumatism, though of some value, is by no means to be taken as a conclusive argument that the present attack is of a rheumatic nature. The really important matter is, that whether the patient has or has not suffered acute rheumatism before the occurrence of the subacute or chronic form, the latter will always be attended by more or less of the specific constitutional disturbance of rheumatism. I would carefully abstain from the assumption that rheumatism is originally dependent on a blood-poisoning, a theory which I believe to be most doubtful and very probably false; but there is, nevertheless, a truly specific character about the general phenomena in acute rheumatism, and I maintain that similar though less-marked phenomena are always to be seen even in the mildest and least acute forms of rheumatism. Thus there will be, invariably, more or less of the peculiar sallow anæmia, together with red flushing of the cheeks when the pain is at the worst; and there will be a certain amount of the oily perspiration which makes the faces of rheumatic patients look shiny and greasy. No doubt these characteristics will sometimes be very slightly developed, but I believe that attentive observation will always discover them in any case which is genuinely rheumatic. One case, in particular, which has been under my care, very strongly impresses me with the value of these diagnostic signs, where otherwise the symptoms are obscure:

L. P., aged thirty-one, single, a printer by trade, applied to me, January, 1863, suffering from what I at first decidedly thought was cervico-brachial neuralgia, the pain having followed exposure to cold and wet, situated in the lower part of the neck, the shoulder, elbow and inner side of the right arm, and existing nowhere else. The character of the pain was described as at least remittent, if not distinctly intermittent. The pulse was not more than 78; the tongue was thickly coated with white fur, but the man did not complain of thirst, and there were no evident signs of fever. As the pains had only existed for about a fortnight, it appeared an excellent case for cure by the hypodermic injection of morphia; and, accordingly this was used in quarter-grain doses twice a day. After about ten days an attempt was made to do without the morphia, but the pains returned, worse than before, and meantime the tongue had remained uniformly coated, and was now very yellow; the appetite was bad, and there was some increase in frequency of pulse. It now struck me, for the first time, that the man presented, in a slight degree, the sallow and red tint and oily features of a rheumatic patient; it was now found that sweat and urine were distinctly acid. Acting on this idea, I administered five grains of iodide of potassium, and thirty grains of bicarbonate of potassium, four times every twenty-four hours, after giving a moderate saline aperient. The result was manifest improvement within twenty-four hours, and almost complete relief of the pain within three or four days (the urine never becoming distinctly alkaline, however.) As the attack subsided, the oily appearance of the skin disappeared, and the rheumatic tint was replaced by mere ordinary pallor, which the patient lost after taking a short course of steel.

At the time this case occurred to me, I was not aware of the importance, in doubtful instances, of looking to the temperature; but subsequent experience has convinced me that in every truly rheumatic case, however limited in extent, there is a real, though it may be a small, rise of temperature. The thermometer will be found to mark from 99-1/4° to 100° Fahr., and this, joined with the appearances above mentioned, and a strong acidity of urine, will be sufficient to distinguish the complaint as rheumatic; and the striking effect of such remedies as iodide with bicarbonate of potash, followed up with sesquichloride of iron, in full doses, helps still further to distinguish the cases from true neuralgias. Since the introduction of the full doses of the iron-tincture in the treatment of acute rheumatism, I have had the opportunity of treating two of these cases of subacute rheumatism in the same manner, viz., with the iron from the first, and the results have been most satisfactory in every way. These cases were independent of a much larger number, treated in the same way, in which the symptoms of rheumatism were more generalized and more severe.

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CHAPTER IX.

PAINS OF LATENT GOUT.

Pains which are connected with a chronic and more or less latent form of gout not unfrequently receive the designation "neuralgic," and are treated upon that erroneous theory of their pathology. I have already endeavored to show that there is by no means that intimate causal relation between gout and neuralgia which is very commonly assumed to exist: true neuralgia is, I believe, only caused in an indirect and secondary manner by the gouty condition setting up changes of the blood-vessels, which precipitate the occurrence of the neuralgic malady, to which the patient was otherwise predisposed from birth. But the common idea, both without and within the profession, seems to be that neuralgia is only one expression, and that a quite common one, of the gouty habit. Nevertheless, with strange inconsistence, the kind of truly gouty pains of which I am now speaking are constantly treated upon a special plan, upon the supposition that they are neuralgic.

There are six situations in which gouty pains are apt to be developed in a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2) more indefinitely within the cranium; (3) in the stomach, simulating gastralgia; (4) in the chest, simulating angina pectoris; (5) in the dorsum of the foot, simulating neuralgia of the anterior tibial nerve; (6) in a somewhat diffuse manner about the hip and back of thigh, simulating sciatica.

It is not really a common thing to find such cases very difficult of diagnosis, provided that the possibility of their occurrence has been carefully noted; for the gouty habit has a number of slight manifestations which are usually enough to discover it even when its more decided symptoms are entirely wanting.

Thus, in the first place, it will be almost invariably found, on inquiry, that the patient has always been intolerant of beer and of sweet wines. Also, he has been liable (either after a single large excess in eating or a prolonged course of a diet too highly animalized in proportion to the amount of exercise taken) to attacks of general malaise, with or without uneasiness, just short of decided pain, about the metacarpo-phalangeal joint of the great-toe, and ending after a few hours or days with a free discharge of uric acid. Less frequently, but still very often, it will be found that he has some deposit of lithate of soda (chalk-stone) in some situation where its presence does not necessarily arrest attention; Dr. Garrod has shown how often these little tophi are found in the cartilage of the ear. Careful examination will sometimes detect their presence in the sclerotic of the eye. But in doubtful cases it would be always well to make a cautious trial of colchicum, which, if the case be gouty, will nearly always produce an amount of relief sufficient to confirm the diagnosis of gout. At least, this rule holds goods for the external forms; but in the case of the supposed gouty pseudo-angina it is far best to trust to opium, as colchicum may prove too depressing to a heart which may quite possibly be already the subject of organic disease. My own impression is, that it was these cases of gouty heart-pain, which are not true angina at all, that procured for opium its high reputation for relieving the latter disease, a reputation which is by no means confirmed by my own experience, since I have found that drug enormously inferior to stimulants like ether in its power to relieve genuine angina.

Lastly, if there be no other possibility of making ourselves certain whether there is or is not a gouty taint at the bottom of the quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the serum of the blood to a search for uric acid (thread-test).

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CHAPTER X.

COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.

Colic, or painful half spasm, half paralysis of the large intestines, is the best example of a kind of spasmodic pains to which some authors accord the name of neuralgia, as it seems to me without good reason. They appear to be quite independent of the operation of the neurotic temperament, and to be caused entirely by the operation of some local irritant, or narcotic irritant, upon the muscular fibres of the viscus. In the case of colic this influence is most frequently and most powerfully exerted by lead, which undoubtedly becomes locally deposited in chronic poisoning with that metal; at other times it is produced by the irritation of indigestible food passing along the alimentary canal.

That there may be such a thing as enteralgia, of really neuralgic character, I do not deny; on the contrary, so far as regards the rectum, I have myself seen such a case. But true neuralgia of the large bowel is exceedingly uncommon; what goes by the name is usually either colic from local irritation of the viscus; or a mere hysterical hyperæsthesia of the lining membrane, which is one of the occasional phenomena of spinal irritation; or else it is a case of neuralgia of the abdominal wall, such as is included in the description of "lumbo-abdominal neuralgia," in Part I. of this work.

There is no occasion to describe minutely the symptoms of so familiar a disease as lead-colic, or as colic from irritation by indigestible food, when they occur in their typical forms. In the former case the marked constipation which ushers in the attack of pain, and the peculiar greenish-yellow sallowness nearly always seen in the countenance, ought to be sufficient to direct examination to the gums (for the blue line) and inquiry as to any possible impregnation of the system with lead, owing either to the nature of the patient's occupation, or to some accidental entry of the poison into the drinking-water, or its inhalation from the walls of newly-painted rooms, etc. In the latter case, the fact that the attack of colic was shortly preceded by a meal, either of obviously indigestible food, or too copious in quantity and heterogeneous in kind, or too hastily eaten without sufficient mastication, supplies a clew.

But there are a few cases representing minor degrees of either of these kinds of colic, that are much less easy to diagnose distinctly.

Lead-poison sometimes enters the system continuously, for a long period, but in proportions too minute to produce the effects which we identify as an attack of lead-colic. I believe that for the production of the latter complaint it is necessary that the poisoning shall be sufficiently intense completely to paralyze a considerable piece of bowel, thus altogether hindering peristalsis, or, rather, making the peristaltic acts of the non-paralyzed portions above worse than fruitless. But there is a minor degree in which it may happen that the local affection (owing, I believe, to a less extensive deposit of lead in the bowel) does not reach the decidedly paralytic stage; the state then is one of irregular and painful spasm of individual fibres (quite possibly intermingled with paralysis of a few others), and the practical result is irregularity of evacuation—now diarrhœa, and again constipation—and the frequent recurrence of twinges of pain that are easily mistaken for abdominal neuralgia. Such symptoms as these are nearly always found to have occurred, if proper inquiry be made, in those examples of chronic lead-poisoning in which the toxic process goes on to the development of epilepsy, or marked symmetrical paralysis of the wrist-extensors, without the patient having ever suffered an attack of ordinary colic. In these slow and insidious cases the constitutional affection may not have reached the height at which the complexion and general aspect of the patient suggests metallic poisoning: and the case may present very neuralgia-like features. The absence of the points douloureux is not, as we have seen, conclusive against neuralgia in its early stages. It is therefore an excellent rule, in all cases of chronic recurrent spasmodic pain in the abdomen, especially in men, to investigate the possibilities of lead-poisoning; and, if the slightest suspicious appearance of the gums be found, this track of inquiry must be followed up exhaustively before we abandon the idea. The absence of all special neurotic history in a patient's family should increase our suspicions respecting pains of this character that continue with an obstinacy which makes it unlikely they are due to improper food.

Pains of abdominal irritation are, however, without doubt produced in some cases by unsuspected faults of diet, and may even recur in such a quasi-periodic manner as to strongly suggest the idea of neuralgia in the lumbo-abdominal nerve. One special variety of this happens, I believe, much more often than is thought. A patient will habitually take considerable quantities of some article of food which he does not readily digest, but which is not at all acutely irritant: under these circumstances a simple accumulation is apt to take place in the colon, especially at the top of the ascending colon, the top of the descending colon, or just above the sigmoid flexure, or else in the cæcum. The result of accumulation in the last of these places is not unfrequently typhlitis and perityphlitis, this part of the bowel having (for some reason) a special tendency to inflammation. Deposits in the other localities named are rarely the cause of inflammation, but they very frequently give rise to violent pain, which is exceedingly apt to be taken for the pain either of gall-stone, of renal calculus, or else of some abdominal neuralgia. In cases, therefore, where there is any possibility that accumulation is the cause of pain, it is highly desirable to commence with a dose of castor-oil and laudanum, followed up, if needful, by the administration of a large warm-water enema, given through an O'Beirne's tube. The most violent and recurrent attacks of pain in the renal region, the flank, the abdomen, or the groin, will sometimes be instantly cured by such means, sufficiently proving the non-neuralgic character of the complaint.

I have elsewhere explained that the impaction of a renal or an hepatic calculus, in the ureter or the ductus choledochus, may set up a true neuralgia in persons with the requisite congenital predisposition. The passage of renal or hepatic calculi may give rise to symptoms falsely suggesting neuralgia, which require just to be mentioned here. But there is no need to dwell much upon the diagnosis, for the passage of renal or hepatic calculi has always attendant symptoms and features of constitutional history, which ought to preserve the physician from mistake. The sensation of constriction, of nausea and vomiting, the faintness approaching to collapse, the persistent and constantly increasing severity of the pain up to the moment at which mechanical relief occurs, to say nothing of other phenomena, are distinctive to the skilled observer, and, when taken in conjunction with the history of past attacks, if any, will always prevent mistakes. In the few cases which might still be doubtful it will be well to try the effect of a relaxing dose of chloroform, which, in the case of calculus, will often put an end to the paroxysm at once and finally.

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CHAPTER XI.

DYSPEPTIC HEADACHE.

A final word or two must be given to the distinction between neuralgia of the head and an affection so utterly different that it is surprising that they should be so frequently confounded. One constantly hears medical men speak of "sick headache" (migraine) as if it were the same thing as headache from indigestion; and, unfortunately, they often treat migraine upon this confused and erroneous notion, doing no little mischief thereby.

But, although migraine, already amply described, is entirely independent of the state of digestion, and its stomach-phenomena are purely secondary to the affection of the fifth nerve, there is a kind of headache really dependent on imperfect digestion. The sufferers from these headaches are dyspeptics whose stomach troubles are the result of chronic gastric catarrhal inflammation. (In the acute form of gastric catarrh there are even more severe headaches; but the general symptoms of the disorder are too marked to allow us to mistake the case for neuralgia complicated with secondary stomach disturbance.) The patients in question have frequently passed so gradually into the dyspeptic condition as to have become accustomed to it, and inclined to forget that the stomach was the organ which first gave them annoyance. The headaches, which occur from time to time, are either frontal or (more frequently) occipital in position, and they are usually quite evenly bilateral; still, there is not enough uniformity of difference between them and true migraine, in this respect, to enable us to establish a decided diagnosis upon it. This much may be said, however: that the pain is rarely or never seated in one parietal region, as is frequently the case with migraine and with clavus. The patient suffers very strikingly, in almost every case, from languor and a feeling of inability to exert himself; and has also much aching pain in the limbs, and usually a pain (sometimes very severe) in the scapular region. The tongue may vary a good deal in appearance, especially as regards the degree of general redness; but it always has enlarged papillæ, most prominent toward the tip, and more or less thick furring at the back, and reaching forward, in some cases, nearly to the tip, to which the "strawberry" aspect is then confined. The headache is frequently joined with nausea, but never with absolute vomiting, unless the stomach has been provoked with a meal that gives it more trouble than usual. The desponding frame of mind which this kind of dyspeptics always exhibit distinguishes them, in most cases, quite sufficiently (together with the unwholesome complexion, the appearance of the tongue, and the great complaints of general malaise and aching and feebleness of the limbs) from the victims of migraine, who are often persons of bright spirits and lively intelligence in the intervals of their attacks; but, above all, there is nothing of the regular and characteristic sequence of events which distinguishes the attacks of migraine. The attacks are not periodic, but nearly always depend on some chance dietary indiscretion, or other imprudence, which has visibly aggravated the stomach irritation. And, when the pain does come on, it has no uniform tendency to go on intensifying for some hours and culminate in vomiting, followed by sleep, after which the patient is free. On the contrary, the digestive disturbance is the provocation, and the pain itself is of a heavy character, with a sense of tension or fulness, and it does not go on intensifying in a regular manner, up to a climax, but hangs about in a dull, tormenting way, and frequently is just as bad after sleep as it was before. The diagnosis of these headaches from neuralgic headache is not really difficult; it only requires the use of a fair amount of caution in observation. It would, however, be exceedingly advantageous that the word "sick-headache" should be dropped altogether, and that migraine should always be called by that name (or "megrim," if you will), and that headaches really proceeding from chronic catarrhal disease of the stomach should be called "dyspeptic" headaches. The present state of nomenclature does much to perpetuate a confusion of ideas which ought not to exist any longer, and which leads to much practical mischief.

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 hyperæsthesia will be found in a prize essay "On Neuralgia" by M. C. Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.

[2] "Senses and Intellect."

[3] "Gunshot Wounds and other Injuries to Nerves." Philadelphia: Lippincott & Co., 1864.

[4] Med. Times and Gazette, March 26, 1864.

[5] "London Hosp. Reports," 1866.

[6] "Stimulants and Narcotics," Macmillan, 1854, p. 86.

[7] Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du Nevralgies," Journ de Med. de Bruxelles, tome xl.

[8] Amer. Jour. Med. Science. Jan. 1850.

[9] "Diseases of the Heart and Great Vessels." Third edition, 1862.

[10] Gaz. des Hop., 114, 117, 120. 1862.

[11] Wien Med. Presse, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p. 120.

[12] Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120.

[13] See Wahn, Journ. de Med. et Chir. Prat. 1854. Also several original and quoted cases in Dr. Handfield Jones's "Functional Nervous Disorders," second edition, 1870.

[14] Journ. de Med. et Chir. Prat., July, 1862.

[15] Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.

[16] Eulenburg, to whose excellent work ("Lehrbuch der functionellen Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to refer, has partly misunderstood the drift and scope of my argument, a misfortune which I owe to the impossibility of giving, in the "System of Medicine," more than the briefest and most superficial sketch, both of my ideas and of the facts on which they rest.

[17] Op. cit., p. 60.

[18] This opinion is somewhat stronger than that expressed in my article in the "System of Medicine." I can only say it is the result of much increased experience.

[19] Journal de la Physiologie, v.

[20] "Ernährungsstörungen der Augen bei Anæsthesie des Trigeminus." Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f. Ophthalm. Band. xiii.

[21] Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from independent sources, of the truth of Meissner's views. His own observation only proved half the case; but he quotes an observation of Buttman's in which the exact converse of his own experience happened, the external fibres being affected without the inner band, and anæsthesia without trophic changes being the result. Moreover, Schiff (Gaz. hebdom., 1867) obtained experimental results (in operating on cats and rabbits) which coincide with Meissner's.

[22] London Hospital Reports, vol. iii., p. 305.

[23] Wegner, loc. cit.

[24] Archiv f. Ophthalm., xv., 1.

[25] "Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware whether Piotrowski has at all altered his opinions since the (subsequent) observations of Ludwig and Cyon upon the "depressor" nerve.

[26] "Functional Nervous Disorders." Churchill, 2d edit., 1870.

[27] "Prize Essay of the New York Academy of Medicine." New York: Wood & Co., 1869.

[28] Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex Lahmungen," von E. Leyden. Leipzig, 1870.

[29] "Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.

[30] Wurzburg. Med. Zeitsch., iv., 56-64.

[31] Med. Cent. Ztg. 21, 1860.

[32] Op. cit., pp. 65, 66.

[33] Idem, p. 8.

[34] "Elektrotherapie." Wien, 1868.

[35] Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)

[36] Practitioner, vol. iv., 1870.

[37] Berlin. klin. Wochensch., 1865.

[38] In a paper on the "Hypodermic Use of Remedies," in the Practitioner of July, 1868, I gave the reasons for this opinion in full; and I see no reason to alter any thing I then said.

[39] Practitioner, vol. iv.

[40] Berlin. klin. Wochensch., 17, 1868.

[41] "System of Medicine," vol. ii.

[42] The English reader may consult Althaus ("A Treatise on Medical Electricity," second edition, Longmans), or Meyer ("Medical Electricity," translated by Hammond: Trubner & Co.)

[43] "A Treatise on Medical Electricity," second edition, Longmans.

[44] Op. cit.

[45] Berlin. klin. Wochensch., 22, 1865.

[46] Op. cit.

[47] "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris, 1864.

[48] Reynolds's "System of Medicine," vol. ii., Art. "Spinal Irritation."

[49] The most complete and careful work of the German school, on this subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin, 1867.)

[50] Lancet, June 10, 1865. (Comment on a case of Dr. J. Hughlings Jackson's.)

[51] Radcliffe, in "Reynolds's System of Medicine," vol. ii.

[52] Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.

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Transcriber's Notes:

Punctuation and spelling errors fixed. Variant spellings and hyphenations changed when there is a clear majority. Other unusual spellings retained.

Hover notes were added in the text to show original versions of changed texts for the following notes:

Discrepancies in headings and outline labels repaired. In some cases, this required adding headings implied but not present in the original, to agree with headings that were present.

Table of Contents, Part 1, Chapter IV: original reads "Diagnosis and Progress of Neuralgia." "Progress" has been corrected to "Prognosis" as shown in the Chapter heading.

P. 51, "but her mensural troubles" changed to "but her menstrual troubles".

P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat." "Chim." is typo for "Chir." as in footnote just above.

P. 96, "investigation of neralgi" changed to "investigation of neuralgia".

P. 105, "genealogical connection between migraine and epilepsy": in all reviewed copies of this 1882 edition, original shows "aological" with 4 or 5 spaces in front of it, an apparent printer error. However, in the 1872 edition, the entire sentence reads as presented here.

P. 206, "I have already causually" changed to "I have already causally".