In a second case, which presented itself in the out-patient room at Westminster Hospital, a young man of markedly-nervous temperament, who had been somewhat given to drink, complained of similarly deep-seated intermittent pain, which he referred, however, to a point nearer the back of the head. He suffered, also, from vertigo, especially after unusually long paroxysms. Blisters to the nape of the neck, and a few subcutaneous injections of morphia, removed the pain and the vertigo completely.
A third example was that of a gentleman, aged thirty-four, who was sent over from the neighborhood of Sydney, Australia, to see me. Here, also, there was deep-seated intracranial neuralgic pain of the most severe kind, which greatly alarmed his local medical attendants; and it was only after a great many remedies had been tried that one medical man gave the opinion that the disease was "neuralgia of the membranes of the brain," and employed the hypodermic injection of morphia. This treatment at once gave great relief, though the pain had been so severe as to cause delirium on several occasions. In order to get thoroughly re-established, he was sent to England, and desired to consult me. As was expected, the voyage proved of the greatest service, as he hardly suffered at all while on the water. On arriving in England he was at first well, but in a week or two began to feel somewhat below par, and one morning, feeling an attack of pain coming on, he came to me. He was a tall and strongly-built man, with nothing peculiar in his appearance except a certain languor and heaviness of the eyes. He appeared to have lived somewhat freely and to have smoked decidedly to excess. His description of the attacks left no doubt of their neuralgic character, and in other respects they seemed quite analogous to the other cases mentioned above, except in one thing, that there seemed a good deal of evidence tending to show a bad local influence in the air of that part of Australia where he usually resided. Almost any change from that had always done him good, though nothing had done anything like so much as the voyage to England. On the occasion of his first visit to me I injected him with one-sixth grain acetate of morphia, thereby stopping the pain. I prescribed muriate of iron and minute doses of strychnia, which he took for some little time, but the pain never recurred during his stay in England and on the Continent. Unfortunately, as he was anxious to return to Australia, I permitted him to do so, after a stay in the Old World of only three or four months; but, very shortly indeed after his return to Sydney, his old complaint attacked him. This time, unhappily, the hypodermic morphia has proved merely palliative, and I have latterly heard very bad accounts from him; still, there has been nothing to throw doubt on the neuralgic character of the disease.
In reflecting upon the anatomy of the nervous branches to the dura mater, I have formed the opinion that there are two situations, one anterior and the other posterior, in which intracranial neuralgia may occur; the former at the giving off of Arnold's recurrent branch from the ophthalmic division, near the sella turcica, the other in the peripheral twigs of this same branch, distributed to the tentorium cerebelli.
Pharyngeal Neuralgia.—A rather common and extremely troublesome form of neuralgia is that which attacks the pharynx. It is very much more common in women than in men, and especially in hysterical persons. The pain commonly commences in a not very acute manner; it may be felt for some days, or even weeks, as a dull aching, coming and going pretty much in accordance with the patient's state of fatigue, or of reinvigoration after meals, etc. Some trivial circumstance, such as a slightly extra degree of exhaustion, or the influence of some depressing emotion, will then change the type to that of decided neuralgia, which may become extremely severe. Nothing is more annoying, and even distressing, than the suffering itself, besides which there are abnormal sensations in the throat which almost irresistibly compel the patient to believe that there are severe inflammation and ulceration, and that the throat is in danger of being closed up. Although the pain is usually one-sided, it sometimes affects both sides, and is felt also at the back of the pharynx. The act of swallowing being painful, there is the greater suspicion of inflammation or ulceration, but careful observation shows that a large bolus of food is swallowed with as little, if not less, pain than a small mouthful of solids or even liquids.
Pharyngeal neuralgia must, I think, be considered mainly an affection of the glosso-pharyngeal nerve; the evidence for this is found in the distribution of the pain. A slight degree of the neuralgia will only involve some one or two points in or behind the tonsil; but, when the pain is strongly developed, it will be found to radiate into the tongue, in one direction, and into the neck (following the course of the carotid) in another, besides spreading well into the region occupied by the pharyngeal plexus. One disagreeable reflex effect of severe pharyngeal neuralgia consists in involuntary movements of the muscles of deglutition, another is seen in the copious outpouring of thick mucus similar to that which collects in the pharynx and œsophagus when a foreign substance has become impacted.
Laryngeal neuralgia concentrates itself mainly in the twigs of the superior laryngeal branch of the pneumogastric which are distributed to the arytæno-epiglottidean folds, the epiglottis, and the chordæ vocales; more rarely a neuralgia is developed lower down, within the cavity of the larynx, apparently in one or more of the scanty twigs to the mucous membrane supplied by the recurrent laryngeal.
Pure neuralgias of the larynx, like those of the pharynx, are more common in women, and especially in weakly hysterical women, than in men. They are easily excited and greatly aggravated by movements of the parts, and thus it happens that, among men, by far the most numerous subjects of laryngeal neuralgia are found among clergymen, professional singers, and others whose occupation compels them to strenuous and fatiguing employment of the laryngeal muscles. It is rather a singular and striking fact, however, that the so-called "clergyman's sore-throat," which is characterized by most unpleasant sensations, and by a more or less complete loss of voice, is not, in the majority of cases, attended with any distinct laryngeal neuralgia. It seems that a predisposition to neuralgia is a necessary element in the latter affection.