Neuralgia and the diseases that resemble it

by Francis Edmund Anstie

We are also certainly entitled to adduce the example of the so-called neuralgic form of chronic alcoholism as an instance of the close relationship of neuralgia to other central neuroses. I refer to those cases, more common perhaps than is generally admitted, in which pains in the extremities, often quite resembling neuralgia in their intermittence, are either superadded to or take the place of the muscular tremors and general restlessness that are more popularly considered as the essential nervous phenomena of chronic alcoholic poisoning. That the pains are usually bilateral, and more diffuse in their character than those of ordinary neuralgia, is a fact which it is not difficult to explain by the modus operandi of the cause; but we shall have more to say on the general relations of alcoholic excess to neuralgia presently. The pains themselves will be fully described in the second part of this book, which treats of the affections that simulate neuralgia; here we need only remark that it is not uncommon for them to occur interchangeably with true neuralgia in the same person.

The occasional interchangeability of migraine with epilepsy is a well-known fact; every practitioner who has seen much of the latter disease will have seen some cases in which the patient had been liable, at some point of his medical history, to "sick-headaches" of a truly neuralgic kind; although it is quite true, as Dr. Reynolds points out, that the kind of sensorial disorder specially premonitory of the attacks consists rather in indefinable distressing sensations, than in actual pain. The genealogical connection between migraine and epilepsy is, as I have already stated, apparently very close. Such instances as one mentioned by Eulenburg are rightly explained by him; it is the case of a girl who suffered at an unusually early age (nine) from migraine; her mother had been a migraineuse, and her sister was epileptic; the strong neurotic family tendency is believed by Eulenburg to account for the appearance of migraine at such a period of life.

This seems the fitting place to introduce some special remarks on migraine in its relations to other neuralgias of the head, because Eulenburg has mentioned and combated my view, according to which migraine is a mere variety of neuralgia of the ophthalmic division of the fifth nerve. I call it my view, because, though several other authors had previously expressed it, I was first lead to entertain it by observations made before I had studied their works, and especially by the impressive teaching of my own case, as to which more will be presently said. Eulenburg, though he fully allows that migraine is a neuralgia, urges a series of objections to the identification of migraine with ophthalmic neuralgias; of which objections one, based on the doctrine of Du Bois Reymond as to the action of the sympathetic in migraine, must be reserved for consideration when we discuss the general pathology of the vaso-motor complications of neuralgia. The other grounds of distinction that he urges are the following: In the first place, he remarks that the site of the pain is by far less distinctly referred to definite foci on the outside of the skull than in trigeminal neuralgia; the patient's sensations very usually lead him to declare that the pain is in the brain itself. Secondly, he says that the points douloureux (in Valleix's sense) are almost constantly absent in true migraine. Thirdly, he specifies the character of the pain in migraine—dull, boring, straining, etc.—as differing from that of trigeminal neuralgia, which is ordinarily much more acute and darting. Fourthly, he notes the long duration of individual attacks of migraine, and the long intervals (very commonly three or four weeks) between them. Fifthly, he dwells on the frequent prodromata of migraine referable to the organs of sense (flashes before the eyes, noises in the ears), or to the stomach (nausea), or more generally to the reflex functions of the medulla oblongata (e. g., convulsive rigors, excessive yawning, etc.)

Now, I should have nothing to say against the accuracy of this description, did it apply merely to the distinctions between highly-typical cases of the "sick-headache" of the period of bodily development, and highly-typical cases of the ophthalmic neuralgias which are commonest in the middle and later periods of life; nor indeed should I greatly care if it were finally decided that migraine and clavus should be separated from the true trigeminal neuralgiæ, provided the following points were well impressed on the minds of practitioners. In the first place, I must insist that in my own experience the great majority of undoubtedly neuralgic headaches, which subordinate stomach disturbance, are far less sharply separated than the above description would allow from the unmistakable trigeminal neuralgias; it is only a minority of cases that wear this extreme type, and a far larger number shade imperceptibly away toward the type of ophthalmic neuralgia pure and simple. And so, again, of the so-called clavus there is every variety, from a form bordering closely on the migraine type to another, differing in nothing from an unusually severe ocular and frontal neuralgia of the fifth, except in the presence of a tremendously painful parietal focus. But the fact on which I would most particularly insist is one that was first taught me by my personal experience, viz., that migraine is, with extraordinary frequency, the primary or youthful type of a neuralgia which, in later years, entirely loses the special characters of sick-headache, and assumes those of ordinary frontal neuralgia, with or without complications. In my own case, the "sick-headache" character of the affection was strongly marked during the first two or three years, after which time it gradually but steadily lost all tendencies to stomach complications, and, what is more, the type of the recurrence became entirely changed. Yet it is quite impossible to believe that the malady is now a different one, in any essential pathological point, from what it was at first; if any disproof of this were needed, it might be remarked that the singular series of secondary trophic changes which have complicated my case have been impartially distributed between the respective periods when the affection was frankly migraineuse, when it was mixed, and when it was simply ophthalmic neuralgia (as it is at present;) indeed, some of the most decided of these trophic complications (orbital periostitis, corneal ulceration, fibrous obstruction of the nasal duct) occurred within the period in which every attack of pain, unless I succeeded in getting to sleep very shortly, ended in violent vomiting. The experience thus gained has made me very attentive to the past history of those who, in later life, complain of frontal neuralgia without stomach complication, and it is surprising to find in how many cases patients, who at first declare that they never had neuralgia before, on reflection will recall the fact that they were often "bilious" in their youth; which "biliousness" turns out to have been regularly preceded by one-sided headache, and to have been severe in proportion to the severity and duration of that previous headache.

I ask the reader to dwell with fixed attention on this fact of the exclusiveness, or almost exclusiveness, with which the neuralgias of the anterior part of the head are represented during the period of bodily development, and especially in the years just succeeding puberty, by migraine or by clavus. When this fact has thoroughly entered the mind, we can hardly help joining with it that other and most important fact already noticed, of the close connection between the predisposition to migraine and the predisposition to epilepsy, and reflecting further on the strong tendency which epilepsy likewise shows to infest the earlier years of sexual life. In view of these things, it is difficult to avoid the inference that both the epileptic and the neuralgic affections of this critical period of life are the expression of a morbid condition of the medulla oblongata, in which the sensory root of the trigeminus has its origin; and further, that this morbid condition (tending to explosive and atactic manifestations of nerve-force) must have its basis in defective nutrition. For, be it remembered, the epoch of sexual development is one in which an enormous addition is being made to the expenditure of vital energy; besides the continuous processes of the growth of the tissues and organs generally, the sexual apparatus, with its nervous supply, is making by its development heavy demands upon the nutritive powers of the organism; and, it is scarcely possible but that portions of the nervous centres, not directly connected with it, should proportionally suffer in their nutrition, probably through defective blood-supply. When we add to this the abnormal strain that is being put on the brain, in many cases, by a forcing plan of mental education, we shall perceive a source not merely of exhaustive expenditure of nervous power, but of secondary irritation of centres like the medulla oblongata, that are probably already somewhat lowered in power of vital resistance, and proportionably irritable. Let us suppose, then, that to all these unfavorable conditions there was added the circumstance that the structure of the medulla oblongata, or of parts of it, was congenitally weak and imperfect; then surely it would be scarcely possible for these loci minimæ resistentiæ to escape being thrown into that state of weak and disorderly commotion which eminently favors pain in the sensory, and convulsion in the motor apparatus.

2. We have so far been mainly considering the relations to the production of neuralgia of certain conditions of the central nervous system which indisputably are inherent from birth. Let us now pass quite to the other extreme, and consider a class of momenta which take a decided part in producing many neuralgiæ, but which are altogether accidental and factitious, and cannot be included among the necessary hostile conditions of life. To push the contrast to the utmost, let us inquire first, what amount of influence in the production of neuralgia can be given by such a purely "functional" influence as educational misdirection of intellect and emotion?

It is somewhat strange, though every one accepts as a mere truism the maxim that sudden emotional shock may produce almost any degree or variety of nervous disorder, the slower but far surer influence of long-continued mental habit is often practically ignored. It cannot, indeed, be left out of sight as a cause of disorders of the mind itself, nor are there many who would deny that such diseases as cerebral softening are, in a considerable number of cases, the premature ending to a life that has been broken down by harassing work and anxiety. But what is far less appreciated is the tendency of certain unfortunate mental surroundings and modes of mental life to produce a generally neurotic condition, which may express itself in a variety of functional disorders, among which not the least common is neuralgia.

I may fairly hope to be acquitted of any predisposition to lay exaggerated stress on this kind of influence in the production of neuralgia, considering all that I have said of the importance of that inevitable cause, the neurotic inheritance, and all that I shall have to say presently as to the effects of a variety of external influences of a totally different kind. But I confess that, with me, the result of close attention given to the pathology of neuralgia has been the ever-growing conviction that, next to the influence of neurotic inheritance, there is no such frequently powerful factor in the construction of the neuralgic habit as mental warp of a certain kind, the product of an unwise education. This work is not intended as a treatise either on religion or psychology, and yet it is impossible for me to avoid some few words that may seem to trench on the province of each: for I believe that there are certain emotional and spiritual and intellectual grooves into which it is only too easy to direct the minds of young children, and which conduct them too often to a condition of general nervous weakness, and not unfrequently to the special miseries of neuralgia. As regards the working of the intellect, it is easier to speak in a free and unembarrassed manner than respecting the other matters. There can be no doubt that, of intellectual work, that sort which exhausts and harasses the nervous system is the forced, the premature, and the unreal kind; and this it is which predisposes, among other nervous maladies, to neuralgia. It is more difficult to speak the truth about emotional influences generally, and especially about those which are concerned with the highest spiritual matters; but I should do wrong were I to suppress the statement of my convictions on this point. I believe that a most unfortunate, a positively poisonous influence upon the nervous system, especially in youth, is the direct result of efforts, dictated often by the highest motives, to train the emotions and aspirations to a high ideal, especially to a high religious ideal. It is not the object that is bad, but the machinery by which it is sought to be attained. In modern society there are two principal methods which are popularly employed for this purpose; I shall describe them, by two epithets which are selected with no offensive intention, as the Conventual and the Puritan methods of spiritual training. By the former is meant that kind of education which deliberately dwarfs the nervous energy, with the hope of preserving the mind from the contamination of unbelief and of sinful passion. It is a system which is not peculiar to the Roman Church, nor even to the Christian religion, and it need the less detain our attention, as its effects, so far as they are evil, are mainly seen in general nervous and mental enfeeblement, rather than in the outbreak of explosive nervous disorders, such as convulsion, insanity, or neuralgia. There are doubtless exceptions to the rule; but that is the rule. It is far otherwise with the spiritual education which is here called Puritan, but which is confined to no party in the Church. This is a system which seeks to purify and exalt the mind, not by enforcing obedience to a series of spiritual rules for which another mind is responsible, but by compelling it to a perpetual introspection directed to the object of discovering whether it comes up to a self-erected spiritual standard. The reader will understand that I have not the remotest intention to depreciate either a true and manly self-restraint in obedience to the direction of "pastors and masters," or an honest watchfulness over one's own conduct and thoughts. But the lessons which our psychologists are rapidly learning, as to the evil effects on the brain of an education that promotes self-consciousness, are sorely needed to be applied to the pathology of nervous diseases generally, and of neuralgia among the rest. Common sense and common humanity, when united with the physician's knowledge, cry out against the system under which religious parents and teachers subject the feeble and highly mobile nervous systems of the young to the tremendous strain of spiritual self-questioning upon the most momentous topics. More especially is such a practice to be condemned in the case of boys and girls who are passing through the terrible ordeal of sexual development—an epoch which, as we have already seen, is peculiarly favorable to the formation of the neurotic habit, and I must emphatically state my belief that among the seriously-minded English middle classes, more especially, whose life is necessarily colorless and monotonous, the mischief thus worked is both grave and widely spread.

Perhaps the maximum of damage that can be inflicted through the mind upon the sensory nervous centres is effected when to the kind of self-consciousness that is generated by an excessive spiritual introspection there is added the incessant toil of a life spent in sedentary brain-work, and checkered with many anxieties, and many griefs which strike through the affections. Doubtless, such a combination of morbid mental influences is sufficient of itself to generate the neuralgic disposition in its severest forms, without any hereditary neurotic influence, and without any other peripheral irritations; I have more than one such instance in my mind at this moment. But, if they can do this, much more can such influences arouse inherent tendencies to neuralgia; to persons who are predisposed in this manner they are most highly deleterious.

3. We come now to the peripheral influences which in a more obvious manner become factors in the production of neuralgia. Of such influences there are an immense variety, and the only common quality that can be predicated of all is the tendency directly to depress the life of the sentient centre upon which their action impinges.