NEURALGIA.
BY J. J. PUTNAM, M.D.
DEFINITION.—It is customary to describe as neuralgic those pains for which no adequate cause can be assigned in any irritation of the sensory nerves from outside, which recur paroxysmally, are unattended by fever, and are distributed along the course of one or more nerves or nerve-branches.
The general use of the term neuralgia further implies the common belief that there is a disease or neurosis, not covered by any other designation, of which these pains are the characteristic symptom. Of the pathological anatomy of such a disease, however, nothing is known; and if it could be shown for any given group of cases that the symptoms which they present could be explained by referring them to pathological conditions with which we are already familiar, these cases would no longer properly be classified under the head of neuralgia.
The attempt has frequently been made, and on good grounds, in obedience to this reasoning, to cut down the list of the neuralgias, strictly so called, and to account for many of the groups of symptoms usually classified under that head by referring them to anæmia or congestion of the sensory nerves, to neuritis, etc.
One of the best and most recent statements of this view is that of Hallopeau,1 who, although he does not wholly deny the existence of a neurosis which may manifest itself as neuralgia, goes so far as to maintain that the gradual onset and decline and more or less protracted course so common in the superficial neuralgias, such as sciatica, suggest rather the phases of an inflammatory process than the transitions of a functional neurotic outbreak, and that, in general terms, a number of distinct affections are often included under the name of neuralgia which are really of different origin, one from the other, and resemble each other only superficially. This subject will be discussed in the section on Pathology, and until then we shall, for convenience' sake, treat of the various neuralgic attacks as if they were modifications of one and the same disease.
1 Nouveau Dict. de Méd. et de Chir. pratiques, art. “Névalgies.”
GENERAL SYMPTOMATOLOGY.—The neuralgias may be conveniently divided into—1, external or superficial; 2, visceral; 3, migraine and the migrainoid headaches.
Superficial Neuralgia.
The most prominent symptom of a neuralgic attack of the superficial nerves is of course the pain, and sometimes, from first to last, no other sign of disease is present. In an acute attack the pain is usually ushered in by a sense of discomfort, which the patient vainly tries to shake off, or by a feeling of weight and pressure or of numbness and prickling, or of itching. Sometimes, though far less often than in the case of migraine, there are prodromal signs of a more general character, such as a feeling of thirst2 or of mental depression or drowsiness.
2 Spoken of by Mitchell's patient with neuralgia of the stump (see below).
A dart of pain may then be felt, which soon disappears, but again returns, covering this time a wider area or occupying a new spot as well as the old. The intensity, extension, and frequency of the paroxysms then increase with greater or less rapidity, but, as a rule, certain spots remain as foci of pain, which radiates from them in various directions, principally up or down in the track of the nerve-trunk mainly implicated. The pain rarely or never occupies the whole course and region of distribution of a large nerve or plexus, but only certain portions, which may be nearly isolated from one another.
In an acute attack the affected parts may at first look pale and feel chilly, and later they frequently become congested and throb. Mucous surfaces or glandular organs in the neighborhood often secrete profusely, sometimes after passing through a preliminary stage of dryness.
The skin often becomes acutely sensitive to the touch, even though firm, deep pressure may relieve the suffering. Movement of the painful parts, whether active or passive, is apt to increase the pain. When the attack is at its height, the pain is apt to be felt over a larger area than at an earlier or a later period, and may involve other nerves than those first attacked. Thus, a brachial becomes a cervico-brachial neuralgia or involves also the mammary or intercostal nerves. A peculiarly close relationship exists between the neuralgias of the trigeminal and of the occipital nerves. It is said that when the attack is severe the corresponding nerves of the opposite side may become the seat of pain. This is perhaps remotely analogous to the complete transference of the pain from one side to the other which is so characteristic of periodical neuralgic headaches, especially if they last more than one day.
Some cutaneous neuralgias pass away after a few hours' or a night's rest, after the manner of a migraine or a headache, and patients in whom this takes place are, as a rule, constitutionally subject to neuralgia or other neuroses. Toward the end of such an attack there is often a copious secretion of pale, limpid urine. In a large class of cases, on the other hand, the attack is of several days' or weeks', or even months' or years', duration, with remissions or intermissions and exacerbations, which may be either periodical or irregular.
The most marked periodicity of recurrence is seen with the neuralgias of malarial origin, which may take on any one of the typical forms of that disease.
These malarial neuralgias affect pre-eminently, though not exclusively, the supraorbital branch of the fifth nerve; but it should not be forgotten that there is also a typically periodical supraorbital neuralgia of non-malarial origin, of which the writer has seen several pronounced examples, the pain usually recurring regularly every morning at eight or nine o'clock and passing away early in the afternoon. The same periodicity is seen, though less often, in other neuralgias. Thus, Trousseau3 speaks of neuralgic attacks from cancer of the uterus in a young woman, which recurred daily at exactly the same hour. Some of the traumatic neuralgias show the same peculiarity to a marked degree.
3 Clin. Méd.
In many neuralgias, on the other hand, the exacerbations are worse at night, like the pains of neuritis. In the intervals between the attacks the pain may be wholly absent, or may persist, usually as a dull aching.
After a neuralgia has lasted a few days—sometimes, indeed, from the outset if the attack is severe—it is usually found that definite spots of tenderness have made their appearance at certain limited points on the course of the nerve. These are the famous points douloureux which Valleix described with such minute accuracy, believing them to be invariably present in true neuralgias. This is certainly not strictly the case, though they are very common. They are not necessarily coincident with the foci of spontaneous pain, as Valleix supposed, but do correspond in general to the points at which the affected nerve emerges from its bony canal or from deep muscles and fascia, and to portions of its area of distribution in the skin. The spinous process corresponding to an affected spinal nerve may also become tender, but this is probably to be looked on, like the same symptom in so-called spinal irritation, not as a sign of local disease, but as due to a general reaction on the part of the nervous system, and as a fact of a different order from the tenderness along the nerve.
The termination of an acute neuralgic attack is usually gradual, like its onset, although in some cases of headache, and in other neuralgias to a less degree, there comes a moment when the patient suddenly declares that he is free from pain.
Neuralgic attacks are usually characterized, besides the pain, by a highly-interesting series of symptoms, which are in part transitory and functional, and in part due to structural changes in the tissues.4
4 See Notta, Arch. gén. de Méd., 1854; Anstie, Neuralgia and its Counterfeits.
The spasm and subsequent dilatation of blood-vessels in the affected area have already been alluded to. A disturbance of secreting organs in the neighborhood of the painful region, the lachrymal gland, the skin, the mucous membranes, the salivary glands, is of equally common occurrence, and is probably in great measure due to direct irritation of the glandular nerves, since the increased secretion is said to occur sometimes unattended by congestion.
The hair may become dry and brittle and inclined to fall out, or may lose its color rapidly, regaining it after the attack has passed.
The increased secretion of urine already alluded to attends not only renal neuralgias, but those of the fifth pair, intercostal, and other nerves. There may be unilateral furring of the tongue (Anstie).
The muscles supplied by the branches of the affected nerve or of related nerves may be the seat of spasm, or, on the other hand, may become paretic; and this is true even of the large muscles of the extremities.
Vision may be temporarily obscured or lost in the eye of the affected side in neuralgia of the fifth pair, and hearing, taste, and smell are likewise deranged, though more rarely. I am not aware that distinct hemianopsia is observed except in cases of true migraine, where it forms an important prodromal symptom.
In connection with these disorders of the special senses the occasional occurrence of typical anæsthesia of the skin of one-half of the body should be noted, which several observers have found in connection with sciatica. The writer has seen a cutaneous hyperæsthesia of one entire half of the body in a case of cervico-occipital neuralgia of long standing. These symptoms are probably analogous to the hemianæsthesia which comes on after epileptic or other acute nervous seizures, or after concussion accidents, as has lately been observed both in this country and in Europe, and it is perhaps distantly related to the hemianæsthesia of hysteria. Local disorders of the sensibility in the neuralgic area are far more common than this, and, in fact, are usually present in some degree. The skin is at first hyperæsthetic, but becomes after a time anæsthetic; and this anæsthesia offers several interesting peculiarities. When this loss of sensibility is well marked, areas within which the anæsthesia is found are apt to be sharply defined, but they may be either of large size or so small as only to be discovered by careful searching (Hubert-Valleroux). The sensibility within these areas may be almost wanting, but in spite of this fact it can often be restored by cutaneous faradization around their margins, and the functional or neurosal origin of the anæsthesia is thus made apparent. Where the anæsthesia is due, as sometimes happens, to the neuritis with which the neuralgia is so often complicated, it is more lasting, but usually less profound and less sharply defined.
These changes may be transient, or, if a neuralgia is long continued and severe, they may pass into a series of more lasting and deeper affections of the nutrition.
The skin and subjacent tissues, including the periosteum, from being simply swelled or œdematous may become thickened and hypertrophied. The writer has known a case of supraorbital neuralgia, at first typically intermittent, to lead to a thickening of the periosteum or bone over the orbit, which even at the end of several years had not wholly disappeared.
Neuralgias of the fifth pair, which are as remarkable in their outward results as they are in their severity and their relation to other neuroses, are said to give rise to clouding and ulceration of the cornea, to iritis, and even to glaucoma.
Herpetic eruptions on the skin sometimes occur, of which herpes zoster is the most familiar instance.
Muscular atrophy is very common, especially in sciatica, and in some cases this occurs early and goes on rapidly, while in others it may be only slight and proportioned to the disease and relaxation of the muscles, even where the neuralgia has lasted for weeks or months.
Neuritis of the affected nerve is a common result or attendant of neuralgia, and may remain behind for an indefinite period after the acute pain has gone, manifesting itself by subjective and objective disorders of sensibility, by occasional eruptions on the skin, or by muscular atrophy.
It is plain that in this list of symptoms a variety of conditions have been described which would never all be met with in the same case, and which, as will be shown in the section on Pathology, are probably due to different pathological causes.
Neuralgia of the Viscera.
These neuralgias are less definitely localized by the sensations of the patient than those of the superficial nerves, and it is not definitely known what set of nerves are at fault.
They are deep-seated and are referred to the general neighborhood of the larynx, œsophagus, heart, or one of the abdominal or genital organs, as the case may be.
The pain is usually of an intense, boring character, and does not dart like the pain of superficial neuralgia, but is either constant or comes in waves, which swell steadily to a maximum and then die away, often leaving the patient in a state of profound temporary prostration.
Deep pressure often brings relief. A patient of the writer, who is subject to attacks of this kind in the right hypochondrium, will bear with her whole weight on some hard object as each paroxysm comes on, or insist that some one shall press with his fists into the painful neighborhood with such force that the skin is often found bruised and discolored.
The functions and secretions of the visceral organs are apt to be greatly disordered during a neuralgic attack, and it is often difficult or impossible to tell with certainty which of these conditions was the parent of the other. Undoubtedly, either sequence may occur, but the pain excited by disorder of function, or even organic disease of any organ, is not necessarily felt in that immediate neighborhood. Thus I have known the inflammation around an appendix cæci, of which the patient shortly afterward died, to cause so intense a pain near the edge of the ribs that the passage of gall-stones or renal calculus was at first suspected.
There seems to be as much variation as to modes of onset and duration among the visceralgias as among the superficial neuralgias, but the tendency to short typical attacks of frequent recurrence seems to be greater with the former.
The visceral neuralgias are quite closely enough related to certain of the superficial neuralgias to show that they belong in the same general category. The two affections are often seen in the same person, and not infrequently at the same time or in immediate succession. Thus in the case of the patient just alluded to above, the attacks of deep-seated neuralgia in the neighborhood of the right flank are at times immediately preceded by severe neuralgia of the face or head. Similarly, intercostal neuralgia may occur in immediate connection with neuralgias of the cardiac or gastric nerves.
The phenomenon of tender points is not entirely wanting in the visceralgias, though less constant and definite than in the superficial neuralgias.
The liver and the uterus especially become the seat of more or less localized tenderness, and possibly the tenderness in the ovarian region which is so common, and so often unattended by real inflammation, is, in part, of this order.
The secondary results of the visceralgias are not easy to study. Besides the disorders of secretion and function above alluded to, swelling of the liver with jaundice and paresis of the muscular walls of the hollow viscera may be mentioned as having been ascribed to neuralgia.
It is not known to what degree neuritis occurs as a cause or complication of these neuralgias, and this is a question which is greatly in need of further study.
Migraine, or Sick Headache.
This is often classified as an affection of a different order from the neuralgias, but there seem to be no real grounds for this distinction.
The superficial neuralgias themselves are probably not one, but a group of affections, with the common bond of severe and paroxysmal pain.
Neither is what is called migraine always one and the same disease.
Although in its most typical form it presents very striking characteristics, such as a marked preliminary stage, with peculiar visual and sensory auras, sometimes occupying one entire half of the body, a short and regular course and periodical return, deep-seated pain without tender points, and prominent unilateral vascular disorders, yet these symptoms shade off by imperceptible degrees into those of neuralgia of the fifth pair, or more often into one or another form of unilateral neuralgic headache which stands midway between the two.
The vascular phenomena of migraine are believed by various observers, as is well known, to constitute the primary and essential pathological feature of the disease, and to be the cause of the pain. But this is a pure hypothesis, and as a matter of fact the cases are abundant in which no greater vascular changes are present than in other neuralgias of equal severity.
Migraine seems to occupy an intermediate position between the grave neuroses, especially epilepsy, and the neuralgias of neurosal origin.
The symptomatology will be described at greater length below.
GENERAL ETIOLOGY.—The causes of neuralgia may be divided into predisposing and exciting causes.
The most important of the first group are—
1. Hereditary tendencies;
2. The influences associated with the different critical periods of life;
3. The influences attached to sex;
4. The action of constitutional diseases, such as phthisis, anæmia, gout, syphilis, diabetes, nephritis, malarial poisoning, metallic poisoning.
The most important of the second group of causes are—
1. Atmospheric influences and the local action of heat and cold;
2. Injuries and irritation of nerves;
3. Irritation of related nerves (so-called reflex and sympathetic neuralgias);
4. Acute febrile diseases.
In most cases more than one cause is to blame, and each should be separately sought for.
PREDISPOSING CAUSES.—1. Hereditary Tendencies.—It is generally admitted as beyond question that neuralgias are most common in families in which other signs of the neuropathic taint are prominent. Such affections as hysteria, neurasthenia, epilepsy, asthma, chorea, dipsomania, and even gout and phthisis as it would seem, are akin to the neuralgic tendency.
The neuropathic family is thought to contain, in fact, a much larger number of members than this,5 but there is danger of exaggerating the importance of an influence of which we know as yet so little.
5 Féré, Arch. de Névrologie, 1884, Nos. 19 and 20, “La famille névropathique.”
It should be remembered, moreover, that even where an inherited taint is present its influence may be but slight as compared with that of some special exciting cause.
Some neuralgias are more closely associated with the inherited neuropathic diathesis than others. The connection is especially close in the case of migraine;6 then follow other forms of periodical headache and the visceral neuralgias. Even the superficial neuralgias7 are more or less subject to this influence. This is thought to be especially true of the facial neuralgias.
6 There is a witty French saying (quoted by Liveing), “La migraine est le mal des beaux esprits;” which might be rendered, “The disease of nervous temperaments.”
7 For tables of illustrative cases see Anstie, Neuralgia and its Counterfeits, and J. G. Kerr, Pacific Med. and Surg. Journ., May, 1885.
Reasons will be offered later for suspecting that many cases usually classed as neuralgia, and characterized by gradual onset and protracted course, are essentially cases of neuritis; and there is need of further inquiry as to how far hereditary influences are concerned in producing them, and whether such influences act by increasing the liability of the peripheral nerves to become inflamed, or only by increasing the excitability of the sensory nervous centres.
2. Age.—Neuralgia is oftenest seen in middle life and at the epochs marked by the development and the decline of the sexual functions. The affection, when once established, may run over into advanced age, but cases beginning at this period are relatively rare and very intractable (Anstie).
Childhood is commonly said to be almost exempt from neuralgia, but, in fact, there seems no sufficient reason for withholding this term from the so-called growing pains of young children8 so long as it is accorded to the almost equally irregular neuralgias of anæmia in the adult. The same remark applies to the attacks of abdominal pain in children, which often seem to be entirely disconnected from digestive disorders.
8 Probably due to anæmia or imperfect nutrition (see Jacobi, “Anæmia of Infancy and Childhood,” Archives of Med., 1881, vol. v.).
Adolescents and children also suffer from periodical headaches, both of the migrainoid and of the neuralgic type. These are obstinate and important affections.9 Migraine especially, coming on in early life, points to a neuropathic constitution, and will be likely to recur at intervals through life, or possibly to give place to graver neuroses.
9 Blache, Revue mensuelle de l'enfance, Mar., 1883, and Keller, Arch. de Névroloqie. 1883.
3. Sex.—Women show a stronger predisposition than men to certain forms of neuralgia, as to the other neuroses, but it is generally conceded that whereas neuralgias of the fifth and occipital and of the intercostal nerves are met with oftenest among them, the brachial, crural, and sciatic neuralgias are commoner among men. This probably indicates that the neurosal element is of greater weight in the former group, the neuritic element in the latter.
4. Constitutional Diseases.—The blood-impoverishment of phthisis and anæmia, the poison of malaria, syphilis, and gout, and the obscurer forms of disordered metamorphosis of tissue, undoubtedly predispose to neuralgia and the other neuroses, as well as to neuritis and others of the direct causes of neuralgic attacks.
Anstie regards the influence of phthisis as so important as to place it fairly among the neuroses. Gout is likewise reckoned by some observers among the neuroses,10 but we tread here upon uncertain ground. Anstie does not regard gout as a common cause of neuralgia, but most writers rate it as more important, and gouty persons are certainly liable to exhibit and to transmit an impaired nervous constitution, of which neuralgia may be one of the symptoms. The neuralgias of gout are shifting, irregular in their course, and sometimes bilateral.
10 Dyce-Duckworth, Brain, vol. iii., 1880.
Syphilitic patients are liable to suffer, not only from osteocopic pains and pains due to the pressure of new growths, but also from attacks of truly neuralgic character. These may occur either in the early or the later stages of the disease. They may take the form of typical neuralgias, as sciatica or neuralgia of the supraorbital nerve (Fournier11), or they may be shifting, and liable to recur in frequent attacks of short duration, like the pains from which many persons suffer under changes of weather, anæmia, or fatigue.
11 Cited by Erb in Ziemssen's Encyclopædia.
There are other obscure disorders of the nutrition, as yet vaguely defined, in connection with which neuralgia of irregular types is often found. Some of these are classed together under the name of lithæmia, and are believed to be due to imperfect oxidation of albuminoid products.12
12 See DaCosta, Am. Journ. of Med. Sciences, Oct., 1881, and W. H. Draper, New York Med. Record, Feb. 24, 1883.
Diabetes seems also to be an occasional cause of neuralgia, especially sciatica, and Berger,13 who has recently described them, says that they are characterized by limitation of the pain to single branches of the sacral nerves, by a tendency to occur at once on both sides of the body, by the prominence of vaso-motor symptoms, and, finally, by their long duration and obstinacy. There may not, at the moment, be any of the characteristic symptoms of diabetes present.
13 Neurologisches Centralblatt, 1882, cited in the Centralbl. für Nervenheilk., etc., 1882, p. 455.
Chronic nephritis also causes neuralgia, either directly or indirectly; and severe neuralgic attacks may accompany the condition, which is as yet but imperfectly known, characterized pathologically by a general arterio-fibrosis and by increased tension of the arterial system.
True rheumatism does not appear to be a predisposing cause of neuralgia.
Anæmia, both acute and chronic, is a frequent cause of neuralgia, both through the imperfect nutrition of the nervous tissues, to which it leads, and, it is thought, because the relatively greater carbonization of the blood increases the irritability of the ganglionic centres.
Even a degree of anæmia which might otherwise be unimportant becomes of significance in the case of a patient who is otherwise predisposed to neuralgia; for such persons need to have their health kept at its fullest flood by what would ordinarily seem a surplus of nourishment and care.
Under the same general heading comes the debility from acute and chronic diseases, and the enfeeblement of the nervous system from moral causes, such as anxiety, disappointment, fright, overwork and over-excitement, and especially sexual over-excitement, whether gratified or suppressed (Anstie), or, on the other hand, too great monotony of life; also from the abuse of tea, coffee, and tobacco.
Lead, arsenic, antimony, and mercury may seriously impair the nutrition of all the nervous tissues, and in that way prepare the way for neuralgia.
IMMEDIATE CAUSES.—1. Atmospheric and Thermic Influences.—Neuralgia is very common in cold and damp seasons of the year, in cold and damp localities, and in persons whose work entails frequent and sudden changes of temperature. Exposures of this sort may at once excite twinges of pain here and there over the body, and may eventually provoke severe and prolonged attacks of neuralgia.
The action of damp cold upon the body is complicated, and it exerts a depressing influence on the nervous centres in general which is not readily to be explained. One important factor, however, is the cooling of the superficial layers of the blood, which occurs the more easily when the stimulus of the chilly air is not sufficiently sharp and sudden to cause a firm contraction of the cutaneous vessels, while the moisture rapidly absorbs the heat of the blood. From this result, indirectly, various disorders of nutrition of the deeper-lying tissues or distant organs; and, among these, congestion and neuritis of the sensitive nerves.
Neuralgia often coincides with the presence or advent of storms. A noteworthy and systematic study of this relationship was carried on through many years under the direction of S. Weir Mitchell14 by a patient of his, an officer who suffered intensely from neuralgia of the stump after amputation of the leg. The attacks of pain were found to accompany falling of the barometer, yet were not necessarily proportionate to the rapidity or amount of the fall. Saturation of the air with moisture seemed to have a certain effect, but the attacks often occurred when the centre of the storm was so remote that there was no local rainfall. It was impossible to study the electrical disturbances of the air with accuracy, but a certain relationship was observed between the outbreak of the attacks and the appearance of aurora borealis.
14 Am. Journ. of Med. Sci., April, 1877, and Philada. Med. News, July 14, 1883.
This patient's neuralgic attacks were almost certainly of neuritic origin, and it is possible that the exacerbations were due to changes of blood-tension in and around the nerve-sheaths. It is also possible that they were the result of circulatory changes and disordered nutrition of the nervous centres, already in a damaged condition from the irritation to which they had been exposed.
2. Injuries and Irritation of Nerves.—Wounds and injuries of nerves15 and the irritation from the pressure of scars, new growths, and aneurisms are prolific causes of neuralgic pain, partly by direct irritation, partly by way of the neuritis which they set up. Neuralgias are likewise common during the period of the healing of wounds, as Verneuil long since pointed out. The pain may be near the wound itself or in some distant part of the body.
15 See S. Weir Mitchell, Injuries of Nerves.
Neuralgia due to the pressure and irritation of tumors, new growths, or aneurisms requires a special word. The pain is apt to be intensely severe, but what is of especial importance is that the symptoms may not present anything which is really characteristic of their origin, except their long continuance; and this should always excite grave suspicion of organic disease.
These attacks of pain may be distinctly periodical; and this is true whether they are felt in the distribution of the affected nerve or of distant nerves.
Not only are direct injuries of nerves a cause of neuralgia, but sudden concussion or jar may have a like effect—whether by setting up neuritis or in some other way is not clear. Ollivier16 reports a case where a blow beneath the breast caused a neuralgia which eventually involved a large portion of the cervico-brachial plexus; and the writer has seen a like result from a blow between the shoulders.
16 Cited by Axenfeld and Huchard, p. 116.
Peripheral irritations, such as caries of the teeth (see below, under Facial Neuralgia) and affections involving other important plexuses, such as those of the uterine nerves, are a frequent cause of neuralgia, and should always be sought for. They act in part by setting up neuritis, and in part evidently in some more indirect manner, since the neuralgia which they excite may be referred to more or less distant regions, forming the so-called—
3. Reflex and Sympathetic Neuralgias.—The term reflex, as here used, is ill chosen, and the term sympathetic only covers our ignorance of the real processes involved, and which we should seek for in detail. Thus, disease of the uterus or ovaries may cause facial, mammary, intercostal, or gastric neuralgia.
Hallopeau17 suggests that some of these results may be brought about by the pressure of enlarged lymphatic glands attached to the affected organ.
17 Loc. cit., p. 766.
Another important centre of nervous irritation is the eye. Slight errors of refraction, or weakness of the muscles of fixation, especially the internal recti, are a source of frontal headaches and other nervous symptoms, and even of typical migraine,18 to a degree which is not usually appreciated. It is improbable that in the latter case the irritation acts as more than an exciting cause, but it may nevertheless be a conditio sine quâ non of the attack.
18 St. Barthol. Hosp. Repts., vol. xix.
Acute and chronic inflammations of the mucous membrane of the frontal sinuses, perhaps even of the nasal membrane, are likewise important; and although it is probable that the opinions sometimes expressed as to the significance of these causes are exaggerated, it is equally true that obstinate and, as it were, illogical persistence in their removal will sometimes be richly rewarded.
It is especially worthy of note that there need be no local sign whatever to call the attention of the patient to the presence of the peripheral irritation.
Nothnagel19 has described neuralgias which come on in the first week of typhoid, and are to be distinguished from the general hyperæsthesia of later stages. He describes an occipital neuralgia of this sort which finally disappeared under the use of a blister. Other acute diseases may have a like effect. The writer has seen a severe facial neuralgia in the first week of an insidious attack of pneumonia in a person who was not of neuralgic habit, and before the fever or inflammation had become at all severe.
19 Virch. Arch., vol. liv., 1872, p. 123.
PATHOLOGY AND DIAGNOSIS.—In surveying the clinical history of the neuralgias and the circumstances under which they occur, we have grouped together a large number of symptoms of very different character from each other, and we have now to inquire to what extent these symptoms are really united by a pathological bond.
Two opposite opinions have been held concerning the pathology of neuralgic affections. According to one opinion, every neuralgic attack, no matter how it is excited, is the manifestation of a neurosis—that is, of a functional affection of the nervous centres—to which the term neuralgia may properly be applied. This view is based on the resemblance between the different forms of neuralgia, or the apparent absence, in many cases, of any adequate irritation from without, and the fact that the persons in whom neuralgias occur usually show other signs of a neuropathic constitution.
According to the other opinion, the various forms of neuralgia are so many different affections, agreeing only in their principal symptom, and are due sometimes to congestion or anæmia of the nerves or the nerve-centres; sometimes to neuritis, the pressure of tumors, or the irritation of distant nerves; sometimes, finally, to a functional disorder of the nervous centres. The arguments in favor of this opinion are that the difference between the symptoms of the different neuralgias as regards their mode of onset and decline, their duration, the persistence of the pain, and the degree to which the attacks are accompanied by organic changes of nutrition in the tissues and in the nerve itself, are so great as to make it appear improbable that we are dealing in every case simply with one or another modification of a single affection.
This is a valid reasoning, and it is certainly proper to exhaust the possibilities of explaining the symptoms that we find in a particular case by referring them to morbid processes which we can see or of which we can fairly infer the presence, before we invoke an influence of the nature of which we understand so little as we do that of the functional neuroses. At the same time, it must be distinctly borne in mind that the symptoms of certain neuralgias, and the relation which the neuralgias in general bear to other neuroses, can only be accounted for on the neurosal theory, and that in a given case we can never be sure that this neurosal tendency is not present and is not acting as at least a predisposing cause. It is especially important to bear this possible influence in mind in deciding upon prognosis and treatment.
We may now review briefly the signs which should lead us to diagnosticate or suspect the presence of the various special causes of neuralgic symptoms.
Neuritis is indicated by the presence of organic disorders of nutrition affecting the skin, hair, or nails, or of well-marked muscular wasting; by pain, not only occurring in paroxysms, but felt also in the intermissions between the paroxysms, or continuous sensations of prickling and numbness, even without pain; by tenderness along the course of the nerve; by anæsthesia, showing itself within the first few days of the outbreak of a neuralgia; by persistent paralysis or paresis of muscles.
Neuritis may be suspected, even if one or all of these signs are absent, in the prolonged neuralgias which follow wounds or strains of nerves or exposure to damp cold, or which occur in nerves which are in the immediate neighborhood of diseased organs; also where the pain is relieved by compression of the nerve above the painful part, or, on the other hand, where pressure on the nerve excites a pain which runs upward along the course of the nerve.
It may also be suspected in the large class of superficial neuralgias which follow a regular and protracted course with gradual onset and decline, and where the pain is felt not only in the region of distribution of a nerve, but also along its course—that is, in the nerve-fibres (either the recurrent nerves or the nervi nervorum) which are distributed in the sheath of the main trunk or the adjoining tissues.20
20 See Cartaz, Des Névralgics envisagés au point de vue de la sensibilité récurrente, Paris, 1875.
It must be remembered that the study of neuritis, and especially of chronic neuritis, is still in its infancy, and that we are by no means in possession of its complete clinical history.21
21 See Pitres and Vaillard, Arch. de Névrologie, 1883.
The presence of congestion of the sensory nerves or nerve-centres may be inferred with some degree of probability where neuralgic attacks of relatively sudden onset and short duration occur in parts which have been exposed to heat or cold, or in connection with suppression of the menstruation, or, it is said, as a result of intermittent fever. The exacerbations of pain which take place in cases of chronic neuritis under changes of weather and after fatigue are very likely due to this cause; and the same may be true of some of the fleeting pains which occur in chlorotic and neuropathic persons who are subject to fluctuations of the circulation of vaso-motor origin.
The same vaso-motor influences which cause congestion may also cause the correlative state of anæmia, which becomes thus a cause of transient and shifting though often severe attacks, which may be irregular in their distribution. General anæmia is also a predisposing cause of severe typical seizures, as has been pointed out above.
The pressure of new growths or of aneurisms is to be suspected when neuralgic attacks are unusually severe and prolonged, recur always in the same place, and occur in persons who are not predisposed to neuralgias. The pains from this cause are apt to be relatively continuous, but they may, on the other hand, be distinctly paroxysmal, and may occupy a part of the body far removed from the irritating cause.
Bilateral pains should also excite suspicion of organic disease, though they may be due to other causes, such as gout, diabetes, and metallic poisoning.
Neuralgic attacks may be supposed to be of neurosal origin when they are of sudden onset and short duration, or when they occur in persons of neuropathic constitution, and, by exclusion, when no other cause is found. These conditions are best fulfilled in the case of migraine and the visceral neuralgias. It must, however, be borne in mind that the neuropathic predisposition is sometimes well marked even in the case of the superficial neuralgias, especially the epileptiform neuralgia of the face.
GENERAL TREATMENT.—To treat neuralgia with satisfaction it is necessary to look beyond the relief of the particular attack and search out the causes by which it was provoked. As has already been remarked, these are usually multiple, and among them will be found, in the great majority of cases, some vice of nutrition or faulty manner of life.
It is safe to say that any dyscrasia occurring simultaneously with neuralgia, whether gout, phthisis, malaria, or diabetes, should receive its appropriate treatment, whatever theory we may hold as to the real connection between the two conditions.
In protracted neuralgias it is always proper to assume that neuritis may be present—i.e. to treat the nerve itself by galvanism and local applications. Local irritations, such as diseases of the eye, ear, teeth, nose, or uterus, should be sought out and removed; and attention may here be called again to the fact that a neuralgia may be due to some local condition which does not of itself attract the patient's attention.
Patients who are subject to pain at changes of weather or on exposure should be suitably protected by clothing, and should have their cutaneous regulatory apparatus strengthened by baths and friction. The best protection, however, is incapable of entirely warding off the effect of atmospheric changes upon the nervous centres. Vaso-motor changes of neurotic origin can be, in a measure, prevented by removing the patient from the influence of irregularity of life and emotional excitement and through an improved nutrition.
If the patient has been subjected to chronic fatigue or nervous strain, not only must these be avoided, but their action should be counteracted by the requisite rest and tonic treatment.
Long hours of sleep at night may often be supplemented to advantage by rest during certain hours of the daytime. If the patient cannot take active exercise, massage is indicated, and in some cases of anæmia this may advantageously be combined with the wet pack, in the manner described by Mary Putnam Jacobi.22
22 Massage and Wet Pack in the Treatment of Anæmia.
Where these measures cannot be carried out, the writer has found it of much service in these, as in a large class of debilitated conditions, to let the patient rub himself toward the end of the forenoon in a warm room with a towel wet in cold or warm water, and then lie down for an hour or so or until the next meal. If acceptable, the same operation may be repeated in the afternoon.
Neuralgic patients are apt to be underfed, and even where this is not distinctly the case, a systematic course of over-feeding,23 with nourishing and digestible food, such as milk, gruel, and eggs, given at short intervals, is often of great service if thoroughly carried out. The full benefit of this treatment cannot always be secured unless the patient is removed from home, and, if need be, put to bed and cared for by a competent nurse.
23 See S. Weir Mitchell, Fat and Blood; and Nervous Diseases, especially of Women.
A change of climate, and especially the substitution of a dry and warm for a moist and cold climate, will sometimes break up the neuralgic habit, for the time at least. In making choice of climate or locality, however, the physician should keep distinctly in view the end that he desires to gain. Thus, the debility or anæmia which is the essential condition of many neuralgias may often be relieved by surroundings which would not be thought favorable to the neuralgic tendency as such. Oftentimes the sedative influence of quiet country life is all that is required.
Of the tonic drugs, cod-liver oil, iron, arsenic, and quinine are by far the most important, and it is often well to give them simultaneously. Iron may be used in large doses if well borne, for a short time at least. Quinine may be given in small doses as a tonic, or in larger doses to combat the neuralgic condition of the nervous system. This remedy has long been found to be of great value in the periodical neuralgias of the supraorbital branch of the fifth pair, but its usefulness is not limited to these cases. It may be of service in periodical neuralgias of every sort, and often even in non-periodical neuralgia.
When the attacks recur at stated intervals care should be taken to anticipate them with the quinine by about four hours, even if the patient has to be waked in the early morning for the purpose. Single doses of fifteen, twenty, or even thirty grains may check the attacks where smaller doses have failed. Such doses cannot, however, be long continued, and are not to be classed as tonic.
Of other remedies which directly influence the neuralgic condition, the following are the most important: opium, aconite, gelsemium, phosphorus, belladonna, chloride of ammonium, cannabis Indica, croton-chloral, electricity, hydropathy, massage, counter-irritation, subcutaneous injections of water, chloroform, osmic acid, etc.; surgical operations.
Opium is usually employed only for the momentary relief of pain, but it has also been claimed that in small and repeated doses it may exert a really curative action. This should not, however, be too much counted on. Opium should never be used continuously for the simple relief of pain unless under exceptional circumstances, the danger of inducing the opium habit is so much to be dreaded. Moreover, both patient and physician are less likely to seek more permanent means of cure if this temporary remedy can always be appealed to. It is best given by subcutaneous injections of the various salts of morphine. The dose should always be small at first (gr. 1/12 and upward), unless the idiosyncrasy of the patient is already known; and there is probably no advantage in making the injections at the seat of pain or in the immediate neighborhood of the nerve supplying the affected part, except such as might attend the injection of any fluid (see below).
Belladonna (atropia), which is so often given with morphine to diminish its unpleasant effects, seems at times, even when given alone, to have an effect on neuralgia out of proportion to its anæsthetizing action, which is very slight. It is considered to be especially useful in the visceralgias.
Aconite, given, if necessary, in doses large enough and repeated often enough to cause numbness and tingling of the lips and the extremities for some days, will sometimes break up an attack, especially of trigeminal neuralgia,24 better than any other means; but its use is liable to depress the heart, and it is a dangerous remedy if not carefully watched. Some patients complain that it causes a marked sense of depression or faintness, and a feeling of coldness; and indeed its full therapeutic effect is sometimes not obtained until such symptoms as these are induced to some degree. The use of the crystallized alkaloid, aconitia, has the advantage of ensuring certainty of dose.
24 See Seguin, Arch. of Med., vol. i., 1879; vol. vi., 1881.
The susceptibility of different persons to this drug is so different that the dose should first be as small as 1/400 gr., but this may be repeated every three hours, and gradually increased to 1/100 gr., or until its physiological effects are felt. Patients must sometimes be kept under its influence for weeks together.25 It is, however, a remarkable fact that occasionally a few full doses will secure an immunity from pain for a long period. Although most useful in facial neuralgias, the writer has known it to be effective in brachial and mammillary neuralgia. Aconitia can now be had in granules of 1/400 gr., or can be given in alcoholic solution.
25 See Seguin, Arch. of Med., vol. vi., 1881.
Gelsemium is also occasionally very useful in facial and even in intercostal neuralgia, and is said to be of special service in the neuralgia due to carious teeth. The commencing dose of the fluid extract is five minims, which may be gradually increased to twenty, or until a slight degree of muscular prostration, ptosis, or dilatation of the pupil is induced.
The use of phosphorus has been revived of late years, chiefly through the efforts of J. Ashburton Thompson, and it is at least occasionally of service. Success is said to be best obtained by full doses (about 1/20 gr. every three or four hours, up to 1/5 or 1/4 gr. daily for some days), watch being kept for signs of gastric irritation. The best preparation is an alcoholic solution (Thompson's), such as the following:
| Rx. | Phosphorus, | gr. j; |
| Abs. alcohol, | fluidrachm vi. | |
| Dissolve with heat. | ||
| Glycerin, | fluidounce iss; | |
| Alcohol, | fluidrachm ij; | |
| Spts. peppermint, | minim v. | |
| One teaspoonful represents gr. 1/20. | ||
Electricity, if properly used, is capable of temporarily, and even radically, relieving the neuralgic state. The forms most often employed are faradic and galvanic electricity, though frictional electricity has also been coming into use of late, mainly as a substitute for faradism. The galvanic current is by far the most efficacious of all. This probably acts mainly by directly inducing better nutritive and better functional conditions in the nerves and nerve-centres, but the fact that it is often of use in cases of undoubted neuritis seems to indicate that it may also influence the grosser structural changes in the affected parts, if such are present. It is impossible to explain its action more exactly, and the teachings of physiological experiments do not lend us much aid.
It is probably not of much consequence which pole is used in the neighborhood of the affected nerve. It should be remembered that the peripheral nerve-trunks are so deeply buried that the electrodes cannot be directly applied to them, as they are to the exposed nerve of a frog in the laboratory, and, further, that instead of being isolated they are surrounded with tissues of good conducting power, into which the current must rapidly flow off. For these reasons the nerve near which either electrode is applied is virtually exposed to the action of both poles in almost equal degree; and although it is more customary to use the positive pole in the neighborhood of parts which are considered to be in a state of irritation, yet clinical experience has not justified the conversion of this custom into a rule. Neither is the direction of the current of material consequence.
It is, however, very important in acute cases to take care that the current-strength should not be rapidly changed; and for this reason the electrode should be drawn slowly to a distance from the nerve before it is removed, or left in situ while the current is gradually diminished by a suitable rheostat. As a rule, the former method is the more practicable.
In the treatment of acute cases moderate currents and short applications, frequently repeated, are the best. On the other hand, in cases of long standing, especially cases of sciatica, strong currents are sometimes more effective, and even interruptions and reversals of the current may be in place.
The choice of a battery is not a matter of indifference. Any stationary battery of high interior resistance will answer the purpose, but most of the portable (zinc-carbon) batteries in common use are objectionable,26 for the reason that their interior resistance is so low in proportion to that of the body that it may almost be counted out as a factor in determining the strength of the current. The latter is liable to rise, therefore, quite suddenly as the resistance of the body—i.e. the vascularity of the skin—becomes modified. This objection is obviated if a large, constant resistance (water or graphite rheostat) is attached to the battery and kept always in the main circuit.
26 Archives of Medicine, April, 1884.
Faradism probably owes its efficiency to the indirect effects of stimulation of the sensitive nerves of the skin. This may be produced either by the wire brush, which causes a sharp irritation and reddening, and is to be compared with the counter-irritants, or by the milder application of a moist or dry electrode or the hand of the operator. The latter procedure may be compared to the superficial manipulation which is sometimes so grateful, especially in nervous headaches.
The value of electricity as a general tonic should be remembered in this connection.
Hydropathy.—Douches and baths of various kinds have doubtless proved of much value in the treatment of neuralgia. The majority of them, however, are difficult of application for the general practitioner, and we confine ourselves to mentioning the tonic and soothing action of the wet pack and of the prolonged warm bath, which should be followed by sponging with cool water, and used under every possible precaution against exposure.
Long-continued local applications of gentle heat (bags of sand or salt, or hot water) are often temporarily grateful, and in the treatment of chronic cases the daily application of hot water or ice-bags to the spine is said to have a good effect. In acute and subacute neuritis, and in those forms of neuralgia in which neuritis plays a large part, such as sciatica, the persistent application of ice-bags along the course of the affected nerve, even for days together, is sometimes of great service. Even where we cannot be sure that neuritis is present, long-continued applications of ice may be of use, but alternations of cold and heat, on the other hand, are usually to be carefully avoided. This treatment is safer in chronic than in acute cases, though it may be useful in either.
Counter-irritation.—A spray of ether may be substituted for ice when only a temporary chilling is desired, for its counter-irritant effect. This has even been used on the face, the eye being protected by some suitable covering, and a good deal of benefit is to be hoped for both from this and from the similar use of chloride of methyl.
Debove27 has found the chloride of methyl, used in this manner, singularly effective in the treatment of sciatica. A considerable and long-continued counter-irritation is thus made over a large surface and without great pain. The neuralgia is said to be greatly relieved and a rapid cure sometimes affected.
27 Bulletin générale de Thérap., cited in the Boston Med. and Surg. Journ., vol. cxii. p. 210.
Counter-irritation is also practised by making applications of cutaneous irritants, such as blisters, mustard, turpentine, chloroform, or of the actual cautery carried in light superficial stripes over the skin, and repeated if necessary at short intervals. As a rule, the counter-irritation is more effective the larger the surface which is covered.
The use of the cautery and of blisters is in place in almost every form of neuralgia where the temporary disfigurement is of no consequence.
Of other cutaneous applications, aconite and chloroform liniments, menthol in substance or in alcoholic solution (drachm j or drachm ij to fluidounce j), aconite and veratrine ointments, are the most useful. A strong aconitine ointment, made with Duquesnet's aconitia and lard (drachm j to ounce j), has been recommended by Webber28 to be used in portions of the size of half a split pea, but, though effective, it needs to be employed with great caution.
28 Nervous Diseases, Boston, 1885.
These applications act in part as irritants, by keeping up a play of sensitive impressions in virtue of the lodgment which they effect in the skin, but also, no doubt, by reducing the sensitiveness of the cutaneous nerve-fibres, and thus removing one source of excitation of the diseased nervous centres. The remarkable temporary benefit sometimes obtained from the instillation of cocaine into the eye in cases of neuralgia of the ophthalmic division of the fifth nerve bears testimony in favor of this explanation.
Surgical operations for neuralgia are of three kinds—section (neurotomy), removal of a piece of nerve (neurectomy), and nerve-stretching. The two former operations are of course rarely practised, except upon the purely-sensitive fifth pair of nerves, the latter upon mixed nerves also.
Neurectomy is now almost always substituted for simple neurotomy, and sometimes still more effective means are taken to prevent the reunion of the nerve, such as doubling over the cut end, destroying the nerve throughout the length of the bony canal in which it lies, and even plugging the canal with cement.29
29 Heustis (Med. News, Dec. 8, 1883) found that the infraorbital nerve could be readily drilled out with a piece of piano wire.
The inconvenience following nerve-section is as nothing compared to the pain of a severe and intractable neuralgia. It has rarely happened that the disease has been increased by the operation, and under proper antiseptic precautions the surgical risks are not great. There is some chance of permanent cure, and a much greater chance of securing an immunity from pain for a long period.
It is important to remember that when the neuralgia occupies the distribution of several branches of the fifth nerve, an operation on the one primarily or most severely affected may relieve the pain in all. On the other hand, the converse may be true,30 inasmuch as the same district is supplied by recurrent fibres from several different sources. Before any operation is decided on it should be remembered that even in apparently desperate cases of trigeminal neuralgia the persistent and thorough use of tonic and other remedies may in the end be crowned with success, perhaps at the moment when it is least expected.
30 Cartaz, Des névralgies envisagés au point de vue de la sensibilité récurrente.
During the past few years the operation of nerve-section has been to some degree superseded by that of nerve-stretching, as being less serious in its immediate (though not necessarily in its remote) consequences, and sometimes more efficacious. Hildebrandt, indeed, raises the question whether the traction which is apt to be exerted when a nerve is cut is not an important element in bringing about the result. On the other hand, cases are reported where neuralgia which had not been relieved by stretching was cured by resection.31
31 Nocht, Ueber die Gefolge der Nerven-dehnung.
The best showing for the operation is in the treatment of sciatica, but most of the other superficial nerves, including the intercostals, have been successfully treated in the same manner.
On the other hand, this treatment is not without its dangers. Apart from the risks of the operation itself, cases have been reported in which the spinal cord has been injured, so that chronic myelitis has been set up, and a greater or less degree of paralysis—rarely permanent, it is true—may be induced by the direct injury to the nerve.
This means of treatment is therefore certainly to be thought of in serious and obstinate cases, but not lightly decided on.
A substitute operation for sciatica is the so-called bloodless stretching, in which, the patient having been etherized, the thigh is forcibly flexed on the pelvis, and then the leg extended on the thigh and the foot on the leg (dorsal flexion), and held for a short time in this position. A very material degree of stretching of the sciatic nerve is doubtless possible in this way, and a number of cures have been thus effected. But, though less dangerous than the stretching of the exposed nerve, this operation is not a trifling one.
In one case of sciatica the writer has seen a neuritis of some severity lighted up by this operation, perhaps because the disease was in too active a state, although it had lasted some months. The operation is probably most indicated in chronic cases.
The anatomical effects of nerve-stretching are manifold. Nerve-fibres are usually destroyed in greater or smaller number, and the conducting power of the nerve correspondingly impaired. Small blood-vessels are broken and the circulation and nutrition of the nerve-trunks altered, and it is probable that adhesions in and around the nerve-sheaths, where such exist, are severed. The nerve-fibres ramifying in the inflamed sheaths of the large trunks may also be ruptured, and it may be that the displacement of the fluid contents of the nerve brings about better nutritive conditions.32 It is also probable that the operation either directly or indirectly affects the nutrition of the nerve-centres,33 and although this is not without its dangers, the chances are in favor of a beneficial result.
32 See “Die Rückenmarks-dehnung,” Hegar, Samml. klin. Vorträge, 239.
33 Hegar, loc. cit.
Another means of directly acting on neuralgic nerves is by subcutaneous injections of water, chloroform, ether, osmic acid, nitrate of silver, and other substances. The deep injection of water over the affected nerve is attended with but little danger, and is occasionally successful. The similar use of chloroform, in doses of 15 to 30 minims, is much more often effective, but sometimes causes great pain, and even abscess. It has been mainly used in sciatica, also in other neuralgias, even those of the fifth pair. In this case the injection is best made through the buccal mucous membrane. This treatment is not without danger of causing collapse, or even death, probably due to the wounding of a small vein. In one case of sciatica treated by the writer the chloroform probably entered the nerve itself to some extent, as the injection was followed by very severe pain lasting for several hours, and eventually by some degree of muscular wasting. The neuralgic pain, which had continued obstinately for a long period, was, however, cured, and had not returned at the end of some days, when the patient was lost sight of.
Osmic acid has been used recently in the same way, and the reports show about an equal number of successes and failures. The dose is about 8 minims of a 1 per cent. solution, and the injection may be repeated at intervals of a few days. It has been used successfully in various parts of the body, including the face and the fingers. The injection causes no great pain, but occasionally, though rarely, excites abscess.
Under the general heading of massage a number of manipulations may be grouped which are of value in the treatment of neuralgia, even of long-standing cases of sciatica and the like.34 When, as often happens in the case of sciatica, the nerve is the seat of congestion and exudation, strong and deep kneading along its course, with vigorous stroking upward in the direction of the lymph-vessels, is the important part of the treatment. Besides this, however, the prolonged and gentle manipulation of the painful region may greatly relieve the patient for a time, apparently by acting on the sensitive nerves and exerting a sort of inhibitory action, in which it is not at all impossible that an influence upon the attention analogous to that of Braidism plays a part.
34 See Reibmayr, Die Massage, etc., Wien, 1883.
A striking instance of the effect of this treatment is seen in the case of nervous headaches, which are often very greatly relieved by a series of gentle, monotonous movements of the finger-tips, as well as by the domestic remedy of gently and persistently combing or brushing the patient's hair. A still more efficient application of a similar kind is the regular vibration communicated by a large magnet or by the instrument devised by Mortimer Granville. A thoroughly satisfactory explanation of the action of this treatment is yet to be furnished.
There is no doubt that in the treatment of neuralgia a persistent and thorough use of the remedies suggested is usually the key to success. Nevertheless, special cases are sometimes reached by special means of treatment, and the following are appended as occasionally useful: Ammonio-sulphate of copper (grs. ij-vj, taken in divided doses in the course of the day); salicylate of soda, in full doses; caffeine; tonka (fluidrachm j of the fluid extract at repeated intervals of a few hours); oil of turpentine; muriate of ammonia.
Special Forms of Neuralgia.35
35 Consult, in connection with this subject, the sections on Symptomatology and Treatment.
MIGRAINE AND PERIODICAL HEADACHE.—In many of the recent treatises upon nervous disease migraine and headache are removed from the category of the neuralgias and placed in that of the functional affections of the sympathetic vaso-motor system of nerves. This classification is based upon the fact that in many of these cases marked vascular changes—congestion or anæmia, as the case may be—are observed in the external tissues of the affected parts, while the sensations of the patient often lead us to infer the presence of similar conditions within the cranium. The pain and the other symptoms of the outbreak, it is thought, are due to the changes in blood-tension in the cortex cerebri or in the region of expansion of sensitive nerves, or, in part, to the spasm of the muscular walls of the vessels themselves. This theory is seductive from its appearance of pathological simplicity and exactness, but the writer believes, with Anstie, Latham, Allbutt, and other observers, that it is not borne out by clinical experience, and that its adoption tends to cloak the wider relationship that exists between the sensory neuroses.
Migraine, nervous headache, and the superficial and the visceral neuralgias hardly differ more fundamentally from each other than individual cases of either affection differ among themselves. It is not improbable, as we have seen, that all the phenomena of some neuralgic attacks are wholly or in part the expression of irritation of the sensory nervous system from without; but in many cases, on the other hand, the signs of the neurosal tendency are clearly marked, and there is hardly one of the symptoms of a typical migraine of which the analogue may not be found, though perhaps faintly pronounced, in one or another form of superficial neuralgia, while the relation of both to the whole family of the neuroses is still more clearly evident.
Migraine is a disease of youth and middle life, characterized, in its most typical form, by attacks of severe headache of a few or many hours' duration, of gradual onset and decline, ushered in by well-marked auras involving one or more of the cerebral functions, and terminating in nausea or vomiting or profuse secretion of pale urine, or in some other critical nervous outbreak. The pain is usually, but not invariably, deep-seated. It may be confined to one side of the head, most often the left, or may involve both sides, either from the outset or in the course of the attack. The forehead or temple is usually the first part to become painful, but in severe or prolonged seizures the parietal and occipital regions are prone to be affected likewise.
The auras are manifold and important. On the day before an attack the patient may feel remarkably well, or may complain only of such sensations as thirst or giddiness. The attack itself is apt to be ushered in by visual hallucinations of dazzling and vibrating points or serrated images, sometimes with prismatic outlines, accompanied by a loss or obscuration of vision over one-half or some other portion of the field, which lasts half an hour or more, and sometimes clearing up in one part while it advances in another. Simultaneously or immediately after this there may be tingling and a sense of numbness of the tongue, lips, hand, or one-half of the body, sometimes followed by partial hemiparesis, and, if the right side be affected, by more or less aphasia or mental confusion. Occasionally the other special senses are affected. Sometimes the aura may constitute the whole of the seizure.
The writer has observed a case in which migraine was represented throughout boyhood by repeated attacks of subjective numbness and tingling of the entire right side of the face, the right arm, and the right half of the body, with aphasia and hemianopsia, followed during many years by trifling headache or none at all; later in life by severe pain. Here migraine as well as neuralgia in other forms was a well-marked family disease.
These auras are especially worthy of notice, because they occasionally point to epilepsy, an affection with which migraine is allied.
The pain may begin on the same side with these prodromal symptoms or on the opposite side. Sometimes drowsiness is a marked symptom throughout the attack, and this differs in significance from the sound, refreshing sleep with which the paroxysm often comes to an end. Sometimes the arteries of the affected side seem strongly contracted, as shown by pallor and coldness of the face and dilatation of the pupil (angio-tonic form); sometimes, on the other hand, they are dilated and pulsate strongly, or the latter condition may follow the former (angio-paralytic form). The radial pulse may show corresponding modifications. These vascular phenomena are often, however, entirely wanting.
Migraine appears to be slightly more common in women than in men. The liability to the attacks often shows itself in extreme youth, usually increases at puberty, and generally ceases at the age of forty or fifty. The attacks sometimes recur at regular intervals of a week, a month, etc., but, on the other hand, they may remain absent for years unless brought on by some exciting cause.
ETIOLOGY AND CLINICAL RELATIONS.—Migraine is a directly inheritable disease, and one which stands in a close relationship to the other grave neuroses, as well as to the neuropathic temperament. Cases are occasionally seen in which the migraine of youth gives place to epilepsy in later years. It is often met with also in families and individuals of neuralgic tendency, and in fact it shades off into neuralgia of the fifth and occipital nerves on the one hand and into periodic nervous headaches on the other. It frequently occurs in gouty persons, and is thought to be related to the brow ague of malaria. The attacks may be brought on by any of the causes which depress the vitality of the nervous system, and by various special irritations, among which errors of refraction are prominent.
The PROGNOSIS is unfavorable in well-marked cases, in which the habit of regular recurrence is established, and where the neuropathic predisposition is pronounced and no special exciting cause can be found. On the other hand, there are many cases where the tendency is less deeply rooted, and where with the removal of the exciting cause or causes the outbreaks cease.
Finally, there is great probability that the disease will cease of itself with advancing years, not always, however, without having left its mark on the patient's mental and bodily vitality.
The TREATMENT should be directed first to the detection and removal of special sources of irritation, whether in the eye, stomach, uterus, or elsewhere. Causes of anxiety and mental strain should be as far as possible avoided, and great caution enjoined in the use of stimulants and narcotics. The nutrition should be maintained at its highest level by tonics, and, if need be, by electricity, massage, and hydropathy. Sometimes, besides this a special diet is advisable, for it seems beyond question that some patients have fewer headaches if they abandon all animal food, while others—whether because of a gouty tendency is not clear—do best on a nitrogenous diet with exclusion of sugar and starch.
Of the drugs used to control the liability to the attacks, the most important is cannabis Indica, given in doses of about half a grain of a good preparation of the extract several times daily for weeks or months together. Valerianate of zinc and the iodide and bromide of potassium in full doses are also recommended, but are less efficacious.
In the treatment of the attack itself, besides absolute rest and quiet, large and repeated doses of guarana or caffeine, either alone or combined with drachm doses of bromide of potassium, are sometimes of use if given at the very outset.
It is thought by some observers that ergot or ergotin is of value if the vessels are dilated, and conversely nitrite of amyl or glonoine if they are contracted. It must not be forgotten, however, in case of doubt, that the throbbing due to the latter drugs may increase the pain.
The writer has known a strong faradic current applied with the moistened hand to the back of the neck to relieve an attack, and prolonged but gentle manipulation of the painful area with the finger-tips may have a like effect if the pain is not too severe; as, for example, toward the end of a paroxysm.
Neuralgias of the Fifth Nerve.
Three varieties of these neuralgias may conveniently be distinguished:
1. Ordinary facial neuralgia, analogous to the neuralgias of the other superficial nerves;
2. Intermittent supraorbital neuralgia, sometimes called brow ague, though by no means always of malarial origin;
3. Epileptiform neuralgia (tic douloureux).
These varieties are of course closely allied, and have many features and causes in common.
THE ORDINARY FACIAL NEURALGIA is a painful and obstinate malady, although not so serious as the typical tic douloureux. The pain may remain fixed in one position or it may shift from one part of the face to another; and the latter is especially common in those forms which occur in anæmic or ill-nourished persons. It associates itself readily with occipital neuralgia, and sometimes also with neuralgia of the pharynx and other parts. It occurs most often in persons of neurotic tendencies or impaired nutrition, and may be provoked by disorders of the ears, teeth, and even distant organs. The possibility of aneurisms of the internal carotid or of cerebral tumor should also be borne in mind, and signs of herpes zoster and locomotor ataxia carefully sought for.
The relation of caries of the teeth to neuralgia of the fifth pair forms a very important chapter, which is admirably treated by J. Ferrier.36 Opinions on this subject are conflicting and unsatisfactory, and the fact that many patients have had nearly all their teeth drawn in the vain attempt to get cured of one of the severe forms of facial neuralgia often creates an impatience of further investigation in the matter. Ferrier points out that as a rule it is not the severest cases of epileptiform tic douloureux that arise in this way, but, on the other hand, that it is a mistake to conclude, because a neuralgia is benefited by medical treatment and made worse by fatigue, exposure, etc., and because it occurs in a person of neurotic temperament, that it is not likely to be due to this form of irritation. The teeth need not themselves be the seat of pain, and the disease in them may be detected only after diligent search.
36 Les Névralgies reflexes d'Origine dentaires, Paris, 1884.
The most important lesions are said to be caries, exostosis, and other affections involving the pulp-cavity, exposure of the sensitive dentine, ulcerations of the gums, injuries caused in extraction, and other diseases of the alveolar process. The wisdom tooth, by its pressure on other roots and on the gums, is not infrequently the one at fault.
Chronic inflammation of the mucous membrane of the nose or pharynx is said to be an occasional cause of neuralgia of the face, as well as of the upper portions of the body.
THE INTERMITTENT NEURALGIA OF THE SUPRAORBITAL is an interesting affection to which too little attention has been paid. One variety seems to bear a certain relationship to migraine, inasmuch as it occurs under similar circumstances—i.e. in distinctly neuropathic individuals and families, and in attacks of about the same duration and periodicity of recurrence.
Another variety approaches the other neuralgias in the longer duration of the attacks, but is characterized by a daily seizure which recurs with absolute regularity, coming on usually at about nine in the morning and increasing in severity for an hour or so, then persisting unchanged until midday or later, when it gradually diminishes, finally disappearing in the course of the afternoon. As a rule, it is brought on by catarrh of the frontal sinuses, often following an acute attack of coryza. A certain amount of neurosal predisposition is often found in this form, and the first attacks may show themselves in early youth, rarely in the decline of life. The writer has seen one family in which a number of members in at least two generations have been attacked in this way, the seizures having been brought on by exhaustion or coryza, or both combined.
This form of neuralgia is often greatly controlled by quinine if given in sufficiently large doses (15 to 20 or 25, or even 30, grains) and as long as four hours before the attack.
Lange37 thinks the action of galvanism is remarkably successful, but the writer's experience does not fully bear this out.
37 Cited in the Centralbl. für Nervenheilkunde, etc., 1881, p. 10.
Seeligmüller38 speaks very highly of the effect of the nasal douche, used for the sake of curing the catarrh of the frontal sinuses, and potassic iodide may be useful by rendering the secretions more fluid.
38 Centralbl. für Nervenheilkunde, etc., June 1, 1880.
THE EPILEPTIFORM FACIAL NEURALGIA, OR TIC DOULOUREUX, is a chronic affliction, characterized by the suddenness of onset and the severity of its paroxysms of pain, which may recur every few minutes with lightning-like rapidity, either spontaneously or brought on by motion of the jaw or the taking of food, and disappear again as quickly. After a group of such paroxysms as this there may be an intermission of some hours or days. During the attack the patient is apt to rub the seat of pain with great violence. The path pursued by the darts of pain may be either in the direction of the nerve-trunks or in an irregularly inverse direction.
In spite of their sufferings, these patients may present an appearance of health. In its worst forms, and especially in advanced life, this variety of neuralgia may be incurable, and at the best it is sure to tax the care and skill of the physician. Anstie thinks that it is apt to be associated with a taint of insanity.
The best TREATMENT consists in the most painstaking attention to hygiene, in the persistent use of galvanism, arsenic, cod-liver oil, quinine, aconite (see under General Treatment), and phosphorus. Croton chloral is occasionally of service.
As a last resort, surgical measures (see above) may be appealed to, but it should be borne in mind that even when the prospect seems most hopeless the relief under medicinal and hygienic treatment may really be near at hand. Where section of nerves is without result, the operation of tying the larger vessels, the carotid or vertebral, on the affected side may be tried, and offers some chance of success.
OCCIPITAL AND CERVICO-OCCIPITAL NEURALGIAS are second only to trigeminal neuralgia in severity, though, fortunately, less common, and either is liable by extension to give rise to the other.
Neuralgic pains in the occipital region may attend Potts's disease of the cervical vertebræ; and this is especially important to bear in mind because the osseous deformity is often wanting for a long time.
The writer has known a persistent pain in this region to be due to intracranial syphilitic disease, and to cease suddenly with the advent of more serious cerebral symptoms.
CERVICO-BRACHIAL AND BRACHIAL NEURALGIAS are less often indicative of the neuropathic taint than the facial neuralgias; and, on the other hand, they are, like sciatica, relatively often due to neuritis set up by injury, amputation, strains, enlarged cervical glands, periarthritis of the shoulder,39 etc., or associated with herpes zoster. When not due to an unremovable cause the prognosis is favorable. The treatment needs no special description.
39 See J. J. Putnam, “A Form of Painful Periarthritis of the Shoulder,” Boston Med. and Surg. Journ., 1882.
INTERCOSTAL NEURALGIA is a very important form, both on account of its frequency and obstinacy, and because it is often associated both with anæmia and chlorosis and with affections of the visceral organs, especially the uterus. The distressing cardiac palpitation of neurasthenic patients often associates itself with pain in the left side, and there is an intimate connection between neuralgia of the cardiac plexus (angina pectoris; see below) and neuralgia of the intercostal and brachial nerves.
Pain in this region, often due to neuritis, may accompany acute and chronic thoracic disorders, and may be the precursor of herpes zoster. Caries of the vertebræ and meningitis should be thought of, and cancer if the neuralgia is very persistent, even if it is paroxysmal in character.
TREATMENT.—Besides the general indications for treatment referred to above, it is worthy of special note that nerve-stretching has been successfully tried for intercostal neuralgia. In one interesting case seven nerves were stretched at one operation.40 The reporter discusses the surgical aspects of the operation, and points out that the nerves should be sought for, not directly beneath the rib, but behind and beneath it, and thinks that the failure to bear this fact in mind might lead to puncturing the pleura.
40 Lesser, Deutsch. Med. Wochenschr., Sto. 20, 1884.
MAMMILLARY NEURALGIA (irritable breast of Astley Cooper), though often met with in company with intercostal neuralgia, may occur entirely independently. It is sometimes bilateral, and is apt to be associated with irregularity of the uterine functions. Cutaneous hyperæsthesia is often present to a distressing degree, and small tumors of either temporary or permanent duration may make their appearance (A. Cooper), which, however, do not affect the prognosis.
There is no especially effective TREATMENT beyond what has been spoken of. Surgical interference is not especially to be recommended, though it has occasionally been useful.
LUMBO-ABDOMINAL NEURALGIA, or neuralgia of that part of the lumbar plexus which supplies the flank and abdomen and the external genital region. These neuralgias are apt to accompany those of the intercostal nerves and share in their significance.
The most important facts with regard to them are that they are intimately associated, in relation both of cause and of effect, with affections of the abdominal and the pelvic organs and of the testis. Neuralgias of the terminal branches of the lumbar plexus, the obturator and anterior crural nerves, though well recognized, are comparatively rare.
One of the chief respects in which they are important is in calling attention to the possible presence of disease of the hip-joint or of periarthritis of the hip, as well as of tumors or inflammation within the pelvis.
NEURALGIA OF THE SCIATIC NERVE is one of the most severe and common forms. While sharing in the common etiology and history of the other neuralgias, it is peculiarly prone to be due to peripheral causes, which give rise to thickening of interstitial and investing connective tissue of the nerve. The distribution of the pain may be coextensive with the whole distribution of the great and little sciatic nerve, but far oftener the patient indicates certain regions as the seat of his severest suffering; and these are especially the sacral region of one side, the neighborhood of the sciatic notch, the popliteal space, the calf, and the outer side of the foot and ankle. Not infrequently the whole course of the sciatic nerve is traced out by the darts of pain; and in this case it is the nerves which supply the sheath of the sciatic itself which are supposed to be the seat of the neuralgic process.
Sciatica is usually unilateral, but exceptionally bilateral, or attacks the two sides alternately. The tender points most often met with are at the sacro-iliac synchondrosis, the posterior border of the great trochanter, just beneath the head of the peroneal bone, below and behind the external malleolus, but numerous others are likewise noted by Valleix. Sometimes no tender points can be found. Sometimes, also, it is one or more of the collateral branches of the sciatic plexus that are the seat of the neuralgia, and the distribution of the pain and of the tender points varies accordingly.
It is in sciatica pre-eminently—in part, no doubt, because of the frequency of neuritis—that disorders of sensibility of the skin are noticed, as well as muscular paresis or spasm. This anæsthesia has been studied with great care by Hubert-Valleroux and others, and it has been shown that it is often confined to limited spots, a centimeter or so in diameter, within which the loss of sensibility may be nearly absolute. Nevertheless, their functional origin is proved by the fact that under faradization they may rapidly disappear.
The duration of an attack of sciatica varies from a week or two to months or even years, and it shows a marked liability to recur, especially with changes of weather. First attacks occur pre-eminently, though not exclusively, in middle life, and oftener in men than in women, evidently because they are oftener exposed to mechanical injury and, through their occupations, to sudden changes of temperature and the like.
The occasional causes are numerous, and include sudden wrenches and jars, even if not very severe, interpelvic pressure from tumors or impacted feces, etc. Gout, syphilis, and diabetes may act as predisposing and even exciting causes, and, it is said, gonorrhœa likewise. Periarthritic inflammations of the hip-joint and varicose veins frequently excite pains in the various sciatic nerve-branches which simulate true sciatica.
As has been indicated, although sciatica may be a pure neuralgia (see under Pathology), running its course without leading to any appreciable change in the nerve, yet subacute and chronic neuritis is very common, either as a primary condition or a complication, and its presence puts a graver aspect upon the case. The pain of neuritis, when severe, is relatively constant, remittent instead of intermittent, dull rather than lancinating, increased by motion and pressure; whereas the purely neuralgic pains are sometimes relieved by movement. It is, however, doubtful whether an accurate differential diagnosis is possible (see above). It is to this neuritis that the muscular atrophy is due which is often so marked, and it may likewise give rise to various cutaneous lesions of herpetic character. The severe pain that accompanies typical herpes zoster of this region is well known.
The TREATMENT of sciatica must vary with the probable cause of the disease and its stage of progress. Diathetic taints are to be met if present, and the greatest measure of physical health secured that the circumstances possibly admit. It is a good precaution in all cases to secure free evacuation of the bowels and to guard against hemorrhoidal congestions.
As against the neuralgia itself, the proper means vary with the acuteness of the attack and the presence or absence of neuritis. For the acute stage absolute rest is almost always desirable as a prime condition. Quinine, belladonna, aconite, and turpentine in full doses should be thoroughly tried, and special reference had to the periodicity of the seizures.
Frequent and extensive but superficial counter-irritation (actual cautery, blistering, ether, or chloride of methyl) is in place in this stage, and galvanism (constant current) is often of great service. It is probable that for the acute stage the prolonged use of mild currents is the best, whereas in more chronic cases the stronger, even very strong, currents, brought to bear as accurately as possible upon the nerve itself, are sometimes more useful.
Hydropathic treatment is in great repute both for acute and chronic cases, but as success in this way demands care and knowledge, the reader is referred to the special treatises.
In cases of long standing the continued application of ice-bags along the length of the limb for days together is often of excellent service, but this method of treatment is not without its dangers and needs to be carefully watched.
In chronic cases deep injections are of service, and nerve-stretching (see above) is in place.
THE VISCERAL NEURALGIAS have not received the attention which is due them both on account of their intrinsic importance and their constitutional significance. Not only are they found in common with the superficial neuralgias in the overtired and the underfed, but they point more strongly than the latter to the neuropathic diathesis, alternating with such symptoms as migraine, asthma, nervous dyspepsia, and insomnia. They occur also in the gouty and among the neuropathic descendants of the gouty, and as a result of functional and organic disorders of the viscera.
The pain of these neuralgias, though usually described as vague, ill-defined, dull, etc., yet often stirs the nervous system to its depths, causing nausea, faintness, sweating, prostration, reflex disorders of the secretions, and like symptoms.
ANGINA PECTORIS is a neuralgia probably of the pneumogastric and sympathetic nervous apparatus of the heart. The pain, which is usually of a heavy, dull, oppressive, or tearing character, and capable of rising to intense agony, is usually deep-seated, and felt to the left of the sternum and beneath the breast, often involving the left arm and side, and occasionally the left side of the face and neck, and even the leg of the same side or the right arm. It may also, as the writer has seen, be confined to the sternal region. In the case referred to this pain recurred every afternoon and evening with great regularity. Sometimes instead of pain the arm may be the seat of a tingling numb sensation only.
During the attacks the action of the heart may continue unchanged, or it may become slow and feeble or intermittent, yet without necessarily being the seat of organic disease. The onset of anginic attacks is usually, but by no means always, sudden, and their duration is commonly short. All the features of the attack, however, are subject to considerable variation, and nervous symptoms of a variety of kinds, which it is not necessary to detail, may precede or attend the seizure. In severe attacks the patient's anguish and prostration are extreme; the face and extremities become pale and cold, and a cold sweat breaks out.
In a large proportion of cases, especially the severest ones, these neuralgic attacks are associated with organic disease of the heart or blood-vessels.
A variety of causes have been suggested to account for the seizures, prominent among which is a widespread contraction of the arterioles, bringing a sudden strain upon the left ventricle of the heart. This theory is especially noteworthy because of the success which has attended the treatment by nitrite of amyl, which brings on a rapid vascular relaxation. In other cases spasm of this kind is manifestly absent. Fraenkel41 has recently defended the view that a momentary paralysis and over-distension of the left ventricle is the exciting cause. In other cases all sign of arterial or cardiac disease is and remains absent.
41 Zeitschr. für klin. Med., 1882.
In this latter group the tendency to the attacks may cease under appropriate hygienic treatment. Thus, in an instance known to the writer a lady of usually good health suffered for several months from slight attacks of præcordial pain, with pain or a sense of numbness in the left arm, and often a feeling of breathlessness on very slight exertion. This condition had manifestly been brought about by prolonged physical and mental strain, and disappeared completely after a period of rest. Other such cases are described by Anstie, Allbutt,42 and others.
42 London Lancet, 1884, i.
In judging of the significance of anginic attacks in a given case the signs of circulatory disease should first be studiously sought, and especially, as more likely to escape notice, indications of cardiac enlargement or weakness, or of increased vascular tension, or of chronic nephritis.
Dull pains in the intervals of the attacks are also regarded as important, as indicating the presence of neuritis of the cardiac nerves, which without doubt often exists. On the other hand, as pointing rather to a neurotic origin of the symptoms, a tendency, individual or inherited, to neuralgias of other forms, to asthma, migraine, and the other neuroses, is to be looked for.
Heredity plays a certain part in the etiology, and among the special causes of the non-organic form abuse of tobacco is said to be important.
The TREATMENT would be likely, of course, to be widely different according to the nature of the case, being on the one hand addressed to the circulatory apparatus, on the other to the health of the nervous system, in both cases following well-known lines.
In the treatment of the individual attacks the diffusible stimulants and the narcotics are of value when there is time to employ them. With regard to nitrite of amyl and the longer-acting nitro-glycerin, which have given so much relief in some cases, it would be premature to confine their use to the cases of demonstrable vascular spasm or even organic disease, and they are fair agents for trial in the apparently non-organic cases as well.
A patient of Romberg's used to get great relief from swallowing pieces of ice.
When the attacks are long continued or frequent, electricity, either as galvanism or by the wire brush, is applicable, and also counter-irritation over the chest, even by vesication.
GASTRALGIA (syns. gastrodynia, cardialgia, gastric colic, cramp of the stomach, etc.) may be associated with organic disease of the stomach or may occur as an independent neurosis. It is met with in individuals and families in which asthma, migraine, gout, etc. are found. In general it is common in persons of nervous, mobile temperament, and is moreover apt to point to temporary exhaustion from some cause, though this is by no means always true. The writer has seen several sensory disorders of this class at the period of life of which the menopause is the chief feature. The pains of apparently hypochondriacal patients doubtless belong sometimes in this group.
The pain of gastralgia is felt primarily at the epigastrium, whence it may radiate upward and backward along the œsophagus and through into the back, as well as laterally in various directions. Allbutt says that it is sometimes associated with anginiform attacks.
Other associated symptoms are dyspnœa, prostration, faintness, coldness of the extremities, or reflex changes in the action of the heart, which may beat feebly, rapidly, and irregularly, or more slowly than normal.
Apropos of the relation of gastralgia to organic disease, it is important to recall the fact that some of the organic diseases of the stomach, notably chronic ulcer and cancer, may fail to reveal their presence by any physical sign. In a case seen by the writer a cancerous growth had invaded the entire stomach, causing an enormous thickening of its walls, yet no tumor was to be felt, and the most marked symptoms were gastralgia and exhaustion.
The relations of gastralgia to the other purely functional disorders of the stomach are interesting and peculiar. It is beyond a question that every variety of digestive disorder, from simply delayed and painful digestion to pyrosis, the formation of gas, and constant vomiting, is much more often of purely neurotic origin than has been supposed.
The DIAGNOSIS of catarrhal gastritis as distinguished from nervous dyspepsia is indeed often difficult or even impossible. Leube has recently recorded a case where the matter vomited during life contained fungoid growths, such as are usually considered pathognomonic of gastritis, and yet at the autopsy the mucous membrane appeared perfectly healthy.
With these nervous disorders of digestion, which are by no means confined to hysterical patients, gastralgia may be variously associated, or it may occur independently of them all, or vice versâ. On the other hand, digestion may be attended with a sense of discomfort, often amounting to severe pain, yet without regular outbreaks.43 This symptom is classified by Allbutt as a hyperæsthesia of the stomach rather than as a neuralgia, but from this to true gastralgia there is only a sliding scale of difference. Sometimes a persistent neuralgic habit is set up by a local disorder which itself passes away entirely.
43 Allbutt, loc. cit.
TREATMENT.—In acute attacks the aim is simply to relieve pain by whichever of the well-known methods promises the best. The real field for thought and care is in the treatment of the underlying states—first, those which, like gout, anæmia, syphilis, or nervous debility, predispose to the attacks; second, the local or special conditions which act as exciting causes. Sometimes it will be found that such patients have special idiosyncrasies with regard to the nature of food or time of meals.
In that condition of the system which is indicated by frequent or paroxysmal excess of uric acid in the urine a long-continued use of Vichy water or lithia is sometimes of service. If it be finally concluded that the stomach is in an hyperæsthetic, not in an inflamed, condition, it may not be advisable to diminish the amount of food, but, on the contrary, by one means or another, to increase it.
NEURALGIA OF THE UTERUS AND OVARIES.—Attention has repeatedly been called to the fact that affections of these organs may excite neuralgias in distant parts of the body or in the lumbo-abdominal nerves; but besides these the uterine and ovarian nerves themselves sometimes are the seat of neuralgia, and it is claimed that menorrhagia and metrorrhagia may occur as a consequence.
The other abdominal organs and the testis are occasionally the seat of neuralgic pains, and attacks which involve the liver may be followed by swelling of the liver and by jaundice.
It is not always easy to assert with confidence whether an attack of abdominal neuralgia affects the external or the visceral nerves.
NEURALGIA OF THE ANUS AND RECTUM is a well-marked and painful affection, and the tendency to it may be hereditary. The seizures themselves may come on spontaneously, especially after fatigue, or may be excited by slight irritations, such as the passage of hardened feces, or may follow seminal emissions. The pain may be accompanied by quick, clonic spasm of the perineal muscles.
The rapid injection of hot water into the rectum often at once relieves the attack.
We have not space to discuss at length the neuralgiform affections of the joints and muscles and those due to the metallic poisons and other causes which do not follow the course and distribution of special nerves.
In accordance with the belief which we have expressed, that neuralgic attacks are not always of the same nature, but are the manifestations of many different conditions, we should be inclined to include many of these irregular affections under the neuralgias instead of classifying them apart, as Anstie and most writers have done. Thus, a patient of the writer, a gentleman of middle life, who has had migraine since childhood and belongs to a neuropathic family, suffers on the slightest exertion from violent pain in both thighs, which comes on very gradually, beginning at the knees and spreading upward, eventually passing away after a night's rest. One might diagnosticate this as myalgia if he confined himself to topographical considerations, but the history of the patient and the regular march of the attacks point to a different conclusion.