The Project Gutenberg EBook of Neuralgia and the Diseases that Resemble it, by 
Francis E. Anstie

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.net


Title: Neuralgia and the Diseases that Resemble it

Author: Francis E. Anstie

Release Date: October 1, 2011 [EBook #37592]

Language: English

Character set encoding: ISO-8859-1

*** START OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT ***




Produced by Bryan Ness, JoAnn Greenwood and the Online
Distributed Proofreading Team at http://www.pgdp.net (This
file was produced from images generously made available
by The Internet Archive/Canadian Libraries)









                 NEURALGIA
                    AND
       THE DISEASES THAT RESEMBLE IT.

                    BY

      FRANCIS E. ANSTIE, M.D., LONDON,

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S
COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER HOSPITAL;
LECTURER ON MEDICINE IN WESTMINSTER HOSPITAL SCHOOL; PHYSICIAN TO THE
BELGRAVE HOSPITAL FOR CHILDREN.

              [Illustration]

                NEW YORK:
      BERMINGHAM & CO., UNION SQUARE.
                  1882.

           W. L. MERSHON & CO.,
   _Printers, Electrotypers and Binders_,
              RAHWAY, N. J.




PREFACE.


I believe it will not be disputed that there was considerable need for
an English treatise dealing rather fully with the subject of Neuralgia,
and therefore I hope that the profession will be willing to give me a
hearing. The present work, moreover, does not profess to be a mere
compilation of standard authorities corrected down to the present time,
but puts forward a substantially new view of the subject--at least, a
view that has been only briefly sketched by me in an article that
appeared, three years ago, in Reynolds's "System of Medicine." My
principal object, in writing this volume, was to vindicate for Neuralgia
that distinct and independent position which I have long been convinced
it really holds, and to prove that it is not a mere offshoot of the
Gouty or Rheumatic diatheses, still less a mere chance symptom of a
score of different and incongruous diseases. In order to set the
diagnosis of true Neuralgia from its counterfeits in the clearest light,
it seemed advisable to draw separate pictures of each of the latter (at
least of as many as are of real importance) and present them separately,
as a kind of gallery of spurious neuralgias, and this I have done in the
second part of the volume. No one who had not tried to do it would
imagine how difficult this latter kind of work is. It was necessary for
the sketches to be very brief (unless my book was to become unmanageably
large), and yet to be as truthfully characteristic as possible; and it
was necessary also that only those diseases which so much resemble
Neuralgia as practically to lead medical men astray in diagnosis, should
be dealt with. The selection of the subjects, and the execution of this
part, took a long time, though it only covers about fifty pages. Then,
as regards Neuralgia itself, it became necessary to completely recast
the chapters on "Pathology" and on "Complications," on account of some
of the polite criticisms which Dr. Eulenburg directed (in his recent
"Lehrbuch der Nervenkrankheiten") to my argument in the article above
referred to, since it was obvious that a too brief statement of my views
had caused them to be partially misunderstood by the German physician.
These chapters (Part I., Chapters II. and III.) are certainly the most
important portion of my book, and I would particularly direct attention
to them, in order that their contents may be affirmed or corrected: the
reader will at any time find that they contain a kind of investigation
never before systematically carried out with regard to Neuralgia. The
causes above mentioned, together with others over which I had no
control, have kept back the appearance of this work so long beyond the
date for which it was originally announced, that I feel I ought to
apologize for an amount of delay that would seem hardly justified by the
moderate size of the volume.

16 WIMPOLE STREET, LONDON, _October_ 1, 1871.




CONTENTS.


    INTRODUCTION--ON PAIN IN GENERAL                7


                 PART I.

             _ON NEURALGIA._

    CHAP.                                        PAGE

       I.--CLINICAL HISTORY                        12

      II.--COMPLICATIONS OF NEURALGIA              79

     III.--PATHOLOGY AND ETIOLOGY OF NEURALGIA     96

      IV.--DIAGNOSIS AND PROGNOSIS OF NEURALGIA   142

       V.--TREATMENT OF NEURALGIA                 149


                 PART II.

     _DISEASES THAT RESEMBLE NEURALGIA._

    CHAP.

       I.--MYALGIA                                196

      II.--SPINAL IRRITATION                      200

     III.--THE PAINS OF HYPOCHONDRIASIS           207

      IV.--THE PAINS OF LOCOMOTOR ATAXY           210

       V.--THE PAINS OF CEREBRAL ABSCESS          213

      VI.--THE PAINS OF ALCOHOLISM                215

     VII.--THE PAINS OF SYPHILIS                  218

    VIII.--THE PAINS OF SUBACUTE AND CHRONIC
              RHEUMATISM                          225

      IX.--THE PAINS OF LATENT GOUT               227

       X.--COLIC, AND OTHER PAINS OF PERIPHERAL
              IRRITATION                          229

      XI.--DYSPEPTIC HEADACHE                     231




INTRODUCTION.

ON PAIN IN GENERAL.


Although it is, in a general way, unadvisable to introduce abstract
discussions into a treatise which should be strictly practical, it is
almost impossible to avoid some few general reflections on the
physiological import of Pain, as a preliminary to the discussion of the
maladies which form the subject of this volume. This whole group of
disorders is linked together by the fact that pain is their most
prominent feature; and, with regard to most of them, the relief of the
pain is the one thing required of the physician. It seems, therefore,
very important that we should ascertain, at least approximately, in what
the immediate state consists, which consciousness interprets as pain. It
is not necessary to enter at this stage into any inquiry as to the
pathological causes of the phenomenon; what we know of these, and it is
unfortunately too little, will be discussed in detail under the headings
of the several affections which I shall have to describe.

The question before us now is this: What is that functional state of the
nerves which consciousness interprets as pain? Is it, or is it not, an
exaltation of the ordinary function of sensation?

The latter question is generally answered affirmatively, without much
thought, by those to whom it casually occurs; but indeed there is plenty
of prescriptive authority for so dealing with it. Pain has been
described by some of the most distinguished writers on nervous diseases
as a hyperæsthesia. Yet there is really little difficulty in convincing
ourselves, if we institute a thorough inquiry into the matter, that pain
is certainly not a hyperæsthesia, or excess of ordinary sensory
function, but something which, if not the exact opposite of this, is
very nearly so.

The leading fallacy in the common view is the confusion which is
perpetually being made between function and action. Now, the function of
individual nerves is very nearly a constant quantity, at least, it
varies only within narrow limits; while the action of the same nerves
may be almost any thing. The function of the nerve is that kind of work
for which it is fit when its molecular structure is healthy; it is the
series of dynamic reactions which are necessarily produced in
nerve-tissue by the external influences which surround and impinge upon
it in the conditions of ordinary existence. The action of nerves, under
the pressure of extraordinary influences, may include all manner of
vagaries which really have nothing in common with the effects of
ordinary functional stimulation; which are, in fact, nothing but
perturbation. No one can suppose, for instance, that the explosive
disturbances of nerve-force which give rise to the convulsions of
tetanus are any mere exaggerated degree of the orderly and symmetrical
action by which the healthy nerve responds to the stimulus of volition
ordering a given set of muscles to contract; they are something quite
different in kind. And so it is with the sensory nerves. The functions
of these conductors, in health, is to convey to the perceptive centres
the sensations, varying only within a most limited range, which
correspond to a state of well-being of the organs, and which excite only
those reflex actions that are necessary to life. Thus the large surface
of sensitive nerve terminals which is represented by the collective
peripheral branches of the fifth cranial conveys to the medulla
oblongata an impression, derived from the temperature and movement of
the surrounding air, when the latter is neither too hot nor too cold,
which imparts to the brain a perception of comfortable sensations, and
excites in return the reflex action of breathing, which is necessary to
life. But the impression produced on this same peripheral expanse of
nerve-branches by prolonged exposure to cold wind may, and often does,
convey to the centres sensations which are quite different and provokes
reflex movements which are altogether abnormal. Pain is the product in
one direction; sneezing, perhaps, in the other. It seems absurd to say
that sneezing is any part of the function of those motor nerves whose
action regulates the performance of expiration. And it appears to me not
less absurd to say that pain is the function of the sensitive fibres of
the trigeminus. But the best way, perhaps, to illustrate the looseness
and incorrectness of applying the term "hyperæsthesia" (implying exalted
function) to the state of sensitive nerves when suffering pain, is to
examine the condition of distinctive perception in the very same parts
to which the painful nerves are distributed. It will invariably be
found, as we shall have occasion to see more fully proved hereafter,
that, in parts which are acutely painful, a marked bluntness of the
tactile perceptions can be detected. The tactile perceptions are, no
doubt, conveyed by an independent set of fibres from those which convey
the sense of pain.[1] Yet it is surely impossible to believe the effect
of the same influence, in functional power can be different--much more
than it can be exactly opposite--in the two cases.

If pain be not a heightening of ordinary sensation, then we seem to be
shut up to the idea that it is a perversion owing to a molecular change
of some part of the machinery of sensation which frustrates function.
For it is to be observed that, while the sensations conveyed by the
healthy nerve are correct in the indications which they afford to the
percipient brain, the indications given by pain are vague and
untrustworthy, and often seriously misleading. Not to speak of the
nerves of special sense, or of the fibres which convey the sensations of
muscular movement, even the nerves of common sensation do carry to the
internal perception, in health, a distinct impression of the well-being
of the organs to which they are distributed. Mr. Bain[2] has well
pointed out the positive character of this feeling, which is so often
incorrectly referred to as if it were a mere negation of feeling. It is
a sensation of equable and diffused comfort, if I may be allowed to use
the expression, which streams in from all parts of the organism; and
there is no possibility of comparing it, in any scale of less or more,
with the sensation of pain; for the latter commonly conveys no correct
information as to the organ from which it proceeds, or appears to
proceed. Especially is this the case in the neuralgias, for more
commonly than not the apparent seat of the pain is widely removed from
the actual seat of the mischief which causes it.

If we inquire a little further into the circumstances under which
various kinds of pain occur, we gain some fresh suggestions. Among the
neuralgias, those are the most acutely agonizing which occur under
circumstances of impaired nutrition incident to the period of bodily
decay, and strong reasons will be hereafter adduced for the belief that
there is especial impairment of the nutrition of the central end of the
painful nerves. To find a parallel to the severity of this kind of pains
we must turn to the case of organic tumors, which, from their position,
structure, and mode of growth, necessarily exercise continuous and
severe pressure on the branches or the trunk of a nerve; or to the class
of pains which attend severe cramp, or tonic contraction of muscles.
Now, it can scarcely be doubted that in the latter instance there is an
abnormally rapid and violent destruction of tissue going on; at the very
least there is an extraordinarily violent and irregular manifestation of
motor force. In any case the patent fact here is dynamic perturbation
of a severe kind; and, in the instance of organic tumors exercising
steady and continuously increasing pressure on nerves, one can scarcely
doubt that a similar perturbation, less intense but more enduring, is
necessarily set up. That which can be done in the way of producing
severe pain by these severe affections of the peripheral portions of
nerves, or of tissues lying outside them, we might _a priori_ expect
would be effected by slighter but continuous changes in the nutrition of
the more important portion of the nerve itself--its central gray
nucleus. One would say that a pathological process which continuously
and progressively lowered the standard of nutrition here must interfere
from hour to hour, certainly from day to day, with that regular and
equable distribution of force which is the essence of unimpeded
function.

Take, again, the case of the very severe pain which frequently attends
inflammation of the pleura and of the peritoneum. Whatever theory of the
causation of these pains we may adopt, it is certain that one most
important element in their production and maintenance is the continual
movement and friction of the affected parts. But there is little doubt
that the moving muscles are involved in the inflammatory process, as Dr.
Inman has correctly observed. It would seem plain that under these
circumstances--an inflamed muscular structure forced to perform its
ordinary contractions as well as it can--there must be powerful dynamic
perturbation going on.

If perturbation of nerve-function--a disturbance quite different from
mere exaltation of the normal development of nerve-force--be the essence
of pain, how comes it that pains of the severest type may be produced by
changes in structures which are usually described, for practical
purposes, as lying outside the nervous system? We must, in the first
place, remark that the externality of any bodily tissue to the nervous
system is more apparent than real. Microscopic researches are constantly
revealing nerve-fibres, in ever-increasing profusion, which penetrate to
parts seemingly the least vitalized in the organism. But, in any case,
the nerves are certainly the ultimate channel of communication between
the suffering part and the sentient centre. It seems, therefore, the
inevitable conclusion that a dynamic perturbation going on in the
non-nervous tissue is continued along the nerves themselves: and that
the severity of the pain perceived by the conscious centres is
proportionate to the tumultuousness, the want of coordination, and the
waste with which force is being evolved in the cramped muscle, or
whatever structure it may be, in which the pain takes its source.

Not to pursue these topics further, we may sum up the considerations
which have now been adduced, in the following general propositions,
which will tend to simplify the examination of the various painful
disorders which we are about to discuss:

1. Pain is not a true hyperæsthesia; on the contrary, it involves a
lowering of true function.

2. Pain is due to a perturbation of nerve-force, originating in dynamic
disturbance either within or without the nervous system.

3. The susceptibility to this perturbation is great in proportion to the
physical imperfection of the nervous tissue, until this imperfection
reaches to the extent of cutting off nervous communications
(paralysis).

FOOTNOTES:

[1] See, on this subject, some remarks, in my work on "Stimulants and
Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception
and Common Sensation."

A very distinct and careful statement of the distinction between pain
and hyperæsthesia will be found in a prize essay "On Neuralgia" by M. C.
Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.

[2] "Senses and Intellect."




PART I.

ON NEURALGIA.




CHAPTER I.

CLINICAL HISTORY.


Neuralgia may be defined as a disease of the nervous system, manifesting
itself by pains which, in the great majority of cases, are unilateral,
and which appear to follow accurately the course of particular nerves,
and ramify, sometimes into a few, sometimes into all, the terminal
branches of those nerves. These pains are usually sudden in their onset,
and of a darting, stabbing, boring, or burning character; they are at
first unattended with any local change, or any general febrile
excitement. They are always markedly intermittent, at any rate at first;
the intermissions are sometimes regular, and sometimes irregular; the
attacks commonly go on increasing in severity on each successive
occasion. The intermissions are distinguished by complete, or almost
complete, freedom from suffering, and in recent cases the patient
appears to be quite well at these times; except that, for some short
time after the attack, the parts through which the painful nerves ramify
remain sore, and tender to the touch. In old-standing cases, however,
persistent tenderness, and other signs of local mischief, are apt to be
developed in the tissues around the peripheral twigs. Severe neuralgias
are usually complicated with secondary affections of other nerves which
are intimately connected with those that are the original seat of pain;
and in this way congestions of blood vessels, hypersecretion or arrested
secretion from glands, inflammation and ulceration of tissues, etc., are
sometimes brought about.

The above is a general description of neuralgia which will identify the
disease sufficiently for the purpose of introducing it the attention of
the reader. We must now proceed to give a more accurate account of its

_Clinical History and Symptoms._--These vary so greatly in different
kinds of neuralgia that it will be necessary to discuss the greater part
of this subject under the headings of the special varieties of the
disease. There are certain common features, however, in all true
neuralgias.

I. In the first place, it is universally the case that the condition of
the patient, at the time of the first attack, is one of debility, either
general or special. I make this assertion with confidence,
notwithstanding that Valleix, and some other very able observers, have
made a contrary statement. In the first place, it is certainly the case
that the larger half of the total number of cases of neuralgia which
come under my care are either decidedly anæmic, or else have recently
undergone some exhausting illness or fatigue; and if other writers have
failed to see so many neuralgic patients in whom these conditions were
present, it must certainly be because they have limited the application
of the term "neuralgia" within bounds which are too narrow to be
justified by any logical argument; as will, indeed, be shown at a later
stage. On the other hand, although a considerable number of neuralgic
patients have an externally healthy appearance, as indicated by a ruddy
complexion and a fair amount of muscular development, it cannot be
admitted that these appearances exclude the possibility of debility,
either structional or functional, of the nervous system. The commonest
experience might teach us that, so far from the nervous system being
invariably developed with a corresponding completeness and maintained
with a corresponding vigor to those which distinguish the muscular
system and the organs of vegetative life, there is often a very striking
contrast between these in the same individual. What physician is there
who has not seen epileptic patients, in whom mental habitude, a low
cranial development, imperfect cutaneous sensibility, and other obvious
marks of deficient innervation, were marked and striking features at, or
even before, the first occurrence of convulsive symptoms, while the body
was robust, the face well colored, and the muscular power up to or
beyond the average? Now, it will invariably be found, on carefully
sifting the history of apparently robust neuralgic patients, that they,
too, have given previous indications of weakness of the nervous system:
thus, women, who, after a severe confinement attended with great loss of
blood, are attached with _clavus hystericus_ or with _migraine_; will
inform us that whenever, in earlier life, they suffered from headache,
the pain was on the same side as that now affected, and chiefly or
altogether confined to the site of the present neuralgia. In a
considerable number of cases, also, in which I have been able to observe
accurately the events which preceded an attack of neuralgia, it has been
found that the skin supplied by the nerves about to become painful was
anæsthesic to a remarkable degree; and it is very often the case that a
more moderate amount of blunted sensation was perceptible in these parts
during the intervals between attacks of pain. A somewhat delusive
appearance of general nervous vigor is often conveyed to the observer of
neuralgic patients, by reason of the intellectual and emotional
characteristics of the latter. Both ideation and emotion are, indeed,
very often quick and active in the victims of neuralgia, who in this
respect differ strikingly from the majority of epileptics. But this
mobility of the higher centres of the nervous system is itself no sign
of general nervous strength; which last can never be possessed except by
those in whom a certain balance of the various nervous functions is
maintained. Much more will be said on this topic when we come to discuss
the etiology of neuralgia. Meantime I may content myself with repeating
the fact which is indubitably taught by careful observation--that
neuralgics are invariably marked by some original weakness of the
nervous system; though in some cases this defect is confined strictly to
that part of the sensory system which ultimately becomes the seat of
neuralgic pain.

Another circumstance is common to all neuralgias of superficial nerves;
and, as a large majority of all neuralgias are superficial in situation,
this is, for practical purposes, a general characteristic of the
disease. I refer to the gradual formation of tender spots at various
points where the affected nerves pass from a deeper to a more
superficial level, and particularly where they emerge from bony canals,
or pierce fibrous fasciæ. So general is this characteristic of
inveterate neuralgias, that Valleix founded his diagnosis of the genuine
neuralgias on the presence of these painful points. Herein he appears to
me to be decidedly in error. I have watched a great many cases (of all
sorts of varieties as to the situation of the pain), and I have
uniformly observed that in the early stages firm pressure may be made on
the painful nerve without any aggravation of the pain; indeed, very
often with the effect of assuaging it. The formation of tender spots is
a subsequent affair: they develop in those situations which have been
the foci, or severest points, of the neuralgic pain. There is however, a
point which, though not always, nor often, the seat of spontaneous pain,
is nevertheless very generally tender. Trousseau, who criticises
unfavorably the statement of Valleix as to the situation of the points
douloureux, insists that this tender spot, which is over the spinous
processes of the vertebræ corresponding to the origin of the painful
nerve, and which he calls the points apophysaire, is more universally
present than any of those pointed out by Valleix. I shall hereafter
endeavor to show that these spinal points are by no means characteristic
of neuralgia; they are present in a variety of affections which were
ably described, under the heading of "Spinal Irritation," many years
ago, by the brothers Griffin. ["Observations on the Functional
Affections of the Spinal Cord," by William and Daniel Griffin. London,
1834] and they are also present with misleading frequency in cases of
mere myalgia, such as I shall have to describe at a later stage.

Another characteristic of neuralgic patients in general is, I believe,
a certain mobility of the vaso-motor nervous system and of the cardiac
motor nerves; but I insist less on this than on the above-named
features, because a more extended experience is necessary to establish
the fact with certainty. Within my own experience it has always seemed
to be the case that persons who are liable to neuralgia are specially
prone to sudden changes of vascular tension, under emotional and other
influences which operate strongly on the nervous system. The observation
of this fact has been made accidentally, without any previous bias on my
part, in the course of a large number of experiments made upon
individuals free from manifest disease at the time, with Marey's
sphygmograph.

Neuralgic attacks are always intermittent, or at the least remittent, in
every stage of the disease.

The manner in which neuralgic pain commences is characteristic and
important. There is always a degree of suddenness in its outset. When
produced by a violent shock, it may, and often does, spring into full
development and severity at once, of which, perhaps, the most striking
example is the sudden and violent neuralgic pain of the eyebrow which
some persons experience from swallowing a lump of undissolved ice.
Usually, however, the first warning is a sudden, not very severe, and
altogether transient dart of pain. The patient has probably been
suffering from some degree of general fatigue and malaise, and the skin
of the affected part has been somewhat numb, when a sudden slight stitch
of pain darts into the nerve at some point which corresponds to one of
the foci hereafter to be particularized. It ceases immediately, but in a
few seconds or minutes returns; and these darts of pain recur more and
more frequently, till at last they blend themselves together in such a
manner that the patient suffers continuous and violent pain for a minute
or so, then experiences a short intermission, and then the pain returns
again, and so on. These intermittent spasms of pain go on recurring for
one or several hours; then the intermissions become longer, the pain
slighter, and at last the attack wears itself out. Such is generally the
history of first attacks, especially in subjects who are not past the
middle age, nor particularly debilitated from any special cause.

A point of interest in connection with the natural history of the
neuralgic access is the condition of the circulation. The commencement
of pain is generally preceded by paleness of skin and sensations of
chilliness. At the commencement of the painful paroxysm, sphygmographic
observation shows that the arterial tension is much increased, owing, in
all probability, to spasm of the small vessels. This condition is
gradually replaced by an opposite state, the pulse becoming large, soft,
and bounding, though very unresisting, and giving a sphygmographic trace
which exhibits marked dicrotism. Simultaneously with this the skin
becomes warmer, sometimes even uncomfortably warm, and there is
frequently considerable flushing of the face.

The final characteristic common to all neuralgias is that fatigue, and
every other depressing influence, directly predispose to an attack, and
aggravate it when already existing.

_Varieties._--It is possible to classify neuralgias upon either of two
systems: first (_a_), according to the constitutional state of the
patient; and, secondly (_b_), according to the situation of the affected
nerves. It will be necessary to follow both these lines of
classification, avoiding all needless repetition.

(_a_) In considering the influence of constitutional states upon the
typical development of neuralgia, it will be convenient to commence with
the group of cases in which the general condition of the organism
produces the least effect. This is the case when the pain is the result
of direct injury to a nerve-trunk, whether by external violence, by the
mechanical pressure of a tumor, or by the involvement of a nerve in
inflammatory or ulcerative processes originating in a neighboring part.
As regards the development of symptoms, the important matters are, that
the pain in these cases commences comparatively gradually, that the
intermissions are usually more or less complete, and that the pain is
far less amenable to relief from remedies, than in other forms of
neuralgia. The little that can be said about the form which is dependent
upon progressively increasing pressure, or involvement of a nerve in
malignant ulcerations, caries of bones or teeth, etc., falls under the
heads of Diagnosis and Treatment, and need not detain us here. The
clinical history of neuralgia from external violence, however, requires
separate discussion:

1. Neuralgia from external shock may be produced by a physical cause (as
by a fall, a railway collision, etc.), which gives a jar to the central
nervous system; or by severe mental emotion, operating upon the same
part of the organism. Under either of these circumstances the
development of the affection may occur at once, but by far the most
frequently it ensues after a variable interval, during which the patient
shows signs of general depression, with loss of appetite and strength.
Sometimes vomiting, and in other instances paralysis, of a partial and
temporary kind, occur. When once developed, the neuralgic attacks do not
differ from those which proceed from causes internal to the organism. In
the greater number of instances, so far as my experience goes, it is the
fifth cranial nerve which becomes neuralgic from the effects of central
shock. Illustrative cases will be given in the section on Local
Classification. Meantime the important facts to note, in relation to the
influence of constitutional states, are these: In the first place, the
tendency of such accidents to excite neuralgia varies directly with the
hereditary predisposition evinced by the liability of the sufferer's
family to neuralgic affections and to the more serious neuroses.
Secondly, the likelihood of a neuralgic attack is indefinitely increased
if he has already had neuralgia. Thirdly, although debility from
temporary and special causes can rarely be sufficient to insure a true
neuralgic access after a severe shock, it probably heightens,
indefinitely, the tendency in a person otherwise predisposed. Delicate
women are many times more liable to experience such consequences, from a
physical or mental shock, than men of tolerably robust constitution.

2. Neuralgia from direct violence to superficial nerves is produced by
cutting or, more rarely, by bruising wounds. Cutting wounds may divide a
nerve-trunk (_a_) partially, or (_b_) completely.

(_a_) When a nerve-trunk is partially cut through, neuralgic pain
occurs, if at all, immediately, or almost immediately, on the receipt of
the injury. One such instance only has come under my own care, but many
others are recorded. In my case the ulnar nerve was partly cut through,
with a tolerably sharp bread-knife, not far above the wrist; partial
anæsthesia of the little and ring fingers was induced, but at the same
time violent neuralgic pains in the little finger came on, in fits
recurring several times a day, and lasting about half a minute.
Treatment was of little apparent effect in promoting a cure; though
opiates and the local use of chloroform afforded temporary relief. The
attacks recurred for more than a month, long after the original wound
had healed soundly; and, for a long time after this, pressure on the
cicatrix would reproduce the attacks. A slight amount of anæsthesia
still remained, when I saw the patient more than a year after the
injury.

(_b_) Complete severance of a nerve-trunk is a sufficiently common
accident, far more common then is neuralgia produced by such a cause;
indeed, so marked is this disproportion between the injury and the
special result, that I have been led to infer that a necessary factor in
the chain of morbid events must be the existence of some antecedent
peculiarity in the central origin of the injured nerve. This opinion is
rendered the more probable because the consecutive neuralgia is in some
cases situated, not in the injured nerve itself, but in some other nerve
with which it has central connections. Two such cases are recorded in my
Lettsomian Lectures, [_Lancet_, 1866], in which the ulnar nerve, and one
in which the cervico-occipital, were completely divided; in all three
the resulting neuralgia was developed in the branches of the fifth
cranial. Here we may suppose that the weak point existed in the central
nucleus of the fifth; and that the irritation, or rather depression,
communicated to the whole spinal centres by the wound of a distant
nerve, first found, on reaching this weak point, the necessary
conditions for the development of the neuralgic form of pain, which
therefore would be represented to the mental perception as present in
the peripheral branches of the fifth nerve. In all the cases which have
come under my notice, the neuralgia set in at a particular period,
namely, after complete cicatrization of the wound, and while the
functions of the branches on the peripheral side of the wound were
partly, but not completely, restored. The same obstinacy and
rebelliousness to treatment are observed as in other instances of
neuralgia from injury.

One of the cases above referred to may here be briefly detailed, as it
shows very completely the clinical history of such affections. C. B.,
aged twenty-four, an agricultural laborer, applied for relief in the
out-patient room of Westminster Hospital, suffering from severe
neuralgic pains of the forehead and face of the left side. Then pains
were felt in the course of the supra-orbital, ocular, nasal, and
supra-trochlear branches, and also in the cheek, appearing, there, to
radiate from the infra-orbital foramen. They had commenced about three
weeks previously to the patient's first visit to the hospital, and about
six weeks after the accident which appeared to have started the whole
train of symptoms. This was a cutting wound, evidently of considerable
depth as well as external size, toward the back of the neck, and so
situated that it must have divided the great occipital nerve of the left
side: and, from the man's account of the numbness of the parts supplied
by the nerve which immediately followed the wound, there could be no
doubt that this had occurred. There was no acute nerve-pain, either
during the healing of the wound, which was rapid, or subsequently, until
more than three weeks from the date of the injury; at this time there
was still a considerable sense of numbness in the skin of the occipital
and upper cervical region; but there now commenced a series of short
paroxysms of pain in the forehead of the same side. These at first
occurred only about twice daily, at regular intervals; the pain was not
very sharp, and only lasted a minute or two. The attacks rapidly
increased in frequency and duration, however, and extended their area.
At the time when I first saw the case the pain was very formidable, it
recurred with great frequency during the day, but would sometimes leave
the patient free for several hours together. The site of the wound was
occupied by a firm cicatrix of about a line in breadth and an inch and a
quarter in length; pressure on this excited only a vague and slightly
painful tingling in the part itself, but severely aggravated the
trigeminal pains, or reproduced them if they happened to be absent. The
regions supplied by the great occipital nerve were still very
imperfectly sensitive. This patient gave me a great deal of trouble. He
continued for many weeks under my care, and I can scarcely flatter
myself that any of the numerous remedies which I administered
internally, or applied locally, had any serious effect in checking the
disorder. The subcutaneous injection of morphia gave some relief, as it
always does, but this seemed to be perfectly transitory; and, although
when the patient ceased to attend the hospital he was decidedly better,
I cannot imagine that there was anything in it except the slow wearing
out of the neuralgic tendency, very much without reference to the
administration of any remedies.

The description of neuralgia from injury would be incomplete without
some special words on a variety of this affection which has only very
recently been described with that fulness which it deserves. I refer to
the pains which are produced by gunshot injuries of nerves, received in
battle, of which no sufficient account had been given until the
publication of the experience of Messrs. Mitchell, Moorehouse, and Keen,
in the late American civil war.[3]

From the interesting treatise of the above-named writers it appears that
not merely is neuralgia of an ordinary type a frequent after-consequence
of wounds, but that certain special pains are not unfrequently produced.
In the more ordinary instances, pain is of the darting, or of the aching
kind; and all writers on military surgery, who have recorded their
experience of the results of wounds received in battle, have spoken of
affections of this kind, for the most part singularly severe and
obstinate, and in not a few recorded instances clinging to the patient
during the remainder of his life. These pains may at times leave the
sufferer, but they infallibly recur when from any cause his health is
depressed, and it is an especially common thing for them to be evoked in
full severity under the influence of exposure to cold, and particularly
to damp cold.

But the American writers introduce us to another and more terrible
neuralgia which is a, fortunately, less frequent result of serious
injuries to nerves. They speak of it as a burning pain of intense and
often intolerable severity; they believe that it seldom if ever
originates at the moment of the injury, but rather at some time during
the healing process; and it is especially noteworthy that it is
sometimes felt not in the nerve actually wounded, but in some other
nerve with which it has connections. After it has lasted a certain time,
an exquisite tenderness of the skin is developed, and a peculiar
physical change of skin-tissue occurs; it becomes thin, smooth, and
glossy. It is a remarkable fact that these burning pains which are so
definitely linked with a nutrition-change of skin are never felt in the
trunk, and rarely in the arm or thigh, not often in the forearm or leg,
but commonly in the foot or hand; and the nutrition changes of the skin
are generally observed on the palm of the hand, the palmar surface of
the fingers, or the dorsum of the foot; rarely on the sole of the foot
or the back of the hand. It is very interesting to remark that these
skin-lesions correspond very nearly, not only to those observed in the
cases of nerve-injury reported by Mr. Paget,[4] in which actual
neuralgia was present (though the kind of pain is not exactly
specified), but also very nearly with the nutritive changes observed by
Mr. Jonathan Hutchinson in a number of cases of surgical injuries of
nerves.[5] The tendency of neuralgic pain accompanied by nutritive
lesions of the skin and nails to seat itself in the hands and feet will
be hereafter noted in connection with the subject of the pains of
locomotor ataxy and of those produced by profound mercurial poisoning.
And it will be seen in the section on Pathology, that very important
conclusions are suggested by the coincidence.

Joined with the burning pains, and the altered skin-nutrition, in the
cases of gunshot injury of nerves which we are considering, there is
nearly always a marked alteration in the temperature of the parts,
either in one direction or the other. In the great majority of instances
of ordinary neuralgia after wounds, this alteration is a very
considerable reduction of the temperature of the parts supplied by the
painful nerves; a change which corresponds with what appears in the vast
majority of all cases of division of sensitive nerves, whether pain be
set up or not. But, in all examples of the burning pain after injury,
Messrs. Mitchell, Moorehouse, and Keen found the temperature of the
painful parts notably elevated.

It would appear that there is no form of neuralgia more dreadful, and
scarcely any so hopeless, as this burning pain coming on as a sequel to
severe nerve injuries. It exercises a profoundly depressing effect upon
the whole nervous tone; the most robust men become timid and broken
down, and their condition is compared by the American writers to that of
hysterical women.

There is another peculiar nutritive affection, first recognized as an
occasional consequence of nerve injuries by Messrs. Mitchell,
Moorehouse, and Keen, namely, an inflammation of joints, and, although
we have no concern here with this symptom, it will be referred to
hereafter as throwing interesting light on certain questions of
pathology. Certain lesions of secretion will also be specially referred
to under the heading of Diagnosis.

II. NEURALGIAS OF INTRA-NERVOUS ORIGIN.--As regards the constitutional
conditions with which the several varieties of neuralgia that arise
independently of external violence, or disease of extra-nervous tissues,
are respectively allied, the following preliminary subdivisions may be
made:

    1. Neuralgias of malarious origin.
    2. Neuralgias of the period of bodily development.
    3. Neuralgias of the middle period of life.
    4. Neuralgias of the period of bodily decay.
    5. Neuralgias associated with anæmia and mal-nutrition.

1. _Neuralgias of malarious origin_ were formerly far more prevalent
than they are at present, within the sphere of the English practitioner
of medicine; with the general decline of malarial fevers, consequent on
improved drainage and cultivation of lands, they have become constantly
more scarce. The districts in which they still are found to prevail with
any frequency are carefully specified in the interesting report of Dr.
Whitley to the Medical Officer of the Privy Council, in the Blue-Book
for 1863.

Of course, however, there are a considerable number of persons
continually returning to England from countries where malarious diseases
are common; and these often bear about with them the effects of paludal
poisoning which occasionally exhibits itself in the form of neuralgia.
Till very lately, however, I had not happened to come across such cases,
although at one time and another I have seen and treated a good many
persons returned from India and Africa, whence I judge that neuralgia
with this special history is less common than many seem to think. In
former times, on the contrary, malarioid neuralgias were so common that
they forced themselves on the notice of every practitioner. The term
"brow-ague," to this day applied by many medical men to every variety of
supra-orbital neuralgia, is a relic of the older experience on this
point, as is also the very common mistake of expecting all neuralgic
affections to present a distinctly rhythmic recurrence of symptoms.

In the year 1864 I published the statement[6] that, "in a fair
sprinkling" of the cases of neuralgia which present themselves in
hospital out-patient rooms, ague-poisoning may be suspected; but I was
then speaking rather from hearsay than from my own experience, which, in
fact, had yielded no clear cases of this sort of neuralgia, and was till
just recently unable to reckon up more than two undoubted and one
doubtful case of the affection, in all of which the fifth cranial nerve
was unattacked. The periodicity in one of the genuine cases was regular
tertian, in the other regular quotidian. A semi-algide condition always
ushered in the attacks; but this was gradually exchanged, as the pain
continued, for a condition in which the pulse was rapid and locomotive,
but compressible, and the strength was further depressed. In both these
cases there was unilateral flushing of the face, and congestion of the
conjunctiva, to a slight degree, during the attack of pain. The pain
became duller and more diffused contemporaneously with the lowering of
arterial pressure; and, after the disappearance of active pain, moderate
tenderness over a considerable tract round the course of the painful
nerves remain for some time. There was no distinct development of
painful points in the situations described by Valleix; but it should be
remarked that the cases were rapidly cured with quinine, which very
probably accounts for this circumstance.

Till lately I had not witnessed neuralgia as an after-consequence of
tropical malaria-poisoning, although I have had many cases of other
diseases, the relics of hot climates, under my care; but within the last
year I have seen a case of extremely severe intercostal neuralgia of a
perfectly periodic type occurring in a patient whose constitution had
been thoroughly saturated with tropical marsh poison, and in whom the
spleen was still much enlarged. The neuralgia was so terrible, and
accompanied by such severe algide phenomena at the beginning of the
attacks, and such a sense of throbbing as the pain developed, as to lead
to serious suspicions of hepatic abscess, for the moment; but the course
of events soon corrected this idea.

2. _Neuralgias of the Period of Bodily Development._--By the "period of
bodily development" is here understood the whole time from birth up to
the twenty-fifth year, or there-abouts. This is the period during which
the organs of vegetative and of the lower animal life are growing and
consolidating. The central nervous system is more slow in reaching its
fullest development, and the brain especially is many years later in
acquiring its maximum of organic consistency and functional power.

That portion of the period of development which precedes puberty is
comparatively free from neuralgic affections. At any rate, it is rare to
meet in young children with well-defined unilateral neuralgia, except
from some very special cause, such as the pressure of tumors, etc. Such
neuralgias as do occur are commonly bilateral, and are connected either
with the fifth cranial or the occipital nerves.

I must here mention an affection which was quite unknown to my
experience, but was brought under my notice by the late Dr. Hillier, who
kindly called my attention to the notes of two cases which were
published in his interesting work on "Diseases of Children." The cases
are those of two female children, aged nine and eleven respectively, in
whom the principal symptom was violent and paroxysmal neuralgic
headache. In both of these children the existence of cerebral tubercle
was suspected, but this proved to be a mistake. In both there were
intolerance of light, vomiting, tonic contraction of the muscles of the
neck, and occasional double vision; but no impairment of intelligence,
no amaurosis, and no paralysis or rigidity of the limbs. Each of these
children died rather suddenly, after a violent paroxysm of pain. The
main, indeed almost the only characteristic post-mortem change was a
marked loss of consistence of tissue, in one case in the pons varolii,
in the other in the pons, the medulla oblongata, and the cerebellum.
These cases are of the highest possible interest, as are also several
other instances of headache in children recorded by Dr. Hillier; notably
one in which severe paroxysmal pains were attended with general
impairment of brain-power, and, on the occurrence of death from
exhaustion, the autopsy revealed an amount of degeneration in the
cerebral arteries (as also in the general arterial system) which was
astonishing, considering that the child was only ten and a half years
old. This case, the full significance and interest of which will be
better seen when we come to discuss the subject of pathology, is an
example of physical changes in the nervous system, which are usually
delayed to an advanced period of life, occurring altogether prematurely,
and bringing with them a kind of neuralgic pain which is far more common
in the decline than in morning of life. It will be seen presently that
functional derangements may be in like manner precociously induced, with
the parallel effect of inducing such pains as are ordinarily the product
of a later epoch.

From the moment that puberty arrives all is changed in the status of the
nervous system. In the stir and tumult which pervade the organism, and
especially in the enormous diversion of its nutritive and formative
energy to the evolution of the generative organs and the correlative
sexual instincts, the delicate apparatus of the nervous system is apt to
be overwhelmed, or left behind, in the race of development. Under these
circumstances, the tendency to neuralgic affections rapidly increases.
It will, however, be seen later that there is a great preponderance of
particular varieties of the disease during this time. This period is
above all things fruitful in trigeminal neuralgias, especially migraine.

There remains to be noticed the fact that sexual precocity sometimes
very much anticipates the peculiar characteristics of the period after
puberty. It is well known that in too many instances children are led,
by the almost irresistible influence of bad example, to indulge in
thoughts and practices which are thoroughly unchildish, and which
exercise a powerfully disturbing influence upon the nervous system. A
child before the age of puberty ought to be distinguished (if moderately
healthy in other respects) by the absence of any tendency to dwell upon
his own bodily health. Under the influence of precocious sexual
irritation he becomes hypochondriacal and self-centred, and often
suffers, not merely from fanciful fears and fanciful pains, but from
actual neuralgia, which is sometimes severe. The attacks of migraine
which are a frequent affection of delicate children whose puberty
occurs at the normal time, are a much earlier torment with children who
have early become addicted to bad practices. It is an anticipatory
effect upon the constitution, strictly analogous to the production of
the so-called "hysteria" in little girls under similar circumstances;
and I suppose there is no physician who has not once or twice, at least,
met with cases of the latter kind. The existence of any severe neuralgic
affection in a young child, if it cannot be traced to tuburcle or other
recognizable or organic brain-disease is _prima-facie_ ground for
suspicion of precocious sexual irritation; though, as Dr. Hillier's
cases show, it is occasionally produced otherwise. Usually, there are
other features which assist in the discovery of precocious sexualism,
when it exists; there is a morbid tendency to solitary moping, and a
moral change in which untruthfulness is conspicuous.

3. _Neuralgias of the Middle Period of Life._--By this period is meant
the time included between the twenty-fifth and about the fortieth or
forty-fifth year. It is the time of life during which the individual is
subjected to the most serious pressure from external influences. The
men, if poor, are engaged in the absorbing struggle for existence, and
for the maintenance of their families; or, if rich and idle, are
immersed in dissipation, or haunted by the mental disgust which is
generated by _ennui_. The women are going through the exhausting process
of child-bearing, and supporting the numerous cares of a poor household,
in some cases; or are devoured with anxiety for a certain position in
fashionable society for themselves and their children; or again, they
are idle and heart-weary, or condemned to an unnatural celibacy. Very
often they are both idle and anxious.

It must not be supposed that there is a sharp line of demarcation
between this period and the last; nevertheless, there are certain
well-marked differences, both in their general tendencies, and as
regards the local varieties which are commonest in each. We shall
discuss the latter point farther on. At present, it is interesting to
remark on the general freedom of the busy middle period of life from
first attacks of neuralgia. A person who has had neuralgia previously
may, and very likely will, during this epoch, be subject to recurrence
of the old affection under stress of exhaustion of any kind. But it is
very rare, in my experience, for busy house-mothers or fathers of
families to get first attacks of neuralgia during this period of life.
It is not the way in which a still vigorous man's nervous system breaks
down, if it breaks down at all. Men frequently do break down, of course,
at an age when their tissues generally are sound enough, and there is no
reason, except on the side of their nervous system, why they should not
remain in vigorous health for years. But it is greatly more common for
the nervous collapse to take the form of insanity, or hypochondriasis,
or paralysis, then that of neuralgia. If a man has escaped the latter
disease during the period when the growth of his tissues was active, it
is not very often that he falls a victim to it till he begins,
physiologically speaking, to grow old.

4. _Neuralgias of Declining Bodily Vigor._--The period here referred to
is that which commences with the first indications of general physical
decay, of which the earliest which we can recognize (in persons who are
not cut off by special diseases) is perhaps the tendency to atheromatous
change in the arteries. The first development of this change varies very
considerably in date; but whenever it occurs it is a plain warning that
a new set of vital conditions has arisen, and especially notable is its
connection with the characters of the neuralgic affections which take
their rise after its commencement. The period of declining life is
pre-eminently the time for severe and intractable neuralgias.
Comparatively few patients are ever permanently cured who are first
attacked with neuralgia after they have entered upon what may be termed
the "degenerative" period of existence. I mentioned the existence of
commencing arterial degeneration as the special and most trustworthy
sign of the initiation of bodily decay; but it is needless to say that
this change is often not to be detected in its earliest stage. Something
has been done of late years, however, to render its diagnosis more easy.
Not to dwell upon the phenomenon of the arcus senilis, which though of a
certain value is confessedly only very partially reliable, we may
mention the sphygmographic character of the pulse as possessing a real
value in deciding the physiological status of the arterial system. There
is a well-known form of pulse-curve, square-headed, with marked
lengthening of the first or systolic portion of the wave, and with an
almost total absence of dicrotism, even when the circulation is rapid,
which will often seem to assure us that atheromatous change of the
arterial system has commenced, even when the physical characters of
inelastic artery are not to be recognized with the finger in any of the
superficial vessels by the touch of the finger. Indeed, the latter test
is in all cases far less reliable than the sphygmographic trace, except
when the arterial change has proceeded to a very marked degree of
development.

To a certain extent, the presence or absence of gray hair is of value in
deciding whether physiological degeneration has begun. Like the arcus
senilis, however, this is only reliable when joined with other
indications, for it may be a purely local and separate change, having
nothing to do with the general vital status of the body.

5. _Neuralgias which are immediately excited by Anæmia or
Mal-nutrition._--Of the neuralgic affections which can be reckoned in
this class, the sole characteristic worthy of note is the circumstances
in which they arise. It would seem that anæmia and mal-nutrition simply
aggravate the tendency of existing weak portions of the nervous system
to be affected with pain; just as they notoriously do aggravate lurking
tendencies to convulsion and spasm. It is very common, for instance, for
women to suffer severely from migraine, and other forms of neuralgia,
after a confinement in which they have lost much blood. According to my
own experience, however, those patients are generally, if not
invariably, found to have previously suffered more or less severe
neuralgic pain, at some time or other in their history, in the same
nerves which now, under the depressing influence of hæmorrhage, have
become neuralgic. One of the very worst cases of clavus which I ever saw
happened after hæmorrhage in labor; the pain was so severe and
prostrating that it appeared likely the patient would become insane. I
discovered, on inquiry, that this woman had been liable for many years
to headache affecting precisely the same region, on the occasion of any
unusual fatigue or excitement.

There is, however, one variety of neuralgia from mal-nutrition which
deserves special consideration, viz., that which is occasionally
produced as an after-effect of mercurial salivation. I have only seen
one instance of this affection, but several are recorded. [Such, at
least, is my impression, but I have not been able to find the reports of
them.] My patient was a woman of somewhat advanced years when she first
came under my notice, but her malady had (though with long
intermissions) existed ever since she was a young girl in service. At
that early date she was severely salivated by some energetic but
misguided practitioner, for an affection which was called pleurisy, but
(according to her description) might well have been only pleurodynia, to
which servant girls are so very subject. At any rate, the consequences
of the medication were most disastrous. Not only did she then and there
lose every tooth in her head and suffer extensive exfoliations from the
maxillæ, but after this process was over she began to suffer frightfully
from neuralgic pains in both arms and in both legs. Tonic medicines and
a change to sea-air brought about a tardy and temporary cure; but from
that moment her nervous system never recovered itself. Whenever she took
cold, or was over-fatigued, or depressed from any bodily or mental
cause, she was certain to experience a recurrence of the pains. At the
time of her application to me she was suffering from an attack of more
than ordinary severity, and which had lasted a long time without showing
any signs of yielding. She apparently could not find words to express
the acuteness of her sufferings. All along the course of the sciatic
nerve in the thigh, all down the course of the middle cutaneous and long
saphenous branches of the anterior crural, in the musculo-spiral,
radial, and the course of the ulnar nerves, and also, in a more
generalized way, in the gastrocnemii, in the soles of the feet, and in
the palms of the hands, the pains were of a tearing character, which she
described as resembling "iron teeth" tearing the flesh. The pains
recurred many times daily; her life was a perfect burden to her, and
always had been during these attacks. This patient was under my
observation, on various occasions, during several years, and I
established the fact that cod-liver oil always did very great good. But
it was evident that nothing would remove the tendency to the recurrence
of the pains. I should mention, as additional proof of the extent to
which the mercurial poison had shattered the nervous system of this
woman, that she had violent muscular tremors at the time of her first
attack, and on several subsequent occasions. A more completely ruined
life was never seen; the poor woman had been on the highway to promotion
in the service of a nobleman when she was mercurialized, but her whole
prospects were blighted by the serious danger to her health which was
caused by the preposterous antiphlogisticism of her medical attendant.

I do not know that the poisonous action of any other metallic poison
than mercury has been distinctly shown to produce neuralgic pains of
superficial nerves. The action of lead is well known to produce colic, a
disease which will be specially dwelt on elsewhere. And undoubtedly a
certain amount of aching pain sometimes attends certain stages of
lead-palsy of the extensor muscles of the forearm. But I know of no
facts pointing to a true saturnine neuralgia. And the chronic poisonous
effects of arsenic on the nervous system seem to produce sensory
paralysis, rather than pain.

We come now to the consideration of the local varieties of neuralgia.
The primary subdivision of them may be made as follows:

I. Superficial Neuralgias. II. Visceral Neuralgias.

I. SUPERFICIAL NEURALGIAS.

Of superficial neuralgias a further classification may be made:

    (_a_) Neuralgia of the fifth (trigeminal, or trifacial).
    (_b_) Cervico-occipital neuralgia.
    (_c_) Cervico-brachial neuralgia.
    (_d_) Intercostal neuralgia.
    (_e_) Lumbo-abdominal neuralgia.
    (_f_) Crural neuralgia.
    (_g_) Sciatic neuralgia.

This arrangement is that of Valleix, and appears to me substantially
correct.

(_a_) _Neuralgia of the Fifth._--The most important group of neuralgias
are those of the fifth cranial nerve.

Neuralgia of the fifth nerve always exhibits itself in the especial
violence in certain foci, which Valleix was the first to define with
accuracy. These foci are always in points where the nerve becomes more
superficial, either in turning out of a bony canal, or in penetrating
fasciæ. In the ophthalmic division of the nerve the following possible
foci are noticeable: (1) The supra-orbital, at the notch of that name,
or a little higher, in the course of the frontal nerve; (2) the
palpebral, in the upper eyelid; (3) the nasal, at the point of emergence
of the long nasal branch, at the junction of the nasal bone with the
cartilage; (4) the ocular, a somewhat indefinite focus within the globe
of the eye; (5) the trochlear, at the inner angle of the orbit.

In the superior maxillary division the following foci may be found: (1)
The infra-orbital, corresponding to the emergence of the nerve of that
name from its bony canal; (2) the malar, on the most prominent portion
of the malar bone; (3) a vague and indeterminate focus, somewhere on the
line of the gums of the upper jaw; (4) the superior labial, a vague and
not often important focus; (5) the palatine point, rarely observed, but
occasionally the seat of intolerable pain.

In the inferior maxillary division the foci are: (1) The temporal, a
point on the auriculo-temporal branch, a little in front of the ear; (2)
the inferior dental point, opposite the emergence of the nerve of that
name; (3) the lingual point, not a common one, on the side of the
tongue; (4) the inferior labial point, only rarely met with.

Besides these foci in relation with distinct branches of the trigeminus,
there is one of especial frequency which corresponds to the inosculation
of various branches. This is the parietal point, situated a little above
the parietal eminence. It is small in size--the point of the little
finger would cover it. It is the commonest focus of all.

Neuralgia may attack any one, or all, of the three divisions of the
nerve; the latter event is comparatively rare. Valleix, indeed, holds a
different opinion; but this seems to me to arise from the fact that his
definition of neuralgia was too narrow to include a large number of the
milder cases of neuralgia, which are, nevertheless I believe, decidedly
of the same essential character with the severer affections. The most
frequent occurrence is the limitation of the pain to the ophthalmic
division, and incomparably the most frequent foci of pain are the
supra-orbital and the parietal.

The most common variety of trigeminal neuralgia is migraine, or
sick-headache, as it is often called. This is an affection which is
entirely independent of digestive disturbances, in its primary origin,
though it may be aggravated by their occurrence. It almost always first
attacks individuals at some time during the period of bodily
development. Under the influences proper to this vital epoch, and often
of a further debility produced by a premature straining of the mental
powers, the patient begins to suffer headache after any unusual fatigue
or excitement, sometimes without any distinct cause of this kind. The
unilateral character of this pain is not always detected at first; but,
as the attacks increase in frequency and severity, it becomes obvious
that the pain is limited to the supra-orbital and its twigs, with
sometimes also the ocular branches. In rare cases, as in all forms of
neuralgia, the nerves of both sides may be affected; I have already
observed that this seems to be relatively more common in young children.
If the pain lasts for any considerable length of time, nausea, and at
length vomiting, are induced. This is followed at the moment by an
increase in the severity of the pain, apparently from the shock of the
mechanical effect; but from this point the violence of the affection
begins to subside, and the patient usually falls asleep. The history of
the attacks negatives the idea that the vomiting is ordinarily remedial.
This symptom merely indicates the lowest point of nervous depression;
but it may happen that a quantity of food which has been injudiciously
taken, lying as it does undigested in the stomach, may of itself greatly
aggravate the neuralgia, by irritation transmitted to the medulla
oblongata. In such a case vomiting may directly relieve the nerve-pain.
When the patient awakes from sleep, the active pain is gone. But it is a
common occurrence--indeed it always happens when the neuralgia has
lasted a long time--that a tender condition of the superficial parts
remains for some hours, perhaps for a day or two. This tenderness is
usually somewhat diffused, and not limited with accuracy to the foci of
greatest pain during the attacks.

Sick headache is not uncommonly ushered in by sighings, yawning, and
shuddering--symptoms which remind us of the prodromata of certain graver
neuroses, to which, as we shall hereafter see, it is probably related by
hereditary descent. In its severer forms, migraine is a terrible
infliction; the pain gradually spreads to every twig of the ophthalmic
division; the eye of the affected side is deeply bloodshot, and streams
with tears; the eyelid droops, or jerks convulsively; the sight is
clouded, or even fails almost altogether for the time, and the darts of
agony which shoot up to the vertex seem as if the head were being split
down with an axe. The patient cannot bear the least glimmer of light,
nor the least motion, but lies quite helpless, intensely chilly and
depressed, the pulse at first slow, small and wiry, afterward more rapid
and larger, but very compressible. The feet are generally actually, as
well as subjectively, cold. Very often, toward the end of the attack,
there is a large excretion of pale, limpid urine.

Another variety of trigeminal neuralgia which infests the period of
bodily development is that known as clavus hystericus: clavus, from the
fact that the pain is at once severe, and limited to one or two small
definite points, as if a nail or nails were being driven into the skull.
These points correspond either to the supra-orbital or the parietal, or,
as often happens, to both at once. But for the greater limitation of the
area of pain in clavus, that affection would have little to distinguish
it from migraine, for the former is also accompanied with nausea and
vomiting when the pain continues long enough; and in both instances it
is obvious that there is a reflex irritation propagated from the painful
nerve. The adjective hystericus is an improper and inadequate definition
of the circumstances under which clavus arises. The truth is, that the
subjects of it are chiefly females who are passing through the trying
period of bodily development; but there is no evidence to show that
uterine disorders give any special bias toward this complaint. Both
migraine and clavus are often met with in persons who have long passed
their youth; but their first attacks have nearly always occurred during
the period of development.

One circumstance in connection with well-marked clavus appears worth
noting, as somewhat differentiating it from migraine. It is, I think,
decidedly more frequently the immediate consequence of anæmia than they;
but it does not appear, from my experience, that the chlorotic form of
anæmia is any more provocative of it than is anæmia from any other
cause. Some of the worst cases of clavus, probably, that have ever been
seen were developed in the old days of phlebotomy. It was then very
common for a delicate girl, on complaint of some stitch of neuralgia or
muscular pain in the side, to be immediately bled to a large extent,
with the idea of checking an imaginary commencing pleurisy. The
treatment, so far from curing the pain and the dyspepsia (which it
produced), often aggravated them; whereupon the signs of inflammation
were thought to be still more manifest, and more blood was taken. Under
such circumstances the most complete anæmia was developed, and very
often the patient became a martyr to clavus in its severest forms. One
does not now very frequently meet with the victims of such mistaken
practice; but I have seen one [since writing this I have seen another
case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus
produced by loss of blood (in a subject who was doubtless predisposed to
neuralgic affections, to judge from his family history). The case was
that of a boy who accidentally divided his radial.

The middle period of life is not, according to my experience, fruitful
in first attacks of trigeminal neuralgia. But, when the neuralgic
tendency has once declared itself, there are many circumstances of
middle adult life which tend to recall it. Over-exertion of the mind is
one of the most frequent causes, especially when this is accompanied by
anxiety and worry; indeed, the latter has a worse influence than the
former. In women, the exhaustion of hæmorrhageal parturition, or of
menorrhagia, and also the depression produced by over-suckling, are
frequent causes of the recurrence of a migraine or clavus to which the
patient had been subject when young. The middle period of life is very
obnoxious to severe mental shocks, which are more injurious than in
youth, because of the diminished elasticity of mind which now exists;
and the same may be said of the influence of severe bodily accident of a
kind to inflict damage on the central nervous system. Special mention
ought to be made, in the case of women, of the disturbing influence of
the series of changes which close the middle portion of their life,
viz., the involution of the sexual organs. It would seem as if every
evil impression which has ever been made on the nervous system hastens
to revive, with all its disastrous effects, at this crisis. Latent
tendencies to facial neuralgia are particularly apt to reassert their
existence, and they are usually accompanied and aggravated by a tendency
to vaso-motor disturbance, which not unfrequently seems to be the most
distressing part of the malady. I have several times been consulted by
women undergoing the "change," whose chief complaint was of disagreeable
flushings and chills, especially of the face; and, on inquiring further,
one has found that they were suffering from severe facial neuralgia,
which, however, alarmed and distressed them less than did the vaso-motor
disturbance, and the giddiness, etc., which were an evident consequence
of it.

It is, however, the final or degenerative period of life which produces
the most formidable varieties of facial neuralgia. Neuralgia of the
fifth, which have previously attacked an individual, may recur at this
time of life without any special character, except a certain increase of
severity and obstinacy. But trigeminal neuralgias, which now appear for
the first time, are usually intensely severe, and nearly or quite
incurable. These cases correspond with the affection named by Trousseau
tic epileptiforme, and it is of them, doubtless, that Romberg is
speaking, when he says that the true neuralgias of the fifth rarely
occur before the fortieth year of life. These neuralgias are
distinguished by the intense severity of the pain, the lightning-like
suddenness of its onset, and the almost total impossibility of effecting
more than a temporary palliation of the symptoms. But they are also
distinguished by another circumstance which too often escapes attention,
namely, they are almost invariably connected with a strong family taint
of insanity, and very often with strong melancholy and suicidal
tendencies in the patient himself, which do not depend on, and are not
commensurate with, the severity of the pain which he suffers. It may
seem a strong view to take, but I must say that I regard a
well-developed and typical neuralgia, of the type we are now speaking
of, as an affection in which the mental centres are almost as deeply
involved as in the fifth nerve itself; though, whether this is an
original part of the disease, or a mere reflex effect of the affection
of the trigeminal nerve, I am not prepared to say. Other reflex
affections are common enough in this kind of facial neuralgia, and
especially spasmodic contractions of the facial muscles, which, indeed,
often form one of the most striking features of the malady, the attacks
of pain being accompanied by hideous involuntary grimaces. Even in the
earlier stages of the disease there is usually some degree of the same
thing, as, for instance, spasmodic winking. In the great majority of
cases, after a little time, exquisitely tender points are formed in the
chief foci of pain; in the intervals between the spasms the least
pressure on these points is sufficient to cause agony, and a mere breath
of wind impinging on them will often reproduce the spasm. Yet, in the
height of the acute paroxysm itself, the patient will often frantically
rub these very parts in the vain attempt to produce ease; and it has
often been noticed that such friction has completely rubbed off the hair
or whisker on the affected side: this happens the more easily, because
the neuralgic affection itself impairs the nutrition of the hair and
makes it more brittle, as we shall have occasion to show more fully
hereafter. The general appearance of a confirmed neuralgic of the type
now described is very distressing, and the history of his case fully
corresponds to it. He is moody and depressed, he dreads the least
movement, and the least current of air; he hardly dares masticate food
at all, more especially if the inferior maxillary division of the nerve
be implicated (as is generally the case sooner or later), for this
movement re-excites the pain with great violence. Nutrition is very
commonly kept up by slops, and is thus very insufficiently maintained:
this failure of nutrition is itself a decidedly powerful influence in
aggravating the disease. And there is a still further calamity which is
not unlikely to occur. The patient may fly to the stupefaction of drink
as a relief to his sufferings, and, if he has once experienced the
temporary comfort of drunken anæsthesia, is excessively likely to repeat
the experiment. But this is another and one of the most fatally certain
methods of hastening degeneration of nerve-centres, and the ultimate
effect, therefore, is disastrous in every way.

Although the neuralgias of the degenerative period are thus fatally
progressive, on the whole, there are some curious occasional anomalies.
Many cases are recorded, and I have myself seen such, in which the
attacks of pain, after reaching a very considerable degree of intensity,
have ceased for many months, whether under the influence of remedies or
not it is difficult to say with certainty, but probably far more from
independent causes. Whatever may be the reason of these sudden arrests,
however, certain it is that they are very seldom permanent, the pain
returning sooner or later, like an inexorable fate.

(_b_) _Cervico-occipital Neuralgia._--As Valleix has remarked, there are
several nerves (in fact, the posterior branches of all the first four
spinal pairs) which are more or less frequently the seat of this
affection. But among them all there is none comparable to the great
occipital, which arises from the second spinal pair, for the frequency
and importance of its neuralgic affections. This nerve sends branches to
the whole occipital and the posterior parietal region. On the other
hand, the second and third spinal nerves help to make up the superficial
cervical branch of the cervical plexus which is distributed to the
triangle between the jaw, the median line of the neck, and the edge of
the sterno-mastoid, and those to the lower part of the cheek. Then there
is the auricular branch, which starts from the same two pairs, and
supplies the face, the parotid region, and the back of the external ear.
Then the small occipital, distributed to the ear and to the occiput.
And, finally, superficial descending branches of the plexus. These,
altogether, are the nerves which at various points, where they become
more superficial, form the foci of cervico-occipital neuralgia.

The most typical example of this form of neuralgia which has fallen
under my notice occurred (after exposure to cold wind) in a lady about
sixty years of age, who had all her life been subject to neuralgic
headache approaching the type of migraine, and who came of a family in
which insanity, apoplexy, and other grave neuroses, had been frequent.
The pain centred very decidedly in a focus corresponding to the
occipital triangle of the neck; it recurred at irregular intervals, and
in very severe paroxysms, lasting about a minute. It was interesting to
follow the history of this case in one respect. It afforded a clear
illustration of the manner in which local tenderness is developed; for
during the first three or four days the patient, so far from complaining
that the painful part was tender on pressure, experienced decided relief
from pressure, although she experienced none from mere rest, however
carefully the neck might be supported. But in the course of a few days
an intensely painful spot developed itself in the occipital triangle,
and the back of the ear became excessively tender. All manner of
remedies had been tried in this case, without the slightest success and
especially there was a large amount of speculative medication, on the
theory of the probably "rheumatic" or "gouty" nature of the affection.
Nothing was doing the least good to the pain, and meantime the old
lady's digestion and general health and spirits were suffering very
severely. Blistering was now suggested, and the affection yielded at
once. The relief afforded must have been very complete, to judge by the
warm gratitude which the patient expressed. The subsequent history of
this patient illustrates several points which will engage our attention
under the section of Pathology. It may be just mentioned here, that she
suffered, twelve months later, from a hemiplegic attack of paralysis.

The tendency of cervico-occipital neuralgias is to spread toward the
lower portions of the face, as observed by Valleix; in this case they
become, sometimes, undistinguishable from neuralgias of the third
division of the trigeminus. In the early stages of the disease, if the
physician had been lucky enough to witness them, the true place of the
origin of the pain would have been easily recognizable; at a later date
it sometimes needs great care, and a very strict interrogation of the
patient, to discover the true history of the disease. Sometimes, even, a
cervico-occipital neuralgia which spreads in this way causes great
irritation and swelling of the submaxillary and cervical glands; and I
have known a case of this kind mistaken for commencing glandular
abscess. The pain and tension were so great in this case, and the
constitutional disturbance was so considerable, that the presence of
deep-seated pus was strongly suspected, and the propriety of an incision
(which would have been a hazardous proceeding) was seriously canvassed.

Experience is too limited, to judge by what I have personally seen, and
the recorded cases with which I am acquainted, to enable us to say
anything with confidence of the conditions, as to age and general
nutrition of the body, which specially favor the occurrence of
cervico-occipital neuralgia. Apparently, however, there is much reason
for thinking that the immediately exciting cause of it is most
frequently external cold. I have known it produced several times in the
same person, by sitting in a draught which blew strongly on the back of
the neck. And I am inclined to think that it is seldom the first form of
neuralgia which attacks a patient, but usually occurs in those who have
previously suffered from neuralgic pains either of the trigeminus or of
some other superficial nerve. I have known it once to occur in a person,
thus predisposed to neuralgic affections, in consequence of reflex
irritation from a carious tooth, as was proved by its cessation on the
extraction of the latter, although there was no facial pain.

(_c_) _Cervico-brachial Neuralgia._--This group includes all the
neuralgias which occur in nerves originating from the brachial plexus,
or from the posterior branches of the four lower cervical nerves. The
most important characteristic of the neuralgias of the upper extremity
is the frequency, indeed almost constancy, with which they invade,
simultaneously or successively, several of the nerves which are derived
from the lower cervical pairs. The neuralgic affections of the small
posterior branches (distributed to the skin of the lower and back part
of the neck) are comparatively of small importance. But the
"solidarite," which Valleix so well remarked, between the various
branches of the brachial plexus, causes the neuralgias of the shoulder,
arm, forearm, and hand to be extremely troublesome and severe, owing to
the numerous foci of pain which usually exist. Perhaps Valleix's
description of these foci is somewhat over-fanciful and minute; but the
following among them which he mentions I have repeatedly identified; (1)
An axillary point, corresponding to the brachial plexus itself; (2) a
scapular point, corresponding to the angle of the scapula. (It is
difficult to identify the peccant nerve here; the one to which it
apparently corresponds, and to which Valleix refers it, is the
subscapular; but we are accustomed to think of this as a motor nerve.
Still, it is certain that pressure on a painful point existing here will
often cause acute pain in the nerves of the arm and forearm.); (3) A
shoulder point, which corresponds to the emergence, through the deltoid
muscle, of the cutaneous filets of the circumflex; (4) a median-cephalic
point, at the bend of the elbow, where a branch of the musculo-cutaneous
nerve lies immediately behind the median-cephalic vein; (5) an external
humeral point, about three inches above the elbow, on the outer side,
corresponding to the emergence of the cutaneous branches which the
musculo-spiral nerve gives off as it lies in the groove of the humerus;
(6) a superior ulnar point, corresponding to the course of the ulnar
nerve between the olecranon and the epitrochlea; (7) an inferior ulnar
point, where the ulnar nerve passes in front of the annular ligament of
the wrist; (8) a radial point, marking the place where the radial nerve
becomes superficial, at the lower and external aspect of the forearm.
Besides these foci, there are sometimes, but more rarely, painful points
developed by the side of the lower cervical vertebræ, corresponding to
the posterior branches of the lower cervical pairs.

The most common seat of cervico-brachial neuralgia has been, in my
experience, the ulnar nerve, the superior and inferior points above
mentioned being the foci of greatest intensity; an axillary point has
also been developed in one or two cases which I have seen. Rarely,
however, does the neuralgia remain limited to the ulnar nerve; in the
majority of cases it soon spreads to other nerves which emanate from the
brachial plexus. A very common seat of neuralgia is also the shoulder,
the affected nerves being the cutaneous branches of the circumflex. I am
inclined to think, also, that affections of the musculo-spiral, and of
the radial near the wrist, are rather common, and have found them very
obstinate and difficult to deal with. One case has recently been under
my care in which the foci of greatest intensity of the pain were an
external humeral and a radial point; but besides these there was an
exquisitely painful scapular point. In another case the pain commenced
in an external humeral and a radial point, but subsequently the shoulder
branches of the circumflex became involved. A most plentiful crop of
herpes was an intercurrent phenomenon in this case, or rather, was
plainly dependent on the same cause which produced the neuralgia.

Median cephalic neuralgia is an affection which used to be comparatively
common in the days when phlebotomy was in fashion, the nerves being
occasionally wounded in the operation. I have only seen it in connection
with this cause, that is to say, as an independent affection. One such
case has been under my care. But a slight degree of it is not uncommon,
as a secondary symptom, in neuralgia affecting other nerves. The
traumatic form is excessively obstinate and intractable.

In the neuralgias of the arm we begin to recognize the etiological
characteristic which distinguishes most of the neuralgic affections of
the limbs, namely, the frequency with which they are aggravated, and
especially with which they are kept up and revived when apparently dying
out, the muscular movements. In the case above referred to, of neuralgia
of the subscapular, musculo-spiral (cutaneous branches), and radial, the
act of playing on the piano for half an hour immediately revived the
pains, in their fullest force, when convalescence had apparently been
almost established.

There is a special cause of cervico-brachial neuralgias which is of more
importance than, till quite lately, has ever been recognized, namely,
reflex irritation from diseased teeth. The subject of these reflex
affections from carious teeth has been specially brought forward by Mr.
James Salter, in a very able and interesting paper in the "Guy's
Hospital Reports" for 1867; and Mr. Salter informs me that he has been
surprised by the number of cases of reflex affections, both paralytic
and neuralgic, of the cervico-brachial nerves, produced by this kind of
irritation, and that he agrees with me in thinking that a peculiar
organization or disposition of the spinal centres of these nerves must
be assumed in order to account for the fact.

The liability of particular nerves in the upper extremity to neuralgia
from external injuries requires a few words. The nerve which is probably
most exposed to this is the ulnar. Blows on what is vulgarly called the
funny-bone are not uncommon exciting causes of neuralgia in predisposed
persons, and cutting wounds of the ulnar a little above the wrist are
rather frequent causes. The deltoid branches of the circumflex and the
humeral cutaneous branches of the musculo-spiral are much exposed to
bruises and to cutting wounds. So far as I know, it is only when a nerve
trunk of some size has been wounded that neuralgia is a probable result.
Wounds of the small nervous branches in the fingers, for instance, are
very seldom followed by neuralgia. I have no statistics to guide me as
to the effect of long-continued irritation applied to one of these small
peripheral branches, but it is probable that that might be more capable
of inducing neuralgia. As far as my own experience goes, however, it
would appear that a more common result is convulsion of some kind, from
reflex irritation of the cord.

(_d_) _Dorso-intercostal Neuralgia._--This is one of the commonest
varieties of neuralgia, and yet it is very likely to be confounded with
other affections not neuralgic in their nature. The disorder with which
it is especially liable to be confounded is myalgia, which will be fully
described in another chapter, and which, when developed in the region of
the body to which we are now referring, is commonly spoken of as
pleurodynia, or lumbago (according as it affects the muscles of the back
or of the side), or muscular rheumatism. It must be owned that the
severer forms of this affection can scarcely be distinguished from true
intercostal neuralgia by anything in the character or situation of the
pains. It will be seen, hereafter, however, that myalgia has its own
specific history, which is very characteristic; at present, it is
sufficient to remember that it is often extremely like neuralgia when
situated in the dorso-intercostal region.

Dorso-intercostal neuralgia is an affection of certain of the dorsal
nerves. These nerves divide, immediately after their emergence from the
intervertebral foramina, into an interior and a posterior branch. The
latter sends filaments which pierce the muscles to be distributed to the
skin of the back; the former, which are the intercostal nerves, follow
the intercostal spaces. Immediately after their commencement they
communicate with the corresponding ganglia of the sympathetic.
Proceeding outward, they at first lie between two layers of intercostal
muscles, and, after giving off branches to the latter, give off their
large superficial branch. In the case of the seventh, eighth and ninth
intercostal nerves, which are those most liable to intercostal
neuralgia, the superficial branch is given off about midway between the
spine and the sternum. The final point of division, at which superficial
filets come off, in all the eight lower intercostal nerves, is nearer to
the sternum; and is progressively nearer to the latter in each
successive space downward. There are thus, as Valleix observes, three
points of division: (1) At the intervertebral foramen; (2) midway in the
intercostal space; (3) near to the sternum. And there are three sets of
branches (reckoning the posterior division) which respectively make
their way to the surface near to these points.

In one of its forms, intercostal neuralgia is one of the commonest of
all neuralgic affections. I refer to the pain beneath the left mamma,
which women with neuralgic tendencies so often experience, chiefly in
consequence of over-suckling, but also from exhaustion caused by
menorrhagia or leucorrhoea, and especially from the concurrence of one
of the latter affections with excessive lactation. It is especially
necessary, however, to guard against mistaking for this affection a mere
myalgic state of the intercostal or pectoral muscles, which often
arises in similar circumstances with the addition of excessive or too
long continued exertions of these muscles. "Hysteric" tenderness also
sometimes bears a considerable resemblance, superficially, to true
intercostal neuralgia, in cases where the genuine disease does not
exist.

A less common but very remarkable variety of intercostal neuralgia than
that just mentioned, is the kind of pain which attends a good many cases
of herpes zoster, or shingles. It is only of recent years that any
essential connection between zoster and neuralgia has been suspected.
The occurrence of neuralgia as a sequel to zoster had indeed been
mentioned by Rayer, Recamier, and Piorry, but the essential nature of
the connection between the two diseases was evidently not suspected by
Lecadre, when, as late as 1855, he published his valuable essay on
intercostal neuralgia. M. Notta was one of the first to present
connected observations on the subject. But it was much more fully
discussed in a paper published by M. Barensprung, in 1861. [_Ann. der
Charite-Krakenhauser zer Berlin, ix._, 2, p. 40. _Brit. and For. Med.
Rev._, January, 1862.] This author showed the absolute universality with
which unilateral herpes, wherever developed, closely followed the course
of some superficial sensory nerve, and gave reasons, which will be
discussed hereafter, for supposing that the disease originates in the
ganglia of the posterior roots, and that the irritation spreads thence
to the posterior roots in the cord, causing reflex neuralgia. We shall
have more to say on this matter. Meantime, it seems to be established,
by multiplied researches, that, though unilateral herpes may and often
does occur without neuralgia, and neuralgia without herpes, the
concurrence of the two is due to a mere extension of the original
disease, which is a nervous one.

In young persons, zoster is not attended with severe neuralgia, but a
curious half-paretic condition of the skin, in which numbness is mixed
with formication, or with a sensation as of boiling water under the
skin, precedes the outbreak of the eruption by some hours, or by a day
or two. Painless herpes is commonest in youth. I remember, for instance,
that, in an attack of shingles which I suffered about the age of eleven,
there was at no stage any acute pain; only, in the pre-eruptive period,
for a short time, I had the curious sensations referred to above: and
the same thing has occurred in all the patients below puberty that I
have seen, if they complained at all. From the age of puberty to the end
of life, the tendency of herpes to be complicated with neuralgia becomes
progressively stronger. The course of events varies much in different
cases, however. In adult and later life the symptoms usually commence
with a more or less violent attack of neuralgic pain, which is
succeeded, and generally, though not always, displaced by the herpetic
eruption. The latter runs its course, and after its disappearance the
neuralgia may return, or not. In old people it almost always does
return, and often with distressing severity and pertinacity. Six weeks
or two months is a very common period for it to last, and in some aged
persons it has been known to fix itself permanently, and cease only with
life. In these subjects a further complication sometimes occurs. The
herpetic vesicles leave obstinate and painful ulcers behind them, which
refuse to heal, and which worry the patient frightfully, the merest
breath of air upon them sufficing to produce agonizing darts of
neuralgic pain. I have known one patient, a woman over seventy years of
age, absolutely killed by the exhaustion produced by protracted
suffering of this kind.

The foci of pain in intercostal neuralgia are always found in one or
more of the points, already enumerated, at which sensory nerves become
superficial. In long-standing cases acutely tender points are developed
in one or more of these situations; not unfrequently the most decided of
these spots is where it gets overlooked, namely, opposite the
intervertebral foramen. H. G., a young woman aged twenty-six, who
applied to me at Westminster Hospital, had suffered for twelve months
from an irregularly intermitting but very severe neuralgia at the level
of the seventh intercostal space of the left side. The violence of the
pain was sometimes excessive, and when the paroxysm lasted longer than
usual it generally produced faintness and vomiting. This patient had no
sign of tenderness anywhere in the anterior or lateral regions, though
the pain seemed to gird round the left half of the chest as with an iron
chain, but an exquisitely tender spot, as large as a shilling, was found
close to the spine; pressure on this always induced a strong feeling of
nausea.

As an illustration of the herpetic variety of dorso-intercostal
neuralgia, running a severe but not protracted course, I may relate the
case of a medical man whom I formerly attended. This gentleman was about
thirty-two years of age, and a highly neurotic subject: inter alia, he
had already suffered from a severe and protracted sciatica; and, very
shortly before the herpetic attack, had been jaundiced from purely
nervous causes. His nervous maladies were undoubtedly caused by
over-brain-work. In this case the neuralgia developed itself during the
latter half of the eruptive period, which was rather unusually
lengthened. It occupied the seventh, eighth, and ninth intercostal
spaces of the side affected with herpes, and was very violent and acute,
so that the patient expressed himself as almost "cut in two" with it.
The pain ceased even before the vesicles had perfectly healed; a rather
unusual occurrence in my experience. I shall refer to this case
hereafter, as an example of what I believe to be the effect of a
particular method of treatment in lessening the tendency to
after-neuralgia. The result of my experience is certainly this--that if
a case of herpes in an adult, or still more in an aged person, be left
to itself, the amount of after-neuralgia will very closely correspond
with the severity of the eruptive symptoms.

There is a variety of intercostal neuralgia which is of more importance
than the commoner kinds. Occurring mostly in persons who have passed the
middle age, it possesses the characters of obstinacy and severity which
belong to the neuralgias of the period of bodily decay. It is at first
unattended with any special cardiac disturbance. By-and-by, however, it
begins to attract more careful attention from the fact that the severer
paroxysms extend into the nerves of the brachial plexus of the affected
side, so that pain is felt down the arm. In the midst of a paroxysm of
intercostal and brachial pain, it may happen that the patient is
suddenly seized with an inexpressible and deadly feeling of cardiac
oppression, and, in fact, the symptoms of angina pectoris, such as they
will be described in a future chapter, become developed. A case of this
kind is at present under my care at the Westminster Hospital. The
patient is a man only fifty-six years of age, but whose extreme
intemperance has produced an amount of general degeneration of his
tissues such as is rarely seen except in the very aged; he has the most
rigid radial arteries, and the largest arcus senilis, I think, that I
ever saw. This man has long been subject to attacks of violent
intercostal neuralgia, and a recent access assumed the type of
unmistakable angina. It is very probable that his coronary arteries have
now become involved in the degenerative process. In this case, before
the development of any marked anginal symptoms, the paroxysmal pain,
from being merely intercostal, had come to extend itself into the left
shoulder and arm.

Intercostal neuralgia not unfrequently accompanies, and is sometimes a
valuable indication of, phthisis. I do not mean to say that the vague
pains in the chest-walls, which are so very common in phthisis, are to
be indiscriminately accounted neuralgia; on the contrary, they are, in
the large majority of instances, merely myalgic, and arise from the
participation of the pectorals, or intercostals, or both, in the
mal-nutrition which prevails in the organism generally. But it happens,
sometimes that a distinctly intermitting neuralgia occurs as an early
symptom of phthisis; in fact, where there is a predisposition to
neurotic affections, I believe that this is not very uncommon. The
subjects are generally women; they are mostly of that class of
phthisical patients who have a quick intelligence, fine soft hair, and a
sanguine temperament. I have had one male patient under my care: this
was a young gentleman aged eighteen, in whom a neuralgic access came on
with so much severity, and caused so much constitutional disturbance,
that the idea of pleurisy was strongly suggested. The paroxysms returned
at irregular intervals for a considerable period: they were quite
unlike myalgic pains, not only in their character, but more especially
with respect to the circumstances which were found to provoke their
recurrence. They were the first symptoms which lead to any careful
examination of the chest; it was then found that there were prolonged
expiration and slight dulness, at one apex. At this period, wasting had
not seriously commenced; but, on the other hand, there was an
extraordinary degree of debility for so early a stage of phthisis. I am
inclined to think that self-abuse was the principal cause both of the
phthisis and the neuralgia, acting doubtless on a predisposed organism,
for his family was rather specially beset with tendencies to
consumption. I may add here, that it has appeared to me that young
persons with phthisical tendencies are specially liable to neuralgic
affections as a consequence of self-abuse.

A special variety of intercostal neuralgia is that which attacks the
female breast. The nerves of the mammæ are the anterior and middle
cutaneous branches of the intercostals; and they are not unfrequently
affected with neuralgia, which is sometimes very severe and intractable.
Dr. Inman has very properly pointed out that a large number of the cases
of so-called "hysterical breast" are really myalgic, and are directly
traceable to the specific causes of myalgia; but there is no question in
my mind that true neuralgia of the breast does occur, and indeed is
frequent, relatively to the frequency of neuralgias generally. There are
several kinds of circumstances under which it is apt to occur. In
highly-neurotic patients it may come on with the first development of
the breasts at puberty; and it may be added that this is especially apt
to occur where puberty has been previously induced by the unfortunate
and mischievous influences to which we had occasion to refer in speaking
of certain other neuralgiæ. A neuralgia of the left breast occurred in a
patient of mine, who attended the Westminster Hospital. She was only
twelve years of age, and small of stature, but the mammæ were
considerably developed. The face was haggard, there was an almost
choreic fidgetiness about the child, and a very unprepossessing
expression of countenance; the result of inquiries left no doubt that
the patient was much addicted to self-abuse; and it seemed probable that
to this was due the fact that menstruation had come on, and was actually
menorrhagic in amount.

A very painful kind of mammary neuralgia is experienced by some women
during pregnancy; but more commonly the mammary pains felt at this
period are mere throbbings, not markedly intermittent in character, and
plainly dependent on mechanical distention of the breast: such
affections are not to be reckoned among true neuralgiæ. A true neuralgia
of a very severe character is sometimes provoked by the irritation of
cracked nipples. I have seen a delicate lady, of highly-neurotic
temperament, and liable to facial neuralgia, most violently affected in
this way. Vain attempts had been made for several consecutive days to
suckle the infant from the chapped breast; when suddenly the most severe
dorso-intercostal neuralgia set in. The attacks lasted only a few
seconds each, but they recurred almost regularly every hour, and were
attended with intense prostration, and sometimes with vomiting.
Discontinuance of suckling was found necessary, for even the application
of the child to the sound breast now sufficed to arouse a paroxysm of
pain. Complete rest, protection of the breast from air and friction, and
the hypodermic injection of morphia, rapidly relieved the sufferer.

(_e_) _Dorso-lumbar Neuralgia._--The superficial branches of the spinal
nerves emanating from the lumbar plexus are considerably less liable to
be affected with severe and well-marked neuralgia than are the
dorso-intercostal nerves. Pains in the abdominal walls, which are a good
deal like neuralgia, are not uncommon; but the majority of them will be
found, on careful observation, to be myalgia. At least, this has been
the case in my own experience.

When true neuralgia of the superficial branches of the lumbo-abdominal
nerves occurs, it develops itself in one or more of the following foci:
(1) Vertebral points, corresponding to the posterior branches of the
respective nerves; (2) an iliac point, about the middle of the crista
ilii; (3) an abdominal point, in the hypogastric region; (4) an inguinal
point, in the groin, near the issue of the spermatic cord, whence the
pain radiates along the latter; (5) a scrotal or labial point, situated
in the scrotum or in the labium majus.

Such is the description given by Valleix; for my own part, I cannot say
that I have seen enough cases to test its accuracy. I believe it to be
generally correct, yet it may fairly be doubted whether the author might
not have revised his description had the natural history of myalgic
affections been as carefully investigated as it has since been. The
hypogastric foci of pain of which he speaks are at least open to
considerable suspicion, as it will be shown, in the chapter on Myalgia,
that an extremely common variety of the latter affection is situated in
this region, and the severity of the pain which it often produces might
well cause it to be mistaken for a genuine neuralgia.

I have, however, seen three or four cases in which the very complete
intermittence of the paroxysms, without any perceptible relation to the
question of muscular fatigue, left no doubt in my mind of the really
neuralgic character of the malady. In one of these instances, oddly
enough, the exciting cause appeared to be fright; and this was as severe
a case as one often sees. The patient was a woman of middle age, and
much depressed by the long continuance of a profuse leucorrhoea. As
she was walking along the street, a herd of cattle, in a somewhat
irritable and disorderly condition, came suddenly toward her; she
immediately began to suffer pain just above the crest of the ilium, and
at the lumber region, and, most acutely, in the labium majus of one
side; and then pain returned daily, about 10 A. M., lasting for half an
hour with great severity. This woman's family history was remarkable:
her mother had been paraplegic, her sister was a confirmed epileptic,
and two of her children had suffered from chorea.

In two other cases of lumbo-abdominal neuralgia which were under my
care, there were also very painful points in the spermatic cord and in
the testicle. One of these cases will be referred to under the head of
Visceral Neuralgia. Another case, in which severe quasi-neuralgic pain
was referred to the groin, will be described in the chapter on the Pains
of Hypochondriasis.

(_f_) _Crural Neuralgia._--This appears to be rare as an independent
affection occurring primarily in the crural nerve. Valleix had only seen
it twice in all his large experience, and I have never seen it myself.
Neuralgic pain of the crural nerve is almost always a secondary
affection arising in the course of a neuralgia, which first shows itself
in the external pudic branch of the sacral plexus; or else occurring as
a complication of sciatica. A remarkably severe example of the latter
occurrence was observed in an old man who still occasionally attends the
Westminster Hospital. He has been a martyr to the most inveterate
bilateral sciatica for between two and three years; and, within the last
three months, it has extended itself into the cutaneous branches of the
curval nerves of both thighs. So great an aggravation of the pain is
produced by any muscular movement, that the patient can only walk at the
slowest possible pace, moving each foot forward only a few inches at a
time. The bilateral distribution of the pain is remarkable in this case;
but there can be no doubt of its really neuralgic character, from the
truly intermittent way in which it recurs, and the absence of any
history whatever to point in the direction of rheumatism, gout, or
syphilis.

The nervous supply to the skin of the anterior and external portion of
the thigh includes: (1) The middle cutaneous, (2) the internal
cutaneous, and (3) the long saphenous branch of the anterior crural
nerve; (4) the cutaneous branch of the obturator; and (5) the external
cutaneous nerve, derived from the loop formed between the second and
third lumbar nerve. The sensitive twigs derived from the two latter
sources, equally with the branches of the anterior crural, are liable to
be secondarily affected by neuralgia, which commences in the
lumbo-abdominal nerves; but it must be a rare event for them to be the
seat of a primary neuralgia. The only occasion on which I have seen
anything which looked like the latter was in the case of a porter, who,
in straining to lift a very heavy load, ruptured some part of the
attachment of the tensor vaginæ femoris. But the susceptibility of all
the nerves of the front of the thigh to secondary or reflex neuralgia
receives numerous illustrations. The extremely severe pain at the
internal aspect of the knee-joint, which is such a common symptom in
morbus coxæ, is evidently a reflex neuralgia of the long saphenous
nerve, the ultimate irritation being situated in the branches of the
obturator nerve which supply the hip-joints. For some reason
unexplained, it happens that this saphenous nerve is specially liable to
be affected in a reflex manner: for instance, this happens in a
considerable number of cases of sciatica. I have a lady now under my
observation, in whom the secondary neuralgia of the saphenous nerve has
become even more intolerable than the pain in the sciatic, which was the
nerve primarily affected. The pain in these cases very frequently runs
down the inner and anterior surface of the leg to the internal ankle.
Sometimes the branches of the anterior crural become the seat of
intensely painful points in the course of a long-persisting sciatica. A
patient at present under my care has a spot, about the size of a
shilling, just at the emergence of the middle cutaneous branch from the
fascia lata, which is intensely and persistently tender to the touch,
and the skin here is so exquisitely sensitive to the continuous galvanic
current that the application of moistened sponge-conductors, with a
current of only fifteen Daniell's cells, causes intolerable burning
pain; whereas at every other part of the limb the current from
twenty-five cells can be borne without much inconvenience.

(_g_) _Femoro-popliteal Neuralgia, or Sciatica._--This is one of the
most numerous and important groups of neuralgia; but, notwithstanding
that there are plenty of opportunities for studying it, I venture to
think it is very commonly mistaken for different and non-neuralgic
diseases, and they for it. The rules of diagnosis which will be laid
down for all the neuralgiæ would nevertheless prevent these errors, if
carefully attended to.

Sciatica is a disease from which youth is comparatively exempt. Valleix
had collected one hundred and twenty-four cases, and in not one was the
patient below the age of seventeen, only four were below twenty. In the
next decade there were twenty-two; in the next, thirty; and the largest
number of cases, thirty-five, occurred between the ages of forty and
fifty. This completely tallies with my own experience, and appears to
afford some support to a suspicion I have formed, that the chief
exciting cause of sciatica is the pressure exercised on the nerve in
locomotion, and that this cause exercises its maximum influence when the
period of bodily degeneration commences. It is further remarkable that,
in elderly persons (whose habits of locomotion are of course more
limited), the proportion of fresh cases rapidly diminishes; and also
that above the age of thirty the number of male patients greatly exceeds
that of female patients attacked. All this seems to point in the same
direction.

According to my observation, there are three distinct varieties of
sciatica. The first of these is obscure in its origin, but may be said,
in general terms, to be connected with a nervous temperament of the
highly impressible kind, which is more or less like what we call
"hysteric," not only in the female, but also in male patients. The
subjects of this kind of sciatica are mostly young persons, and hardly
ever more than middle-aged; they are generally found to be liable to
other forms of neuralgia; and the actual attack of sciatica is produced
by some fatigue or mental distress, which at other times might have
brought on sick headache, or intracostal neuralgia, etc. Very many of
these patients are anæmic; and chlorotic anæmia seems specially to favor
the occurrence of the affection. The greater number of the victims are
females, and in very many, whether as cause or effect, there is impeded,
or at least imperfect, menstruation. This kind of sciatic pain is not
usually of the highest degree of intensity, but it generally spreads
into a great many branches, both in a direct and a reflex manner. It is
probable that this variety of the disease is, at least very often,
dependent upon, or much aggravated by, an excited condition of the
sexual organs; certainly, I have observed it with special frequency in
women who have remained single long after the marriageable age, and in
several male patients there has been either the certainty or a strong
suspicion of venereal excess. Sciatica of this kind also occurred in the
case of a single woman aged about thirty, who to my knowledge was
excessively addicted to self-abuse.

The second variety of sciatica occurs for the most part in middle-aged
or old persons who have long been subject to excessive muscular
exertion, or have been much exposed to damp and cold, or who have been
subject to the combined influence of both these kinds of evil influence.
One must also include, I think, in this group a considerable number of
cases where the age is not so advanced, but the patient has been
obliged, by the nature of his business, to maintain the sitting posture
daily, for hours together, exercising pressure on the nerve; this is
especially liable to happen in these persons.

The sufferers from this variety of sciatica are mostly, as already said,
of middle age or more; but this statement must be understood to be made
in the comparative sense, which refers rather to the vital status of the
individual than to the mere lapse of years. Many of these people have
hair which is prematurely gray, and in some the existence of rigid
arteries, together with arcus senilis, completes the picture of organic
involution, or senile degeneration. In particular cases, where
depressing influences have been at work for a long time, or unusually
active, these appearances rectify the false impression we should
otherwise derive from learning the mere nominal age of the person; this
is especially often the case with regard to patients who have for a long
time drunk to excess. The prematurely and permanently gray hair (it will
be seen hereafter that permanency of grayness is an important point),
together with well-marked inelasticity of arteries, very often tells a
tale which is most useful in informing us, not only of the vital status
of the patient, but of the kind of sciatica under which he labors; and
also influences our prognosis seriously. There is otherwise a somewhat
deceptive air about the appearance of many of these degenerative cases;
for instance, a ruddy complexion is not uncommon, nor the retention of
considerable, or even great, muscular strength. It is probable that
these appearances deceived Valleix and many others, or they could hardly
have failed, as they have, to observe the frequency of the degenerative
type among the most numerous group of sciatic patients, namely, those
between thirty and fifty years of age. These persons are not truly
"robust," although at a hasty glance they might at first seem to be so.
It would be a serious mistake to omit the search for the important vital
evidences which have been referred to, since these therapeutic and
prognostic indications are of the highest value.

A prominent feature in this kind of sciatica is its great obstinacy and
intractability. Another, equally marked, is the tendency to the
development of spots around the foci of severest pain which are
intensely and permanently tender, and the slightest pressure on which is
sufficient to set up acute pain. This is a symptom much less developed,
if developed at all, in the variety of sciatica which we first
discussed. The places which are especially apt to present this
phenomenon of tenderness are as follows: (1) A series, or line of
points, representing the cutaneous emergence of the posterior branches,
which reaches from the lower end of the sacrum up to the crista ilii;
(2) a point opposite the emergence of the great and small sciatic nerves
from the pelvis; (3) a point opposite the cutaneous emergence of the
ascending branches of the small sciatic, which run up toward the crista
ilii; (4) several points at the posterior aspect of the thigh,
corresponding to the cutaneous emergence of the filets of the crural
branch; (5) a fibular point, at the head of the fibula, corresponding to
the division of the external popliteal; (6) an external malleolar,
behind the outer ankle; (7) an internal malleolar.

I have already mentioned that in sciatica the pain frequently spreads in
a reflex manner to nerves which are connected, by their origin from the
plexus, with the sciatic. It will be remembered, also, that I related
cases in which the formation of tender points, in the course of the
nerves thus secondarily affected, was even more distinct and remarkable
than anywhere in the branches of the sciatic itself.

Another circumstance which distinguishes the form of sciatica which we
are now describing is, the degree in which (above all other forms of
neuralgia) it involves paralysis of motion. [The subject of the
complication of neuralgia will be treated in a general manner farther
on; but it seems necessary to note here the special liability of sciatic
patients to this and to the most material complications]. By far the
largest part of the motor nervous supply for the whole lower limb passes
through the trunk of the great sciatic; it might therefore be naturally
expected that a strong affection of the sensory portion of the nerve
would produce, in a reflex manner, some powerful effect upon the motor
element. This effect is most frequently in the direction of paralysis.
Complete palsy is rare, but in a large proportion of cases which have
lasted some time there will be found, independently of any wasting of
muscles, a positive and considerable loss of motor power. It is of
course necessary to avoid the fallacy which might be produced by
neglecting to observe whether movement was restricted merely in
consequence of its painfulness. Not long since, I had occasion to test
the electric sensibility in a case of sciatica, in which there was
extremely severe pain, affecting chiefly the peroneal region of the leg,
and great weakness of the leg, amounting to inability for walking. The
gastrocnemius could hardly be got to contract at all, when the most
powerful Faradic current was directed upon the nerve in the popliteal
space of the affected limb, though the muscle of the sound side reacted
with great vigor.

_Anæsthesia_ is also a common complication of sciatica, far commoner, I
venture to think, than it has been represented either by Valleix, or
Notta. It is necessary, however, to be explicit on this point. In the
early stages, both of this form of sciatica, and of the milder variety
previously described, there is almost always partial numbness of the
skin previous to the first outbreak of the neuralgic pain, and during
the intervals between the attacks. By degrees this is exchanged, in the
milder form, for a generally diffused tenderness around the foci of
neuralgic pain, while other portions of the limb remain more or less
anæsthetic. In the severer forms it sometimes happens that, besides an
intense tenderness of the skin over the painful foci, there is diffused
tenderness over the greater part or the whole of the surface of the
limb. But it is important to remark that both in the anæsthetic and the
hyperæsthetic conditions (so called) the tactile sensibility is very
much diminished. I have made a great many examinations of painful limbs,
in sciatica, and have never failed to find (with the compass points)
that the power of distinctive perception was decidedly lowered.

_Convulsive movements of muscles_ are met with in a moderate proportion
of cases of sciatica in middle and advanced life, in which affection
they are entirely involuntary. They differ from certain spasmodic
movements not unfrequently observed in the milder form (and especially
in hysteric women), for these are more connected with morbid volition,
and are in truth, not perfectly involuntary. In several cases of
inveterate sciatica I have seen violent spasmodic flexures of the leg
upon the thigh. Cramps of particular muscles are occasionally met with.
I have seen the flexors of the toes of the affected limb violently
cramped, and in one case there was agonizing cramp of the gastrocnemius.
It is chiefly at night, and especially when the patient is falling
asleep, that this kind of affection is apt to occur.

A third variety of sciatica is the rather uncommon one so far as my
experience goes, in which inflammation of the tissues around the nerve
is the primary affection, and the neuralgia is mere secondary effect,
from mechanical pressure on the nerve, which, however, is not apparently
itself inflamed. I believe that these cases are sometimes caused by
syphilis, and sometimes by rheumatism. One of the most violent attacks
of sciatic pain which ever came under my notice was in a syphilized
subject, a discharged soldier, who had been the victim of severe
tertiary affections, and had been mercilessly salivated into the
bargain. This unfortunate man suffered dreadful agony, which was
aggravated every night, but was never totally absent. The pain started
from a point not far behind the great trochanter: pressure here caused
intolerable darts of pain, which ramified into every offshoot of the
sciatic nerve, as it seemed, and made the man quite faint and sick.
Large doses of iodide of potassium, together with the prolonged use of
cod-liver oil, completely removed the pain and tenderness. It need
hardly be said that cases of this kind are essentially different, and
require perfectly different principles of treatment from neuralgias in
which the disturbance originates within the nervous tissues themselves.

The chronic rheumatism does also, occasionally, affect the sheath of the
nerve in such a manner as to produce a deposit which sets up neuralgic
pain, must also be admitted, although I believe the number of such cases
to be preposterously over-estimated by careless observers. It has
several times happened that a patient has come under my care with
so-called "rheumatic affection of the nerves" of the thigh and leg, and
that on examination one has found all the symptoms and clinical history
of a neurosis, but not the slightest valid argument for a diagnosis of
the rheumatic diathesis. Indeed, upon this point, I think it is time
that a decided opinion should be expressed. I firmly believe that a
large number of sciatic patients have their health ruined by treatment
directed to a supposed rheumatic taint which is purely imaginary. The
state of medical reasoning, suggested by the way in which too many
practitioners decide that such and such pains are rheumatic in their
origin, is a melancholy subject for reflection. Nearly always it will be
found, on cross-examination, that the state of the urine has been made
the basis of a confident diagnosis; the practitioner will tell you that
the urine was loaded, _i. e._, with lithtaes. He ignores the fact that
nothing is more common, in neurotic patients who are perfectly guiltless
of rheumatic propensities, than a fluctuation between lithiasis and
oxaluria, neither of which phenomena, under the circumstances, indicates
any more than a temporary defect of secondary assimilation of food,
produced by nervous commotion. I may perhaps find room, on a future
page, for a few further remarks on the subject; at present I only put in
a caution against too ready an acceptance of the rheumatic hypothesis.

II. VISCERAL NEURALGIAS.

_Uterine and Ovarian Neuralgia._--This is an important group of
neuralgic affections, and one which I cannot help thinking is strangely
misappreciated, very often, in a therapeutic point of view. In one
aspect these affections possess a special interest, namely this, that
they are more frequently dependent on peripheral irritation for their
immediate causation than any other group of neuralgias. If we consider
the great copiousness of the nervous supply to the uterus and ovaries,
and the powerfully disturbing character of the functional processes
which are periodically occurring in these organs, we shall be at no loss
to understand how this may be. The amount force of the peripheral
influence and which are brought to bear upon the central nervous system
by the functions of the uterus and ovaries are greater than any that
emanate from the diseases and functional disturbances of any other organ
in the body.

The most common variety of peri-uterine neuralgia is that which attends
certain kinds of difficult menstruation. It would be hardly correct to
give the name of neuralgia to the pain existing in these very numerous
cases of dysmenorrhoea in which the suffering is apparently altogether
dependent on the mere retention or difficult escape of the menstrual
fluid, although the character of the pain often resembles the neuralgic
type. There is another group of dysmenorrhoeal affections however, in
which the pain may fairly be called neuralgic, since it is apparently
independent of the circumstances of the discharge of menstrual fluid,
and simply attends the process, seemingly on account of a
naturally-exaggerated irritability of the organs concerned. There is a
large class of young women in whom, and more especially before marriage,
the time of menstruation is always marked by the occurrence of more or
less severe pain. Formerly I used to believe that this pain was relieved
on the occurrence of the discharge, but I have seen too many cases of a
contrary nature to retain this opinion. I now believe that the subjects
of the kind of menstrual pain to which I am referring are naturally
endowed with a very irritable nervous apparatus of the pelvic organs,
and that there is a certain character at once of immaturity and
excitability in their sexual organs, especially in the virgin condition.
So far from these females being disposed to sterility, as is too often
the case with those dysmenorrhoeal subjects whose troubles depend upon
occlusion, distortion, or narrowing of the outlets, they are often
extremely apt to the generative function; and, what is more, the full
and natural exercise of the sexual function appears necessary to the
health of their organs, as is shown by the fact that these menstrual
pains lose their abnormal character, completely or in great part, after
marriage, and especially after child-bearing. The contrast between the
two types of dysmenorrhoeal patients is sharply brought out by the two
following cases:

CASE I.--S. M., a housemaid, aged twenty-three when first under my
notice, was the picture of physical health and strength, very
intelligent, and a girl of excellent character and most industrious
habits. At every menstrual period, however, she suffered, for some hours
previously to the occurrence of the flow, from severe pain in the
uterine region, which was tumefied and tender. Hot hip-baths gave some
relief, apparently by hastening the discharge; as soon as the latter was
established, the pain rapidly subsided. This young woman married a
healthy and vigorous young man, but has never had any children, and at
the date of my last inquiries still suffered periodically from her old
troubles.

CASE II.--Mrs. B. was married at the age of twenty-six. Up to the date
of her marriage she used to suffer the most severe pain at every
menstrual period; the pain, however, bore no relation to the freedom of
the discharge, but always lasted about the same length of time, under
any circumstances, or was only less or more according as the general
bodily vigor was greater or less at the moment. From the date of
marriage these troubles steadily declined; a child was born at the end
of twelve months, and the menstrual troubles have never resumed a
serious shape up to the present time, a period of nearly nine years.
This lady is herself a neuralgic subject, liable to migraine in
circumstances of fatigue, and suffering horribly from it during her
pregnancies; and she comes of a family in whom the nervous temperament
is strongly developed.

It must not always be concluded, because the menstrual pain is very
severe before the discharge and is relieved at or soon after its
appearance, that the case is one of occlusion, and not of neuralgia.
There is a class of cases in which the affection appears to be a very
severe ovarian neuralgia, attended with a vaso-motor paralysis which
causes great engorgement of the ovary and consequent difficulty of
"ovulation." I have seen several instances which I could not explain in
any other way.

CASE III.--One patient I particularly remember, from the fact that she
was always attacked with dreadful pain, which was sometimes seated in
one groin and sometimes in the other, but was regularly attended with
large and palpable tumefaction of the ovary, which began to subside when
the discharge commenced. This woman married rather late, but her
menstrual troubles immediately became less, and she became pregnant and
was happily delivered, nearly as soon as was possible. She, too, was a
decidedly neuralgic subject, independently of her tendency to
dysmenorrhoeal ovarian pain.

In some women who remain single long after the marriageable age, ovarian
or uterine neuralgia becomes a constantly-recurring torment, not only at
the menstrual period, but at various other times when they are depressed
or fatigued in body or mind. As might be expected, this tendency is
greatly aggravated in the rarer cases where the patient's mind dwells in
a conscious manner on sexual matters, especially if by an evil chance
she becomes addicted to self-abuse. Among the many reproaches that have
been thrown upon the indiscriminate use of the speculum in examining
unmarried women, it has often been urged that it tends to excite sexual
feelings. I do not for a moment doubt that this is the case, or that the
indiscriminate use of the instrument is altogether indefensible. But I
expect that neuralgic pain of the uterus or ovaries, in unmarried women,
connected with an already irritable condition of the sexual organs, has
often been the reason why such women have applied for advice and have
consequently been examined with the speculum; and that the same thing
has frequently happened in the case of women who have been left widows
at a time of life when the sexual powers were still in full vigor. These
patients deserve great pity.

The peripheral irritation which gives rise to peri-uterine neuralgia is
not always originally seated in the organs of generation. The following
are various sources of external irritation which I have known to produce
the affection:

1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman,
aged thirty-four, single, was under my care in King's College Hospital
many years ago, under suspicions of ulcerated cervix. On examination, no
lesion could be detected. It was discovered that the rectum was infested
with ascarides, and, after the use of appropriate vermifuges and tonics,
the patient entirely lost the uterine pains and also a tormenting
pruritus vaginæ, from which she suffered. This woman had at various
times suffered from neuralgic headache a good deal.

2. Profuse and intractable leucorrhoea, whether associated or not with
ulceration of the cervix, may produce peri-uterine neuralgia, even of
great severity, when there are strongly-marked neurotic tendencies. It
must be noted, however, that many cases of pain in leucorrhoeal
subjects, which superficially bear the aspect of neuralgia, turn out on
closer investigation to be merely examples of myalgia of the abdominal
muscles or aponeuroses.

3. Calculus in the kidney, or in the ureter, sometimes causes
intolerable ovarian neuralgia. In the case of a woman who was under my
care at the Chelsea Dispensary, some years ago, this was the unsuspected
origin of severe neuralgic pains in the left ovary, which recurred
several times a day, and which certainly contributed to the patient's
death by the exhaustion which they produced. A calculus was found
tightly impacted in the ureter, near the kidney.

4. Prolapsus uteri sometimes gives rise to severe peri-uterine
neuralgia, or what appears to be such; though it is difficult here to
draw the line between neuralgia and myalgia. The commonest kind of pains
from prolapsus uteri are not neuralgic in their nature at all, but are
of a "bearing down" character, and probably depend upon actual
contractile movement of the walls of the uterus.

5. The presence of tumors, either cancerous or fibroid, in the uterus or
its appendages, gives rise, frequently, to severe and indeed almost
intolerable pains of a distinctly intermittent character. In the early
stages of cancerous diseases these pains are usually felt at the lower
part of the back; in the later stages they are felt also in the
hypogastric region, and are then much more severe.

6. Ulcer of the cervix, of a non-malignant kind, probably sometimes
gives rise to neuralgic pain of the uterus, though this is not so severe
as in cancer.

7. Large masses of scybalous fæces, impacted in the rectum, will
occasionally, by the pressure which they exert on nerves, set up violent
neuralgia of uterus or ovaries, the true nature of which is accidentally
discovered by the use of aperients which unload the intestine and put an
end to the suffering. No doubt it is chiefly in persons with neuralgic
predisposition that this effect is produced; for, common as is the
occurrence of extreme constipation in women, it is comparatively very
rare for us to hear of distinctly neuralgic pain being caused by it.

8. The condition known as "irritable uterus," ever since Gooch's
classical description of it, is always attended with uterine pain, which
is continuous, but is liable to periodical exacerbations of great
severity. In this disorder there is no recognizable physical disease of
the pelvic organs, and the patient will generally be found to have
suffered neuralgia in other parts of the body on previous occasions.
[There is some difference of opinion about this affection: some authors
(_e. g._, Hanfield Jones) considering it as distinct from the true
neuralgias.]

9. Reflex irritation, the source of which is in some quite distant part
of the body, has in many recorded instances occasioned uterine
neuralgia, in highly-predisposed persons. I have seen one case in which
severe pain of this kind was clearly proved to have been excited by the
presence of a carious tooth which was itself little, if at all, painful,
but the removal of which at once cured the pelvic pain.

Neuralgia of the urethra is an affection which is occasionally seen,
both in males and females. I have observed it three times; all these
cases were apparently traceable to the effects of excessive self-abuse.
The male subject was an unmarried man, aged forty-two, of cadaverous
appearance, much emaciated, with clammy, perspiring skin, and habitual
coldness of the extremities; he suffered much from dyspepsia and
palpitation of the heart. The pain ran along the under side of the
penis, which was very large, with an elongated prepuce. The paroxysms
were severe, and came on chiefly in the morning, soon after he awoke. No
remedies did this man any permanent good, and he passed out of my sight,
being at that time in a condition of wretched feebleness, and with
symptoms of threatened dementia. Of the female subjects, one was a
married woman, who accused her husband of impotence, and from her
account it would certainly appear that effective connection had never
taken place; the hymen was completely destroyed, however. The neuralgic
pains recurred nightly in several paroxysms, and were especially severe
about the time of the monthly periods. In this case the patient was, she
stated, induced to give up her malpractices; at any rate, the pain
subsided in a manner which could not be well accounted for by any direct
influence of the medicinal treatment. The other female patient was a
widow in whom the morbid habit was suspected from her general
appearance, and from the existence of enlarged clitoris and other signs
of irritation about the external parts: she became rather rapidly
phthisical, and suffered severely from neuralgic headaches.

Neuralgia of the bladder has been specially described by various
writers; the pain is usually spoken of as seated at the neck of the
bladder, and as accompanied by frequent desire to micturate. I have seen
two cases, both in women: the first was eventually discovered to be an
instance of malignant disease of the fundus of the bladder; the other
was apparently the result of a long-continued menorrhoeal flux, which
had greatly impaired the health, and produced extreme anæmia. In neither
of these instances was the pain referred to the external meatus, as in
the female patients above mentioned who were suffering from urethral
neuralgia. I have never seen the extreme examples of vesical neuralgia
described by some writers, in which actual paralysis of the coats of the
bladder was secondarily produced; but the reflex influence of the
neuralgic affection in both the examples just mentioned appeared to
produce great weakening of the muscular power of the rectum, occasioning
most obstinate and troublesome constipation.

It would appear, from recorded cases, that both the bladder and the
uterus are liable to be affected with neuralgia from malarious
influences; but I have never chanced to see any such cases.

Neuralgia of the kidney is spoken of by several writers, and I suppose
there is no doubt that it may exist as a special neurotic disease with
obvious organic cause. For my own part, I cannot say that I have ever
seen it except in instances where there was either the certainty, or a
very strong suspicion, that the cause was the mechanical pressure and
irritation of a calculus within the kidney. The diagnosis of the simple
functional disorder must be excessively perplexing; for in the first
place there is the greatest difficulty in making sure that the pain is
not external, and seated either in the muscles of the back, or in the
superficial dorsal or lumbar nerves, and certainly I am strongly
inclined to suspect that this has been really the case in many examples
of so-called renal neuralgia. That neuralgia of the kidney may arise
secondarily, as a reflex extension of pelvic neuralgia, does, however,
appear probable enough; for it is almost certain that in the latter
affection at least, the vaso-motor nerves of the kidneys must be
strongly influenced in a reflex manner; since the crisis or acme of a
paroxysm of pelvic pain is not unfrequently attended with a copious
secretion of pale urine.

Neuralgia of the rectum has been carefully described by Mr. Ashton, but
is probably not often seen except by practitioners who possess special
opportunities of observing rectal diseases. In the one pure case which
has fallen under my notice the patient complained of acute paroxysmal
cutting pains extending about one inch within the anus, and, as these
were greatly increased by defecation I suspected the existence of
fissure. Nothing of the kind, however, was found on examination; and the
pain ultimately yielded to repeated subcutaneous injections of atropine.
This patient had got wet through, and had sat in his damp clothes,
getting thoroughly chilled; the pain came on with great suddenness and
severity, and the tenderness which has been mentioned was developed very
quickly. Probably the influence of cold and wet is among the commonest
causes of the complaint. Mr. Ashton also reckons as causes, reflex
irritation from other parts of the alimentary canal, and the influence
of malaria. He observes that the subjects of the affection are most
frequently anæmic, and of a generally excitable and deranged
susceptibility, and that females, who, from menorrhagia, or frequent
child-bearing with much hæmorrhage, have lost a great deal of blood, are
specially predisposed.

Neuralgia of the testis (as an independent affection and not a mere
extension of lumbo-abdominal neuralgia) is fortunately a much less
common malady than the corresponding affection of the ovary; as might
indeed be expected, from the much less degree of functional perturbation
to which, in ordinary physiological circumstances, the former organ is
exposed than the latter. Except from actual growths within the testis,
of which it was a mere symptom, I have never seen neuralgia of the
testis save from one of three causes. In one remarkable example it was
produced as a reflex effect of severe herpes preputialis. Secondly, it is
sometimes observed as a symptom of calculus descending the ureter. And,
thirdly, I have seen it several times undoubtedly produced by excessive
self abuse.

The occurrence of testicular neuralgia, in one case of epilepsy, as to
the cause of which I had been previously much puzzled, led to the
discovery of the real origin of the fits. I should observe here that I
do not believe that self-abuse is ever more than an immediately exciting
cause of epilepsy, a predisposition to the disease having previously
existed in all cases. In the patient just referred to, there was a
family history of epilepsy, but it was difficult to explain the exciting
cause until this was suggested by the occurrence of neuralgic pain in
the testicle. The patient relinquished his habit, and both the pain and
the epilepsy ceased, and, for some twelve months during which I had him
under observation, had not recurred at all. A medical friend has
informed me of an instance in which the same habit had produced a
neuralgia of the testis so severe as to strongly tempt the patient to
castrate himself, and he would probably have done so but that he was too
much of a coward with regard to physical pain. The attacks of pain were
so severe as frequently to produce vomiting and the greatest
prostration.

_Hepatic Neuralgia._--It must be allowed that the evidence even for the
existence of neuralgia of the liver is at present in an unsatisfactory
state. At the same time, there are carefully-recorded cases, by
Trousseau and other[7] writers of unquestionable authority, which leave
no doubt in my mind, corroborated as they are by a certain amount of
experience of my own, that such a form of neuralgia really exists. I
must, of course, be understood to refer to something altogether
different from the spasmodic pain which is produced by the difficult
passage of a gall-stone toward the bowel. I have now seen several cases
in which, as it appeared to me, there was sufficient evidence of
neuralgic pain seated in the liver itself, and not dependent either on
gall-stone or any so-called organic diseases of the viscus.

The subjects of hepatalgia are probably never troubled only by pain in
the liver; they are persons of a nervous temperament, in whom a slight
shock to, or fatigue of, the nervous system, habitually provokes
neuralgic attacks; the pain localizing itself sometimes in the branches
of the trigeminal, sometimes in those of the sciatic, sometimes in the
intercostal nerves, etc. In one instance which has been under my
observation, the attacks of hepatalgia alternated with cardiac neuralgia
assuming the type of a rather severe angina pectoris. In another case
the patient, a man aged sixty-seven, was very liable to attacks of
intermittent abdominal agony, in which one could hardly doubt that the
pain was located in the colon, and was attended with paralytic
distention of the bowel; the peculiar feature of the case being the
sudden way in which the symptoms would appear and depart, independently
of any recognizable provocation or the use of any remedies. On two
separate occasions this patient was attacked with pain of a precisely
similar kind, but limited to the right hypochondrium, attended with
great depression of spirits, and followed by a well-pronounced jaundice.
So remarkable was the conjunction of symptoms in these two attacks that
a strong suspicion of biliary calculus was raised, but not the slightest
confirmation of this idea could be obtained; and indeed one
symptom--vomiting--which nearly always attends the painful passage of a
biliary calculus, was altogether absent.

Putting aside a considerable number of cases in which "pain in the
liver" was vaguely complained of by patients who were plainly
hypochondriacal, and whose account of their own sufferings could not be
relied on, I have altogether seen five instances of what I regard as
genuine hepatalgia. The first of these was very remarkable in its
history and in all its features. The patient was a respectable girl of
eighteen, subject to migraine, who had reason to fear that she had
become pregnant, though this proved, ultimately, not to be the case.
Under these circumstances she was attacked with intermittent pains, in
the right hypochondrium, of intolerable severity; resembling, in fact,
the pain of biliary calculus, but without the sense of abdominal
constriction, and without any vomiting. These recurred daily at about
the same hour in the morning, for about ten days; when rather
suddenly, a jaundiced tint appeared upon the face, and very shortly the
whole skin was colored bright yellow; there was intense mental apathy;
the urine was loaded with bile-pigment, and the fæces clay-colored. This
state of things lasted only about a week and then very rapidly
disappeared; but as the jaundice subsided there was a partial recurrence
of the neuralgic pains, which, for a day or two, were as severe as they
had ever been; The other four cases of hepatalgia which I have seen,
including that of the man above mentioned, have all been in persons in
advanced life; but, except the latter, neither of them displayed any
symptoms of disordered biliary secretion; and the diagnosis (as to
situation, for the character of the attacks was manifestly neuralgic)
rested mainly on the fact that the pain radiated to the shoulder.

There remains to be noticed one clinical feature of the disease, which,
I believe, is characteristic; namely, the peculiar mental depression
which attended all the cases I have seen, but was most marked in the two
in which jaundice occurred. In the girl above referred to, the apathy,
during the period when there was jaundice but no pain, was even
alarming; it reminded one of the mental state in commencing catalepsy;
during the painful stages it was more like the gloom of suicidal
melancholia. Of course, the acute mental anxiety which this patient had
suffered would account for a good deal of this; but the symptom was as
distinct, though less severe, in the case of an elderly lady, whom I
have attended on another occasion for migraine; here there was no
recognizable source of anxiety; and, on the other hand, there was no
reason to suspect the retention of bile-elements in the blood. It seems,
therefore, as if an essentially depressing influence on the mind was
excited by hepatic neuralgia; or else, that emotional causes are the
chief source of the malady.

_Neuralgia of the Heart._--If there be any hesitation in treating this
disease as exactly conterminous with angina pectoris, it can, I think,
be only reasonably justified on two grounds: In the first place, it may
be urged that acute pain of the neuralgic type is not always present in
angina pectoris; and, secondly, it may be urged that many cases of
painful neurosis of the heart have been observed, in which the
recurrence of pain with some amount of cardiac embarrassment has gone on
for years, whereas the popular conception of true angina almost
necessarily involves rapid fatality.

There is doubtless some force in these objections, especially in the
second, for it does seem rather inconvenient to call by the same name so
deadly a disorder as the worst form of angina, and so comparatively
harmless a malady as some of those instances of chronic tendency to
spasmodic pain of the heart which are not very uncommon, and in which
the patient survives, perhaps, to an old age. Yet, after all, there is
the greatest difficulty in drawing any rational line of distinction; for
the basis of the affection seems the same in every case, whether pain or
spasm be the predominant feature, and whether the course of the disease
be long or short. All that appears to be necessary for its production is
a certain originally neurotic temperament (with possibly some congenital
weakness or some post-natal disease of that part of the spinal-cord
centres which Von Bezold has described as furnishing three-fourths of
the propulsive power of the heart) and the presence of almost any kind
of difficulty or embarrassment of the action of the heart. The most
common source of this embarrassment is perhaps failure of nutrition in
the muscular walls of the heart, from disease of the coronary arteries.
Indeed, it is not known that any organic change of the heart or great
vessels, even of the slightest kind, is necessary to the production of
angina; on the contrary, there is every reason to think that mere
fatigue and depression may bring on the attacks in persons of a strongly
nervous temperament. For my own part, I am inclined to believe, however
that there really always is disease somewhere in the cardiac centre of
the spinal cord, though that disease may consist in no more than a
disposition to minute interstitial atrophy. But we shall say more about
this presently.

It is at any rate certain that cardiac neuralgia is always a most grave
complaint, from the almost total uncertainty whether succeeding attacks
will not involve a fatal amount of spasm. As for the expression angina
pectoris, it is just one of those mischievous terms which, arising out
of the mystified ignorance in which the elder physicians found
themselves as to the pathology of internal diseases, have since been
attached in turn to various definite organic changes, with none of which
they had any essential connection; and it is therefore much to be wished
that it could be altogether done away with. At the same time, there is
so much that is peculiar in the case of cardiac neuralgia, owing to the
importance of the organ affected, that it will be necessary here to
treat not merely its symptoms, but also its diagnosis, prognosis,
etiology, pathology, and treatment, in a separate and continuous manner.

_Clinical History and Symptoms._--Cardiac neuralgia usually shows itself
for the first time with considerable abruptness. The patient may or may
not have been consciously ill before the actual seizure, but it rarely
happens, even when the heart has notoriously been the subject of some
organic disease, that there has been any thing to lead him to expect the
kind of attack from which he now suffers. In the midst of some little
unusual effort, or even without this kind of provocation, suddenly the
patient is attacked with severe pain, usually at the lower part of the
sternum; this pain darts through to the back and left shoulder, and
nearly always runs down the left arm. Sometimes, indeed, it is felt
acutely over a large area of the chest, and runs down both arms; this is
the case in a patient now under my care, in whom the affection is more
obviously a neurosis, and less attended with coarse organic changes,
than is usually the case. Along with the pain, which is always very
distressing, but varies greatly in severity in different cases, there is
a variable amount of another sensation which can be compared to nothing
but cramp, or rather compression; the patient usually describes it as
feeling as if some one were grasping the heart in his hands, and, when
this sensation is at all prominent, the idea of impending death is most
strongly impressed on the sufferer's mind. His outward appearance seems
to confirm the idea. In cases where the sense of compression is great,
the face is of an ashen gray; the lips white, with a faint livid tinge;
the pulse small, feeble, and unrhythmical, or imperceptible, at the
wrist; cold perspiration breaks out upon the face; in short, all the
signs of approaching dissolution are present. In cases where the
suffering is chiefly or entirely confined to severe pain, of a darting
or burning character, the state of the circulation is often different.
The heart bounds against the ribs, in rapid and painful palpitation, the
face is flushed deep crimson, the pulse at the wrist is large, bounding,
but very compressible; in fact, the outward appearance of the patient is
so different from that of one who suffers from the more depressing kind
of angina, that it is difficult to consider the two affections as
essentially similar. But there can be no question, if we carefully
examine the matter, that they are mere varieties of the same disorder,
especially as they both may successively occur in the same person.

The course of cardiac neuralgia varies extremely. Supposing the malady
to be purely neurotic, and not complicated with organic disease, which
forms a constant source of cardiac embarrassment, then the patient may
only experience one or two attacks, under some special circumstances of
exhaustion, which may never recur; or, on the other hand, he may develop
a strong tendency to cardiac neuralgia which may beset him during almost
any number of years. In the latter case, it is an even chance whether
the patient will at last sink from the anginal affection; for, even
supposing him to escape any fatal intercurrent disease of an independent
nature, the fatal event may be at last produced by cerebral softening,
or by apoplexy, or other central nervous disease. In fact, the frequency
with which the latter kind of termination occurs is very significant of
the essential nature of the disease.

The manner in which cardiac neuralgia commences varies very greatly. In
the celebrated case of Dr. Arnold, the first attack did not occur till
he was forty-seven years of age; it at once assumed full intensity, and
proved fatal in two hours and a half. There is also reason to believe
that Dr. Arnold's father died in a first attack of angina. I have myself
known a first attack prove fatal in the course of an hour; there was
very considerable ossification of the coronary arteries and fatty
degeneration of the heart-walls. Again, there are many cases which
commence gradually, and with great mildness, and with little appearance
of danger to life in the first attacks; but the subsequent attacks are
progressively more severe and dangerous up to a fatal result, after
weeks, months, or years. On the other hand, I have known three instances
in which the first attacks of spasmodic heart-pain very nearly proved
fatal, but the subsequent fits were milder (in one there was no second
attack): all those patients are living, six, eight, and three years
respectively, after their first attacks.

It can hardly be doubted that neuralgic spasm is the true cause of
sudden death in some cases of stenosis of the aortic orifice, which, but
for some accidental circumstances, would not have died suddenly at all,
but would have gone through a long and gradual course of deterioration.
I particularly remember an instance in which extreme and calcareous
constriction of the aortic orifice, in a boy not yet come to puberty,
was entirely unsuspected, until one day, in running fast, he screamed
out and fell down, and was almost instantaneously dead. I remember
another case very similar, in which extreme mitral constriction produced
almost as sudden death, apparently from painful spasm, under the same
kind of exertion. On the other hand, sudden death, when produced by the
form of heart-disease which (as Dr. Walshe points out) is most likely to
cause such a catastrophe, viz., aortic regurgitation pure, without
hypertrophy, does not seem to be due to painful spasm, but to simple and
complete failure of the muscular power, and is perhaps partly of the
nature of paralysis from a syncopal condition of the brain, the
unhypertrophied heart having become for the moment unable to supply
blood enough to the brain to carry on nervous function at all.

A good instance of the form which angina takes, when the element of
organic cardiac change is well pronounced, was afforded by the case of a
young gentleman recently under my care. He was twenty-one years of age,
and from early boyhood had been accustomed to a great deal of muscular
exercise; in fact, it is probable that he had undermined his health by
the frequent and extraordinarily long walks which he took, for his frame
was particularly small and slight, and the muscles small and soft. He
came of a family in whom the tendency to neurotic disorders is obviously
very strong; both his father and his brother are subject to bad attacks
of migraine, and he had himself repeatedly suffered from the same thing.
The family disposition, altogether, is highly nervous and excitable. The
remarkable circumstance in this young gentleman's case is, that although
he had taken for years an extraordinary amount of pedestrian exercise
(including mountain-climbing), and latterly had exchanged this for the
even more trying exertion of rowing, he had never suffered from any
noticeable symptom of cardiac distress up to the very day of his anginal
attack. For some months, however, he had been growing thin and pale, and
I had given him certain cautions, and had made him take cod-liver oil
and steel, as I entertained some fears of his becoming phthisical. On
the day of the attack there was nothing particular in his appearance,
but he complained of a slight cold, and had no appetite for his six
o'clock dinner. He retired to rest at eleven o'clock, having taken a
small dose of laudanum and chloric ether for his cold. In less than half
an hour he awoke out of his sleep in fearful agony; so severe and
prostrating was the anginoid pain that he had the greatest difficulty in
crawling out of bed to unlock his door. I found him bathed in cold
sweat, pale as a sheet, and with livid lips. He groaned with pain, which
he described as "cutting him across" from the sternal notch to the
nipple, and going down the left arm; and there was so marked a catching
of the breath as to make it almost certain that there was diaphragmatic
spasm; in fact, it was this which alarmed him, and made him say that he
was certainly dying. The heart, however, appeared to be pushed up
somewhat, and it was thought that this might be partly due to stomachic
distention, but a mustard emetic produced little effect. The
heart-sounds were so weak that the presence or absence of bruit could
not be safely predicated; meantime, the pulsations intermitted in a most
alarming manner. Large doses of brandy and sulphuric ether at length
(after several relapses) seemed to subdue the pain and spasm, and in an
hour and a half from the commencement of the attack the patient, though
utterly worn out, sank into a tolerably quiet sleep. The spasms did not
recur, but for the next three or four days he was in a state of great
exhaustion. When his tranquillity of mind had been somewhat restored, a
careful physical examination was made, and it was discovered that there
was a moderately loud and somewhat thrilling systolic bruit at the site
of the aortic valves, and extending some distance into the vessels. The
pulse still remained strikingly intermittent, and, though of fair
volume, was very compressible. Percussion indicated considerable
enlargement of the heart, and the physical signs pointed, on the whole,
to dilatation without hypertrophy. Some doubtful signs of consolidation
were observed at both apices of the lungs.

It is remarkable that, notwithstanding the serious degree of cardiac
mischief indicated by the above signs, the patient, a very few days
later, took a walk of some ten miles, and, though much exhausted,
suffered no recurrence of his formidable spasmodic symptoms in
consequence of this imprudence. He was sent to the mild climate of
Mentone, and subsequently to Nice; the angina never recurred, but the
patient remained weak, and liable to more or less dyspnoea for fifteen
or sixteen months; now he lives an ordinary life, doing his duty as a
Swiss citizen and officer. The cure of some hæmorrhoids, about twelve
months after the anginal attack, seemed greatly to benefit him. What the
future of this case may be it is impossible to say, but of course there
is no security against the angina recurring on extraordinary excitement
or over-exertion.

Of the purely neurotic variety of angina it is impossible to determine
the frequency; but it seems certain that the affection is common, and I
suspect that it occurs more often than is supposed, as a sequel to
asthma. The probable relationship between the two affections was long
ago indicated by Kneeland.[8] I have certainly seen several cases of
asthma in which spasmodic pain of the heart has occurred on various
occasions after or during a very severe asthmatic paroxysm. One case was
that of a gentleman, of a highly delicate and neurotic temperament, who
had suffered for fifteen or sixteen years from well-marked spasmodic
asthma: this case is remarkable as an illustration of several points
which will be dwelt upon in other parts of this volume. For some time
before the outbreak of cardiac neuralgia, he had suffered repeatedly
from severe facial neuralgia, and these attacks on more than one
occasion culminated in facial erysipelas, or what was entirely
indistinguishable from that affection. He then began to suffer from
cardiac pain and spasm after his asthmatic paroxysms, and these new
symptoms speedily assumed the form of a very severe intermittent angina:
in several of the attacks he appeared about to die. The pain in these
attacks is very severe; it occupies a large area in the centre of the
chest, and runs down both arms; and, what is strange, the arms become
remarkably swollen and hot after an unusually long bout of pain, I
presume from vaso-motor paralysis. At present (nearly five years from
the commencement of the cardiac neuralgia) the cardiac attacks, though
of frequent occurrence, are decidedly more tolerable than they were at
first, and the sense of squeezing or pressure, though never quite
absent, does not amount to the dreadful sort of feeling which used to
convince the patient that he was at the point of death. In this case,
the heart has been repeatedly explored without any positive result, and
the pulse has been frequently tested by the sphygmograph. The latter
instrument is the only mode of examining by which I have been able to
elicit even suspicious evidence that there is any organic change of the
heart; by means of it I have lately obtained some grounds for suspecting
that there is slight dilatation of the heart, but it is uncertain
whether anything of the kind existed at the commencement of the anginal
symptoms. In this case I am inclined, on the whole, to doubt whether the
angina will ever prove fatal, unless the bronchitis, with which the
patient's asthma has for some time past been liable to be complicated,
should occur in a severe form; in that case it is likely that the
additional embarrassment of the heart's action may bring on fatal
spasms.

One of the best examples I ever saw of cardiac neuralgia (ultimately
proving fatal) was one of which the origin was entirely nervous. It
occurred in a gentleman in the prime of life, and naturally of a
powerful physique, whose very active and capacious mind had been greatly
overwrought. The whole weight of responsibility for an undertaking of
national importance, and which involved great difficulties and much
anxiety, for a long time rested on his shoulders. Under these influences
he broke down, and never effectually recovered himself. At first, the
symptoms were those of mere ordinary nervous exhaustion, but after a
time he became subject to frequently recurring attacks of agonizing
spasmodic heart-pain, with a sense of impending dissolution; from these
he was invariably relieved by the inhalation of a small amount of
chloroform. Not the slightest organic heart mischief could be detected,
either during life or after death.

_Pathology._--Angina stands in so peculiar a position that I deem it
well to discuss it as a whole, and not merely its clinical history, in
this place. As I have already said, there is nothing in the morbid
appearances found after death which is characteristic of fatal angina,
and in the milder kinds of cardiac neuralgia we are driven back upon the
general probabilities which we deal with in reasoning as to the origin
of neuralgias in general. As to morbid changes, it is impossible to say
any thing more exhaustive of the facts known than the following words of
Dr. Walshe:[9] "First, there are few, if any, structural diseases either
of the heart, its orifices, and its nutrient arteries, or of the aorta,
found recorded in the narratives of the post-mortem examination of
different victims of angina pectoris. Secondly, there is no conceivable
disease of these structures and parts which has not in various
individuals reached the highest point of development, without anginal
paroxysms, even of a slight kind, having occurred during life; to this
proposition extensive calcification of the coronary arteries perhaps
furnishes a solitary exception. Thirdly, the organic changes most
frequently met with have been fatty atrophy and flabby dilatation of the
heart; obstructive disease of the coronary arteries by atheroma and
calcification of the orifice and arch of the aorta. Fourthly, the rarest
have been hypertrophy and hypertrophy with dilatation. In truth, it may
be doubted whether these conditions in their genuine form, without any
combination of fatty atrophy, have ever been the sole morbid states
present." From all this Dr. Walshe concludes that the fundamental
mischief of angina is neurotic; and, while he believes that some
textural change in the heart is necessary as an irritant to generate
this neurotic susceptibility to dynamic disturbance from slight causes,
he recognizes only one common quality in these various cardiac lesions,
viz., that they indicate mal-nutrition and weakened power. Dr. Walshe
does not appear to believe the neurotic disturbance can arise without
the kind of irritation which is kept up by such cardiac changes. In
spite, however of the great authority of this author, it certainly seems
very probable that organic cardiac change is by no means necessary to
the occurrence of angina, and this for two reasons: In the first place,
though full reliance may be placed on the details of the post-mortem
examinations made by Dr. Walshe himself, they are very few (twelve or
fourteen) in number; and other observers who have recorded cases are as
little trustworthy, considering their evident tendency to find some
disease where none exists, as the older narratives which Dr. Walshe
naturally distrusts were unreliable when they declared that no morbid
change was present. And, secondly, his view hardly takes it into account
that there are still two other alternatives, even supposing that one or
other of the above changes is always present: (_a_) it is possible that
the neurotic disturbance and the cardiac lesions might both be the
result of a common cause; and (_b_) it is even possible that the
alterations of tissue in the heart and vessels are due to a morbid
influence proceeding from a diseased nervous centre, either spinal or
sympathetic.

As for the state of the muscular fibre which immediately causes death,
Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and
he urges in favor of this view the fact that in his large experience he
has never known the pulse to intermit during the attack--it was always
regular, however feeble. In this respect he is in opposition to some
distinguished authors, however, and, as he allows that he has not seen
original attacks in their height, but only when they were subsiding, it
would be possible that the spasm stage had subsided. However Dr. Walshe
admits that there may be exceptional cases in which spasm, or cramp (_i.
e._, spasm with rupture or dislocation of fibre), really occurs, and
suggests that this is very probable in the rare cases where death is
attended by general tetanic spasm of the muscles. As far as my own
opinion is worth anything, I could insist that at least Dr. Walshe must
be right as against Dr. Latham and Dr. Inman, in affirming that cardiac
cramp, if it occurs, is the consequence and not the cause of the
neuralgic pain.

_Causes._--In some respects it is impossible to deal with the etiology
of angina apart from the pathology, just as we remarked with regard to
neuralgias in general. But there are certain special features in the
causation of angina pectoris which require separate notice, just as
there are special features in its pathology.

Of predisposing causes, the majority are the same as those of which we
have spoken in our general remarks on the etiology of neuralgia. A
family history of a tendency to the graver neuroses is I believe
universal, and, indeed, direct inheritance of angina from father to
son, as in Arnold's case, has happened in many recorded instances. A
very remarkable fact is the time of life at which the disease originally
appears: Walshe says it is rare before the age of fifty, but excessively
rare before forty. This is very interesting, as placing angina in the
same category with the severe and intractable forms of facial and other
neuralgias which are so highly characteristic of the period of bodily
degeneration. One may even gather a suspicion, though it goes but a
short way toward proof, that the essence of angina is an atrophy either
of the cardiac plexus or of the nucleus of the vagus, or of that part of
the spinal cord, already mentioned, which seems to be the centre of the
major part of the propulsive force of the heart.

On the other hand, there is a fact, even more remarkable than the
influence of age, which tells somewhat in a contrary direction. There is
a most extraordinary preponderance of males among the victims of angina.
Sir John Forbes found eighty males among eighty-eight patients suffering
from this disease. On the first blush it would seem natural, indeed
almost necessary, to explain this by supposing that, as men take a much
larger amount of strong physical exercise than women, they will furnish
a much larger proportion of subjects in whom an ill-nourished heart will
break down under its work and be seized either with paralysis or cramp
(for the two states are, after all, not opposed to each other, but only
varying shades of debility.) Upon this theory one would have to believe
that the origin of angina was far more peripheral than central, if we
are to suppose that spasm is the ordinary condition of the heart during
the anginal paroxysm. But we do not know that this is the case; indeed,
there are many arguments against it; and at any rate we must suppose
that in a considerable number of cases the muscular state is one of
relaxation from want of power. And certainly it is infinitely more
probable that paralysis or spasm of a muscular viscus should occur as a
reflex consequence of neuralgia occurring in a nerve whose central
nucleus was closely connected with the motor centre of the organ, than
that mere paralysis of the viscus should convey a reflex impression to
sensitive nerves which should express itself in the form of acute pain.
It must be confessed that the matter hangs in doubt; but the evidence
is, on the whole, very strong for the belief that central nervous
mischief is the most important element in angina.

Another very important class of predisposing causes of angina is the
mental emotions. It is notorious that the disease is one not common in
humble life; it chiefly assails the more cultivated class, and
especially men who are much engaged in affairs in which great mental
anxiety or emotion is mingled with severe toil of intellect. Thus the
professional class has always shown a sad predominance in tendency to
this disease; a large number of the victims have been found among
overworked clergymen, lawyers, doctors, engineers, etc. The various
forms of heart-lesion which have been already mentioned must doubtless
be considered highly predisposing, when there is already a neurotic
susceptibility, more especially those which, like fatty degeneration of
the muscular structure, greatly enfeeble the heart's action. I do not
believe that these diseases will cause angina in a person who is free
from the peculiar nervous susceptibility.

The immediately exciting causes are very various. The most common of all
is doubtless some exertion of body, or distress of mind, which at once
agitates and embarrasses the heart's action; and, where the tendency to
cardiac neuralgia has once declared itself by an actual attack, very
slight excesses of this kind will usually suffice to re-excite the
paroxysm. Sexual excitement is particularly provocative of the attacks,
in the predisposed. But much slighter causes suffice, in those cases
where the irritability of the cardiac nerves has become very intense:
thus a mere puff of cold air upon the face, and other similar slight
peripheral impressions, by acting in a reflex manner, have frequently
produced the paroxysm. I have seen an extremely severe anginal attack
brought on by the slight shock of the sudden slamming of a door. And it
would even appear that some peripheral excitements of a powerful kind
may operate with such force as to generate angina in persons who are
merely in weak health, but who cannot be supposed to be specially
predisposed to angina; it is in this way, I presume, that we must
explain the extraordinary occurrence, reported by Guelineau,[10] of an
epidemic outbreak of angina, in which numbers of men, belonging to a
ship's crew, were simultaneously affected. The men had been badly fed,
and their quarters were very unhealthy; but the powerful exciting cause
seemed to be the rapid change from a very hot to a very cold climate.
Not only were there many cases of severe angina, but other forms of
neuralgia, and severe colics, were observed in others of the crew. Among
the sources of peripheral irritation which ought to be particularly
considered, in relation to angina, are the diseases and injuries which
produce powerful irritation of the branches of the trigeminus. Lederer's
cases[11] of violent vomiting and cardiac pain, from the operation of
pivoting teeth, and Remak's instances[12] of violent palpitation and
cardiac distress, produced by disease of the last molar tooth, seem to
show that, both through the vagus and the sympathetic, the most
powerful reflex action may be produced in the heart and stomach by
irritation of the fifth cranial.

Another occasional excitant of angina is an interesting link in the
chain of proof that angina is _au fond_ a neuralgia, namely, the
malarial poison, which has in a good many well-observed cases distinctly
induced the disease.[13] Finally, the occasional influence of excessive
tobacco-smoking in producing anginal attacks, in persons not affected
with any discoverable organic heart-disease, affords the strongest
corroborative evidence of the essentially neurotic character of angina
pectoris. M. Beau[14] has recorded many serious, and some fatal, cases
from this cause. Probably in both the malarial cases and those induced
by tobacco-poisoning the special neurotic tendency existed already.

_Diagnosis._--The diagnosis of angina pectoris, in those severe forms
with which the popular idea of the disease is chiefly connected, can
hardly be a matter of much difficulty. When we see an elderly man lying
in a state of deathly collapse, which has suddenly come on, with cold
sweats and nearly extinguished pulse, gasping for breath, and
complaining of intolerable pain in the chest and arm, and a sense of
oppression more dreadful, even, than the pain, we can hardly doubt that
the case is angina in its worst form. On the other hand, when a young
person, especially a young female, complains even of very severe pain in
the cardiac region, together with breathlessness, especially if the
heart be palpitating and the face flushed, the diagnosis, though not
immediately certain, already very strongly indicates the probability
that the case is not one of primary cardiac neuralgia at all. These are
extreme instances, however. In more doubtful cases, the following are
the principal materials for decision:

        _Affirmative Signs._                  _Negative Signs._

  1. Age over forty.                  1. Age under forty.

  2. Male sex.                        2. Female sex.

  3. Nervous temperament (personal    3. Temperament either not nervous
      and family) without marked          at all, or markedly hysterical
      hysteria or hypochondriasis.        or hypochondriacal.


  4. Existence of arterial            4. No signs of arterial
      degeneration.                       degeneration.

  5. Existence of valvular disease    5. No discernible valvular
      of the heart.                       disease.

  6. Extension of the pain to         6. Heart sounds clear and strong.
      one or both arms.

  7. Vivid sense of approaching       7. Pain fixed to one spot and
      dissolution.                        increased or relieved by
                                          muscular movements of the
                                          painful parts.

                                      8. Pain running round one side,
                                          but not extending to shoulder
                                          or arm.

It is scarcely necessary to say that no single one of the above signs is
individually of positive worth for the decision, which must be made
after a careful review of the comparative arguments, _pro_ and _con_.
The disorders with which angina is most likely to be confused are (1)
Myalgia of the intercostal or pectoral muscles; (2) intercostal
neuralgia; (3) acute commencing pleurisy. Either of these may very
perfectly simulate the more formidable disease, as regards the two
elements of acute pain and catching of the breath; but the condition of
the circulation, taken together with the consideration of the above
named points, will generally decide the question. Especially important
is the deep persuasion of impending dissolution, when present, as a
positively affirmative symptom.

It should be born in mind that, if we are summoned to a patient's
assistance, and have no previous history to guide us, our diagnosis, to
be useful, must be rapid; and it is always better to err on the side of
angina than in other directions, and to employ remedies boldly in that
sense, if there be any reasonable ground for believing the case to be of
that nature. A more mature and careful diagnosis may be made when the
patient has recovered from the severe symptoms of the paroxysm.

_Prognosis._--The prognosis of cardiac neuralgia is at best doubtful,
and, in many cases, positively bad in the highest degree. If the attacks
occur for the first time in a patient who has passed middle life, and is
physiologically old for his age, _i. e._, shows tendency to degenerative
changes of vessels, arcus senilis, gray hair etc., they are of very
gloomy import; more especially if any signs exist which make a fatty
change in the ventricle probable, or if there be serious valvular
lesions. The probability here is greatly in favor of a speedy fatal
termination; if the first attack does not kill, a second or third very
probably will; at any rate, the patient is not likely to survive any
considerable number. If the attack occurs in a younger person, in whom
there is not much likelihood that arterial degeneration has seriously
commenced, or the heart-muscles become fatty, more especially if the
attacks have been brought on by such an accidental circumstance as a
very exhausting bout of mental or physical toil, then there is
considerable reason to hope that the disease may soon wear itself out.
Even patients who have serious valvular lesions may, with young and
undegenerated tissues in their favor, quiet down again into a regular
habit of semi-health, in which they may live for a long time without
any recurrence of cardiac neuralgia. The more purely neurotic form,
again, especially when it develops gradually out of some pre-existing
chronic neurosis, such as asthma, is usually slow in its progress; and
it may well happen, in such cases, that the danger to life is more on
the side of serious nervous lesions than from the anginal attacks
themselves. At the same time, it must be remembered that, even in the
milder cases, any very unusual excitement, bringing on an unwontedly
severe attack, may produce fatal results at any period of the disease.

There is some reason to believe that cardiac neuralgia is occasionally
produced in a reflex manner in consequence of a severe existing
intercostal neuralgia. I cannot say that I have witnessed any thing
which can be considered as completely proving this; but it certainly
seems likely that, in some of the few cases of excessively painful
herpes zoster which have proved fatal (of which I have given one
example), cardiac spasm or paralysis may have been secondarily induced,
and may have occasioned the catastrophe. It is likely enough that, if
this was the case, the reflex irritation operated upon motor centres
which themselves were predisposed to take on the morbid action; but this
again is a fresh illustration of the uncertainties to which prognosis is
liable in a disease like angina, the very fundamental character of which
is that, upon increase of the irritation, the gravity of the resulting
functional affection is liable to be indefinitely and most rapidly
increased.

_Treatment._--The treatment of cardiac neuralgia is (1) prophylactic,
and (2) palliative of the attacks.

As regards the prophylactic treatment, it is unnecessary to repeat the
remarks which we have made elsewhere upon the general principles of
tonic and nutritive medication in neuralgias of every kind. One especial
prophylaxis, in the case of this formidable variety of neuralgia, is
concerned with the preservation of the heart from certain disturbing
influences which would render the occurrence of the fit more probable.
All violent emotions and all strong physical exercise (but especially
such forms of it as, like boating, are well known to "pump" the heart
severely) are to be carefully avoided. Even indigestion and flatulence
are to be carefully guarded against since these are quite capable of
embarrassing the action of the heart to a degree which, though it might
be trivial in the case of ordinary health, may prove fatal by exciting a
flabby ventricle to irregular and embarrassing contraction. It is even
possible that the strong irritation set up by some varieties of
indigestible food might propagate an irritation to the spinal cord which
would produce an interbitory paralysis at once.

But besides these obvious precautions against interference with the
regular and tranquil action of the heart, there are some special
medicinal remedies which deserve particular notice. Whether we really
possess any means of so influencing the nutrition of the muscular tissue
of the heart as to prevent its lapsing into a fatty degeneration, it is
impossible to say; but this may be affirmed with some confidence, that,
in cases where awkward threatenings of cardiac neuralgia have occurred,
and simultaneously it has been noticed that the heart-sounds become weak
and the circulation languid, a most marked improvement has been produced
in all respects by the administration of iron and strychnia. I usually
give tincture of sesquichloride of iron, ten minims, and strychnia,
one-fortieth of a grain, three times a day. Still better, where it can
be borne, is the syrup of the triple phosphate of quinine, iron, and
strychnia, which undoubtedly has an extraordinary influence upon tissue
nutrition, as exemplified in its remarkable effects in many cases of
phthisis. It must be observed, however, that it is not every neuralgic
patient who will bear the combination of quinine with iron; it has
occurred to me to meet with several in whom the union of these two
remedies proved violently disturbing to the nervous system, causing
distressing headache and palpitation of the heart, which could not be
attributed to any want of care in the apportioning of the dose, or in
the mode of administration. Iron is more especially indicated, of
course, in cases where there is anæmia; but there are some cases in
which strychnia given alone seems to produce a very beneficial
influence. (_vide_ Chapter V., on "Treatment.")

By far the most important prophylactic tonic against cardiac neuralgia,
however, is arsenic. That this drug should prove useful in cardiac
neuroses might readily be anticipated from its very great utility in
many cases of asthma, a disease which, as already remarked, has a close
relationship to the former. Dr. Philipp has recently recorded a case
which is perhaps an extreme instance of this beneficial influence of
arsenic, but is none the less encouraging, especially as it only
corroborates what has been advanced by other observers. Given in doses
of from three to five minims of Fowler's solution, twice or thrice
daily, arsenic is an invaluable remedy in cardiac neuralgia; the one
objection to it being that some neurotic patients possess such an
irritable intestinal canal that the remedy cannot be borne, as it
produces diarrhoea. Even here we may sometimes succeed by combining it
with very small doses of opium. It is more especially with regard to
those cases in which the neurotic character of the disease is very
prominent--_i. e._, in which the nervous temperament of the patient
betrays itself in other ways besides the tendency to spasmodic
embarrassment of the heart's action, that arsenic holds such a very high
place as a remedy. And it should be carefully remarked that the
prophylaxis of angina extends itself, in such cases, beyond the limits
of actually-declared and well-defined angina, which is, of course, an
uncommon disease. This remedy is important, and may be most usefully
employed in the far larger group of cases in which a marked tendency to
spasmodic pain in the chest, on the occurrence of some comparatively
trifling excitement, is observed in patients who either have some
organic heart-disease, or who are liable to severe attacks of asthma. It
cannot be too often repeated that there is no intelligible separation,
except one of degree, between these cases and the malignant forms of
angina. It may be added that, in my experience, I have found the whole
group of cases to be bound together in a singular way by the tolerance
of arsenic which, with certain exceptions already referred to, they
display. Commencing with the small doses above mentioned, I have found
it possible, in many cases, to advance to the administration of twice or
thrice the quantity, and to continue this medication for months
together, not only with no evil effect, but with the best results.

Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but
little. Truth to say, it is a nervine tonic of occasional great value,
but which, on the whole, I have found so unreliable that I am somewhat
prejudiced against it; and perhaps have not given it a fair trial in
those milder cases of cardiac pain to which it might be suited. It does
appear, however, to have some preferential action on the vagus, and
might therefore be possibly more useful than I am at present inclined to
think it.

The treatment of the acute neuralgic stage itself is a matter in which
we are sadly limited by the exigencies of the case. Relief must be
excessively rapid if we are to save life in the most threatening cases,
or to deliver the patient from a most prostrating agony, which might
have lasted for hours, in other instances.

The remedy which the highest authority, Dr. Walshe, seems to put first
in efficacy is opium; and he directs the dose to be measured by the
intensity of the pain, as much as forty to sixty drops of laudanum being
given in a severe case. He says, however, that it should be given with
an antispasmodic, such as brandy, or ether, or sal-volatile; and I
confess that I believe the antispasmodic treatment to be by far the most
important. Indeed, so marked is the success which I have found to attend
the use of ether in the paroxysm, that till lately I scarcely cared to
make further experiments, with drugs, for the relief of the patient at
this stage. One teaspoonful of ether in two ounces of thickish mucilage
should be given at once, and repeated in a short time if the patient
does not rally.

In a few instances, angina seems to be provoked by the irritation of
indigestible food, and when there is good reason to suspect this an
emetic should be given. I strongly recommend that mustard should be
used for this purpose, for the effect of a mustard-emetic is by no means
merely to empty the stomach, it has a powerfully rousing influence on
the heart.

Upon the subject of the inhalation of chloroform for cardiac neuralgia,
I have only to say that, though I have seen it usefully employed, I
should not, with my present experience, ever think of employing it
myself. Every possible advantage which it could give is obtained by the
internal use of ether, and many serious dangers are avoided, which would
attend the use of chloroform. For it must be remembered that the only
kind of chloroform inhalation which would be useful would be that in
which a carefully measured small dose of a weakly impregnated atmosphere
should be inhaled, and, without large experience in the administration
of chloroform, the practitioner will be unable to secure this effect
with certainty. And the effect of a powerfully-charged atmosphere,
breathed only once or twice even, would be instantaneously fatal.

Hot epithems to the epigastrium are probably of some use, and besides
this the temperature of the body should be carefully kept up by hot
bottles to the feet, hot tins to the epigastrium, etc. Brandy should be
freely administered during the attack, if we cannot immediately obtain
either ether or a remedy now to be mentioned. I refer to the nitrite of
amyl, which, at the time when the first part of this chapter was
written, I had not had the opportunity of testing.

Nitrite of amyl is a highly-vaporizable fluid, which possesses the
following remarkable physiological action: the inhalation even of a very
small quantity is followed, after a minute or so, by a sudden
acceleration of the heart's action, accompanied by intense crimson
congestion of the vessels of the face and conjunctiva, and a sense of
enormous fulness in the head; these phenomena are extremely fugitive,
passing away completely in two or three minutes, unless the inhalation
is renewed. These characteristic effects had for some years been
experimentally exhibited by Dr. Fraser and others, but the practical
application of amyl to the treatment of angina was first suggested, I
believe, by Dr. Brunton, in the case of a patient under the treatment of
Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The
angina was in this case symptomatic, there being advanced valvular
disease of the heart. Comparative examinations with the sphygmograph,
during the intervals and during the paroxysms, made strikingly manifest
the fact that, during the attacks, there was an increase of arterial
tension which was directly proportionate to the severity of the pain and
cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that
nitrite of amyl, by relaxing the systemic arteries, might remove the
unnatural tension, and give relief to the pain; and the result confirmed
this hope. Doses of five and ten drops were inhaled from a towel, with
the uniform result of at once quieting the pain; it might return in a
few minutes, but a second dose usually removed it entirely for many
hours. Various other cases have since been reported, in which similar
relief was obtained, and I had occasion to employ it myself in one
instance. The gentleman whose case has been related above (see page
101), as an example of the relief obtainable by the use of ether began
to suffer rather more severely from his attacks than had been the case
for some time, toward the end of the year 1869. I now determined to try
the amyl, and accordingly left a small bottle containing half an ounce
of it in his possession, with exact instructions to the following
effect: On the first symptoms of a paroxysm of angina, he was to get the
bottle open, and as soon as their character was fully declared he was to
put the bottle to one nostril (closing the other with the finger, and
keeping the mouth shut) and take one long, powerful inspiration. The
result of his first experiment was very remarkable: the first sniff
produced, after an interval of a few seconds, the characteristic
flushing of the face and sense of fulness of the head; the heart gave
one strong beat, and then at once he passed from the state of agony to
one of perfect repose and peace, and at his usual bedtime slept
naturally. This experience was repeated on several occasions, and for a
considerable time the patient retained such full confidence in the
remedy that he discarded all use of ether, and greatly reduced his
allowance of stimulants, with very marked benefit to his appetite and
general health. The new remedy did not lose any of its power by
repetition, but unfortunately the patient at last conceived a horror of
it, which caused him to abandon its use. So distressing and alarming to
him was the sense of fulness in the head produced by the amyl, that,
notwithstanding his certain knowledge that he could at once cut short a
paroxysm, he could not persuade himself to continue its use, and for
some time past he has returned to the use of the ether and (though in
less quantities than previously) of the brandy, for this purpose. And
here it must be remarked that this objection, although probably needless
in the case of this particular patient, may have real importance in
certain circumstances. The admirable physiological researches of Dr.
Brunton leave no doubt that the effect of inhalation of amyl is to
relax, very suddenly, the tonic contraction of the systemic arteries,
and in the case of the brain it would appear that a serious strain must
be suddenly thrown upon the capillary net-work. This being the case, it
appears likely that, where the atheromatous change has considerably
invaded these delicate vessels, they might prove too brittle to stand
the sudden distention, and a rupture and consequent cerebral hæmorrhage
might ensue. This suspicion, then, that such pathological changes exist,
ought to seriously affect our judgment as to the administration of
amyl; and this suspicion ought to be always entertained, _prima facie_,
in the case of patients who have much passed the age of fifty, more
especially if they have gray hair and an arcus senilis, or if the
sphygmograph yields a pulse-trace of the decidedly square-headed type,
or if they have been long addicted to alcoholic intemperance. In such
patients I should be disinclined to allow the use of amyl.

[Although I have thought fit here to give an outline of angina pectoris
as a connected whole, I shall have occasion to recur to the subject
again under the heads of Pathology and Treatment of Neuralgias in
General.]

_Gastralgia._--Neuralgia seated in the stomach itself is not to be
distinguished with accuracy from neuralgic pains occupying one or other
of the neighboring nervous plexuses. It must be remembered that not
merely is the stomach itself copiously supplied by the pneumogastric
nerves with afferent fibres, but the great solar plexus is close behind
it, the coeliac plexus springs from the fore part of the latter, and
these, with the coronary and superior mesenteric plexus, may all be said
to be well within the region in which "gastralgic" pain is felt. It is
not particularly important, however, in my opinion, to make any very
exact diagnosis here, as to the site of the pain, since all these
neuralgias must be considered to belong to the pneumogastric nerve, the
branches supplied from which are probably the sole means by which these
plexuses become the seat of neuralgia.

Abdominal pneumogastric neuralgia is an extremely distressing and
occasionally a very intractable disorder. The subjects of it are almost
invariably in a state of marked and evident debility, and inquiry
generally elicits the fact that they have suffered at other times from
neuralgia elsewhere than in its present seat. By far the most common
history of previous affections of this kind is that of trigeminal
neuralgia, especially of the supra-orbital branch; and it has several
times occurred to me to observe the direct sequence of a gastralgia upon
a unilateral browache. Anæmia is a specially frequent attendant of
gastralgia, more so than of other neuralgias. Women are, by the general
consent of authors, more liable to gastralgia than men.

The special mark of true neuralgic pain in the abdominal pneumogastric,
as distinguished from other deep-seated pains in the epigastrium, is the
remarkably direct relation of its severity to the patient's exhaustion,
particularly in regard to the weakness induced by want of food. While
the great majority of dyspeptic pains are increased by filling the
stomach, gastralgia, on the contrary, is invariably relieved by food,
often most strikingly and completely. Pressure from without, also, while
it aggravates most pains dependent on local organic mischief, nearly
always more or less relieves gastralgia. Equally striking is the comfort
given by stimulants, especially by hot brandy-and-water; in this respect
gastralgia resembles colic. There is something special in the degree of
mental depression which attends gastralgic pain. In this it resembles
the pains of hypochondriasis, but there is a resilience of the spirits
when the pain has been relieved which is not seen in the latter
affection. A very frequent complication of gastralgia is severe
palpitation of the heart, but during the paroxysm itself the pulse,
whether rapid or not, is commonly small, at first tense, and afterward
soft, but not acquiring any considerable volume till the pain has
ceased.

So severe is the pain, and so complete the mental and physical
prostration in bad attacks of gastralgia, that the first aspect of the
patient might suggest--indeed often has suggested--the occurrence of
gastric or duodenal perforation; but, as soon as the paroxysm is over
all the alarming appearances vanish, leaving only a certain amount of
tenderness on deep pressure. In the more typical cases there are no
signs of dyspepsia whatever, no fulness nor excessive redness of the
tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the
neuralgic affection is complicated with more or less gastric catarrh;
but this is a much rarer occurrence, in my experience, than some writers
would lead one to believe; and, moreover, where a certain amount of
organic disorder of the stomach is observed, it is usually a mere
secondary result of the neuralgia. The most severe example of gastralgia
which I ever saw was entirely unaccompanied by dyspepsia; this patient
absolutely attempted suicide to escape from his agonizing pains, which
recurred with the greatest frequency and obstinacy, but were at last
entirely removed by strychnia. In another patient whose very interesting
case will be again alluded to under the head of Complications of
Neuralgia, violent abdominal pneumogastric pain was succeeded by a
severe attack of trigeminal neuralgia, accompanied by inflammation of
the eye, which inflicted irreparable damage; here, too, the gastralgia
was entirely uncomplicated by any other stomach-symptoms.

_Cerebral Neuralgia._--We enter, here, on an extremely obscure and
doubtful subject: Can there be pain in the central masses of the
encephalon? There are undoubtedly a not inconsiderable number of cases
of pain, neuralgic in type on the whole, in which the suffering cannot
be referred to any recognizable superficial nerve. It seems deeply
situated within the cranium. I have also quoted cases of Dr. Hillier's
in which not merely was there deep-seated headache in children, but
there was something like a characteristic general change observed in the
brain-tissues after death, viz., a great moisture and softness of
texture. Notwithstanding all this, I am not convinced, nor indeed much
disposed to believe, that pain is ever felt in the structure of the
brain; I rather believe that, in the cases where this seems to occur,
the pain is either in the intracranial portion of the nerve trunks, or,
far more probably, in the twigs of nerves that are distributed to the
cerebral membranes. In that case they are, strictly speaking, only
varieties of neuralgia of the fifth nerve, and might have been properly
discussed under that heading; but it is more convenient to speak of them
apart, since their phenomena present considerable differences from those
of the external neuralgias of the head and face.

I have now seen several of these cases of intracranial neuralgias, and
very perplexing and (at first sight) alarming they certainly are. The
first of these cases came under my care in 1868. The patient was a
single lady who had greatly over-tasked an intellect that was not,
perhaps, originally very strong, by trying to do hack literature on
conscientious principles; insisting, for instance, on knowing something
about every subject she wrote upon. Her age was thirty-eight when she
applied to me; menstruation was scanty but regular; and, on the whole,
she could not be said to have passed an unhealthy life, although
"nervous-headaches" and "sick-headaches" had occasionally beset her.
This time the trouble seemed to be more serious. Ten days before
applying to me, she had awaked in the morning with a feeling that
something was very wrong in her head; there was not so much pain as a
dull, brooding sort of weight, felt deeply within the cranium, and
rather anteriorly. This had not lasted many hours when she was seized
with a sensation of intense cold, amounting almost to rigors, and then
before long was suddenly attacked with acute splitting pain in the same
situation as the feeling of weight already mentioned had occupied. This
pain, which came and went, or rather intensified and remitted, without
ever completely ceasing, lasted about two hours, and then rather
suddenly disappeared, leaving the patient with a deep "bruised and sore
feeling in her brains." The pain recurred about the middle of the next
day, lasting for several hours, and again leaving behind it the sore
feeling. Day by day the paroxysms returned, and, on the day before her
visit to me, the patient had, she told me, been driven frantic by her
sufferings and had become actually delirious. Her appearance, when I
first saw her, was wretched; the face haggard, both eyes sunken and
surrounded with deep rings of dusky pigment, both conjunctivæ bloodshot,
the whole face almost earthy in its pallor. At that hour (11 A. M.) the
pain had not positively recommenced, but she was in momentary dread of
its recurrence. She complained of giddiness, muscæ volitantes, and great
feebleness of vision, and dreaded attempting to read, as the mere effort
of fixing her eyes on anything intently caused flashes of fire before
them. It was difficult at first to believe that there was not some
serious organic brain-mischief; but on the whole I concluded that there
was an absence of any genuine symptoms of such disease. At the same
time, the pain was decidedly not referred to any cutaneous sensory
nerve; and on the whole it appeared probable that the affection was
intracranial. There remained the diagnosis of meningeal neuralgia, and
to this I provisionally made up my mind. The opinion that the pain did
not depend on any fixed organic disease was decisively justified by the
results of treatment. One-sixth of a grain of morphia was injected on
the occasion of the first visit, and this was repeated every day, and
sometimes twice a day, for a fortnight; by this sole means, with rest,
quietude, and light nourishing food, the patient was brought to
comparative convalescence. The injections were then gradually
discontinued, and she got quite well.

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 oesophagus 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.

FOOTNOTES:

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

[4] _Med. Times and Gazette_, March 26, 1864.

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

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

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

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

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

[10] _Gaz. des Hop._, 114, 117, 120. 1862.

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

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

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

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




CHAPTER II.

COMPLICATIONS OF NEURALGIA.


The secondary affections which may arise as complications of neuralgia
form a deeply interesting chapter in nervous pathology, and one which
has only been explored in quite recent years. The excellent treatises of
Valleix and Romberg, written only thirty years ago, make but most
cursory and superficial mention of these complications, and do not
attempt to group them in a scientific manner. The reflex convulsive
movement of the facial muscles in severe tic-douloureux had of course
been long observed; and Valleix added the correct observation that
gastric disturbance was often secondarily provoked in facial neuralgia,
thus improving greatly on the old view, which supposed that, where
trigeminal neuralgia and stomach disorder coexisted, the latter must
have been the antecedent and the cause of the former. Still, he did not
explain the pathological connection. And as regards certain other most
interesting results of neuralgia, which he could not avoid meeting with
from time to time, _e. g._, lachrymation, flux from the nostril,
salivation, altered nutrition of the hair, he only speaks of these as
occasional phenomena, and in no way classifies them, or explains their
relation to the neuralgia itself.

There did exist, however, one too little known work of some years
earlier date, which, though not dealing specifically with neuralgia, and
though based upon the necessarily very imperfect knowledge of the
functions of the nervous system prevalent in its day, had nevertheless
done much to lay the foundation of a comprehensive view of the
complications of neuralgia; we refer to the work of the brothers
Griffin, on "Functional Affections of the Spinal Cord and Ganglionic
System," published in 1834. In this most interesting treatise, the
record of acute and extensive observations made in a quiet and
unpretending way by two Irish practitioners, numerous examples are cited
in which neuralgic affections were seen to be inseparably united with
secondary affections of the most various organs, with which the
neuralgic nerves could have no connection except through the centres, by
reflex action. The authors, while firmly grasping the fact of the common
connection of the nerve-pain and the other phenomena (convulsions,
paralysis, altered special sensation, changes in secretion, changes even
in the nutrition of particular tissues) with the central nerve system,
were doubtless in error in thinking that they could detect the precise
seat of the original malady, by discovering certain points of tenderness
over the spinal column. But their facts were observed with the greatest
care, and can now be interpreted more intelligently than was possible at
the time. Here, for example, is a case which forestalls one of the most
interesting pieces of information which more recent research has made
generally known:

"CASE XXIV.--Kitty Hanley, aged fourteen years, catamenia never
appeared; about six months ago was attacked with pain in the right eye
and brow, occurring only at night, and then so violently as to make her
scream out and disturb every one in the house; it afterward occurred in
the infra-orbital nerve, and along the lower jaw in the teeth, and there
was inflammation of the cornea, with superficial ulceration and slight
muddiness. Tenderness was found at the upper cervical vertebræ, pressure
on any of them exciting severe pain in the vertex and brow; but none in
the eye or jaws, where it is never felt except at night."

The above is a well-marked example of neuralgia of the trigeminus
causing secondary inflammation and ulceration of the eye of a precisely
similar kind to that which had been experimentally produced by Magendie
by section of the fifth, at or posterior to its Gasserian ganglion. We
shall see, hereafter, how extremely important are this and similar
facts, not only in regard to the clinical history, but also to the
pathology of neuralgia in general.

The first regular attempt, I believe, to classify the complications of
neuralgia, was made by M. Notta, in a series of elaborate papers in the
"Archives Generales de Medecine" for 1854. We may specially mention his
analysis of a hundred and twenty-eight cases of trigeminal neuralgia,
which is well fitted to impress on the mind the frequency, though, as we
shall presently see, it does not adequately represent the seriousness,
of these secondary disorders. As regards special senses, Notta says that
the retina was completely or almost completely paralyzed in ten cases,
and in nine others vision was interfered with, partly, probably, from
impaired function of the retina, but partly, also, from dilatation of
the pupil or other functional derangement independent of the optic
nerve. The sense of hearing was impaired in four cases. The sense of
taste was perverted in one case, and abolished in another. As regards
secretion, lachrymation was observed in sixty-one cases, or nearly half
the total number. Nasal secretion was repressed in one case, in ten
others it was increased on the affected side. Unilateral sweating is
spoken of more doubtfully, but is said to have been probably present in
a considerable number of cases. In eight instances there was decided
unilateral redness of the face, and five times this was attended with
noticeable tumefaction. In one case the unilateral tumefaction and
redness persisted, and were, in fact, accompanied by a general
hypertrophy of the tissues. Dilatation of the conjunctival vessels was
observed in thirty-four cases. Nutrition was affected as follows: In
four cases there was unilateral hypertrophy of the tissues; in two, the
hair was hypertrophied at the ends, and in several others it was
observed to fall out or to turn gray. The tongue was greatly tumefied in
one case. Muscular contractions, on the affected side, were noted in
fifty-two cases. Permanent tonic spasm, not due to photophobia, was
observed in the eyelid in four cases, in the muscles of mastication four
times, in the muscles of the external ear once. Paralysis affected the
motor oculi, causing prolapse of the upper eyelid, in six cases; in half
of these there was also outward squint. In two instances the facial
muscles were paralyzed in a purely reflex manner. The pupil was dilated
in three cases, and contracted in two others, without any impairment of
sight; in three others it was dilated, with considerable diminution of
the visual power. Finally, with regard to common sensibility, M. Notta
reports three cases in which anæsthesia was observed. Hyperæsthesia of
the surface only occurred in the latter stages of the disease.

To Notta's list of complications of trigeminal neuralgia must be added
the following, all of which have been witnessed, and several of them in
a large number of instances: Iritis, glaucoma, corneal clouding, and
even ulceration; periostitis, unilateral furring of the tongue, herpes
unilateralis, etc. In writing on this subject three or four years ago, I
mentioned that all these secondary affections had been seen by myself,
except glaucoma. That is now no longer an exception; indeed, my
attention has been so forcibly called to the connection between glaucoma
and facial neuralgia, that I shall presently examine it at some length.

The trigeminus is, of all nerves in the body, that one whose affections
are likely to cause secondary disturbances of wide extent and various
nature, owing to its large peripheral expanse, the complex nature of its
functions, and its extensive and close connections with other nerves.
Moreover, its relations to so important and noticeable an organ as the
eye tends to call our attention strongly to the phenomena that attend
its perturbations. But there is every reason to think that all secondary
complications which may attend trigeminal neuralgia are represented by
analogous secondary affections in neuralgias in all kinds of situations;
and we may classify them in the principal groups which correspond to
disturbance of large sets of functions:

1. First, and on the whole, probably, the most common of all secondary
affections, we may rank some degree of vaso-motor paralysis. It may be
doubted if neuralgia ever reaches more than a very slight degree without
involving more or less of this; for so-called points douloureux are
themselves pretty certainly, for the most part, a phenomenon of
vaso-motor palsy; and the more widely-diffused soreness, such as remains
in the scalp, for instance, after attacks of pain, even at an earlier
stage of trigeminal neuralgia than that in which permanently tender
points are formed, is probably entirely due to a temporary
skin-congestion. The phenomenon presents itself in a much more striking
way in the condition of the conjunctiva seen in intense attacks of
neuralgia affecting the ocular and peri-ocular branches of the fifth;
one sometimes finds the whole conjunctiva deeply crimson; and, in one
remarkable instance that I observed, the same shade of intense red
colored the mucous membrane of the nostril of the same side. In several
instances, I have seen a more than usually violent attack of sciatic
pain followed by the development of a pale, rosy blush over the thinner
parts of the skin of the leg, especially of the calf, which were then
extremely tender, in a diffuse manner, for some time after spontaneous
pain had ceased.

2. Not merely the circulation, however, but the nutrition of tissues,
becomes positively affected, in a considerable number of cases. It is
difficult to judge, with any exactness, in what proportion of neuralgic
cases this occurs, but its slighter degrees must be very common. It has
very frequently happened to me, quite accidentally, in examining with
some care the fixed painful points, which are so important in diagnosis,
to be struck with the decided evidence to the finger of solid
thickening, evidently dependent on hypertrophic development of
tissue-elements; in severe and long-standing cases, I believe this
condition will always be found. Probably the change is, more usually
than not, sub-inflammatory; but it is certain, on the other hand, that
there are great variations in the kind of tissue-changes complicating
neuralgia, and that inflammation is no necessary element in them. This
subject has greatly engaged my attention, and I find myself able to give
what is probably a fuller account of the matter than any yet published
connectedly.

The following tissues have been seen by myself to become altered under
the influence of neuralgia in nerves distributed to them, or to the
parts in their immediate neighborhood.

(_a_) The hair has changed in color in many cases. Of twenty-seven
patients suffering from neuralgia of the ophthalmic division of the
fifth, eleven had more or less decided localized grayness of hair on
that side. The amount of this varied greatly, from mere patches of gray
near the roots of the hair to decided grayness of the majority of the
hairs over the larger part of half the head, nearly to the vertex; but
in each case it was a change of color that did not exist on the other
side of the head. In four of these cases there was also grayness of part
of the eyebrow on the affected side. A very remarkable phenomenon, which
I have sometimes identified, is fluctuation of the color, the grayness
notably increasing during, and for some time after, an acute attack of
pain, and the same hairs returning afterward more or less to their
original color. My attention was first called to this curious occurrence
in my own case. I have so often related this case [see, for instance, my
article on Neuralgia in "Reynolds's System of Medicine," vol. ii.] that
I shall merely recall the fact that, when pain attacks me severely, the
hair of the eyebrow on the affected side displays a very distinct patch
of gray (on some occasions it has been quite white) opposite the tissue
of the supra-orbital nerve, and that the same hairs (which can be easily
identified) return almost to the natural color when I am free from
neuralgia. I must, however, add the very curious fact, which I observed
accidentally in experimenting (as regards urinary elimination) on the
effects of large doses of alcohol, that a dose sufficiently large to
produce uncomfortably narcotic effects invariably caused the same
temporary change of color in the hair of the same eyebrow, even when no
decided pain was produced, but only general malaise. The subject will
be again referred to under the heading of Pathology.

Change in the size and texture of the hairs, in neuralgia, has been
noted by Romberg and Notta, and has been several times observed by
myself. Occasionally the individual hairs near the distribution of the
painful nerve become coarsely hypertrophied; at times the number of
hairs appears to multiply, but I imagine this is only a case of more
rapid and exuberant development of hairs that would be otherwise weak
and small. In one very remarkable instance of sciatica this came under
my observation; the whole front of the painful leg, from the knee nearly
to the ankle, became clothed, in the course of about six months, with a
dense fell of hair, which strongly reminded me of similar abnormal
hair-growths that have been occasionally seen in connection with
traumatic injuries to the spinal cord. More commonly, the effect of
neuralgia upon hair is to make it brittle, and to cause it to fall out
in considerable quantities; one young lady, who consulted me for a
severe migraine, was seriously afraid of having a good head of hair
completely ruined in this way, but the hair gradually grew again after
the neuralgia had disappeared.

(_b_) The periosteum of bone and the fibrous fasciæ in the neighborhood
of the painful points of neuralgic nerves not unfrequently take on a
condition of subacute inflammation, with marked thickening and
tenderness on pressure. The most striking instance of this that I have
seen was in a lady suffering from severe cervico-brachial neuralgia. In
the neighborhood of the emergence of the musculo-spiral nerve at the
outer side of the arm, there was developed what looked for all the world
like a large syphilitic node, except that the skin was brightly reddened
over it; this disappeared altogether some little time after the
neuralgia had been relieved by ordinary treatment. I must say that, but
for the peculiar circumstances of the case, putting syphilis out of the
question, I could not have avoided the suspicion, at first, that the
swelling was specific. But I have several times seen similar, though
less developed, swellings in neuralgia, and in one case I noticed the
occurrence of such a swelling on the malar bone, in an old woman in whom
the neuralgic pain was limited to the auriculo-temporal and the
supra-orbital branches of the fifth.

A very important point is to be noted in connection with these
sub-inflammatory swellings in connection with neuralgia. Pressure on
them will, frequently, not merely excite the neuralgic pains in the
branches of the affected nerve, but send a powerful reflex influence
through the cord to distant organs, causing vomiting, for instance, or
affecting the action of the heart in a very perceptible manner. I shall
show, when I come to speak of the phenomena of so-called spinal
irritation, that this circumstance has led to erroneous influences in
many cases. These exquisitely tender points are often found where
Trousseau places his neuralgic _point apophysaire_, namely, over, or
very near, the spinous processes of the vertebræ. The tenderness is
quite unlike that which is known as hysterical hyperæsthesia; it is much
severer, and is limited to one, two, or three points, corresponding, in
fact, to the superficial part of the posterior branches of as many
spinal nerves.

(_c_) The nutrition of the skin over neuralgic nerves is sometimes
notably affected even when the process does not reach the truly
inflammatory stage, which will be more particularly mentioned presently.
A certain coarseness of texture of the skin has struck me much, in
several cases of long-standing facial neuralgia. And there is a most
curious phenomenon (which will be especially considered hereafter in
regard to the singular influence of the constant galvanic current upon
it), the distribution of a greater or less amount of dark pigment to the
skin near the painful part. This phenomenon is much more marked during
the paroxysms, and in the slighter cases entirely disappears in the
intervals, but in old-standing severe cases it becomes more or less
permanent.

(_d_) The mucous membranes, in situations where we can observe them, not
unfrequently show interesting changes, the nutrition of the epithelium
of parts covering the painful nerve being exaggerated. It has been noted
by various observers, in neuralgia affecting the second and third
divisions of the trigeminus, that the half of the tongue corresponding
to the painful nerve was covered with a dense fur. This is by no means
universally the case, but I have seen it occur several times. In my own
case, in which the neuralgia is limited for the most part to the
ophthalmic division, and only rarely spreads even to the second division
of the nerve, this does not usually occur, but I have noticed it on one
or two occasions. And I once made the still more singular observation
that a large narcotic dose of alcohol, which was sufficient to cause
comparatively free elimination of unchanged alcohol in the urine, caused
furring of the tongue, which was decidedly thicker on the side of the
affected nerve than on the other half of the tongue.

(_e_) We come now to a group of complications of neuralgia which are
exceedingly important, and by no means adequately appreciated as yet,
viz., the acute inflammations which directly result from neuralgic
affections in a certain percentage of cases, probably much larger than
has been at all generally suspected.

The most familiar of the inflammatory complications of neuralgia is
herpes zoster, the favorite seat of which is the skin which covers one
or more of the intercostal spaces: the eruption, as occurring in this
situation, is so well known that it would be waste of time to describe
it. In young subjects zoster is commonly painless, at least the
sensations are those of heat, pricking, and irritation, rather than of
acute pain; but from puberty onward there is an increasing tendency,
especially in those otherwise predisposed to neuralgia, for zoster to be
preceded, accompanied, or followed by neuralgia of the intercostal
nerves corresponding to the distribution of the eruption. Most commonly,
the eruptive period is, in my experience, nearly or quite free from
neuralgia, but it often recurs, or breaks out for the first time, when
the vesicles are drying up, but more especially if, as is sometimes the
case, especially in elderly people, the scabs fall off and leave
superficial ulcers. Neuralgia may last, after herpes zoster, for any
time from a few days to many weeks, and I have known it so agonizingly
severe and so persistent as actually to kill an aged woman from sheer
exhaustion. In spite of sundry objections that have been raised to the
theory of the nervous origin of zoster, it appears to me that the
evidence in favor of it is overwhelming, more especially now that it is
proved that the disease, with all the same characteristics presented by
it when seen on the chest or abdomen, may occur on the face (following
the branches of the trigeminus), or on the forearm (following the course
of nerves from the brachial plexus). Two of the severest cases of
neuralgia attending herpes that I have ever seen were in private
patients (whose family history, unfortunately, I had no means of
ascertaining) who were affected, respectively, in the facial and in the
brachial nerve-territories.

A far more formidable occasional complication of neuralgia is
inflammation affecting the eye. Mr. Jonathan Hutchinson records several
cases in which neuralgic herpes zoster of the face was attended with
iritis, with serious or even irremediable damage to the organ. For my
own part, I have witnessed several instances in which neuralgia of the
first and second divisions of the fifth has been attended with
skin-inflammation, but only in one of these (just alluded to) did the
inflammation present the characteristic appearances of herpes: in all
the rest it far more closely resembled erysipelas. The skin was
excessively reddened in an almost or quite continuous patch over the
whole territory through which ran the painful nerves; by no means only
linearly in the course of the nerves, though accurately limited to the
district of the first or first and second divisions of the fifth. In the
first case I saw (a woman, aged thirty-two), nothing could be more
startling than the rapidity with which an irregular patch of the skin,
including half of one cheek, the side of the nose, and a large part of
the forehead and scalp on the same side, became converted into the
dense, fiery-red, brawny tissue, with minute vesicles scattered over its
surface, which looks so characteristic of erysipelas; this commenced
immediately on the subsidence of severe neuralgic pain. During the
erysipelatoid inflammation, though there was no spontaneous pain, the
neuralgia could be instantly lighted up for a moment by pressure on the
infra-orbital foramen, on the supra-orbital notch, or upon the malar
bone, about its centre. Since that time I have seen several cases of a
similar character; two of these, which were reported in the _Lancet_ for
1866, I shall here reproduce: [Extensive inquiries convinced me that the
tendency to erysipelatous complication of facial neuralgia is
exceedingly common. Eulenburg expressly confirms my original statement
to this effect, and extends it to all neuralgias.]

CASE I.--A woman, aged sixty-three, presented herself in the out-patient
room at Westminster Hospital, suffering from neuralgia of ten days'
standing (which for the present, however, seemed to have abated
considerably), but asking advice chiefly for an erysipelatoid
inflammation which had come on a day or two before, and occupied the
area of the painful nerve-district. The neuralgia had affected the
supra-orbital nerve, running up toward the vortex, and the
auriculo-temporal branch of the third division of the fifth; although
there was no very acute pain present at this time, pressure over the
supra-orbital notch, or at a point just in front of the ear, would at
once cause a brief paroxysm of pain. It was curious to find that there
was a thickened and tender spot over the malar bone (and corresponding
to the exit of some nerve filaments from the bone) which had never been
the seat of spontaneous neuralgia, but pressure here sent a dart of pain
into the auriculo-temporal and supra-orbital nerves. The inflammation
was markedly limited to the general area of distribution of the twigs of
the auriculo-temporal and of the ophthalmic division; it was of a
continuous deep-red color, and attended with much thickening of the
skin. The conjunctiva was intensely congested, and there were
lachrymation and very marked photophobia, but there were no signs of
iritis, and no corneal clouding.

CASE II.--M. W., a woman, aged forty-two, well-nourished and
healthy-looking, married and had one child; had never suffered any
serious ailment except once, about five years previously. She then had a
decided attack of "erysipelas," very accurately limited to the right
half of the face. Five months before coming to me she sustained a severe
shock from being thrown out of a chaise, without suffering any external
or visible damage. An hysterical tendency, which she had always
possessed, became more marked; it revealed itself by palpitations,
occasional dysphagia, and a disposition to weep causelessly. The menses
were flowing at the time of the accident; they ceased abruptly soon
after (they had been scanty for some time previously), and did not recur
till four months later. The hysteric disturbance progressively increased
during a fortnight, and then the patient was attacked with violent
intermittent neuralgia, commencing in the eyeball and spreading over
the district supplied by the branches of the first and second divisions
of the trigeminus. The pain was accompanied by intense conjunctival
congestion and photophobia [Dr. Handfield Jones remarks that
photophobia, in his experience, is only a rare accompaniment of facial
neuralgia. I have latterly come to the same opinion. Redness of the eye
and lachrymation are very common; true photophobia uncommon. Notta's
experience would seem to have been similar]. It lasted on the first day
fourteen hours, and returned daily for the next fifteen or sixteen days.
An attack of erysipelas, strictly limited to the district of the painful
nervous branches, then set in. From that moment the neuralgic attacks
became less frequent and severe. A second similar onset of erysipelas
occurred some three or four weeks after the first. Finally, the
neuralgia disappeared about four months after its first occurrence, and
the menses reappeared in tolerable abundance about the same time. About
a fortnight before this the patient had discovered that her right eye
was dim; as the photophobia had previously disabled her from opening the
eye, she could not be sure how long this dimness had existed. At the
time of her visit to me the cornea was blurred with a large patch of
interstitial lymph, with the remains of a superficial ulcer in the
centre; the iris was turbid and discolored, showing the traces of recent
but past iritis; the pupil was regular in form and active to light; the
conjunctiva was slightly congested. Ophthalmoscopic observation was
attempted by a skilled observer, but could not be satisfactorily carried
out, from the turbid state of the media. The conjunctiva was slightly
congested. In place of the lachrymation that had prevailed during the
neuralgic period, there was a remarkable insensibility of the lachrymal
apparatus, for the patient had noticed that the smell of onions, which
would make the other eye weep profusely, had no influence on the
affected one.

The family history of this patient is a most remarkable one. All the
members of her mother's family, for two generations back, had died at
middle age, either from apoplexy or some disease involving hemiplegia.
This case has, by a mistake, not been added to the list of twenty-two
private cases in which the family history was carefully investigated,
that will be found in the chapter on Pathology; this arose from the fact
that the patient was not properly under my care, but was sent to me as a
medical curiosity; the notes of her case were therefore taken in a
different book from the others. The case certainly ought to be taken as
a counterpoise to such a one as No. XVI. in the list, which is that of a
gentleman who suffered from the most complicated neurotic maladies
(asthma, angina pectoris, facial neuralgia, more than once attended with
erysipelas), but whose family history, so far as it was known, presented
no traces of tendency to neurotic disease.

To these two cases of inflammation, secondary to neuralgia, I shall add
a third, which is even more interesting, and which came under my notice
not long since.

CASE III.--H. T., watchmaker's assistant, aged forty-two, suffered for
about three weeks with very severe remittent abdominal pain, entirely
unconnected with dyspepsia, constipation, or diarrhoea. It was
intermittent in character, but observation soon showed that the times at
which it came on were simply those at which the stomach had gone longest
without food, especially the early morning, and that nourishment never
failed to relieve it. The suffering was great, and the man failed
considerably in general health, notwithstanding that his appetite and
digestion were unimpaired. He had only been under my care about ten days
when he presented himself one day at the hospital, and stated that the
pains in the stomach had entirely left him, but that he suffered the
most frightful pains in and around the right eye. I found a well-marked
conjunctival congestion and lachrymation, but there were as yet no
tender points; the neuralgia was felt most severely in the globe of the
eye and in one tolerably straight line, darting up toward the vertex
from the brow. The iris seemed clear and free, and the cornea was not
cloudy. I gave the man a subcutaneous injection of one-sixth grain
acetate of morphia, for present ease, and ordered him muriate of iron
and small doses of strychnia three times a day. When he next appeared,
four days later, I was alarmed to perceive that unmistakable iritis had
fully developed itself, the iris was already turbid and discolored and
the pupil irregular, from a serious amount of adhesions. By this time
there were fully-developed tender points, supra-orbital and parietal;
besides this, pressure on the globe caused paroxysms of pain, in all the
branches of the ophthalmic division, but there was not much spontaneous
pain. I dropped atropine in the eye, applied blistering fluid to the
back of the neck, [the nape of the neck is the point most suitable for
blistering which is intended to affect the eye, and the ophthalmic
division of the fifth, generally,] and desired the man to come to see me
at my own house next day, intending to take him to an ophthalmic
surgeon. Unfortunately he failed to do this, and three days later, when
he came to see me at the hospital, the cornea was studded with
opacities, the pupil was almost closed with effused lymph, there was
violent ocular pain, and a great and increasing sense of tension. I
begged him to go without loss of time to the Eye Hospital, as my own
ophthalmic colleague was not at Westminster that day; and I have never
heard any more of the patient.

Glaucoma is a still more serious disease of the eye, which I think there
is now sufficient evidence to show is sometimes entirely, and very often
in considerable part, neuralgic in its origin. Since my attention was
directed, some six years ago, to the frequent connection between the
so-called rheumatic iritis and neuralgia, I have taken much interest in
the subject of acute eye-affections; and the occurrence of one or two
cases of glaucoma in personal friends of my own has made this interest
even painfully strong. I am necessarily without the means of personally
observing glaucoma on the large scale, but I have now seen two cases in
which, if I possess any faculty of clinical observation whatever, the
whole genesis of the disease was a neuralgic disorder of the trigeminus;
and it was to me a melancholy reflection that nothing better than
iridectomy in one case, and excision of the eyeball in the other, could
be done in the present state of ophthalmic science. There are now a good
many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell
Carter, of St. George's, and the South London Ophthalmic Hospital,
recently assured me that nervous aspect of some form of glaucoma
presents itself the strongly to his mind, though he does not commit
himself to any theory. Two cases were reported by Mr. Hutchinson, in
Ophthalmic Hospital Reports IV. and V.; but the most complete and
interesting cases that I have met with are recorded by Dr. Wegner;[15]
they are two out of four that occurred within a very short time in the
clinic of Prof. Horner at Zurich, and they form the basis of some
researches by Wegner into the nature of the influence of the trigeminus
upon ocular tension, which will be referred to, along with others, in
the chapter on Pathology. The second of these cases is so important that
I shall reproduce it in full.

A. Hediger, aged twenty-four, a moderately strongly-built young woman,
seen first in August, 1860. From her own and her mother's account, it
seemed she had long suffered from convulsive attacks that did not appear
to have been truly epileptic. Some days previously her left eye became
very painful, and the sight failed, without any inflammatory symptoms.
On inspection the pupil was somewhat dilated, the eye somewhat
hypermetropic, fundus normal; No. 5, Jager's type, was read with
difficulty. Wegner could not explain the condition. At the end of
October the eye was much worse; after severe paroxysms of pain, No. 16
type was the smallest legible, the field of vision was decidedly limited
in all directions, but especially on the inner and upper portions. An
unusually long hysteric attack was now observed. The patient was for
twenty-four hours in a half-sleep, the extremities, meantime, were much
jerked, the speech sometimes coherent and sometimes incoherent; she
cried out to her friends, etc., but had no severe convulsion-fit with
spasm of glottis. She was removed to the hospital, where she stayed six
weeks. The hysteria improved under treatment with valerian and morphia
(Prof. Greisinger had confirmed the opinion that there was no true
lesion of the centres), but the neuralgia of the globe was
extraordinarily severe, both day and night. From January to June, 1861,
Wegner saw her occasionally. The visual power of the left eye fluctuated
between 15 and 19 Jager. Field of vision very limited. Pupil very
dilated and insensitive, the globe painful to the touch, and injected.
The right eye weakly hypermetropic; normal field of vision, normal
pupil, no pain. The scene suddenly changed on the 29th of June. She was
attacked with fearful pain, and an enormous mydriasis with extreme
amblyopia of the right eye; the fingers could hardly be counted when
placed quite close. The optic disc appeared somewhat cloudy, with very
evident venous pulsation. The mydriasis, amblyopia, and neuralgia lasted
some time, while simultaneously the left eye could only read 19-17 type,
but was painless. The pathology seemed quite obscure, and the surgeon
remained almost passive till August, when he performed paracentesis on
the left eye. The patient could distinguish fingers at that time at a
foot's distance with the right eye; with the left read No. 11, but
suffered fearful pains. These diminished after the puncture; the eye
could read No. 20 next day, and improved after that to 19; the pains
recurred in the next day, but for the first time ceased to disturb
sleep. The scene again changed in the most surprising manner on the 27th
of August. The most frightful pain again attacked the left eye. The
pupil was dilated to the maximum (far beyond what occurs in oculo-motor
paralysis); the globe was extremely painful on touch, visual power
fallen to 19 Jager. On the other hand, the right eye had a normal pupil,
was painless, and could read No. 12. Paracentesis of the left eye
improved its vision and diminished pain, but only temporarily, so that
it had to be repeated at short intervals. The condition was so far
stationary toward the end of October that the right eye continually
gained visual power, but the left stood still and fluctuated from worse
to better, with the greater or less severity of the neuralgic paroxysms.
Pupils always in extreme dilatation. In the end of October and beginning
of November (the patient had worn a large seton for a month) remarkable
changes occurred; the neuralgia of the left globe diminished steadily,
the pupil got smaller, the visual power increased, the neuralgia now was
only on the lower lid, which was slightly red and painful to the touch,
and had continual spontaneous pain. Visual power of right eye No. 3, of
left eye No. 5. Visual field intact; with full illumination by weak
light there is a peripheral torpor, but only in a narrow zone. The
hyperæmia now extended more and more over the lower lid and the upper
part of the cheek; this was apparent during the paroxysms, which were
very severe, and destroyed sleep; it did not allow the skin to be
touched; the color was deep (with high temperature) and extended to the
angle of the mouth. This phenomenon lasted till the beginning of
December, when neuralgia again attacked the left globe, with strong
mydriasis and diminution of visual power (15 to 20 Jager), till at last
the movements of the hand could hardly be distinguished, and this state
of things continued with fluctuations up to the end of the month. The
seton had been taken off just before the new outbreak; it was put in
again on December 31st. In January the pains continued severe in the
eye, with only one remission (from the 17th to the 20th), when the
hyperæmia recurred in the cheek. On the 26th the pupil was very dilated,
and fingers could not be seen at half a foot's distance. Visual field
very limited, globe hard. A large upper iridectomy was made. After this
the pupil was contracted, the pains diminished, visual power 10 Jager,
field seven inches. In the middle of February the hysterical attacks
recurred with great force; the patient was unconscious half the day; she
was clear enough in senses when awake, but complained of buzzing in her
head, as if a cock-chafer were inside it. From this till the middle of
March, the left eye did not alter, the impairment of vision remained,
with normal pupil and no pain in the globe, and the iridectomy seemed at
least to have done good in one direction; but on the 13th of March the
operated eye was again attacked with pain, visual power fell to No. 17,
pupil became dilated, and after a few days the swelling, heat, and
tenderness of the cheek recurred. During the years 1862 and 1863 the
condition remained pretty much the same; _i. e._, the right eye sound,
the left painful (in spite of the iridectomy) with dilated pupil,
concentrically narrowed visual field, visual power fluctuating between
No. 15 and mere finger-counting without any ophthalmoscopic appearances.
A number of paracentesis and subcutaneous injections of morphia (which
last were the more indicated as the supra-orbitalis was tender on
pressure) always brought relief merely for a few hours. On the 19th of
April, 1864, vision being complete in right eye, and No. 19 in left,
Wegner punctured the latter. On the 2d of May the eye read No. 10
slowly, the pains had gone and not returned, the pupil became smaller.
On the 31st of March, 1865, the patient was pronounced well; the eye was
painless, the pupil somewhat larger than the other; the finest type
could be read when looked at very close.

3. The next group of affections secondary to neuralgia are the paralysis
of muscles. These are pretty common; I find them in twenty-eight of the
hundred cases which have been referred to. But of these twenty-eight
instances of paralytic affections no less than twelve were connected
with neuralgia of the trigeminus, and in most of these it was one or
more of the muscles connected with the eye that were affected. Sciatica
is nearly always attended with much weakening of voluntary power of the
muscles of the thigh and leg; and in some instances this reaches to
decided or even complete paralysis. In looking for this phenomenon we
must be very careful that we do not mistake the mere reluctance to move
the limb, on account of the painfulness of all movements, for true
paralytic weakness of nerve and muscle. And it is also necessary to bear
in mind, in prolonged cases, the probability that much of the weakness
may have been caused by degeneration of the muscles owing to forced
inaction. Still, there is a class of secondary paralyses that are in no
way to be confounded with such effects as these: for instance, it
occasionally happens, almost in the very first onset of severe sciatic
pain, that the limb hangs absolutely helpless; and in one such case
lately, being struck with the completeness of the loss of power, I
tested the Faradic irritability by directing a sharp current on
comparatively exposed portions of the painful nerve (_e. g._, in the
popliteal space, and behind the head of the fibula), and elicited only
the most feeble contractions, entirely unlike what the same current
evoked in the opposite limb. I regret that I have as yet found it
impossible to carry out a regular inquiry as to the sensibility to the
different currents of motor nerves which are centrally connected with
neuralgic sensory nerves.

Muscular viscera which are composed of unstriped fibre, like the
intestines, or of a mixture of striped and unstriped, like the heart,
are probably very liable to a secondary paralytic influence from certain
special neuralgiæ. It is ascertained that the pain of a certain degree
of severity in the branches of the fifth may absolutely stop the heart's
action for a moment--an effect which is succeeded, usually, by violent
and disorderly pulsations. I have myself once known the operation of
"pivoting" a tooth, which gave frightful pain, cause instantaneous and
most alarming arrest of the heart's motion, which for a minute or two
seemed as if it were going to be fatal. But the variety of visceral
paralysis which is probably far the most frequent is secondary paralysis
of the bladder, from neuralgia in one or other of the pelvic organs, or
of the external genitalia; and next to this comes paralytic distension
of the cæcum, colon, or rectum, secondary to various abdominal and
pelvic neuralgic affections. In one instance of acute ovarian neuralgia
that I saw, the paralytic distention of the colon was by far the most
remarkable circumstance, so enormously was it developed; and for some
days after the neuralgia had ceased, and when the flatulence had nearly
disappeared, the intestine remained absolutely torpid.

4. Convulsive actions of muscles, as every one knows, are very common
complications of neuralgia. In trigeminal neuralgias these may be
observed (according to the division or divisions of the nerve that are
affected) in the proper muscles of the eye, or in those supplied by the
fourth and sixth nerves, or (perhaps only when two or three divisions
of the fifth are neuralgic at once) by the portio dura. It is curious,
however, that those formidable spasmodic affections of the face which
belong to the same order as torticollis and writer's cramp, are not
frequently, if ever, directly associated with trigeminal neuralgia. The
only connection between them seems to be that these peculiar spasmodic
affections are only developed in highly-neurotic families, some of whose
members are almost sure to be found suffering from some form of regular
neuralgia. In severe sciatica it has several times happened to me to see
convulsive action of the flexors, bending the leg spasmodically upon the
thigh. And in a very large proportion of all neuralgias, wherever
situated, attentive observation of the patient during the paroxysms will
detect the existence of local twitching or local spasm of muscles,
though these may be slight in degree.

Among the convulsive affections must be reckoned convulsive movements
and tonic spasms of various portions of the alimentary canal. Vomiting
is a common example of this; in migraine it is the regular and necessary
climax of attacks which last with severity for a certain time; indeed,
any severe attack of neuralgia involving the ophthalmic division of the
fifth may excite vomiting. Convulsive action of the pharyngeal muscles,
as a complication of pharyngeal or laryngeal neuralgia, occasionally
occurs to such an extent as to render deglutition difficult or
impossible for the time. And I have seen what I do not doubt to have
been a spasmodic condition of the rectum induced by peri-uterine
neuralgia. The genito-urinary organs are also not unfrequently affected
spasmodically in consequence of a neuralgic affection either
peri-uterine or pudendal. I have seen spasmodic stricture of the male
urethra thus produced, and likewise vaginal spasm.

5. Impairments of sensation, both common and special, are very frequent
attendants of neuralgia. As regards the special sensations, we may first
mention that of touch; this is almost constantly impaired, immediately
before, during, and some little time after a neuralgic paroxysm, in the
skin supplied by the painful nerves. I was first led to make this
observation by my own experience; the skin all round the inner angle of
my right eye is permanently less sensitive to distinctive impressions
than that of the opposite side, and this impairment is always decidedly
greater, and spreads over a larger surface, before, during, and for some
time after, the attacks of pain. More extended observation has convinced
me that a certain amount of bluntness of distinctive skin-sensation
accompanies nearly every neuralgia. As regards the sense of taste, I
have found this decidedly perverted, at the time of an attack, even in
my own case, although the neuralgia never extends into the third branch
of the nerve. It is interesting to notice, in connection with this,
that the epithelium of my tongue has been seen, on one occasion, to be
exaggerated on the side of the neuralgic affection, showing a
probability that there is perturbed function, at any rate of certain
fibres, of the third division. But I have seen much more decided
alteration, indeed temporary entire abeyance of the power to distinguish
between the tastes of different substances, with the affected side of
the tongue, in a case of severe epileptiform tic in which the third
division was strongly affected with neuralgia; and Notta records a
similar instance. As regards vision, besides minor perversions and
disturbances, I have observed more or less complete amaurosis in several
instances of ophthalmic neuralgia; in one case it was absolute, and
lasted, with but slight improvement in the intervals between the
paroxysms, for nearly a month, but disappeared entirely, though somewhat
gradually, after the final cessation of the neuralgia. As regards
hearing, I have noticed serious impairment only in five cases, all of
them of a severe type of trigeminal neuralgia, involving all three
divisions of the nerve. Smell, I have never observed to be more than
doubtfully impaired, except in one case (_vide_ Chapter III), where it
was completely destroyed.

Common sensation was reported by Notta as affected in only three cases
out of a hundred and twenty-eight; but my own experience has afforded a
much larger proportion of instances in trigeminal neuralgia. Indeed, in
all situations neuralgia appears to me to involve this effect, in the
larger number of instances, in the early stages; later, it is supplanted
in part by great tenderness on pressure in the well known _points
douloureux_, and sometimes the tenderness becomes diffused over a
considerable surface. I agree with Eulenburg in thinking that anæsthesia
is more frequent in sciatica than in other neuralgias.

6. Secretion is often very notably affected in neuralgia; the phenomena
are necessarily more easily observed in connection with affections of
the trigeminal than of other nerves. In the great majority of cases the
affection is in the direction of increase; at least, the watery elements
of secretion are often poured out in profusion. Thus, profuse
lachrymation is exceedingly common in ophthalmic neuralgia; in a large
number of cases there is also copious thin nasal flux on the affected
side; sometimes, however, the secretion, though copious, is
semi-purulent, or bloody. Increased salivation has been noticed, by a
large number of observers, in neuralgia involving the lower division of
the fifth. In a smaller number of instances, the secondary effect on
secretion is precisely opposite; thus both Notta and myself have
observed complete dryness on the nostril on the affected side in
ophthalmic neuralgia.

I might expand this chapter on the complications of neuralgia to a very
much greater length; but, as regards the clinical history of these
affections, it is perhaps better not to occupy more time and space. It
will, however, be necessary to return to the consideration of the
subject in connection with Pathology.

FOOTNOTE:

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




CHAPTER III.

PATHOLOGY AND ETIOLOGY OF NEURALGIA.


The pathology and the etiology of neuralgia cannot be considered apart;
they must be discussed together at every step. I do not mean to say that
neuralgia is singular among diseases in this respect; it seems to me
merely a case in which the intrinsic defects of the conventional system
of separating the "causes" of disease from its pathology happen to be
more glaring and more easily demonstrable than usual.

Neuralgia possesses no "pathology," if by that word we intend to signify
the knowledge of definite anatomical changes always associated with the
disease, in a manner that we can exhibit or exactly describe. It also
possesses no demonstrable causes, if we employ the word "causes" in the
old metaphysical sense. And yet I am very far from admitting, what seems
to be so generally taken for granted, that we know less about the seat,
the nature, and the conditions of neuralgia than of other diseases. On
the contrary, I believe, with all deference to the supporters of the
ordinary opinion, that we know more about neuralgia, in all these
respects, than we do about pneumonia, only our knowledge is not of the
superficial and obvious kind, but requires the aid of reason and
reflection to develop and turn it to account. It has long been a matter
of surprise to me, that even able writers have been content to talk
about this disease (as, indeed, they have been content to speak of many
nervous diseases) with an inexplicable looseness of phraseology. They
speak of its "protean" forms; whereas, in my humble judgment, its forms
are by no means specially numerous. They insist on the mysterious and
unintelligible manner of its outbreaks, remissions and departure; but I
shall try to show that, although, in the investigation of neuralgia, we
are continually stopped in particular lines of inquiry by what seems to
be ultimate facts, susceptible of no further immediate solution, the
channels of information open to us are so unusually numerous as to
enable us to accumulate a mass of information which, upon further
reflection, will be found to furnish the materials of a synthesis of the
disease singularly clear and effective for every practical purpose of
the physician. In one important particular I especially hope to convince
the reader that a large proportion of the mystification as to the
pathology of neuralgia is gratuitous, and the result of great
carelessness in estimating the comparative value of different facts. I
hope to show clearly that, as regards both the seat of what must be the
essential part of the morbid process, and the general nature of the
process itself, we possess very definite information indeed. I expect,
in short, to convince most readers that the essential seat of every true
neuralgia is the posterior root of the spinal nerve in which the pain is
felt, and that the essential condition of the tissue of that nerve-root
is atrophy, which is usually non-inflammatory in origin. This doctrine
seems, at first sight, presumptuous,[16] in the confessed absence or
extreme scarcity of dissections which even bear at all upon the
question. But one source of the extraordinary interest which the
pathology of neuralgia has long possessed for me resides in this very
fact, that I am convinced we can demonstrate the above apparently
difficult theorem by means of pathological observations on the living
subject, taken in conjunction with physiological experiments, and with
only the aid of a very few isolated facts of positive morbid anatomy. I
need hardly say that I am none the less anxious for that further
assurance which we shall one day, perhaps, obtain by means of
greatly-improved processes for microscopic detection of minute changes
in nerve-centres; but, looking to the necessary rarity of opportunities
for post-mortem examinations of the nervous system in any but the most
advanced stages of neuralgias, it will hardly be disputed that, if I am
right in my main position, we are singularly fortunate to be so
unusually independent of the need for this source of information.

1. The first fact which strikes me as of decided importance is the
position of neuralgia as an hereditary neurosis; and this character of
the disease is so pregnant with significance, that I shall take some
considerable pains to put the fact beyond doubt in the reader's mind.

There are two series of facts which support the theory of the
inheritance of the neuralgic tendency: (_a_) instances in which the
parent of the sufferer had also been affected with the disease; and
(_b_) instances in which the family history of the patient being traced
out more at large it appeared that, among the members of two or more
generations, while one, two, or more individuals had been actually
neuralgic, other members had suffered from other serious neuroses (such
as insanity, epilepsy, paralysis, chorea, and the tendency to
uncontrollable alcoholic excesses), and, in many instances, that this
neurotic disposition was complicated with a tendency to phthisis.

(_a_) The question of the direct transmission of neuralgia itself from
the parent seems the easiest of decision, though even this cannot always
be satisfactorily cleared up by the hospital patients, among whom one
collects the largest part of one's clinical materials. However, I have
been at the pains of investigating a hundred cases of all kinds of
neuralgia, seen in hospital and private practice, with the following
results: twenty-four gave distinct evidence that one or other parent had
suffered from some variety of neuralgia; fifty-eight gave a distinctly
negative answer; and eighteen would not undertake to give any answer at
all. Among the twenty-four affirmatives are inserted none in which the
history of the parent's affection did not clearly specify the liability
to localized pain, of intermitting type, but recurring always in the
same situation during the same illness. In three of these twenty-four
instances, the patient stated that both parents had suffered from such
attacks, and, in one of these, it appeared that the grandfather had
likewise suffered.

(_b_) The question of the tendency of a family, during two or more
generations, to severe neuroses of more or less varying kinds, including
neuralgia, is difficult to work out perfectly, though in a large number
of instances we may get enough information to be very useful. I have
spent much time and trouble in endeavoring to collect such information;
but there are two main difficulties in connection with all such
attempts. From hospital patients you frequently can get no reliable
information whatever respecting any members of the family farther back
than the immediate parents; and, even respecting uncles and aunts and
first cousins, it is often impossible to learn any thing. And when you
get to a higher class of society, especially when you approach the
highest, although the information may exist, it may be withheld, or you
may be purposely mystified. One would doubt beforehand, under these
circumstances of difficulty, whether it would be possible to obtain
affirmative evidence of the neurotic temperament of the families of
neuralgic patients in general; but, in truth, the evidence is so
overwhelming in amount, that more than enough can be obtained for our
purpose. I shall give, first, the results of one special inquiry which,
by the kindness of a patient, I have been able to carry out with more
than usual completeness; it relates to the medical genealogy of a
sufferer from sciatica; the account is fairly complete for four
generations. The great-grandfather was a man of splendid physique (an
only son), who lived very freely, but died an old man. His children were
three sons, one of whom (though strictly temperate) was a man of
eccentric and somewhat violent temper, and suffered from a spasmodic
facial affection. This one, the grandfather of my patient, married a
lady who died of phthisis, and among the ten children she bore him, two
sons died of phthisis, two sons became chronically insane, one son died,
probably of mesenteric tubercular disease (aged fifty-six), two sons are
still alive at very advanced ages, and have always been perfectly
healthy and strong; one daughter died in middle age, it is not certain
from what cause; one daughter lived healthily to the age of eighty, and
then was attacked by facial erysipelas, followed by violent and
intractable epileptiform tic, which clung to her for the remaining four
years of her life; and the remaining daughter, an occasional sufferer
from migraine, died at the age of sixty-seven, almost accidentally, from
exhausting summer diarrhoea. The fourth generation, in this branch of
the family, consisted of thirty-one individuals; of whom seven have died
of phthisis, or scrofulous disease; one from accidental violence, one
from rheumatic fever, one from scarlet fever; and among the surviving
twenty-two one has been insane, but recovered; two are decided
neuralgics; one is occasionally migraineuse, and once had a smart attack
of facial erysipelas, corneitis, and iritis, as the climax to a severe
neuralgic attack; one has been a sufferer from chorea; one has become
phthisical; one developed strumous disease, but has fairly recovered
from it. The remaining fifteen enjoy good health, but are distinguished,
almost without exception, by a markedly neurotic temperament, indicated
by an anxious tendency of mind, quickness of perception, æsthetic taste,
disposition to alternations of impulse and procrastination. Of the young
fifth generation growing up, there have been twenty-five children, of
whom only one has died (from fever), the rest are apparently healthy
(most of them specially so); but, as few have yet reached the age for
the development either of phthisis or of neurotic diseases, the future
of this generation can only be guessed at. [It is unnecessary to trace
the other descendants of the second generation, but I may state that
their medical history, also, strongly supports the theory of inheritance
of the neurotic tendency, and of the influence of an imported element of
phthisis in aggravating the latter.] I suspect that, as regards the
young children now growing up, everything will depend on the care with
which they are fed, and the kind of moral influences brought to bear on
them, two subjects which will be fully dwelt on in the chapter on
Treatment.

Of less perfect inquiries on the subject of neurotic disposition
inherited by neuralgic patients, I have made a great number, though I
regret to say that I have not attempted the task in the whole number of
those from whom I inquired as to direct inheritance of neuralgia from
their parents. However, in eighty-three cases this was done with all
possible care, and any deficiency of completeness in the results is not
my fault. I shall take first those that were private patients,
twenty-two in number, respecting whom, I may say, that the evidence is
of the best, as far as it goes, since I was better able to discriminate
as to the worth of statements, than in dealing with hospital patients,
and have rejected every case in which the informant did not seem
intelligent enough, or otherwise to have the means, to give a thoroughly
reliable account.

    I. Neuralgia cervico-brachialis; in a lady, aged seventy-one.
       Mother suffered from epileptiform facial tic; uncle was
       paralyzed; patient herself eccentric to the verge of insanity.

   II. Bilateral sciatica of great severity; in a gentleman, aged
       seventy-three. Gout, paralysis, and neuralgia, have been
       frequent in the family.

  III. Cardiac neuralgia; in a man, aged twenty-four. Father epileptic
       and a drinker; grandfather died of softening of the brain,
       aged thirty-eight.

   IV. "Cerebral" neuralgia; in a single lady, aged thirty-eight.
       Mother has been insane; first cousin epileptic.

    V. Lumbo-abdominal neuralgia; in a gentleman, aged fifty-two.
       Father a drinker; mother insane; maternal grandfather
       phthisical.

   VI. Severe neurotic angina pectoris; in a gentleman, aged fifty.
       Almost every one of the graver neuroses among patient's near
       relations.

  VII. Migraine and cervico-occipital neuralgia; in a young lady, aged
       twenty-five. Immediate causes, brain-work, and influence of
       cold weather. Father and brother both epileptic; father's
       family much affected with neurotic diseases.

 VIII. Sciatica; highly-nervous temperament. Father died insane from
       drink; and probably other members of the family also nearly or
       quite insane.

   IX. Auriculo-temporal neuralgia; in a married lady, aged
       twenty-eight. Father's family markedly phthisical and neuralgic.

    X. Intercostal neuralgia; in a girl (phthisical), aged twenty-four.
       Mother and two uncles phthisical; maternal grandfather epileptic
       and a drinker.

   XI. Facial neuralgia (third branch trigeminal); in a gentleman, aged
       fifty-four, a great whiskey-drinker. Drinking hereditary for
       three generations; father died insane; grandfather epileptic;
       sister phthisical; two brothers very "eccentric."

  XII. Migraine, severe; in a lady, aged thirty-three. Grief was the
       immediate cause. Mother hemiplegic at forty-second year; first
       cousin insane; two aunts (maternal) epileptic.

 XIII. Extremely severe sciatica and cervico-brachial neuralgia of the
       left side, with singular inflammatory consequences; in a lady,
       aged fifty-two. A family history remarkably free from neurotic
       diseases and from phthisis. The neuralgia was probably caused
       partly by excessive ptyalism, partly by over brain-work.

  XIV. Migraine; in a young lady, aged sixteen; very profuse
       menstruation, which had lasted for two years. Family history
       very free both from phthisis and neuroses.

   XV. Frontal and nasal neuralgia; in a man. Repeated attacks of
       localized facial erysipelas; drinking-habits for some years;
       fatal acute insanity in middle age. Father insane, committed
       suicide; mother subject of violent epileptiform tic.

  XVI. Angina pectoris (neurotic); spasmodic asthma, twenty years;
       facial neuralgia and erysipelas; in a gentleman, aged fifty.
       Family medical history scanty and imperfect; but, as far as it
       goes, entirely without evidence of either phthisis or neuroses.

 XVII. Neuralgia of testis, immediately caused by local irritation.
       Father died of phthisis; paternal uncle epileptic and insane.

XVIII. Ovarian neuralgia; in a girl, aged twenty-six, liable to
       occasional migraine. Mother has suffered sciatica; brother
       died of phthisis.

  XIX. Gastralgia; in a man, aged twenty-seven; highly intellectual and
       nervous. Family history very free from neuroses; but some
       evidence of phthisis, in two previous generations, on mother's
       side.

   XX. Sciatica; in a lady, aged sixty; second attack. Ancestors, on
       both sides, for some generations, clever, and in several
       instances decidedly eccentric, if not insane; much neuralgia
       in the family.

  XXI. Migraine; in a young lady, aged seventeen; menstrual
       difficulties. No neurotic nor phthisical family history.

 XXII. Sciatica; in a married lady, aged twenty-seven; first pregnancy;
       had rheumatic fever and subsequent chorea in childhood. Paternal
       uncle epileptic; mother had rheumatic fever and cardiac disease;
       paternal grandfather suffered from sciatica late in life.

No one, I think, can look down the above list and fail to be struck with
the great preponderance of cases in which the general neurotic
temperament plainly existed in the patients' families; and let me add
that, in not a few of these cases, the neuralgia in the individual under
observation might have been easily set down as dependent merely upon
peripheral irritation, which, indeed, plainly did act as a concurrent
cause.

Fortunately, however, I am not dependent upon my own evidence alone, for
the proofs of the proposition that neuralgia is eminently a development
of hereditary neuroses. The great French alienists, Morel and Moreau of
Tours, some years ago laid the foundations of the doctrine of hereditary
neurosis. They enforced this chiefly with reference to the manner in
which insanity is transmitted through a chain of variously-neurotic
members of a family stock; and Moreau laid special stress on the deeply
interesting connection of the phthisical with the neurotic tendency.
Since then various observers have insisted on the same thing. Of late,
Dr. Maudsley has worked out this subject with great ability, in his work
"On the Physiology and Pathology of Mind," and in his recent "Gulstonian
Lectures;" and Dr. Blandford dwells on it with emphasis in his
interesting "Lectures on Insanity." [Dr. Blandford does not, however,
admit that the phthisical diathesis has any such close and causal
relation with neuroses as has been imagined by some recent pathologists;
and, on the other hand, he points out that phthisis in neurotic
subjects, _e. g._, the insane, must, in a large measure, be considered
the product of the accidentally unhealthy circumstances in which they
pass their lives. In the latter opinion I entirely agree.] Indeed, it
may be taken as a recognized fact, among the more advanced students of
nervous diseases, that hereditary neurosis is an important antecedent of
neuralgia, in at least a very large number of instances. I shall
conclude this part of the argument by stating the general results of my
inquiries respecting sixty-one hospital patients. Of these cases,
twenty-two were migraine, or some other affection of the ophthalmic
division of the fifth nerve; seven were sciatica; two were epileptiform
facial tic; ten were neuralgias affecting chiefly the second and third
divisions of the fifth nerve; three were intercostal neuralgias pure;
one was intercostal neuralgia plus anginoid pain; seven were intercostal
neuralgias with zoster; three were brachial neuralgias; and five were
abdominal neuralgias (hepatic, gastric, mesenteric, etc.) Of
eighty-three hospital and private patients [It must be understood that
the respective numbers do not indicate with any accuracy the relative
frequency of the different neuralgias as seen in my practice. (Sciatica,
_e. g._, was proportionally more frequent.) They represent but a small
part of the neuralgic patients whom I have seen during fourteen years of
dispensary, hospital, and private practice, and they were selected for
inquiry merely because I happened to be able to give the time for the
necessary questions. Every one who knows out-patient practice will
understand how seldom this happened.] I obtained evidence of the
presence, among blood-relations, of the following diseases: Epilepsy,
fourteen cases (eight were examples of migraine); hemiplegia or
paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen
cases; "consumption," eighteen cases; "St. Vitus's dance," four cases.
I am well aware that these figures must be taken with caution, and that
considerable doubt must rest on the accuracy of some of these details,
more especially with regard to "epilepsy," as it was impossible, with
the greatest care, to be sure that this was not given, by mistake, for
hysteria in some cases; and the same may apply to the statement that
relations had suffered from "consumption." The facts are given for what
they are worth, and with the express reservation that their total
reliability is far less than that of the accounts obtained respecting
private patients belonging to the more educated classes. But, in one
respect, viz., as regards drunken habits, it is possible that a truer
estimate is gained from the statements of hospital patients than from
those of private patients, who would usually be more prone to reticence
on such a topic.

The evidence as to the hereditary character of neuralgia assumes a yet
higher importance when supplemented by the facts respecting the
alternations of neuralgia with other neuroses as the same individuals.
Every practitioner must be aware how frequent is the latter occurrence.
Nothing is more common, for example, than to see insanity developed as
the climax of minor nervous troubles, especially of neuralgia. And there
is one form of neuralgia, the true epileptiform tic, which is intimately
bound up with a mental condition of the nature of melancholia, and even
with the markedly suicidal form of the latter affection. I have lately
had under my care a lady in whom the prodromata of a severe facial
neuralgia were mental; the disturbance commenced with frightful dreams,
and there was great mental agitation even before the pain broke out;
this disturbance of mind, however, continued during the whole period of
the neuralgia, and was relieved simultaneously with the cessation of the
attacks of pain. This is contrary to what happens in some cases; thus,
Dr. Maudsley quotes the case of an able divine who was liable to
alternations of neuralgia and insanity, the one affection disappearing
when the other prevailed. Dr. Blandford has met with several instances
in which neuralgia has been followed by insanity, the pain vanishing
during the mental disturbance, and reappearing as the latter passed
away. And he remarks that, in the transition of a neuralgia (to mental
affection), we may well believe that the neurotic affection is merely
changed from one centre to another, from the centres of sensation to
those of mind. He says that the ultimate prognosis of such cases is bad;
a point to which we shall have to refer again.

The prominent place which quasi-neuralgic pains hold in the earlier
history of locomotor ataxy is a fact that cannot but engage attention.
In this volume we have not treated these pains as belonging to the truly
neuralgic class, for the very practical reason that they are but
incidents in a most important organic disease, and that in a diagnostic
and prognostic point of view it is necessary to dwell on their
connection with that disease. But, in considering the pathological
relations of neuralgia, it would be improper to omit the consideration
of the pains of locomotor ataxy, which bear a striking semblance to
neuralgic pains. The fact that they are an almost if not quite constant
feature of a disease which is from first to last an atrophic affection
(mainly of the posterior columns of the cord), in which the posterior
roots of the nerves are almost always deeply involved, has a bearing on
our present inquiry too obvious to need further remark.

Equally important to our investigation is the fact that pains, closely
resembling neuralgia, are not very uncommonly a part of the phenomena of
commencing, and more frequently of receding, spinal paralysis. I have
the notes of three cases of partial recovery from paraplegia, in all of
which the patients remained for years, in one case for nearly twenty
years (ending with death), the victims to a singularly intractable
neuralgia of both lower extremities. In the worst of the cases the
patient was the victim of excessive and continuous labor at literary
work of a kind which hardly exercised the mental powers, but was
extremely exhausting to the general power of the nervous system; he
broke down at about the age of fifty, but dragged on a painful existence
for the long period above mentioned.

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.

If we search among the external influences which contribute to the
production of neuralgia for one that is apparently trivial as to the
amount of material disturbance which it can cause, and yet is very
frequently effective, we may select the agency of cold. The effect of a
continuous cold draught of air impinging on the naked skin for some time
is comparatively frequently seen in the provocation of neuralgic attack:
we say comparatively, because this influence is more frequently
effective than blows, wounds, or temporary irritations of any kind,
applied to the peripheral ends of sensory nerves. But if neuralgia be a
more frequent consequence of cold than of these other influences, a
moment's reflection will show that it is by no means an absolutely
common result. One has only to think of the numerous omnibus-drivers,
engine-drivers, cab-drivers, etc., etc., who pass their whole working
lives in presenting the (more or less) naked expanse of their trigeminal
and their cervico-occipital nerves to every variety of wind, to perceive
that, were this sort of influence very potent in itself, male neuralgic
patients should swarm as thick as bees in our hospital and dispensary
out-patient rooms; which is notoriously quite contrary to the fact. The
same remarks, in both directions, may be applied to the direct influence
of atmospheric moisture, either with or without the effect of wind (of
course I am not speaking of the more recondite effects of damp soil on
the persons who live about it). [Among the hundred patients who formed
the basis of the inquiries mentioned in this work, forty-one accused
external cold of producing the attack, but many of these produced
insufficient evidence that such was the case.] In short, the direct
effects of atmospheric cold would seem to be these. Mere lowness of
temperature goes for something, but not much; [The most marked instance
of the effect of cold, _per se_, that I have seen, was exhibited by a
young lady who was under my care during the past severe winter
(1870-'71). During much of the time she was confined to a
carefully-warmed apartment, on penalty of a violent paroxysm if she left
it.] for about as much, perhaps, as it does in the way of aggravating
all neurotic tendencies. Cold joined with wind is much more powerful.
And the maximum of ill-effect seems reached by very cold wind mingled
with sleet or driving rain, which keeps the skin sodden. But the
conclusion at which I long ago arrived is, that none of these influences
ever take more than a small (though it is sometimes an important) part
in the production of neuralgia; and that in the majority of cases there
is no pretence for supposing that they had the slightest share in its
causation.

A word or two must be said as to the _modus operandi_ of cold and cold
wind, as these are the most frequent of external, so-called "exciting"
causes. The popular use of such phrases as the latter has an
extraordinary influence in disguising the plain fact, which is, that
these influences operate wholly in the direction of robbing the nerves
of force. The continuous abstraction of heat from the surface, which of
course is materially aided by rapid movement of the air, must
necessitate a readjustment of the distribution of energy, the only
result of which must be to drain the sensory nervous centre of its
reserve of force. But, in fact, there is an experiment, ready performed
to our hands, which may amply satisfy us as to the kind of influence
exerted by cold on superficial nerves, viz., the sensations experienced
in recovering from frost-bite, which has been severe enough to paralyze
the nerves without causing actual gangrene of the tissues. The passage
of the nerves back from temporary death to full functional life is
marked by a half-way stage in which there is agonizing pain.

4. We must next consider the effects of a class of peripheral influences
which act, where they exist, in a more constant manner than any others;
viz., those in which the trunk or periphery of a sensory nerve either
receives a severe injury, or becomes more or less engaged in
inflammatory processes, or compressed or otherwise damaged by the growth
of tumors or the spread of destructive ulcerations.

With regard to ordinary nerve-wounds as a cause of neuralgia, we have
already said (_vide_ Chapter II.) nearly as much as it is necessary to
say; we need only here point out that, like the influence of cold
applied to superficial nerves, that of wounds must necessarily be a
depressing one to the centre with which the wounded nerve is connected,
and the resulting neuralgia must be regarded as an expression of impeded
and imperfect nerve-energy, not of heightened nerve-function. The pain
is set up during the process of nerve-healing; that is to say, at a
stage intermediate between those of abolished function and completely
restored function; and there can be little doubt that the obstinacy with
which it is often protracted is due to the slowness with which a wounded
nerve recovers its full functional activity; when once the latter is
completely restored there is an end of neuralgic pain. It is exactly
analogous to the course of events in recovery from freezing.

There remain for consideration, however, (a) a small class of cases of
nerve-wounds in which the healing process is not simple; but the lesion
is followed by the development of a tumor of the kind denominated true
neuroma. The process consists of hyperplastic changes in the
nerve-fibres; its commonest examples are seen in the extraordinarily
painful swellings that occur on the ends of nerves left in stumps after
amputations; but, in fact, a neuroma of this kind may occur after any
kind of severe nerve-injury, as, _e. g._, a cut from broken glass, the
impaction of foreign bodies, etc. The true neuromata are composed mainly
of nerve-tissue, with a relatively small element of connective tissue:
the nerve-fibres can be traced directly to the nerve-tumor. Besides the
traumatic neuromata which form permanent tumors, incapable of being got
rid of except by actual excision, a minor variety of the same kind of
change has in several cases been known to take place in consequence of
an abiding local irritation from the impaction of a foreign body, on the
removal of which the neuromatoid enlargement completely disappeared. (b)
There are likewise a certain number of cases in which a tumor is
developed from the neurilemma, and does not consist of nervous tissue;
these are distinguished as false neuromata, and may be of various kinds,
the fibromatous and gliomatous being far the most common, but cysts and
cystic tumors also sometimes occurring.

The case of the neuromata is well worth reflecting upon, in the course
of our endeavors to clear up the Pathology and Etiology of Neuralgia. If
ever we could find a merely peripheral influence which would of itself
be invariably competent to excite neuralgic pains, it would surely be
found in neuroma; but the case is not merely not so, it is strikingly
contrary. Just as wounded and inflamed nerves frequently go through the
whole processes of disease and recovery without once eliciting a
neuralgic pang, so is it with neuromata; they are not unfrequently quite
indolent, and neither excite neuralgia, nor are themselves at all
particularly tender to the touch. And what is most remarkable is, that,
as Eulenburg correctly remarks, among the pseudo-neuromata the kind of
tumor which is most frequently associated with neuralgia is by no means
the dense fibroma or glioma, which might be expected by its mechanical
pressure to excite inevitable neuralgic pain, but the far softer and
more yielding cystic tumors. I do not know how the facts may affect the
reader, but to me they suggest the strongest possible arguments against
the belief that peripheral irritation can of itself produce neuralgia
without the intervention of some centric change. The tendency to such
change (from inherent constitution) in the sensory root of the nerve
must surely be the reason why neuroma causes neuralgia in a given number
of subjects, instead of letting them go scot-free, as it does other
persons.

The same remarks apply to the result of observations on the effect of
tumors commencing in tissues altogether unconnected with the nerve, and
merely coming to involve it, secondarily, in pressure. It has been often
noted that, among these tumors, fluid-containing cysts and soft
medullary cancers are far more frequently the cause of decided and
distressing neuralgia than the denser and less yielding neoplasms. Of
kinds of tumors that are specially apt to produce severe and even
intolerable neuralgia by the pressure on nerves, it has been remarked
that aneurisms are among the worst: here every pulsation often sends a
dart of agony through the nerve. There is a reason here, however, which
is often left out of sight; not merely is the perpetually varying
pressure specially harassing and exhausting to the nerve, but in many of
these cases there is general arterial degeneration, and the sensory root
of the nerve is exceedingly likely to be very badly nourished. [This
result will be more directly brought about when the aneurism happens to
press on the ganglion of a posterior root.] We pass now to the
consideration of the influence exerted by other great series of
peripheral impressions in the production of neuralgia. These impressions
are connected chiefly with the functions of the digestive and of the
genito-urinary organs, the functions of the eye, and the nutrition of
the teeth.

To take the least important of these first, I may surprise some readers
by the statement, which I nevertheless make with much confidence, that
irritation of any part of the alimentary canal is, on the whole, a rare
concurrent cause, even in the production of neuralgia. There are, as has
been already fully explained, cases of neuralgia seated in these viscera
themselves (or the plexuses in their immediate neighborhood), although
their number is immensely smaller than that of the neuralgias of
superficial nerves. But it is not at all common--it is even exceedingly
rare--for irritation conveyed from the alimentary canal to take any
important part in setting up neuralgia of a distant nerve, even when
that nerve has close connections, through the centres, with those coming
from the irritated portion of the alimentary canal. Valleix had the
great merit to perceive this, even in the case of neuralgias of the
head, where appearances are so likely to lead the observer to a contrary
opinion. And it is not a little remarkable that this should be the case,
when we consider the close central connections which the vagus, the
great sensory nerve of a large portion of the alimentary canal, has with
the sensory root of the trigeminus. In fact, however, there are certain
peculiar forms of gastric irritation which do react upon the trigeminus;
for instance, a lump of unmelted ice, suddenly swallowed, almost
invariably produces acute pain in the supra-orbital branch of the fifth,
on one side or the other, and occasionally (as in a case cited by Sir
Thomas Watson) in other nerves. But that common dyspeptic troubles at
all frequently or importantly contribute to the production of neuralgia,
I do not for a moment believe: it needs some very powerful irritation,
such as that just mentioned, or as impaction of great masses of scybalæ
in the intestines, or severe irritation from worms, to produce such an
effect.

It is far otherwise with the genito-urinary apparatus; in a large number
of cases, irritations proceeding from these organs do undoubtedly
contribute to the production of neuralgia, though by no means in the
important degree which many authors seem to have assumed. There can be
no doubt, for example, that the irritation of a calculus, either within
the kidney itself, in the ureter, or in the bladder, may set up violent
neuralgia, which for the most part is localized in the branches of the
lumbo-abdominal nerves. The instance of the eloquent Robert Hall is an
example of renal calculus acting in this way: he suffered the most
excruciating agony for years, and was obliged to take enormous
quantities of opium in order to make life endurable. An instance of
calculus impacted in the ureter, in a gentleman somewhat past middle
age, occurred in my own practice; the lumbo-abdominal neuralgia occurred
in frequent paroxysms of dreadful severity; and another case, already
referred to was that of a woman, in whom ovarian neuralgia was
undoubtedly in great part due to the irritation of an impacted calculus
in the ureter. These cases, however, are very rare in comparison with
others in which the peripheral source of the neuralgia is either the
uterus or ovary, or the external genitals. I have no means of
ascertaining, with anything like accuracy, the frequency with which the
internal sexual organs are the starting-point of neuralgia, because the
majority of such cases pass, naturally, to the care of physicians who
practice chiefly in the diseases of women, and consequently not
adequately represented either in my hospital or my private practice;
still, I have seen a good many of these affections, and, though I speak
with the reserve necessitated by the circumstances just named, I am much
inclined to believe that even such powerful centripetal influences as
those of the states of commencing puberty, of pregnancy, of the change
of life, and uterine diseases generally, are very rarely the cause of
true unilateral neuralgia, except in subjects with congenital tendencies
to neuralgia. But in predisposed subjects there can be no doubt that
these influences assist most powerfully in producing the malady.

Of the power of irritation of the external genitalia to act as a
so-called "exciting cause" of neuralgia, there is abundant evidence. I
would especially call attention to the remarkable monograph of M.
Mauriac, ["_Etude sur les Nevralgies Reflexes symptomatiques de
l'Orchi-epididymite blenorrhagique_" Par C. Mauriac, Medecin de
l'Hospital du Midi. Paris, 1870.] on the neuralgias consecutive to
blenorrhagic orchi-epididymitis, as illustrating this with a force that
was to me, for one, surprising. I shall, perhaps, have further occasion
to these researches; here it will be enough to mention that M. Mauriac's
enormous experience of blenorrhoea and orchitis at the Midi has shown
that, in an exceedingly large number of cases, certainly not less than
four per cent., this combination is followed by reflex neuralgias, of
which a large number are not seated in the genital apparatus, but affect
the track of some distant sensory nerve, through the intermediation of
the spinal centres; and that with these reflex pains there is often
profound general disturbance, including very often an extremely profound
general anæmia. The most frequent kind of these neuralgias is
rachialgia, _i. e._, pain in the superficial posterior branches of
spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and
crural, visceralgic (abdominal), etc.; and besides all these there are
numerous instances of neuralgia in the testis. As to the nervous
"reflection," more hereafter.

It has surprised me, somewhat, that while M. Mauriac has seen so many
reflex neuralgias set up by orchi-epididymitis, he does not appear to
have noticed cases of trigeminal neuralgia from this source; because, in
the very analogous instance of the peripheral irritation produced by
excessive masturbation, we undoubtedly do frequently get a development
of the tendency to migraine, and also to other forms of neuralgia of the
fifth: moreover the effect of such local irritation can be occasionally
traced with much distinctness in the trigemini, by a tendency to certain
forms of eye-disease without positive neuralgia. This was remarkably
exemplified in a case which was under my care some years ago, and in
which both eyes were greatly damaged by vaso-motor and trophic changes;
partial insanity also supervened with hallucinations of sight and
hearing.

We come now to one of the most powerful sources of peripheral irritation
tending to set up neuralgia; viz., functional abuse of the eye. This is
one of the very few peripheral influences which occasionally we see
producing neuralgia unaided by hereditary predisposition, or any other
observable cause whatever, and in a far larger number producing it with
the sole aid of more or less defective general nutrition. The latter
occurrence is well exemplified by a case which Mr. Carter sent me the
other day, and which also illustrates (second attack) the effect of the
superaddition of syphilitic taint:

Matilda W----, aged thirty-three, married, and has three very healthy
children. Comes of a remarkably healthy family, of which she told me the
entire history for three generations, with unusual intelligence and
clearness. No neuroses, properly so-called, in any of her relatives
during all this time. She herself was a very strong and hearty girl
until the age of seventeen; between this date and her marriage, three
years later, she was obliged to work tremendously hard at fine sewing,
by which means she gained a very scanty livelihood. After a
comparatively short period of this work she began to suffer from typical
attacks of migraine, very severe, and recurring every three or four
weeks, but in no particular connection with the menstrual function,
which was normal. On her marrying and ceasing to do needle-work, the
migraine entirely disappeared, and she retained perfect health till the
commencement of 1871. At this time she had suckled a very hearty baby
for ten months, and was not able to furnish such good living as usual.
She was attacked early in January, with violent neuralgia affecting all
three branches of the right fifth, and she the more readily applied for
advice because she soon found that the neuralgia was becoming
complicated with dimness of vision in the eye of the affected side, "as
if she was going to have a cast." Was quite unconscious of ever having
had syphilis. The medical man encouraged to believe that the whole
malady was nervous, and would soon disappear under appropriate remedies,
and gave her quinine, under which treatment she declares that she was
rapidly improving, both as to pain and vision, but that her resources
came to an end, and she could no longer pay for the medicine. She then
neglected herself, and rapidly got worse in all regards, till at last
she was compelled to apply to the South London Ophthalmic Hospital,
whence Mr. Carter sent her to me, on the 6th of April. At this time the
paroxysms were excessively violent and frequent, though brief. On
examination, tender points were found at the supra-orbital notch, at the
infra-orbital foramen; in front of the ear; in the temporal region; in
the parietal region, and the inferior dental region. There was strongly
marked anæsthesia of the skin of the right half of the face, of the
gums, and of the side of the tongue. The teeth were absolutely perfect:
not one spot of caries could be seen. Taste was completely destroyed in
left half of anterior part of the tongue. Smell was totally lost on both
sides, and had been so, the woman declared, from a very early period in
the illness. The right eye showed complete paralysis of the levator
palpebræ and of the external rectus; nearly complete paralysis of the
superior and inferior rectus, rather less marked paralysis of the
internal rectus. Pupil normal, conjunctiva moderately congested,
lachrymation profuse, photophobia partial. The functions of the retina
were perfect. Accommodation was affected in the following degree and
manner. The vision of the affected eye was perfect at long distances,
very imperfect at short distances. With both eyes open she saw every
thing double, but could still count all the bricks in a whitewashed wall
at sixteen feet distant. There was no secondary disturbance of the
stomach whatever. On the first visit she assuredly had no visible
signs, in skin or throat, of syphilis; the perfect health of her
children, and absence of abortions, made syphilis the less probable. But
on her second visit she complained of sore throat, and a week later a
palpably specific sore appeared on the soft palate. She declared, with
apparent sincerity, that it was the first symptom of the kind she had
ever had. The neuralgia rapidly disappeared under thirty grains of
iodide of potassium daily. The lesions of taste and smell disappeared
exactly pari passua with the trigeminal pains. The ocular paralysis
threaten to be much slower in departing. I think we must believe that
this woman contracted syphilis after the birth of her last child. It is
at any rate certain that the migraine of her youth was perfectly
unconnected with syphilis, being as unlike the pains evoked by the
latter as it is possible for two kinds of pain to be. In all probability
she was infected during her last lactation.

Last among the peripheral influences of sufficient importance to be
specially mentioned as effective factors in the production of neuralgia,
must be mentioned caries of the teeth, and the comparatively rare
accident of the mal-position or abnormal growth of a "wisdom-tooth." It
is an undoubted fact that these things may cause neuralgia even of a
very serious type, and attended with extensive complications; as in Mr.
Salter's cases, already mentioned, of reflex cervico-brachial neuralgia
from carious teeth. Looking to the extreme frequency of caries, however,
as compared with the rarity of true neuralgia (not mere toothache) as a
consequence of it, it is impossible not to suppose that the share of the
carious teeth in the production of such neuralgia must be very small,
compared with that of other influences.

5. The next influence which we shall mention as undoubtedly very
effective in assisting the production of neuralgia in certain cases is
that of anæmia and mal-nutrition generally; but it is not necessary to
dwell on this at any length. The fact is notorious that severe loss of
blood is always followed by headache; and if there be the least
predisposition to neuralgia, this headache will very commonly take the
form of the severest clavus. And, in like manner, chronic states of
anæmia and of mal-nutrition undoubtedly aggravate every existing
neuralgia, and bring out lurking tendencies to the disease. But I do not
believe that anæmia, or starvation pure and simple, ever generates true
neuralgia by its sole influence.

6. The question how far, and in what way, the neuralgic tendency is
helped by certain constitutional diatheses, such as rheumatism and gout,
and by certain toxæmiæ, such as malaria, alcoholism, lead-poisoning,
etc., is a very much more difficult one than might be supposed from the
off-hand manner in which many writers speak of the "rheumatic," the
"gouty," or the "alcoholic" forms of "neuralgia." We may, however,
simplify it a good deal. In the first place, it seems obvious to me that
the only manner in which alcohol helps the production of true neuralgia
is by its tendency, after long abuse, to produce degeneration of the
nervous centres: it will therefore be considered, shortly, under another
division of the present subject. Lead-poisoning, again, only produces so
highly special a form of neuralgia (if colic be neuralgia at all) that
it need not detain us here. The influence of malaria is, for the most
part, an utter mystery to us, but by so much as we can see it appears
plain that one of the most important features in the disease is a
powerful disturbance of the spinal vaso-motor centres. But the most
interesting consideration that we have to deal with is the question of
the supposed relations of the rheumatic and the gouty diatheses, and the
syphilitic dyscrasia, to the neuralgic tendency. On this point I am
obliged to disagree _in toto_ with the popular view that assigns these
diatheses among the most frequent predisposing causes of neuralgia.

To take the case of rheumatism first, I am willing to allow that there
are a number of facts which superficially appear to countenance the idea
of a close connection of this disease with neuralgia. But of these facts
a considerable proportion consist only of examples of inflammation of
the nerve-sheath, with a certain amount of effusion within and around
it, occurring in persons who have never shown any symptoms which warrant
the assumption of a general rheumatic diathesis; and these local
phenomena really differ in nothing from many trophic and vaso-motor
changes which have been already described as plainly secondary to
ordinary neuralgia in which there could be no pretence of a rheumatic
pathology except on the slender foundation of a suspicion that the
affection was immediately excited by the influence of cold, which is
really no argument at all. Such patients will be found to have
exhibited, not special rheumatic, but special neuralgic tendencies in
their past history. On the other hand, there undoubtedly are a certain
number of patients who, having previously given signs of a tendency to
generalized rheumatic inflammation of fibrous membranes, are, on some
particular occasion, attacked with similar inflammation extending over a
more or less considerable tract (not a small limited spot) of a nerve
sheath. But so far from agreeing with those who think that this is a
frequent case, my experience teaches me that it is quite exceptional;
nor do I believe that the common opinion could ever have arisen had it
not been for the rage that exists for connecting every disease with a
special diathesis which the profession flatters itself that it
understands. Few persons have taken more pains than myself to ascertain
the frequency with which neuralgic patients show a history of previous
rheumatism, whether in the so-called "fibrous," or in the synovial
form; but it is remarkable how seldom I have found this to be the
case--a result which surprised me, because it happened that I, a
neuralgic subject, had suffered in youth from regular acute rheumatism,
and had fancied that I should discover a close connection between
rheumatism and neuralgia. Eulenburg states that neuralgia caused by cold
more frequently attacks the sciatic nerve than any other, and thinks
that the tendency to sciatica is characteristic of the relations of
rheumatism to sensory nerves. For my own part, I see no reason to call
in the rheumatic diathesis as a _deus ex machina_ to explain the
frequency with which sciatica follows comparatively trifling peripheral
impressions like that of cold. The true reason I believe to be, that
what would have been a slight and trivial neuralgia elsewhere, becomes a
serious affection in the instance of the sciatic nerve, by reason of the
strong muscular pressure end dragging which are always going on in the
thigh in locomotion. I shall return to this subject when speaking of
Treatment.

As regards the relations, of gout to neuralgia, I can hardly express my
own view better than by quoting the words of Eulenburg:[17] "Much more
doubtful is the influence of gout, which in rare cases, perhaps,
produces neuralgia directly, by means of neuritis, or by the deposit of
tophus-like calcareous concretions in the nerve-trunks. Gout has been
reckoned as a great influence among the causes of superficial neuralgias
(sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but
this influence is more probably only an indirect one, operating through
circulation changes which are often produced by chronic liver-diseases
or by diseases of the heart and vessels, (_e. g._ Valvular diseases and
narrowing of the coronary arteries in angina)." To which I will add this
argument against any close connection of gout with neuralgia, that it is
exceedingly seldom that colchicum effects any decided good, a fact which
is as unlike the relations of colchicum to true gout as any thing could
be. For, whatever may be thought of the advantages or disadvantages, on
the whole, of employing colchicum against gout, at least no one with any
experience will deny that in the immense majority of cases of true gouty
pain, it gives rapid relief to the acute suffering. I doubt if it
ever[18] acts in that way in real neuralgia, though I have occasionally
seen it apparently useful in a more limited way, as will be said
hereafter.

As regards the relation of the syphilitic dyscrasia to neuralgia, I
agree in general with Eulenburg. "Syphilis," he says, "may be the direct
cause of neuralgia, either by the development of specific gummata in
the nerve-trunks or in the centres, or by arousing chronic irritative
processes in the nerve sheaths, the membranes of the brain and spinal
cord, or, especially, in the bones and periosteum (syphilitic osteitis
and periostitis)." The case of periostitis, however, is a doubtful one:
it may be questioned whether this affection (which will be among the
diseases discussed in Part II. of this work) ever give rise to true
neuralgia. Persons who are, by inheritance, highly predisposed to
neuralgia, may from the mere general lowering of their health produced
by constitutional syphilis, become truly neuralgic simultaneously with,
or subsequently to, the appearance of painful nodes on their bones. And
as regards the whole relations of syphilis to neuralgia, I must, from my
experience, conclude that the former is, after all, but rarely concerned
in the production of the latter. Syphilis has a strong specialty for
producing limited motor paralyses, but a much weaker one for producing
limited affections of the sensory system.

7. We now come to the discussion of a group of momenta whose influence
in the production of neuralgia is at once very powerful, and of the
highest significance as regards the general pathology of the disease.
These are the degenerative changes of the arterial and capillary systems
which are a part of the normal phenomena of old age, but may occur at
earlier periods of life, in consequence either of certain constitutional
diseases, especially gout, or of special toxic influences on nutrition,
of which persistent alcoholic excess is very far the most important.

The reader does not need to be told the familiar story of the
degenerative changes in the vessels which, commencing usually some time
during the fifth decenniad, by degrees convert the elastic arterial
coats, and the almost membranous walls of the capillaries, into more or
less rigid tubes; nor does he need to be informed that the tendency of
these changes, as they operate in the great motor and intellectual
centres, is notoriously to produce innutrition of the tissues that
depend for their blood supply on the affected vessels, whence cerebral
softening so commonly results. That analogous changes take place in the
vessels supplying the spinal centres is certain; but it is a remarkable
fact that these do not very commonly produce motor paralysis. What they
do produce is rather a slow enfeeblement both of (spinal) sensation and
motion, but where the process of decay has been prematurely forced, or
the inheritance of neurotic weakness is very marked, the process of
sensorial decay (the decline, that is, of true sensorial function) is
apt to be mingled with pain. That this pain should be localized, often
in a single nerve, is no more surprising than the fact that the
degenerative process itself should vary so greatly in the degree of its
development at one point from that which it shows at others. I have
already insisted (_vide_ Chapter I.) on the marked correspondence
between the period of life in which degenerative changes commence and
progress (the last third, roughly speaking, of a fairly long life), and
that in which the most severe, intractable, and progressively increasing
neuralgias are developed. I must here notice a singular statement of
Eulenburg's, that neuralgia never attacks people who are over seventy.
That statement shows that persons of a greater age than seventy are rare
in this world, and that no such patient happened to come under
Eulenburg's notice; for I have (by mere chance, doubtless) seen several
instances of first attacks occurring after seventy; and almost the worst
case of epileptiform tic I ever saw began when the patient was eighty;
she was a member of a highly neurotic family whose medical genealogy is
given at a previous page. In general terms, it may be said that every
additional year of life after fifty increases the probability that a
neuralgia, should such arise, will be severe and rebellious to
treatment; and in the very aged the cure of such affections is probably
impossible.

8. This seems the proper place to introduce such facts as have been
observed, and they are very few, that directly illustrate the material
changes occurring in neuralgia.

Very much the most important of these facts is the history of a
remarkable case recorded by Romberg. ["Diseases of Nervous System," Syd.
Soc. Trans., vol. i.] The patient, a man sixty-five years old at the
time of his death, had suffered for several years from the most violent
and intractable epileptiform trigeminal neuralgia, complicated with
interesting trophic changes of the tissues. Post-mortem examination
showed that the pressure of an internal carotid aneurism had almost
destroyed the Gasserian ganglion of the painful nerve, that the trunk
and posterior root of the nerve were in a state of advanced atrophic
softening, and the atrophic process had extended in less degree to the
nerve of the opposite side. Now, the value of this case is by no means
restricted to the fact that it records the existence of a particular
anatomical change in one example of neuralgia. Its most striking
teaching is the fact that the acutest agonies of neuralgia can be felt
in a nerve, the central end of which is reduced to such a pitch of
degeneration that conduction between centre and periphery must very
shortly have entirely ceased had the patient lived. And hardly less
important is its illustration of the fact that permanent injury to the
ganglion of the posterior root of a spinal nerve impairs the vitality of
the posterior root itself--a fact which has been independently made out
by the physiological researches of Bernard and of Augustus Waller.

On the other hand, if we examine the tolerably numerous histories of
cases in which the painful nerves have been examined at the apparent
site of pain, we discover nothing to lead us to connect neuralgia
definitely with any one sort of change. Assuredly, for example, local
neuritis is by no means universally, it is probably even not commonly,
present in the early stages of neuralgia; it has also been repeatedly
detected in nerves that had been wholly free from neuralgia; and, on the
other hand, it has been entirely absent in nerves that have been the
seat of the severest pains. Moreover, many facts which have been put
down without reflection, as showing a local peripheral cause for
neuralgia, are at least open to another and, as I believe, truer
explanation; as (_e. g._) in the following remarks of Eulenburg on
mechanical irritations of nerves as causes of neuralgia: "Diseases of
bones are extraordinarily frequently the cause of neuralgias in
consequence of compression or secondary disease, which affects the
branches of nerves passing through canals, foramina, fissures, or over
processes of bone. The appearances which the opportunities of resections
of the trigeminus for facial neuralgia have permitted to be discovered,
have given us valuable information in that direction. Flattening and
atrophy of nerves from periostitis, or from concentric hypertrophy in
narrowed bony canals, have frequently been discovered. The neurilemma at
the narrowed parts was often seen reddened, ecchymosed, infiltrated with
serum, or surrounded with fibrous exudation; occasionally inflammation
had been followed by partial thickening of the neurilemma (fibrous
knots) and turbidity (Trubungen) of the nervous cord at the
corresponding spot. Similar appearances have been noted in other
neuralgias (neuralgia-brachialis, sciatica)." For my own part, I believe
that the above description represents the facts from an erroneous point
of view. True neuralgia, if by that we understand a pain of intermittent
character limited to one or more nerves, is in my experience an
extremely uncommon result of periosteal disease, or of inflammation of
the linings of bony canals; but in a great number of instances such
diseases appear to be set up as the secondary consequence of the
neuralgic process (whatever the essential nature of that may be) going
on in sensory nerves which supply the parts when these inflammations
appear. And it must be remembered that the specimens obtained by
resection of nerves are comparatively few in number, and are taken
universally from old-standing and desperate cases of disease; in short,
from cases which are just in those advanced stages of neuralgia in
which, as has already been amply shown, these secondary inflammations
are almost always present. On the other hand, I have myself had one
opportunity of examining the local condition of an intercostal nerve,
which during life, and quite up to death, had been the site of the most
pronounced neuralgia, which, however, had only existed for a few days.
The patient, a young man, aged twenty-seven, was probably insane, and
had attempted suicide. Not a trace of inflammation, either in the nerve
itself or in any of the tissues to which it was distributed, could be
detected. (This was a case in which I greatly regretted the
impossibility of getting a family history that was at all reliable.) The
spinal cord, unfortunately, could not be examined. And I strongly
believe, from the marked absence of tenderness on pressure which is
almost universally observed in ordinary cases of neuralgia at an early
stage, that primary inflammation of neurilemma, periostem, etc., as a
cause of neuralgia, is altogether exceptional; so much so, that we are
entitled to believe it can never be more than a concurrent, and then not
the most important, cause.

It is necessary here to inquire, more particularly than we have yet
done, into the nature of the "painful points" first signalized by
Valleix as a distinctive symptom of neuralgia. Very great differences of
opinion have prevailed among subsequent writers, both as to the
frequency and the significance of these points. It may be said, however,
to be now quite settled that the presence of definite points, painful on
pressure, and also corresponding to the foci of severest spontaneous
pain, is far from universal in neuralgia. Upon this point there is
probably no reason to doubt the correctness of Eulenburg's observations
made in the surgical clinic of Greifswald and the polyclinic of the
University of Berlin; he says that he discovered the existence of tender
points in "Valleix's sense," in rather more than half the cases of
superficial neuralgia, but in the rest he could not by any means
discover them. In many other cases, however, he found more indefinite
points of tenderness, not accurately corresponding to nerve-branches,
but affecting individual portions of skin, bone, or joints; the relation
of these to the neuralgic symptoms was difficult of explanation.
Eulenburg lays down the principle that "hyperæsthesia" may depend on
three sorts of causes--(1) On local disease of the peripheral ends of
nerves; (2) on alterations of the psychical centres; and (3) on morbidly
exaggerated conduction in the nerve-trunks themselves; and it is to this
third source that he attributes many of the phenomena of the neuralgic
painful points, and especially their multiplicity, in many cases. The
_locus in quo_ of the mischief which sets up this exaggerated conduction
of sensory impression is, upon this theory, between the psychical centre
and the main point of branching of the nerves; hence a large number of
peripheral nerve-termini might be practically sensitive to touch,
because the mischief, though localized in a comparatively small spot,
might easily affect many bundles of fibres, which diverge widely from
each other in their course. It will be seen presently with what limits
and for what reasons we believe this to be a true theory. But to return
to the question of painful points in Valleix's sense, we must state one
or two facts which seem certain from our own experience, but have not
been adequately recognized, we believe, by others. The first is, that
localized tender spots, accurate pressure on which will set up or
aggravate the neuralgic pain, are not early phenomena, save in
neuralgias of exceptional severity of onset; but that a certain
persistence and severity of neuralgia are always followed by the
formation of one or more true points douloureux. The second fact relates
to the clinical history of migraine. Roughly speaking, it is true, as
Eulenburg states, that, in pure migraine, painful points in Valleix's
sense are not to be found; in place of them we observe, after the
paroxysms have passed away, a more generalized soreness of considerable
tracts of the scalp, forehead, etc., or diffuse tenderness of the
eyeball. But I must here again refer to the fact, first observed in my
own case, and afterward verified in many others, that migraine may be
only the youthful prelude to a regular trigeminal neuralgia attended
with the formation of characteristic localized painful points at a later
period. And the third fact that must be specially mentioned is that the
true Valleix's point, when it has become established for some time, is
not a mere spot of sensitive nerve, but is the scene of trophic changes,
involving hyperæmia and thickening of parts surrounding the nerve. To
give one example, it is quite a frequent thing to find a patch of tender
and sensibly thickened periosteum of irregular shape, but equal
sometimes to a square inch in size, over the frontal bone at and
immediately above the inner end of the eyebrow, in cases where
supra-orbital neuralgia has recurred frequently during some years,
although no such thing was present when the neuralgia first commenced.
In my own case, the bone has become sensibly thickened at that point.

The general result of such post-mortem and clinical information as can
be had seems clearly to be that positive anatomical changes, either of
nerve-terminals or superficial nerve-branches, are but casual and
infrequent factors in the first production of neuralgia, and, in
particular, it would seem that inflammation of a nerve itself by no
means necessarily produces neuralgic pain, but (far more commonly)
simple paralgesia or anæsthesia of the parts external (peripheral) to
the lesion. The one marked exception to this general proposition is to
be found in the case of the severe and peculiar injuries inflicted on
the trunks of nerves by gunshot-wounds which, as we have seen (from the
American experiences), can produce some of the most dreadful forms of
neuralgia. But the nature of the injury here inflicted is, it must be
remembered, quite different from any thing which either disease or
accident in civil life would produce, save in the most exceptional
instances. For the chief material element in the production of the
neuralgias of ordinary life we are really driven, by exclusion, to the
condition of the posterior roots of special nerves, in some cases,
perhaps, to the (spinal) ganglia on which the nutrition of these roots
probably is considerably dependent.

With the field thus narrowed for us, it is surely legitimate, in the
necessary scarcity of anatomical records referring directly to the state
of the nerve-roots in ordinary neuralgia, to place great weight on the
facts of a disease like locomotor ataxy, in which the main anatomical
change is a progressive atrophy of the posterior columns which usually
falls with peculiar severity on the posterior nerve-roots, or on the
parts of the gray matter immediately adjoining these, and in which
neuralgia may be said, for practical purposes, to be a constant and most
characteristic phenomenon. If any one desires to see how strikingly the
connection of the neuralgic phenomena with the anatomical-change comes
out, I recommend him to study Dr. Lockhart Clarke's papers on locomotor
ataxy (_vide_ "St. George's Hospital Reports, i." 1866; _Lancet_, June,
10 1865; "Med.-Chir. Soc. Transactions," 1869), or the excellently
reported case by Nothnagel (_Berlin Klin. Wochensch._, 1865). It is
really not too much to say that the only important difference between
the clinical aspect of the pains of locomotor ataxy and those of
ordinary neuralgia is simply such as depends on the fact that the
anatomical change in the former case is bilateral, and usually affects
the roots of several, sometimes of a great many pairs of nerves. I
infer, from a conversation with Dr. Clarke, that he fully recognizes the
force of the analogy, and the great strength of the presumption which it
sets up in favor of an atrophic change of the posterior roots in
neuralgia.

It may, of course, be urged, against the view that neuralgia depends on
any change analogous to those which occur in ataxy, that quantities of
cases of the former recover speedily, and must be supposed to be either
independent of material change altogether or, at any rate, to have
involved only very trivial anatomical changes, not formidable diseases,
like atrophy of nerve-centres. I find it impossible to admit that this
argument has the slightest force. Are we to suppose that the posterior
nerve-roots alone, of all tissues and organs of the body, are incapable
of minute and partial changes in the direction of molecular death which
may be perfectly recovered from in weeks, months, or even days? I, for
one, cannot doubt, that such changes are of frequent occurrence, in all
parts of the central nervous system, when I can consider the absolute
dependence of these portions of the organism upon a perfect
blood-supply, and the immense number of possible causes of temporary
interference with that source of nutrition. And I can see no probable
difference, except in degree and persistence between the effects on
sensation which would be produced by such a change of the posterior
roots as this, and that which would result from the more serious and
fatally continuous change which is involved in locomotor ataxy.

9. We come now to a most important but most complex and difficult
portion of the argument respecting the _locus in quo_ of the essential
pathological process (if such there be) in neuralgia; viz., as to the
paths and the character of the so-called "reflex" influences which
intervene in the causation, both of neuralgia itself, and also of the
numerous complications with which we have seen that neuralgia is liable
to be attended. The clinical facts which confront us here, and demand
explanation, are the following: (1) Irritation so called, of sensory
fibres may apparently evoke pains attributed to the site of the
irritation, or to the parts on the peripheral side which are supplied by
the same sensory nerves. (2) Peripheral irritation of a particular
sensory nerve may evoke neuralgic pains in nerves connected with that
irritated only through the spinal centre. (3) Neuralgia in a sensory
nerve may (and almost always does, to some extent) produce secondary
vaso-motor paralyses: these paralyses may affect fibres which run in the
same branch of the nerve as that which is painful, or fibres that run in
another branch of the same nerve, or fibres that run with another
sensory nerve, or the ganglionic chain of the sympathetic itself. (4) In
like secondary manner, neuralgia may produce vaso-motor spasms in any of
the directions just specified; this is usually a short-lived phenomenon,
giving place quickly to paralysis; but Du Bois Reymond's often-quoted
analysis[19] of his own sufferings from migraine seems to show that
spasm-producing irritation of the trunk of the sympathetic may last
during some hours. (5) Neuralgia in a sensory nerve may increase, alter,
or (more rarely) suspend the secretions of glands supplied by fibres
bound up either in the same branch, or in another branch of the same
nerve, or in a different nerve with which it is connected only through
the centre or (possibly) only through a plexus. (6) Neuralgia in a
sensory nerve can produce paralysis of muscles supplied by motor fibres
bound up with the painful branch, or with another branch of the same
nerve, or in muscles supplied by a totally distinct nerve connected only
through the centre. (7) It may produce convulsion and spasms of muscles,
in all the above directions; this usually alternates with great
weakness, or actual paralysis of the same muscles. (8) It may produce
partial or complete loss of common or special sensation in nerve-fibres
that run either with the same branch, or with another branch of the same
nerve. (9) It may produce trophic changes, either in the direction of
simple atrophy or of subacute inflammation with proliferation of
lowly-vitalized tissue (_e. g._, connective) in the parts with which are
supplied with sensation by the painful branches or by other branches of
the same nerve.

It is necessary to go over again the proof of these facts; they are
given pretty copiously in the chapter on Complications; and could have
been made much more numerous. But the point to which I desire to compel
the reader's attention is the impossibility as it seems of me, of
accounting for the variety and complexity of these phenomena, except by
the supposition that there is in every case of neuralgia a central
change, which is the one most important factor in the producing both of
the pain and of the secondary phenomena. For the result of my experience
is that neuralgia, unless very slight and brief, is never unattended by
these complications and in the great majority of cases involves several
different secondary alterations of function which must (so to speak)
radiate from the central end of the sensory nerve, and from no other
place whatever. And it must be remembered that the most elaborate
"_symptome-complexe_" is found equally in cases where no suggestion of
any peripheral origin of the pain can be made, and in cases where, at
first sight, one might fancy there was a very obvious peripheral cause
for pain. I am quite willing to admit, with Eulenburg and others, that
the evidence, powerful and varied though it be of the relations of
neuralgia to hereditary neuroses, to alcoholic and senile degeneration,
etc., only raises a strong probability that some part of the central
nervous system is the _locus in quo_ of the essential morbid processes
in the majority of neuralgias. But the case stands far otherwise now
that we are able to show, not merely that the majority of neuralgic
patients suffer from such influences as those above mentioned, but that
every variety of neuralgia is liable to be complicated with secondary
affections of the most divergent nerves, the only common meeting-place
of which is in the spinal centre of the painful nerve; and when we find
moreover, that many of these secondary affections can equally be
produced by undoubted atrophic changes (as in ataxy of those same
posterior roots).

At this point we must introduce a remark relative to the true nature of
so-called "reflex" effects. The word is constantly used, and is also
much abused, as Eulenburg remarks. We all understand, of course, what is
intended by the commonest use of the word: the case of sneezing produced
by the irritation of snuff applied to the peripheral branches of the
fifth nerve in the nose is a stock example. But another application of
the phrase, of much more questionable propriety, is that where it is
employed to designate functional nervous actions, which merely arise
simultaneously with or subsequently to sensory phenomena as to which
there is no proof whatever that they were produced by peripheral
irritation. This particular inaccuracy of customary speech has probably
contributed largely to the inveteracy with which writers on nervous
disease have insisted on assuming a peripheral origin in every case for
neuralgia itself. In the case of sciatica, for example, complicated,
secondarily, with paralysis of the flexors of the limb, it seemed easy
and scientific to speak both of the neuralgia and the paralysis as
"reflex" effects of a local peripheral mischief--gouty, rheumatic, or
the like; and it appears to have been perfectly forgotten by many that
the whole phenomena might be explained by an original morbid action in
the sensory root of the nerve, extending subsequently to the motor root,
without any intervention of peripheral irritation whatever, or under the
influence only of the ordinary peripheral impressions, which, in health,
evoke no painful nor paralytic symptoms. It is by this kind of extension
of a central morbific process, leading to radiation of the perturbing
influence centrifugally along divers nervous paths, that I believe we
must explain the facts observed in complicated cases.

Take, for example, the following case, which, in its history of
twenty-three years, presents a fair example of a type of trigeminal
neuralgia which I believe to be the rule rather than the exception,
though the trophic changes were somewhat unusually varied and
interesting. The following would be the pathological order of events,
according to the radiation theory: First or true migrainous stage;
failure of nutrition of a portion of the sensory root of the right fifth
nerve within medulla oblongata, lesser degree of the same condition in
the adjoining and closely-connected vagus root (hence supra-orbital
pain, local anæsthesia and vomiting); extension of the morbid process to
the motor root (hence vaso-motor paralysis and secretory and trophic
changes in the cornea, superciliary periosteum, etc). Second period:
recovery, to a large extent, of the nutrition of the posterior root of
the trigeminus, complete recovery of the root of the vagus (hence
alteration of the type of recurrence of the pains, which now occur at
increasingly long intervals, and needed special provocation, _e. g._,
excessive fatigue, to bring them on; hence, also, disappearance of the
stomach symptoms); continuance of the affection of the motor portion of
the nerve (hence, continuance of the tendency to trophic, secretory, and
vaso-motor changes); development of the true points douloureux during
and after the paroxysms, instead of the diffused tenderness following
the old attacks of migraine. Third stage: neuralgic attacks become rare
and comparatively unimportant; tendency to trophic changes greatly
lessened; local anæsthesia persists. Presumption, that the nutrition of
the nerve-centre has nearly recovered itself, but that that centre is
still the _locus minimæ resistentiæ_ of the central nervous system,
liable to suffer from any cause of general nervous depression.

Now, in interpreting the above phenomena, as I do, upon the theory of
one essentially uniform nutritive change affecting the fifth nerve
within the medulla oblongata, I shall be met with the following
objections: First, there is the common and superficial difficulty that
pain and paralysis of sensation must be opposite states, and that it is
impossible to refer them both to one and the same pathological process.
I have already in many places given instances how constantly pain and
sensory paralysis interchange in a manner which is totally
incomprehensible except upon the supposition that their physiological
basis is essentially the same; but the most satisfactory evidence,
perhaps, that could possibly be produced on this point is to be found in
the perusal of a group of cases observed by Hippel,[20] and entitled by
him "Anæsthesia of the Trigeminus," the loss of sensation being the most
remarkable feature. The cases are so deeply interesting that I would
gladly transfer them bodily to these pages, but must abstain from want
of space. Suffice it to say here, that, in the first place, the
anæsthesia was accompanied, in every one of these cases, by a most
distinct and typical neuralgia; and, secondly, that trophic changes
occurred which most interestingly (though not with absolute
completeness) reproduced the phenomena observed after complete section
of the trigeminus at the Gasserian ganglion.

The second objection sure to be raised to the theory of a simple
spreading of a nutritive central change, as the cause of all the
phenomena in such a case as the above, is this: It will be asked how the
process extended itself to the motor root, which, in the case of the
fifth nerve, is removed by a somewhat formidable anatomical distance
from the sensory root. I am, of course, well aware of the latter fact,
and it is an additional reason for selecting neuralgia of the fifth, as
an extra difficult test of the value of my theory. A few words must be
premised, reminding the reader of the physiological anatomy of the
nerve.

The trigeminus is in all its characters a spinal nerve; but it has
sundry peculiarities both of structure and of connections with other
nerves. Its posterior or sensory root is enormous, and, as Schroder van
der Kolk showed, takes a direction from behind downward and forward,
which is intended to facilitate its numerous and important connections
with the nuclei of other nerves: of these the most notable are its
connections with the vagus, facial, glosso-pharyngeal, and hypo-glossal
nuclei. The motor root, much smaller than the sensory, was shown by
Lockhart Clarke to be traceable as low as the inferior border of the
olivary body, as a column of cells which occupies a situation
corresponding to that of the anterior course of the spinal gray matter.

As this column passes onward in the medulla oblongata, on a level with
the glosso-pharyngeal nerve, it forms a group of cells of large size.
Besides numerous other connections which it forms, Clarke describes the
motor root as sending processes forward, like tapering brushes or tails
of fibres, in connection with more scattered cells lying in their
course, which may be frequently seen to communicate with the transverse
bundles which traverse the "gray tubercle" and the sensory roots of the
fifth contained therein. In this way the sensory root, though seemingly
much separated from, is really in very direct connection with, the motor
root.

Now, proofs, which must be considered almost positive, have recently
been adduced to show that the nerve-fibres concerned in those peculiar
alterations in the tissues supplied by the ophthalmic division of the
fifth, which occur in section of the trigeminus, come entirely from the
motor root of the fifth, and form a very small band in the inner or
medial margin of the ophthalmic trunk. The observation of Meissner[21]
goes to show that it is possible (by good luck) to divide the trunk in
such a partial manner as to cut only the inner fibres, and thereby
produce the trophic eye-changes without any anæsthesia, or only the
sensory fibres, and thereby induce anæsthesia without any trophic
changes; and it must be owned that this really affords the only
reasonable explanation of the discrepancy between the experimental
results obtained by Magendie and Bernard; and also the facts of such
cases as those related by Mr. Hutchinson,[22] who in two instances found
that a completely anæsthetic eye recovered perfectly well from the wound
made in a surgical operation. The nature of the nervous influence
(whether ordinary vaso-motor only, or a special trophic function) has
been greatly disputed. Dr. Wegner,[23] from observing the remarkable
group of glaucomatous cases under Horner (of which one has been
related), made experiments, from which he concluded that the
augmentation of intra-ocular pressure in glaucoma was a phenomenon
dependent upon the sympathetic, which was irritated by reflection from
the trigeminus. But the researches of Hippel and Grunhagen, especially
their latest,[24] give a different explanation, excluding the
sympathetic; they found that irritation of the medulla oblongata, in the
neighborhood of the trigeminus root, produced a lasting and very
pronounced augmentation of intra-ocular blood-pressure, an effect which,
they remark, could not depend on irritation of the vaso-motor centre,
since that must produce contraction of the vessels and lowering of the
blood-pressure. They conclude that "the trigeminus contains specific
fibres which possess the property of actively dilating the blood-vessels
of the eye;" and in reference to the secretion of the fluid humors of
the eye, they conclude also that "the trigeminus also plays the part of
an (active) nerve of secretion."

Of these conflicting opinions I can have no difficulty in at any rate
rejecting that of Wegner; for the clinical phenomena of the
complications attending trigeminal neuralgia, such as they are described
in my last chapter (and could have been described at much greater
length), seem to me utterly to exclude vaso-motor spasm except as a
temporary phenomenon at the commencement of the attacks of acute pain.
Vaso-motor palsy undoubtedly is very often present, in fact every attack
of neuralgia of a certain severity is thus complicated; and there is no
reason to doubt that this paralysis could be caused by lesions within
the medulla. Are we, then, to admit functions of active dilatation of
vessels, and active impulse to secretion in certain fibres of the fifth?
It is necessary at any rate to clear the ground in one respect: it must
not be supposed that I for a moment entertain the idea that there can be
direct active dilatation, _i. e._, that there can be any system of
muscular fibres (and nerve-fibres stimulating them) whose office is to
open the calibre of the vessels; the idea is wildly improbable--in fact
almost inconceivable by any one who reflects on the necessary
machinery--and there is not a single observed anatomical fact to give it
support. If, then, I speak of the possibility of "active" dilatation, it
must be understood that I refer to a theory of "inhibition," which
supposes certain fibres to be gifted with the power of paralyzing or
inhibiting the vaso-motor nerves. It is my duty to speak with all
reasonable reserve on that most difficult _quæstio vexata_, the
existence of special inhibiting systems of nerves, and the extent to
which a double series of opposed nervous actions is generalized in the
body; but it is impossible to avoid the subject altogether, and I offer
the following remarks, with deference, to our professional
physiologists. The strongest instances of the apparent inhibiting action
are probably afforded by the _nervi erigentes_, as shown by Loven, the
cardiac depressor, by Ludwig and Cyon, and the splanchnics (upon the
intestine), by Pfluger. But there is not a single one of these examples
that has not been challenged by experimenters of repute. Thus the theory
of the distinctive restraint-action of the splanchnics upon the
intestine, and of the vagus upon the heart, has been especially
controverted by Piotrowski, who, indeed, rejects the whole theory of
special inhibitory nerves.[25] And, from another point of view, Mr.
Lister long ago attacked the views of Pfluger, maintaining that it was
possible to produce exactly opposite effects through the medium of the
very same nerves, according as the experimental irritation applied to
them was weak or strong. To Dr. Handfield Jones[26] this seems a still
unanswerable objection to the inhibitory theory. And in the remarkably
able and judicial summary of the "Physiology and Pathology of the
Sympathetic or Ganglionic System,"[27] by Dr. Robert T. Edes, a less
decided but still tolerably strong acquiescence is given to Mr. Lister's
criticisms of this theory. Personally, I must express very strongly the
distrust (which is probably felt by many others) of doctrines which
assert an exact opposition between the functions of any two nerves, on
the basis of an observation that the same apparent effects may be
produced by section of the one and galvanization of the other; both
processes seem far too pathological, and too remote from the conditions
of ordinary vitality, to admit of any such absolute deductions from
their results.

In the present state of our information I am inclined to explain all the
congestive complications of trigeminal neuralgia on the basis of
vaso-motor paralysis. And I further believe that the cause of that
paralysis is a direct extension of the original morbid process from the
sensory root to the motor, affecting the origin of fibres in the latter,
which are destined to govern the calibre as ocular and facial vessels.
These fibres I suppose it is that Meissner succeeded in dividing when he
partially cut the trigeminus, and got nutritive and vascular changes
without anæsthesia.

There must be more than this, however, to account for the whole of the
trophic phenomena; for there is a great body of evidence to show that
mere vaso-motor paralysis does not produce any phenomena of such an
actively morbid kind as those we are endeavoring to explain. The
phenomena on the side of secretion might indeed be possibly explained by
vaso-motor paralysis. [It must be remembered that I am speaking of such
augmented secretion as is seen in neuralgia. I agree with Prof.
Rutherford (Lectures on Experimental Physiology, Lancet, April 29, 1871)
that it is difficult thus to explain the effects of galvanization of the
chorda tympani on the submaxillary gland.] Consisting as they do (a), in
the great majority of cases, of a mere outpour of what seems little more
than the aqueous part of the secretion, and (b) in a few cases of
arrested secretion, a phenomenon otherwise by no means unfamiliar as the
result of sudden, passive engorgement of glands. But the mere cessation
of vaso-motion will not account for such facts as the rapid and
simultaneous development of erysipelatous inflammation, of corneal
clouding and ulceration, of iritis and glaucoma, of nutrition-changes in
hair and mucous membrane. I must, for the present, be content to believe
it probable that there is a special set of efferent fibres in the
trigeminus, emanating from the motor-root, whose office it is in some
unknown way to preside over the equilibrium of molecular forces in the
tissues to which the nerve is distributed; trophic nerves, in fact,
though not active dilators of blood-vessels.

It seems to me that, without enlarging further on this almost endless
topic, I should be justified in assuming that I had shown the very high
probability that the common starting-point both of the neuralgia and of
its vaso-motor secretory, and trophic complications, was in the sensory
root of the trigeminus. But the argument is greatly strengthened when we
consider the fact that loss of peripheral common, and also tactile
sensation, to a greater or less degree, is constantly observed to occur
simultaneously with the pain and with the other complications. When we
observe a patient suffering from racking supra-orbital and ocular
neuralgia, and discover that at the very same period the skin round the
eye is markedly insensitive to impressions, except in the _points
douloureux_, what can we rationally suppose, except that both pain and
insensibility are the result of one and the same influence, which
radiates from the sensory centre?

Nor are we likely to reach a different conclusion, if we test the matter
by the consideration of a rarer, but still sufficiently common kind of
case, such as I have described in Chapter I., in which a very strong
peripheral influence (traumatic) produces neuralgia, accompanied by
vaso-motor and secretory phenomena, and by anæsthesia, but not in the
district of the painful nerve, but in the territory of a quite different
nerve. How can we doubt, in the case, _e. g._, of a trigeminal neuralgia
thus complicated, the exciting cause of which was a wound of the ulnar
nerve, that the morbid influence, traveling inward from the lesion,
would have passed without any special consequences (as happens in
thousands of such nerve-wounds), had it not, in its passage along the
medulla, encountered a _locus minoris resistentiæ_ in the roots of the
trigeminus? It seems impossible to account for the phenomena on any
other theory. [Eulenburg says, in reference to my reported cases of the
kind: "_Solche Falle begunstigen in hohem Grade die Annahme
pradisponirender Momente, die in der ursprunglich schwacheren
Organisation einzelner Abschnitte des centralen Nerven-apparates
beruhen._" _Op. cit._, p. 56.]

It is necessary, in the next place, to consider a very important
question, how far irritation can pass over from one nerve to another,
without reflection through a spinal centre, solely in virtue of a
connection through the medium of a nervous plexus. The case which
apparently presents such phenomena in the most unmistakable way is that
of _angina pectoris_.

The site to which the essential heart-pain is referred in this disease
is probably the cardiac, or this and the aortic plexus; in a
comparatively small number of cases the pain does not extend farther.
But much more frequently it spreads in various directions, and we have
to account for its presence (_a_) in intercostal nerves, (_b_) cervical
nerves, (_c_) nerves springing from the brachial plexus.

Before we inquire into the mechanism by which this extension of the pain
takes place, we ought in strictness to ask ourselves whether the
essential heart-pain is felt only in the spinal sensory branches, or
whether the sympathetic fibres are themselves capable of feeling pain.
The latter supposition, notwithstanding all that has been argued in its
favor from the supposed analogies of the pain of colic, gall-stone,
etc., seems to me very doubtful. It would appear more probable that both
the latter pains, and also those of angina, are really connected with
branches either of the vagus or of other spinal nerves. And there is no
need to invoke the sympathetic as a sensory nerve, to account either for
the essential heart-pain of angina, or for its extension into arm,
chest-wall, and neck. For the plexus cardiacus receives spinal branches,
both from the vagus and also (through the medium of the sympathetic
ganglia of the neck) from the whole length of the cervical and the
uppermost part of the dorsal cord-centres. And, in this way, it would
seem quite possible intelligibly to account for the pain radiating into
intercostal, cervical, and brachial nerves, merely by extension of a
morbid process essentially seated in the cord. Usually, however, one
sees it explained not in this way, but by the inter-communications that
exist outside the spine, between the branches from the cervical ganglia
and the lower cervical and upper dorsal nerves; and the pain in the arm
is especially explained by the connection (outside the spinal canal) of
the inferior cervical ganglion, on the one hand with the lower cervical
nerves, which go to the brachial plexus, and, on the other hand, with
the heart itself. There remains to be explained, however, the singular
tendency of the arm-pain to be one-sided (this happens in at least four
cases out of five); and this explanation seems to me insuperably
difficult, on the theory that the transference of morbid action to the
brachial nerves takes place through external anastomoses. It appears
greatly more probable that angina is essentially a mainly unilateral
morbid condition of the lower cervical and upper dorsal portion of the
cord; liable of course to be seriously aggravated by such peripheral
sources of irritation as would be furnished by diseases of the heart,
and especially by diseases of the coronary arteries; the latter
affection probably involving constant mechanical irritation of the
cardiac and the aortic plexuses. It is noteworthy that the arm-pain is
sometimes (I do not know how often) accompanied by vaso-motor paralysis
in the limb; this phenomenon could also certainly be more easily
accounted for on the supposition of radiation from a spinal vaso-motor
centre (to which the morbid process had extended from a posterior
nerve-root) than on that of communication between painful sensory nerves
and vaso-motor nerves; through either of the plexuses independently of
the spinal centres.

In truth, I suspect that, whatever part the plexuses, with their
reenforcing ganglionic cells, may play during physiological life, they
are not often the channels of mutual pathological reaction of one kind
of nerve with another. It would be possible to argue this even more
strongly in the case of trigeminal neuralgias; but I must not
unnecessarily expand this already too lengthy discussion.

From the varied considerations which have now been adduced, the reader,
unless I altogether miscalculate the value of the facts, will probably
have arrived at the following conclusions: (1) That the assumption of a
positive material centric change as the essential morbid event in
neuralgia is almost forced upon us; (2) that, whereas the morbid
process, if centric, is _a priori_ infinitely more likely to be seated
in the posterior root of the painful nerve, or the gray matter
immediately connected with it, than anywhere else; so, again, the
assumption of this locality will explain, as no other theory could
explain, the singular variety of complications (all of them nearly
always unilateral, and on the same side as the pain) which are apt to
group themselves around a neuralgia; and some of which are very seldom
absent in neuralgia of any considerable severity. To this we may
certainly add that it is extremely probable that the vast majority of
neuralgic patients inherit the tendency to this localized centric
change; in support of this we may finally mention two considerations
derived from the sex and the ages most favorable to neuralgia. Eulenburg
saw a hundred and six cases of neuralgia of all kinds, of which
seventy-six were in women and only thirty in men; my own experience is
very similar; namely, sixty-eight women and thirty-two men out of a
hundred hospital and private patients. The strong connection between the
hysteric and the neuralgic temperament in women, and the great
preponderance of women among neuralgics, strengthen in no small degree
the probability of inherent tendencies to unstable equilibrium as a very
common predisposing factor in neuralgia. And, on the subject of age, I
need only recall what I have said so strongly about the coincidence of
neuralgia with particular epochs in life, as affording evidence of the
most powerful kind that neuralgics are, save in exceptional instances,
persons with congenitally weak spots in the nervous centres, which break
down into degeneration, temporary or permanent, under the strains
imposed by one or other of the physiological crises of the organism, or
the special physical or psychical circumstances which surround the
patient's life.

Having thus decidedly expressed my belief in the essential material
participation of the nerve-centre in neuralgia, it remains for me to
discuss two points: first, as to the character of the material change in
the nerve-root, and next, as to the extent to which mere peripheral
influence, without special inherited tendencies, may suffice to set this
process going.

The morbid change in the nerve-centre is probably, in the vast majority
of cases, an interstitial atrophy, tending either to recovery, or to the
gradual establishment of gray degeneration, or yellow atrophy, of
considerable portions of the whole of the posterior root, and the
commencement of the sensory trunk as far as the ganglion.

It is probable, however, that in a certain number of cases, the atrophic
stage may be preceded by a process of genuine inflammation, and that
this inflammation is centripetally produced in consequence of
inflammations of peripheral portions of the nerve. The considerations
which make this probable are chiefly derived from the analysis of cases
in which a more or less chronic, but severe, visceral disorder has been
followed by so-called reflex paralysis, but in which neuralgic
phenomena, have been conspicuous. In reference to this subject I
recommend to the reader's attention the very interesting paper on
"Reflex Paralyses" by Prof. Leyden, of Konigsberg.[28] He is immediately
commenting upon a case in which dysenteric affection of the bowel were
followed by the symptoms of myelitis, attended with febrile
exacerbations, and also with severe pains in the region of the sacrum,
in the course of the dorsal intercostal nerves of the right side, and in
the knees, and semi-paralytic weakness of the lower extremities, and
with pains between the shoulder-blades and the left arm. Leyden
discusses the doctrine of reflex paralyses in general, starting from
the cases of urinary paraplegia brought forward by Stanley, in 1835, and
tracing the growth of opinion through the phases represented by Graves,
Henoch, and Romberg, by Valentine and Hasse, then by Pfuger, and other
professors of the inhibitory doctrine; by Brown-Sequard (in his
well-known, and now very generally discredited, theory of spasm of the
vessels in the nervous centres), by Jaccoud in the "Erschopfung"
(exhaustion) theory, down to the more careful and reliable researches of
Levisson on the temporary reflected paralyses induced by experimental
squeezing of the kidney or uterus of animals; and then gives the history
of the more recent doctrine of a positive material change in the cord
centripetally introduced. Gull[29] (1856) may be said to have
inaugurated the new doctrine of a morbid process transmitted along the
pelvic nerves to the cord, and causing material changes there.
Remak,[30] on the other hand, suggested a material change operating in
the opposite direction; _a neuritis descendens_, starting in the very
nerves (within the pelvis) which showed the paralysis in the
extremities. The symptoms are supposed by him to be distinctive,
inasmuch as there is both violent pain in the nerves of the soles of the
feet, and also tenderness of the same. On the other hand, Remak said
that myelitis, with neuritis, might be the origin of paraplegia and
simultaneous palsy of bladder and rectum. The theory of neuritis
descendens was supported by Kussmaul,[31] in the record of a case where
disease of the bladder was complicated with pelvic inflammation,
atheromatous degeneration of the arteries, and consequent fatty
degeneration of the sciatic nerves, causing direct paraplegia. We return
to the centripetal theory of urinary paralysis with Leyden's own cases,
published in 1865; of three patients with urinary paraplegia, two died,
and the existence of a secondary (centripetal) myelitis seems to have
been established, and by all analogy it must have existed in the third
case, which recovered. The only puzzle and doubt that ensued was caused
by the fact that there was an absence of neuritis in the different
nerves themselves; though it seemed plain that the starting point of the
myelitis was at the entrance of these nerves into the cord. This mystery
seemed to be cleared up by the important experiments of Tiesler, ("Ueber
Neuritis" Konigsberg, 1860) a pupil of Leyden's. This observer excited
local traumatic inflammation in the sciatic nerve of rabbits and dogs;
the rabbit became paraplegic and died three days afterward. At the site
of the artificial irritation there was a localized formation of pus, and
there was a second similar formation within the vertebral canal at the
point where the posterior roots of the sciatic enter the cord; but
there was no neuritis of the intervening portion of the nerve.

Upon this and similar evidence is based the modern doctrine of a
neuritis migrans, with centripetal tendencies, upon which it is supposed
that a very large proportion, at least, of the urinary, dysenteric, and
uterine paraplegias, miscalled "reflex," depend; and it is clear that
the application of the word "reflex" in such a case is a grave abuse,
tending to produce such confusion of thought and error in practice. In
relation to the subject of our own inquiry--neuralgia--it is obviously
of the highest consequence to investigate the question whether
peripheral irritations, analogous to those which produce urinary
paraplegia, are at all frequently the cause of the changes in the
posterior roots which produce true neuralgia; for of course an
inflammation may be the beginning of an atrophy which may presently
exhibit no distinction whatever from one of which the origin was
altogether non-inflammatory. I think that there is strong reason for
thinking that this is not at all frequently the case. In the first
place, all the evidence that exists respecting these centripetal
inflammations of the cord is opposed to the idea that, save in the
rarest instances, the inflammatory process limits itself to one small
segment of the cord. Secondly, the description of the pains that have
usually accompanied such inflammations of the cord is considerably
different from the strictly localized, frankly intermittent character of
a true neuralgia; in fact, all we know of the history of myelitis
(except when complicated with a large amount of meningitis) forbids us
to suppose that severe pain would be an immediate symptom. But, thirdly,
a far more important objection to the theory of an origin in localized
centripetal myelitis, the result of a neuritis migrans, is the rarity of
motor paralysis as an early symptom, instead of which we ought to find a
very distinct history of decided paralysis (much more decided than those
secondary paralyses which actually do occur in some neuralgias) of the
muscles supplied by the anterior roots of the painful nerve, in every
case in which such a peripheral origin could be assumed. Again, the
totally feverless commencement of neuralgias, a character which is
maintained throughout the progress of the milder cases, is entirely
opposed to the idea of a direct connection between myelitis and
neuralgia. The superficial appearance of pyrexia is sometimes given by a
local vaso-motor paralysis, which makes the neuralgic part, after a long
bout of pain, hot and red; but of general pyrexia there is nothing.

Taking every thing into consideration, one is inclined to say that there
is a probability that in a very limited number of cases peripheral
irritation does cause actual limited myelitis, which escapes recognition
at the time, but which issues in an atrophy, the subjective expression
of which is actual neuralgic pain. We may well ask ourselves, also,
whether there is not some likelihood that a peripheral irritation, which
stops short of producing an actual neuritis migrans capable of
centripetally exciting a myelitis, may not, by a lower degree of
centripetal irritation, give a bias toward certain forms of
non-inflammatory atrophy in cells of posterior nerve-roots which are
congenitally of weak organization. I am inclined to believe strongly
that this does occur. For example, I should explain thus the majority of
the peripheral cases of ciliary neuralgia, migraine, etc., that we meet
with in poor young needle-women, especially the hypermetropic, who, at
an age when they can ill afford the strain, work so constantly and
strenuously at an occupation which fearfully taxes the eye.

I would also go farther, and express the opinion that peripheral
influences of an extremely powerful and continuous kind, where they
occur with one of those critical periods of life at which the central
nervous system is relatively weak and unstable, can occasionally set
going a non-inflammatory centric atrophy which may localize itself in
those nerves upon whose centres the morbific peripheral influence is
perpetually pouring in. Even such influences as the psychical and
emotional, be it remembered, must be considered peripheral--that is,
they are external to the seat and centre of the neuralgia. And there are
probably few practitioners of large experience who have not seen a
patient or two in whom the concurrence of some unfortunate psychical
with some other noxious peripheral influence, the whole taking place at
some critical period of life (especially in the years between puberty
and marriage), seems to have totally deranged the general balance of
nervous forces, and induced morbid susceptibilities and morbid
tendencies to some particular neurosis. It is a comparatively frequent
thing, for example, to see an unsocial solitary life (leading to the
habit of masturbation), joined with the bad influence of an unhealthy
ambition, prompting to premature and false work in literature and art.
The bad peripheral influence of constant fatigue of the eyes in study
may so completely modify a young man's constitution as to make a wreck
of him in a very few years, changing him from the state of habitual and
conscious health to that of chronic neurosis of one sort or another.
And, though it is doubtless on persons with congenital tendencies to
nervous diseases that such a combination of bad influences produces its
most serious effects, yet there unquestionably are a few persons in whom
they appear to entirely generate the neurotic constitution. I have
already touched upon the part that misdirected psychical influences,
especially religious and other forms of emotional excitement, may play
in this unfortunate perversion of the natural and healthy nervous
functions, more especially in youth; and need only add, here, that
perhaps the most fatal combination of all the bad influences is the
melancholy union of highly-strained religious sentiment with peripheral
sexual irritation, which is, unfortunately, a too common phenomenon
under certain systems of education. The most frequent neurotic
consequences of the class of influences which have now been referred to
are probably neuralgia--in the form either of migraine, of nervous
angina, or of sciatica--or else asthma.

But, if the combination of several such centripetal influences may
generate the neurosis unaided, even a single one of them operating
powerfully for a long period may produce most serious consequences in
those who are hereditarily predisposed. The influence of prolonged
fatigue of the eyesight, independently of any special intellectual or
emotional strain, was strongly illustrated in my own case about three
years ago. I was then engaged upon a piece of scientific writing which
demanded no great intellectual effort, but was being done against time,
and by working, night after night, many hours by gas-light. My neuralgic
(trigeminal) attacks came on with great severity, accompanied by
vertiginous sensations of so alarming a kind as to make me fear the
invasion of some serious brain-mischief. I broke off all work, and went
to the sea-side, but was greatly disappointed to find, for the first few
days, that the symptoms were not in the least mitigated. The mystery was
soon explained. The weather had been such as to confine me a good deal
to the house, and, thinking it would do no harm, I amused myself with
reading newspapers and novels. At last I suspected that the use of my
eyes in reading was altogether mischievous; I desisted from reading any
thing, and in forty-eight hours every symptom had vanished.

Among peripheral influences of a more mechanical kind there is one cause
of neuralgia, the force of which has been variously estimated, but which
some authors rate as very important, viz.: the influence of the
pressure, and especially of the varying pressure, of blood-vessels, or
other hollow viscera, upon the trunks of the nerves. We must set aside
one such action which is undoubtedly very powerful, as essentially
differing from the others; I mean the pressure of dilated blood-vessels,
especially aneurisms, when this happens to be exerted upon the ganglion
of the sensory trunk. Here there can be no doubt of the mischief; for
the pressure, if at all severe, gradually destroys the life of the
ganglion, upon which, as was proved by Waller, the nutrition of the
posterior nerve-root hangs with very intimate dependence, and the
pulsations of the vessel seem greatly to aggravate both the irritation
and the centripetal tendency to atrophy. In short, it is plain that such
lesion of a ganglion may be the whole and sufficient cause of a
neuralgia of the most desperate and incurable kind. It is another matter
when we are asked to believe that the mere varying pressure of
intestines, in different states of fullness, or plexuses of pelvic veins
liable to temporary congestions, can so affect the sciatic nerves as to
set up neuralgia. Considering the extreme frequency of cases in which
such momenta must be partially coming into operation, especially in
women--a frequency altogether out of proportion to that of sciatica--I
cannot admit the probability that this influence is more than an
occasional and very secondary factor, and that only in cases where the
disposition to neuralgia is uncommonly strong.

A sufficiently complete explanation of my theory as to the pathology and
etiology of neuralgia has now been given, although the subject might be
elaborated at far greater length; and I hope it will be apparent to the
reader that the view now advocated is at once important, and also
vouched for by strong evidence. I claim for it that the whole argument
shall be taken together, for it is a case of cumulative proof; every
link must be weighed and tested, before the remarkable strength of the
chain can be felt. And it may fairly be said that, if the proof of a
definite kind of material change in a definite organ, as the essential
factor in neuralgia, has been established upon reasonable grounds, an
important step has been taken toward removing a serious opprobrium and
difficulty in practical medicine. Although the true neuralgias are not
among the most frequent of human diseases, they form a class of enormous
practical importance, for they are sufficiently common to be sure to
occur in considerable numbers in the practice of every medical man, and,
both from the suffering which they inflict, and the rebelliousness which
they often show to treatment, they are among the gravest sources of
anxiety which the practitioner is likely to encounter. There are
probably few disorders which so often occasion mortification and loss of
professional credit to the physician. The helplessness which men, who do
not enjoy special opportunities of seeing those diseases with frequency,
so often show in dealing with them, is largely caused by the extreme
timidity and vagueness with which the standard treatises on medicine
deal with the question of their pathology; and a very unfair advantage
has thus been given to the specialists, who, by the mere force of
opportunity, and continual blind "pegging away" in an entirely empiric
manner, have acquired a certain rude skill in the treatment of these
maladies which enables them to outshine practitioners who often have far
more in them of the veritable _homme instruit_ as regards general
scientific education and habits of mind. It will be evident, as a mere
abstract proposition, that the enunciation of a reasonable pathology of
the disease, and the sweeping away of a mass of unmeaning phrases about
"mysterious functional affections" and the like, must be a distinct gain
to practitioners of plain common-sense and good general knowledge, to
whom neuralgia is merely one of a vast number of different diseases
among which their attention and study are divided. And I hope that, in
the further remarks on Diagnosis, Prognosis, and Treatment, yet to be
made, the value of clear pathological ideas of disease will be brought
more practically and clearly into view. [The reader will find, at the
end of Part I. of this volume, a note which contains a brief discussion
on the "Erschopfung" theory of Jaccoud, and the doctrines of Dr.
Handfield Jones respecting inhibition, with which I thought it best not
to encumber the text of the present chapter.]

FOOTNOTES:

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

[17] _Op. cit._, p. 60.

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

[19] _Journal de la Physiologie, v._

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

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

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

[23] Wegner, loc. cit.

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

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

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

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

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

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

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

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




CHAPTER IV.

DIAGNOSIS AND PROGNOSIS OF NEURALGIA.


_Diagnosis._--This subject is much simplified and shortened, in regard
to our present purpose, by the plan of the present work, which, by
separately describing (in Part II.) the other disorders which resemble
neuralgia, and are liable to be confounded with it, avoids the necessity
for stating here the negative diagnosis of neuralgia itself. We are only
concerned here to give a clear picture of the positive signs which it is
necessary to verify before we can suppose disease to be neuralgia. The
special modes of searching for these are interesting, and in some
respects peculiar;

(1) The first and most essential characteristic of a true neuralgia is,
that the pain is invariably either frankly intermittent, or at least
fluctuates greatly in severity, without any sufficient and recognizable
cause for these changes.

(2) The severity of the pain is altogether out of proportion to the
general constitutional disturbance.

(3) True neuralgic pain is limited with more or less distinctness to a
branch or branches of particular nerves; in the immense majority of
cases it is unilateral, but when bilateral it is nearly always
symmetrical as to the main nerve affected, though a larger number of
peripheral branches may be more painful on one side than on the other.

(4) The pains are invariably aggravated by fatigue or other depressing
physical or psychical agencies.

The above are characteristics which every genuine neuralgia possesses,
even in its earliest stages; if they be not present, we must at once
refer the diagnosis to one or other of the affections described in Part
II. of this work.

Supposing the above symptoms to be present, we expect to find--

(5) In by far the largest number of instances that the patient has
either previously been neuralgic, or liable to other neuroses, or that
he comes of a family in which the neurotic disposition is well marked.
Failing this, we are strongly to doubt the neuralgic character of the
malady, unless we detect that there has been--

(6) A poisoning of the blood by malaria (but this very rarely causes
neuralgia, save in the congenitally predisposed); or--

(7) A powerfully operating or very long-continued peripheral irritation
centripetally directed upon the sensory nucleus of the painful nerve;
which irritation may be (_a_) "functional," as where the eye has been
persistently and severely over-strained and trigeminal pain results, or
a sudden severe shock has been received; or, (_b_) coarsely material, as
where inflammation, ulceration, etc., of surrounding tissues involve the
periphery of the painful nerves in a perpetually morbid action, or
chronic but profoundly depressing psychical influences; or--

(8) A constitutional syphilis. In this case there will either be marked
syphilitic local affection of the trunk of a nerve, or if, as is more
common, the syphilitic change is in the nerve-centre, there will most
likely be other syphilitic centric mischiefs, leading to scattered motor
or vaso-motor paralyses, characteristic modifications of special
sense-functions, etc.

If the neuralgia be of some standing and a certain degree of severity,
there will inevitably be found--

(9) Some of the fixed tender points of Valleix, in such situations as
have been described in Chapter I.; and--

(10) Secondary affections (_a_) of secreting glands, or (_b_) vaso-motor
nerves; or (_c_) of nutrition of tissues; or secondary localized
paralyses of muscles, or localized anæsthesia of a somewhat decided
though not complete kind, as described in Chapter II.; any one or any
number of these various complications may be present.

I must insist that the above picture includes only the essentials for a
diagnosis of neuralgia; if the painful affection will not answer to the
conditions therein included, we have no right to call it a neuralgia--it
belongs, for every practical purpose, to some other category of disease.
Let me add one more essential characteristic, which is, that the pain
begins and assumes its characteristic type before any other of the
phenomena appear, with the single and partial exception of anæsthesia.

There are some special modes of diagnosis of the varieties of
neuralgia, developed of late years, that require notice here; they are
chiefly the result of the researches of Moriz Benedikt.

As regards the quality of the pain, Benedikt says that the curve of
intensity has an intimate relation to the _locus in quo_ of the
neuralgia (_i. e._, whether in the periphery, trunk, or roots). An
inflammatory irritation set up at the periphery of a nerve (by a
joint-inflammation, for instance) produces a continuous pain; the same
kind of irritation, attacking a nerve-trunk (_e. g._, in the bony
canals), produces a paroxysmal pain; an inflammation spreading from the
vertebræ to the nerve-roots or the cord-centres produces momentary
lancinating pains. The latter characteristic he supposes to be
especially characteristic of the centrally-produced neuralgias; and I
may observe, as so far confirmatory of this idea, that this is
especially the character of the pains in locomotor ataxy. There are
sundry special cases to be considered, however: thus, Benedikt himself
remarks that the pain set up by the pressure of a pulsating aneurism is,
from the nature of things, lancinating from moment to moment.
Eulenburg,[32] moreover, says that Benedikt's tests of the locality of
the primary mischief only hold good under the following circumstances:
(1) When the irritability and the exhaustibility of the nerves are in a
normal condition during the neuralgia; (2) when the irritation that
calls forth the paroxysm is either identical with the original cause of
the disease, or at least operates upon the same spot. The two
conditions, however, do not concur. The irritability and exhaustibility
may be sometimes excessive in neuralgias, sometimes normal, and perhaps,
in certain cases, beneath the normal standard; by which means the form
of the curve of intensity must be considerably modified. Moreover, the
irritation that provokes an attack may from the periphery attack the
primary seat of the disease, even when this is central, on account (says
Eulenburg) of exaggerated conductivity of the nerves (his second
cause[33] of "hyperæsthesia"), as is, in fact, very frequently the case.
He also thinks the distinction between paroxysmal and lancinating pains
too indefinite to serve as a sufficiently reliable basis of diagnosis,
especially considering the endless _nuances_ of the form which the pain
is apt to take. I agree with Eulenburg upon this point; and am
convinced, from my own observations, that such a distinction as that
between lancinating and paroxysmal pains is illusory, [I have taken some
pains to investigate the character of the pains, not only in neuralgia,
but in locomotor ataxy. It is true that the lancinating character
predominates, on the whole, in the latter disease; but there are great
differences in different individuals, and even in the same patient at
various times, which plainly depend on subjective influences. Compare
for instance, Dr. Headlam Greenhow's report on an ataxic patient, with a
report on the same man by Dr. Buzzard and myself. ("Trans. Clin. Soc.,"
vol. i., 1868, pp. 152-162.)] the two kinds being frequently found
alternate in the same case. The only useful distinction, in my opinion,
is Benedikt's first one: he is probably right in saying that, where such
an affection as an inflamed joint forms the source of peripheral
irritation that immediately provokes a neuralgia, the pain is apt to be
unusually continuous.

The extent to which the pain of neuralgia spreads into different termini
of the same nerve has been made the basis of distinctions as to the seat
of the original mischief. For example, it has been said that pain in the
mental branch of the third division of the trigeminus, which does not
invade the auriculo-temporal branch, can hardly depend on an irritation
operating on the trunk of the inferior dental; it must be distinctly
peripheral, or else it must act upon limited portions of the central
origin of the fifth nerve. But the fact seems rather to be that, whether
the neuralgia was excited by lesions at the periphery, in the
nerve-trunk, or in the centre, it is equally possible that either a
small or a large part of the peripheral expanse of the nerve may become
the seat of the pain: this almost necessarily follows from the entire
independence of individual fibres in nerves.

As regards the evidence afforded by the motor, vaso-motor, and trophic
complications, there is this very positive diagnostic value in
them--that they enable us to say, with greater assurance than we could
otherwise do, that the disease is a real neuralgia. But, the only
evidence that they afford as to the situation of the mischief is, that
they uniformly point to the central end of a particular nerve; and
accordingly I have already shown, in the chapter on Pathology, that the
attentive study of these very complications furnishes us with some of
the most powerful arguments upon which rests my theory that in neuralgia
there is always centric mischief. What share in the production of the
malady, in any given case, has been taken by the centric disease, and
what if any by a peripheral irritation, the existence of these
complications in no way helps us to determine; far less does it enable
us to localize a peripheral lesion which may have acted as a concomitant
cause; on the contrary, I believe that there is no more fertile source
of erroneous judgment on this very point, than some of these
complications, especially the vaso-motor and trophic. I suspect that it
has happened, in hundreds of instances, that a localized congestion or
inflammation, which is a mere secondary phenomenon, produced in the
centrifugal manner already so fully explained, has been taken for the
veritable _fons et origo_ of the malady: hence the neuralgia has been
confidently reckoned as one peripherally produced, and, what is even
worse, the whole energy of treatment has been directed to a mere
outlying symptom, under the idea that the primary source of mischief was
being attacked.

The application of electricity as a test of the nature of a neuralgia
has been employed by Benedikt,[34] who lays down certain laws as the
result of his researches. He says that (_a_) in idiopathic peripheral
neuralgias the nerves are not sensitive to the current; (_b_) in
neuralgias dependent on neuritis or hyperæmia of the nerve-sheath there
is general electric tenderness of the nerve; (_c_) in cases where the
pain has been set up by morbid processes in tissues surrounding the
nerve, there is electric tenderness only at the site of these changes. I
may, in general terms, express concurrence in these statements; but I
must add that, as diagnostic rules they apply only to the early stages
of neuralgia; for the occurrence of secondary complications may and does
altogether change the condition of electric sensitiveness. It need
hardly be said that the above remarks on diagnosis apply for the most
part only to the superficial neuralgias, which, however, include an
immense majority of the cases of neuralgias. The diagnosis of visceral
neuralgias is, it need hardly be said, in most cases, a far more
difficult and complicated matter. In these diseases we have often little
more to guide us, in the actual symptoms, than (_a_) the intermittence
of the pain, and (_b_) the absence of commensurate constitutional
disturbance, especially the complete freedom from sense of illness in
the intervals between the pains. We shall be obliged to rely greatly on
such historical facts as the presence or absence of neurotic tendencies
in the patient and his family; the possibility of his having been
exposed to blood-poisoning (_e. g._, from malaria or chronic alcoholic
excess, or extreme over-smoking); the circumstance that he has been
habitually overworked, or greatly exposed to agitating psychical
influences; perhaps that he has been subject to a combination of several
of these morbific momenta. To say truth, the diagnosis of visceral
neuralgias must, at the best of times, be a difficult and anxious
matter, and we can hardly ever thoroughly satisfy ourselves until we
have procured some decided results from treatment; fortunately, however,
it happens tolerably often that we can do this, and sometimes in a very
striking way.

_Prognosis._--The prognosis of neuralgia varies exceedingly, according
to the form and situation of the disease, and many other considerations.
There are, of course, in the first place, certain neuralgias in which
the prospect is perfectly hopeless as to cure; such are the cases in
which the nerve is involved in a continuously growing tumor (especially
within a rigid cavity, like the skull), or a slow but persistent
ulcerative process.

Supposing, however, that the case is none of these, the very first
prognostic consideration is that of age.

Of the neuralgias of youth, the majority either disappear altogether
after a first attack, or recur a certain number of times during some
years, the neuralgic tendency either disappearing or becoming greatly
mitigated when the process of bodily consolidation is over. In another
group the neuralgic tendency is never lost, but the form of the attacks
changes, and there is far less spontaneity in the manner of their
production. It is exceedingly common to see delicate boys and girls
between puberty and the age of eighteen or twenty, attacked with typical
migraine, which recurs regularly every three or four weeks for perhaps
two or three years, then ceases to occur at regular periods, then loses
the tendency to stomach complication; and, by the age of twenty-five or
somewhat later, has left, as its only relic, a tendency to attacks of
ophthalmic neuralgia, which come on when the patient is excessively
fatigued, or encounters the close air of a theatre, or undergoes an
unusual strain of mental excitement or anxiety, etc.; but which never
come on without some such special provocation. So, again, there is a
variety of sciatica which belongs mainly to the period between puberty
and the twenty-fifth to thirtieth year, and which seems really to
belong, pathologically, to the age of unsettled and irregular sexual
function, the tendency to it usually disappearing after the patient has
settled down happily in married life. Ovarian and mammary neuralgia have
very commonly a similar history.

On the other extreme we find the neuralgias of the period of bodily
decay: these are of very bad prognosis. A neuralgia which first develops
itself after the arteries and capillaries have begun to change decidedly
in the direction of atheroma is extremely likely, even if apparently
cured for a time, to recur again and again, with ever-increasing
severity, and to haunt the patient for the remainder of his days. It
therefore becomes exceedingly important, in a prognostic point of view,
to assure ourselves as soon as possible whether this arterial
degeneration has decidedly commenced; and for this purpose I am in the
habit of insisting to pupils on the great importance of sphygmographic
examination for all neuralgic patients who have passed the middle age.
Where we get the evidence which is furnished by the formation of a
distinctly square-headed radial pulse-curve, even though there be no
palpable cord-like rigidity of superficial arteries, we are bound to be
exceedingly cautious of giving a favorable prognosis.

In women the period of involution of the sexual apparatus forms a crisis
which, in regard to neuralgias, is of great prognostic importance. On
the one hand, if the general vital status be good, and the arterial
system fairly unimpaired, we may look to the completion of the process
of involution as a probable time of deliverance from neuralgic troubles
that have hitherto beset a woman; we know that she will probably suffer
a temporary aggravation of her pains, but we hope to see her lose them
altogether. On the other hand, if it should happen that she enters on
the period of sexual involution with her general nutrition considerably
impaired and her arterial system decidedly invaded by atheroma, it is
only too likely that neuralgias recurring now, or attacking her for the
first time, will assume the worst and least manageable type.

Of almost or quite equal importance with the question of the
physiological age of the patient is that of his personal and family
history with regard to the tendency to neuralgia and to other severe
neuroses. Upon this subject I have dwelt so very fully in other parts of
this work, that it is merely necessary here to repeat, that the balance
of chances is most heavily swayed to the bad side by all evidence
tending to prove congenital neurotic tendencies in the patient and vice
versa.

Of prognostic hints that are to be gathered from our knowledge of the
immediate causes of the attack, there are none so valuable as those
which we gather from the detection of a malarial or a syphilitic factor
in the production of the malady. In the former case, we hope to cure the
patient either with quinine or arsenic, with almost magical certainty
and rapidity; in the latter, we expect an almost equally brilliant
result from iodide of potassium.

The particular nerve in which the neuralgia is seated does not so
decidedly influence the prognosis, according to my experience, as is
stated by some authors; nevertheless, there are differences of this
kind. For instance, sciatica, though by no means so frequently a mild
and trifling complaint as Eulenburg would make it to be, is certainly,
on the whole, more curable than the trigeminal neuralgias taken as a
group. I, however, cannot share Eulenburg's opinion as to the rarity of
a central cause for sciatica, nor his consequent explanation of its more
frequent curability; the latter I explain by the fact that it is
possible far more completely to remove the concomitant causes in
sciatica than in trigeminal neuralgia. By simply keeping a sciatic
patient in the prone posture, shielded from cold and from pressure on
the nerve, we have it in our power to remove nearly all peripheral
sources of irritation; but in trigeminal neuralgia there are many
influences, particularly psychical ones, which cannot be shut out, and
which will continue to act with disastrous effect in many cases. With
all this, however, we see a sufficiently large number of incurable
sciaticas, on the one hand, and of severe trigeminal neuralgia cured on
the other. It is only the genuine epileptiform tic, occurring in
subjects whose arterial system is an advanced stage of degeneration,
that stands out clearly and unmistakably pre-eminent among neuralgias
for rebelliousness to treatment of every kind.

FOOTNOTES:

[32] _Op. cit._, pp. 65, 66.

[33] Idem, p. 8.

[34] "Elektrotherapie." Wien, 1868.




CHAPTER V.

TREATMENT OF NEURALGIA.


I now approach what is really the most difficult portion of my task;
for, although it would be easy enough to write copiously on the
treatment of neuralgia, it is extremely difficult to keep a just medium
between the opposite extremes of undue meagreness and of useless
profusion of detail in the handling of this subject. There are also
difficulties connected with the present uncertain and transitional state
of opinion, even among high authorities, as to the value of particular
remedies, and even of large groups of remedial agents, altogether there
has been more hesitation in my mind as to this part of the present work
than about any other, and the present chapter has been rewritten more
than once. I mention this only to account for what there may very likely
be found in it--an imperfect literary style such as too commonly marks
work which has been repeatedly patched and corrected. At the same time,
it should be said that my hesitation does not apply to the main
principles of treatment which will be recommended below; it proceeds
rather from the fear of seeming to ignore from carelessness modes of
treatment which are still much used, but which I have really rejected,
because, after full trial, they appeared to me valueless. Space is,
after all, limited, and a complete account of all the remedies for
neuralgia in vogue, in English and Continental clinics, would of itself
fill a large volume.

The treatment of neuralgia may be divided into four branches: (1)
Constitutional remedies; (2) narcotic-stimulant remedies; (3) local
applications; (4) prophylaxis.

1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_)
anti-toxic, and (_c_) medicinal tonic.

(_a_) The importance of a greatly-improved diet for neuralgic patients
is a matter which is more fully appreciated by the English school of
medicine than by either the French or the German; it has, for instance,
very much surprised me to notice the almost entire silence of Eulenburg
on this topic. For my part, the opinions expressed three years ago[35]
on this matter have only been modified in the direction of increasing
certainty; I have learned by further experience that the principle is
even more extensively applicable than I had supposed.

That neuralgic patients require and are greatly benefited by a nutrition
considerably richer than that which is needed by healthy persons, is a
fact which corresponds with what may be observed respecting the chronic
neuroses in general; and it gives me much satisfaction to point out this
position of neuralgia as belonging to this large class of disorders, not
merely by its pathological affinities, but by its nutritive demands. In
a very excellent and suggestive paper by Dr. Blandford[36] it is stated,
as the result of a large experience in mental and other nervous
disorders, that the greater number of chronic insane and hypochondriacal
cases, as well as neuralgic patients, are remarkably benefited by what
might seem at first sight almost a dangerously copious diet.
Occasionally it happens that the patients discover this by the teaching
of their own sensations, and the apparent excesses in eating which some
epileptic and hypochondriacal persons habitually commit are looked on by
many practitioners as the mere indications of a morbid _bulimia_ which
represents no real want, but only the craving of a perverted sensation
which ought to be interfered with and allayed rather than encouraged. It
is now many years since I began to doubt the justice of this opinion;
the particular instance which called my attention to it being that of
epilepsy, of which disease I saw a considerable number of cases, within
a short period of time, that were distinguished by the presence of
enormous appetite for food; and I finally came to the conclusion that,
so far from this symptom being of evil augury, and likely to lead to
mischief, it is, with certain limitations, a most fortunate occurrence.
It is hardly necessary to say that over-eating, such as produces
dyspepsia and distention of a torpid intestine with masses of fæces, may
distinctly aggravate the convulsive tendency; but the truth is that,
with a little careful direction and management of the unusual appetite,
these bulimic patients can in most cases be allowed to satisfy their
desires without harm of this kind following; a larger portion of food
really gets applied to the nutritive needs of the body, and the nervous
system unmistakably benefits thereby, the tendency to atactic disorder
being visibly held in check.

That which I have thus observed in the case of epilepsy, and which Dr.
Blandford more particularly affirms concerning chronic mental diseases
and the large number of neuroses that hover on the verge of insanity,
has been most distinctly verified in my experience of the treatment of
neuralgia. It is, unfortunately, by no means a frequent occurrence that
the sufferer from this malady is inclined to eat largely, but the few
patients of this type that I have seen were, in my judgment, distinctly
the better for it. Far more common in neuralgia is a disposition of the
patient to care little for food, to become nice and dainty, and in
particular to develop an aversion--partly sensational and partly the
result of morbid fear about indigestion--for special articles of diet.
Dr. Radcliffe pointed out the special tendency of neuralgics to neglect
all kinds of fat; partly from dislike, and partly because they believe
it makes them "bilious;" and I have had many occasions to observe the
correctness of this observation. In fact, by the time patients have
become sufficiently ill with neuralgia to apply to a consulting
physician, they have already, in the great majority of cases, got to
reject all fatty foods, and have cut down their total nutriment to a
very sufficient standard. Young ladies suffering from migraine are
especially apt to mismanage themselves, to a lamentable extent, in this
direction: this is natural enough, because the stomach disorder seems to
them the origin of the pain, instead of being, as it is, a mere
secondary consequence of the neurosis. But it is not only the sufferers
from sick-headache in whom we find this tendency to insufficient eating,
especially of fat; not to mention that all severe pain usually tends to
disorder appetite and make it fastidious, there is nearly always some
wiseacre of a friend at hand, ready to suggest that neuralgia is
something very like gout, that gout is always aggravated by good living,
and, _ergo_, that the patient should be "extremely cautious as to diet;"
the end of which is that the poor wretch becomes a half-starved
valetudinarian, but, so far from his pain getting better, it steadily
becomes worse. I cannot too strongly express the benefits that I have
seen accrue, in the most various kinds of neuralgic cases, from
persistent efforts to remedy this state of things, and to convert the
patient from a valetudinarian to a hearty eater; and I wish particularly
to say that this success has always been most marked when I have from
the first insisted on fat forming a considerable element of the food.
Cod-liver oil is the form in which I much prefer to give it, if this be
possible; there can be no mistake about the relatively greater power of
this than of any other fatty matter, I believe simply from its great
assimilability. But the very cases in which we most urgently desire to
give fat are often those in which the patient's fantastic stomach openly
revolts at the idea of the oil; we must then try other fats; and we
should go on trying one thing after another--butter, plain cream,
Devonshire cream, even olive or cocoanut oil (though these are the
poorest things of the sort we can use)--till we get the patient well
into the way of taking a considerable, if possible a decidedly large,
daily allowance of fat, without provoking dyspepsia. It is surprising
what can be done in this way by perseverance and tact, and it is no less
striking to observe the good effects of the treatment. Nothing is more
singular than to see a girl, who was a peevish, fanciful, and really
very suffering migraineuse, brought to a state in which she will eat
spoonful after spoonful of Devonshire cream, and at the same time lose
her headaches, lose her sickness, and develop the appetite of a
day-laborer; and, though such very marked instances as this are
uncommon, they do sometimes occur, and a minor but still important
degree of improvement is very frequent.

As for the _modus operandi_ of the fatty food, there is no certainty.
Dr. Radcliffe believe it acts as a direct nutrient of the nervous
centres; and I also cannot help feeling that there is some evidence in
favor of this idea. But, whether this be so or not, there is another
kind of action of fat that is more simple and obvious; namely, it seems
to be certain that the enrichment of the diet by fat greatly assists the
assimilation of food in general, and thus the patient's nutrition is
altogether improved.

It is not merely, however, by increasing any one element of food that we
should seek to enrich the diet of neuralgics, but rather by such a
steady and persistent effort as Dr. Blandford describes, to increase the
total quantity of nutriment to perhaps as much as one-third more than
the patient would probably have taken in health. To those who from
prejudice are incredulous of the propriety of this method, I would say,
"Try it, and I venture to say your incredulity will disappear." More
especially I would urge the great importance of this system in modifying
the nervous status of very young, and also of aged, sufferers from
neuralgia; it is the indispensable basis of a sound treatment for such
patients.

This seems the proper place for such remarks as must be made upon the
function of alcohol in neuralgia; for, though this agent is a true
narcotic when given in large doses, it is not under that aspect that I
can recommend its use in neuralgia at all. I have written so much on
this subject lately, that I shall here content myself with an emphatic
repetition of my protest against the use of alcoholic liquors as direct
remedies for pain. They ought only to be given, in neuralgia, in such
moderate doses, with the meals, as may assist primary digestion without
inducing any torpor, or flushing of the face, or artificial
exhilaration. I cannot too expressly reprobate the practice of
encouraging neuralgics, especially women, to relieve pain and depression
by the direct agency of wine or spirit; it is a system fraught with
dangers of the gravest kind.

(_b_) The anti-toxic remedies include agents addressed to the
modification of a special condition of the blood and tissues induced by
the presence of morbid poisons, of which syphilis, malaria, and (more
doubtfully) gout and rheumatism, are the representative examples.

Of syphilitic neuralgia the treatment may be summed up in a few words:
Give iodide of potassium in doses rapidly increased up to a daily
quantum of twenty to thirty grains. If this fails, give one-twelfth of a
grain of bichloride of mercury thrice daily.

Of malarial neuralgia I can only speak from such a limited experience
that I am by no means in a position to give an exhaustive account of the
treatment. Quinine is, of course, the remedy that should first be tried;
and, as the paroxysms are usually regular in their recurrence, I prefer
to give the drug after the plan which is, I think, incontestably the
best in ordinary ague--_i. e._, to administer one large dose (five to
twenty grains) about an hour before the time when the attack is
expected. With a few exceptions the malady, unless it had taken very
deep root before we were consulted, will yield to a few doses given in
this way; after the morbid sequence has been thus interrupted, it will
be proper to continue the action of quinine in smaller and more frequent
doses, given for three or four weeks continuously. For the comparatively
rare cases in which quinine fails, the prolonged use of arsenic
(Fowler's solution, five to eight minims three times a day), especially
with the simultaneous employment of cod-liver oil, is to be recommended.

The part which gout may play in inducing neuralgia is, as I have already
said, a far more doubtful question than the popular medical traditions
assume it to be; and treatment directed to gout as a cause is an
extremely uncertain affair. The direct relief of neuralgic pain by the
administration of colchicum, for example, is, in my experience, a very
rare occurrence, even where the gouty diathesis is unmistakably present;
and, on the other hand, the depressed vitality which gouty neuralgics
usually show in a marked degree, renders it very doubtful whether the
relief of the pain may not be too dearly purchased at the cost of the
general lowering effects of colchicum. It is probable that neuralgia
occurring in gouty subjects is more safely, and equally effectually,
treated upon general principles. At the same time it may be admitted
that, in the subordinate function of an adjuvant to the aperients which
it is sometimes advisable to give, small doses of the acetic extract of
colchicum seem to possess some value.

The question of treatment addressed to a supposed rheumatic element in
neuralgia will, of course, be differently judged according to the
respective ideas of various practitioners as to the pathological
affinities of the two diseases; and the reader already knows that I
believe these affinities to be different in kind from what is generally
believed. The utmost that I should concede is, that in a certain very
limited number of cases the peripheral factor in neuralgia is an
inflammation of the nerve-sheath, or surrounding tissues, which forms
part of a chain of phenomena of local fibrous inflammations in different
parts of the body. Iodide of potassium, in five or ten grain doses
three times a day, is the proper treatment for such cases. I have never
found alkalies do any direct good to the pain.

(_c_) The medicinal tonic variety of constitutional treatment is more
especially represented by the use of iron and arsenic in cases where
poverty of the blood seems to exist in a marked degree, and by the
administration of certain tonics--quinine, phosphorus, strychnia, and
zinc--which are supposed to exert a specially restorative influence upon
the nervous tissues.

The use of quinine as an anti-malarial agent has been already referred
to; its employment in non-malarial cases is of much more restricted
scope and benefit. Experience has taught me to agree in general with the
opinion of Valleix, that it is a very unreliable agent; the one marked
exception to this being the case of ophthalmic neuralgias. What the
reason may be I cannot in the least say, but it is a fact that quinine
does benefit these neuralgias, in cases where there is no room for
suspicion of malaria, with a frequency which is very much greater than
in the treatment of the painful affections of any other nerve in the
body. The quantity given should be about two grains three times a day.

The preparations of phosphorus which I have employed in the treatment of
neuralgia are the phosphuretted oil, the hypophosphite of soda (five to
ten grains three times a day), and pills of phosphorus (according to Dr.
Radcliffe's recommendation) containing one-thirtieth of a grain, given
twice or thrice daily. Either of the two last will do all that
phosphorus can do, but its utility is not very extensive or reliable. I
have found it to do most good in cases where there was a high degree of
anæsthetic complication.

Preparations of zinc have, in my hands, done no particular good,
although I have tried them in all manner of doses.

Strychnia, on the other hand, is a remedy which I have learned to prize
much more highly during the last few years than previously. Its most
decided efficacy has been shown in some of the visceralgiæ, especially
gastralgia, and (to a less extent) angina pectoris. Its internal use for
these complaints is best effected by giving doses of five to ten minims
of tincture of nux-vomica three times a day; but a method which I have
several times employed with good effect is the subcutaneous injection of
very small doses of strychnia (one-eightieth to one-fiftieth of a grain)
twice daily. For the superficial neuralgias, on the other hand, I
generally administer one-fortieth of a grain, with ten or fifteen minims
of tincture of sesquichloride of iron, by the stomach, three times a
day; this is a very powerful prophylactic remedy to prevent the
recurrence of the attacks when once the sequence of them has been broken
through by other means.

Of iron generally, as a remedy in anæmic cases, I have only to remark
that, in order to get its full benefits, it is necessary to use large
doses. I give the saccharated carbonate in twenty-grain doses twice or
three times a day.

But of the sesquichloride of iron I am inclined to say something more;
it has seemed to me that, besides its effects on the blood, it has a
marked and direct influence upon the nervous centres, which is different
from anything which one observes in the action of other preparations of
iron. It is certain that the action of sesquichloride of iron, in those
cases of chlorosis which are distinguished by profound nervous
depression, is something quite peculiar; and the effect which it
produces in the anæmic neuralgias, more especially of young women, is
equally remarkable. I cannot help alluding here to the striking effects
which large doses of the tincture, as recommended by Dr. Reynolds,
produce in acute rheumatism; the severest pain is often checked within
twenty-four hours after the commencement of this treatment. Both in this
disease and in neuralgia, I employ the old-fashioned tincture: if given
alone it should be used in large doses (thirty or forty minims three
times a day); but an excellent combination is that, already mentioned,
of ten-minim doses of this tincture with one-fortieth of a grain of
strychnia. There is something in the revivifying effects of this mixture
that is quite peculiar. I have very lately employed it in the case of a
gentleman, aged thirty-five, who was the subject of frontal neuralgia
complicated with paralysis of the internal rectus, and who was decidedly
anæmic, and greatly depressed and worried in mind by the consciousness
of his inability to overtake professional work which had accumulated
upon him. This patient improved with great rapidity, and in the course
of three weeks lost, not merely his neuralgia, but also his strabismus,
almost entirely; but he then got into a condition which, though not of
permanent importance, was sufficiently undesirable to make me mention it
here, especially as I have seen the same thing in more than one patient
besides him. It is a peculiar state of restlessness during the day and
sleeplessness at night, without any positive exaltation of reflex
excitability such as one used to see from strychnia in the days when
mischievously large doses of that drug were very commonly given, and
patients used to complain of decided twitchings and startings of the
limbs. It is clearly not a strychnia effect pure and simple, nor an iron
effect only; it is a _tertium quid_ compounded of the actions of both
drugs.

The direct effects of arsenic in the improvement of the quality of the
blood seem to me incontestable; and its use for this purpose in anæmic
neuralgias is certainly something over and above its special neurotic
action. No one, who has employed it much in the cases of anæmic children
suffering from chorea after rheumatism, can have failed to observe its
frequently striking influence upon blood-formation even long before the
nervous ataxia is materially reduced. The misfortune is, however, that
we possess no indications by which to judge beforehand whether we may
reckon on its most favorable action in any given (non-malarious) case,
with certain special exceptions. In angina pectoris it has a most direct
effect, which is rarely altogether missed, and is sometimes surprising:
the cases in which it succeeds best are those distinguished by anæmia,
but we may well suppose, from its remarkable action upon other neuroses
of the vagus, that it is something more than an action on the
blood-making process which produces such powerful effects in allaying
the tendency to recurrence of the paroxysms. My attention was called to
its action in this disease chiefly by the remarkable case published by
Philipp;[37] this was a purely neurotic angina, but one of the severest
type, and the influence of arsenic was very striking. Since that time I
have employed it in several cases, and, after trying various forms of
administration, I conclude that nothing is better than Fowler's
solution, in doses of three minims (gradually increased, if the remedy
be well tolerated, up to eight or ten) three times a day. Unfortunately,
there are some neurotic patients who cannot bear arsenic, the
irritability of their alimentary canal is such that the drug always
provokes vomiting, or diarrhoea, or both; this was the case with one
of my patients, in whose case I had allowed myself to hope for the very
best results from arsenical treatment. But where the patient tolerates
it--and usually he tolerates it extremely well--the prolonged use of
arsenic seems really to root out the anginoid tendency, or at least to
confine it to the more trivial and manageable manifestations. I believe
that in at least three patients, I have so completely broken down a
succession of cardiac neuralgic attacks as to substitute for them a mere
remnant of a tendency to "tightness at the chest" after any severe
bodily exertion or mental emotion. It might be a question, in cases
where the stomach does not tolerate the ordinary administration of the
agent, whether it would not be worth while to try the effect of
subcutaneous injection (two to four minims of Fowler), or inhalation of
the smoke of arsenical cigarettes. But, in truth, it is not certain that
even in this case we escape the characteristic effects of the drug upon
those persons who are abnormally sensitive to it.

A remarkable instance of the beneficial influence of arsenic occurred in
the case of a woman, aged forty-six, the solitary example of severe
angina in a female that I have ever seen. [It is by no means uncommon,
however, to see the milder forms of cardiac neuralgia in women; the
remarkable statistics of Forbes, quoted in Chapter I., must certainly
have been taken exclusively from cases of the severest type of the
disease.] This was a hospital patient, who had always suffered much
from hysteria, and from childhood had been liable to hemicranic
headache; she had entered on the period of "change" at the time the
attacks began, but menstruation, though irregular, still continued, and,
in fact, did not cease till four years later, long after the anginal
attacks had been subdued. The patient had been attacked for the first
time at the end of a heavy day's washing; she dropped on the ground with
the sudden agony and faintness, and thought she should "never come to
life again." The paroxysms returned five times within the next month,
though not always so severely as on the first occasion; but the poor
woman lived in a constant state of terror. On the occasion of her second
visit to me, she had a most severe attack in the waiting-room at the
hospital: being called to her I found her very nearly pulseless,
gasping, and with the kind of complexion which is so suggestive of
approaching death. She was recovered by a large dose of ether. It was a
rather uncommon feature in this case that the pain was only at and
around the lower end of the sternum, except that occasionally it shot
along the sixth intercostal space. The employment of Fowler's solution
(in doses gradually mounting to twenty-one minims daily) for six months
completely eradicated the anginal tendency; the proof that it was a real
therapeutic effect was given by the result of an attempt to leave the
medicine off at the end of eight weeks' treatment; the patient
immediately began to suffer again. When she really left off, at the end
of six months' treatment, she had had no tendency to heart-pang for more
than a month, and, besides this, looked quite another creature in her
improved vitality and vigor. Yet the menstrual troubles went on, and the
function was not finally suppressed for a long time afterward.

I suspect, however, that the most frequent successes with arsenic will,
after all, be made in the cases of more or less anæmic male patients who
are attacked with the neurotic form of angina in the midst of a career
(as is especially the case with some professional careers) that implies
not merely incessant labor, but great anxiety of mind. The drug does
little good, however, if not positive harm, in that form of angina
pectoris minor which is not the result purely of these causes, but of
these, or some of these, plus the morbid action of the alcoholic excess,
to which the patient has fled in order to relieve mental harassment and
the fatigue that comes from overwork, especially overwork at tasks that
are not congenial to his natural disposition; there is usually in such
cases a heightened irritability of the alimentary canal, which is almost
sure to cause arsenic to disagree: the really useful treatment is
quinine for the first few days, and then, when the stomach will bear it,
cod-liver oil in increasing doses, up to a large daily amount given for
a long time together.

On the whole, arsenic, from its singularly happy combination of powers
as a blood-tonic, a special stimulant of the nervous system, and withal
as a special opposer of the periodic tendency, must be regarded as one
of the most powerful weapons in the physician's hands, and (although it
seems to act best in the neuralgias of the vagus and of the fifth) there
is a possibility of its proving the most effective remedy in almost any
given case which may come before us.

2. The narcotic-stimulant treatment for neuralgia includes some of the
most powerful remedies for the disease which we possess. These remedies
have very different properties, but they all agree in this, that in
small doses they appear restorative of nerve-function--in large doses
depressors of the same.

Four very different types, at least, of narcotic-stimulant drugs are
useful in neuralgia: (_a_) There is the opium type, by which pain is
very directly antagonized, and, besides this, sleep is also directly
favored. (_b_) There is the belladonna type, by which pain is also much
relieved, though with far greater certainty in some regions than in
others (_e. g._, much the most powerful effect is seen in cases of pelvic
visceralgia), but sleep is by no means so certainly or directly produced
as by opium. (_c_) There is the chloral type, which is almost purely
hypnotic; it is represented almost solely by chloral itself, which is
resembled by scarcely any other drug. (_d_) There is bromide of
potassium, which stands alone for its powerful action on the cerebral
vaso-motor nerves, and which is useful in neuralgia simply by its power
to check psychical excitement directly (through the circulation) and
indirectly (through the production of sleep).

(_a_) Opium and the remedies that resemble it are, for the treatment of
neuralgia, fully represented by the hypodermic use of morphia, which is
the only kind of opiate treatment that ought ever to be employed, save
in very exceptional instances. The great reasons for the preference of
the subcutaneous administration over the gastric are, the economy of the
drug which it affects and the much smaller degree of disturbance of
digestion which it causes. The hypodermic injection of morphia, if
conducted on correct principles, enables us, when necessary, to repeat
the dose a great number of times with but little loss of the effect, and
consequently with a much smaller rate of progressive increase of the
quantity required; and the absence of depressive action on digestion
enables us to carry out simultaneously that plan of generous nutrition
which has already been shown to be so important a part of treatment.
Indeed, the case is hardly expressed with sufficient strength, when we
say that hypodermic morphia is usually harmless to the digestive
functions; for in a great number of instances it will be found actually
to give an important stimulus both to appetite and digestion; and the
patient, who without its aid could hardly be persuaded to take food at
all, will not unfrequently eat a hearty meal within half an hour after
the injection.

The remarkable effects of hypodermic morphia have, however, caused it to
be rashly and indiscriminately used, and so much harm has been done in
this way that it is necessary to be exceedingly careful in the rules
which we lay down for its employment. Upon these grounds I must hope to
be excused if, in order to render this work complete, I repeat a good
deal of what I have already said in other places. In the first place, I
shall speak of the mode of administration, and then of the dose.

As regards the mode of administration, I prefer the use of a solution of
five grains of acetate of morphia to the drachm of distilled water; if
the acetate be a good specimen, this will dissolve easily (and keep some
time without precipitation) without the use of any other solvent. With a
solution of this strength we require nothing elaborate in the form of
the syringe; a simple piston arrangement does well; only it is advisable
that the tube shall have a solid steel triangular point, and a lateral
opening. As regards the place of injection, I must repeat the
opinion[38] which I have already published, that Mr. Hunter's plan of
injection at an indifferent spot is, in the great majority of instances,
fully as effective as the local injection would be; nevertheless, there
is one consideration which in some cases may properly induce us to adopt
the latter plan. Very nervous and fanciful patients will sometimes be
much more readily brought to allow the operation when it seems to go
directly to the affected spot, when they would be sufficiently
incredulous of the benefits of an injection performed at a distance to
indulge their dislike of incurring pain by refusing to submit to it. And
there is one class of cases in which it is likely that there are real
physical advantages in the local injection; in instances of old-standing
neuralgia with development of excessively tender "points," which are
also the foci of the severest pain, it will sometimes be advisable to
inject into the subcutaneous tissue at these points. There is undeniable
reason for thinking that the sub-inflammatory thickening of tissues
around a certain point of nerve delays the transit of the morphia into
the general circulation, and enables it to act more directly and
powerfully on the nerve, which it thus renders insensitive to external
impressions; an important respite is thus gained, during which the
nerve-centre has time to recover itself somewhat. At the same time it
must be remarked that this immediate injection of a tender point is apt
to be exceedingly painful, and it may be absolutely necessary to apply
ether-spray before using the syringe. In early stages of neuralgia,
before the formation of distinct tender points, there is no advantage
whatever (except the indirect one above mentioned) in the local
injection. And, on the other hand, it is often of great consequence not
to run the chance of disfiguring such a part as the face, the neck,
etc., when the injection can easily be done over the deltoid, or in the
leg, or in some other part which even in women is habitually covered by
the dress.

The dose to be employed is an exceedingly important matter, and one as
to which practitioners are still very often injudicious. We ought never
to commence with a larger dose than one-sixth of a grain; but very often
as little as one-twelfth of a grain will give effective relief, and in
not very severe cases it is well worth while to try this smaller
quantity. When no larger quantity than one-sixth of a grain is employed
we commonly observe no narcotic effects, _i. e._, there is no
contraction of pupil, no heavy stupor, and, although the patient very
often falls asleep, on waking he does not experience headache, nor is
his tongue foul. I cannot too strongly express the opinion that it is
advisable by all means to content ourselves with this degree of the
action of hypodermic morphia, unless it fails to produce a decided
impression on the pain. But in very severe cases our small doses will
fail; and then, rather than allow the patient to continue having severe
paroxysms unchecked, we must frankly admit the necessity of using a
narcotic dose from one-quarter to one-half of a grain, according to
circumstances. Whatever actual dose be employed, it is important not to
repeat it with unnecessary frequency; once a day in the milder, and
twice a day in the more severe cases, will be all that is advisable,
save in very exceptional cases: the point being to administer it as
quickly as possible after the commencement of an exacerbation. If by
these means we can prevent the patient having any severe pains during a
period of several days, we often give time to the affected nerve to
recover itself so completely, especially with the aid of other measures
to be presently mentioned, that the tendency to neuralgia is completely
broken through, and we can drop the injections, either at once or by
rapid diminution of the dose, and thereafter treat the case merely with
tonics, and with the precautionary measures to be dwelt upon under the
heading of Prophylaxis. But, if we have been driven to the use of
distinctly narcotic doses, and these do not very speedily break the
chain of neuralgic recurrence, it will not do to continue to rely upon
hypodermic morphia; it will be best to try some of the local remedies
(blistering, galvanism) with it. If this combination fails, we should
then try the effect of atropine, the sulphate of which, hypodermically
injected, fully represents for all useful purposes the mydriatic class
of narcotics.

(_b_) The commencing hypodermic dose of atropine should be one-one
hundred and twentieth grain; it is not often that so small a quantity
will do any good, but it is necessary to use this agent with great
precaution, as we occasionally meet with subjects in whom extremely
small doses provoke most uncomfortable symptoms of atropism, as dry
throat, dilated pupil, delirium, and scarlet rash. Commonly we shall
find ourselves obliged to increase the dose to one-sixtieth,
one-fiftieth, or one-thirtieth of a grain; and in a very few cases it
may be necessary to go even as high as the one-sixteenth or one-twelfth.
In my experience such instances are excessively uncommon; and I cannot
but suppose that the practitioners who use the high doses frequently
must inject in such a manner as to fail to get the whole dose taken up.
[Absolutely inexplicable to me is the statement of the illustrious
Trousseau--that hypodermic remedies are "less active" (!) than gastric
remedies--except on his hypothesis.]

The most remarkable effects that I have seen from hypodermic atropia
were obtained in cases of peri-uterine neuralgia, especially
dysmenorrhoeal neuralgia. Speaking generally of atropine, it must
undoubtedly be counted far inferior to morphia as a speedy and reliable
reliever of neuralgic pain, but for all pelvic neuralgias it appears to
me on the whole to surpass morphia. And besides this, in other
neuralgias, where opiates altogether disagree (as with some subjects
they do), it is not uncommon to find that atropia acts with
exceptionally good effect. And to some extent I am inclined to confirm
Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does
so more permanently than morphia.

There is another special use of hypodermic atropine which I have not
seen mentioned by any one but myself, but which is probably very
important, namely, in ophthalmic neuralgia where acute iritis, or
especially glaucoma, seems coming on. I may be mistaken, but I believe
that in three cases I have succeeded, by prompt injection of sulphate of
atropine (one-sixtieth to one-fortieth of a grain), in saving a
neuralgic eye from damage, and possibly from destruction, from impending
glaucoma.

(_c_) The class of cases for which merely hypnotic remedies are of much
value is limited; nevertheless, in the milder kinds of migraine and
clavus, especially when they have been brought on or are kept up by
mental worry or hysterical excitement, these remedies will sometimes
prove very useful. In former days, before we knew chloral, I used to
employ camphor for this purpose; three or four grains being administered
every two hours: and in hysterical hemicrania of a not very severe type
this not unfrequently produced a short sleep, from which the patient
awoke free from the pain. But chloral infinitely transcends in value any
agent of this kind that was known before. Perfectly valueless for the
really severe neuralgias, it is of the greatest possible use as a
palliative in migraine and clavus, where the great object, for the
moment, is to get the patient to sleep. A single dose of twenty to
thirty grains will often effect our object: it may be repeated in two
hours if sleep has not been induced; it should be given as soon as the
pain has at all decidedly commenced.

And here I wish to make some special remarks on the subject of
"palliation," and the relation it bears to "cure." Nothing is more
common than to read serious admonitions, in medical works, about the
folly of trusting to remedies which only palliate for the moment but
leave the root of evil untouched; and, of course, there is a certain
respectable modicum of the fire of truth behind all this orthodox smoke.
In the case of neuralgia, however, it is most important to understand
that mere palliation, that is, stopping of the pain for the moment, may
be either most useful or highly injurious, according to the way in which
it is done. The unnecessary induction of narcosis for such a purpose,
doubtless, is most reprehensible; but if it were possible simply to
produce sleep from which the patient should awake refreshed, without any
narcotic effects, then, certainly, that sort of palliation must be good.
That is precisely what the judicious use of chloral does; and I may
mention, as resembling though not equalling it, the action of Indian
hemp, which has been particularly recommended by Dr. Reynolds. From
one-fourth to one-half of a grain of good extract of cannabis, repeated
in two hours if it has not produced sleep, is an excellent remedy in
migraine of the young. It is very important, in this disease, that the
habit of long neuralgic paroxysms should not be set up; and if the first
two or three attacks are promptly stopped, by the induction of sound,
non-narcotic sleep, we may get time so to modify the constitution, by
tonics and general regimen and diet, as to eradicate the neuralgic
disposition, or at least reduce it to a minimum. But I would decidedly
express the opinion that such remedies as either opium or belladonna are
mostly unsuited to this purpose. If the migraine of young persons does
not yield to chloral, to cannabis, or to muriate of ammonia (in twenty
or thirty grain doses), it will not be advisable to ply the patient with
any remedies of the narcotic-stimulant class, but to trust to tonic
regimen and the use of galvanism.

The mention of muriate of ammonia, which, for migraine and clavus and
the milder forms of sciatica, not unfrequently proves useful in stopping
the violence of a paroxysm and enabling the patient to get some
refreshing sleep, leads me to notice that not only may a variety of the
milder narcotic-stimulants be employed in this way, but the external
stimulus of heat to the extremities (very hot pediluvia) greatly
assists the action of any such remedies; especially if mustard-flour be
added, so that a mild vapor of mustard rises with the steam and is
inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is
to give twenty grains of chloral, and make the patient plunge his feet
in very hot mustard-and-water and breathe the steam. He can hardly fail
to fall asleep for a longer or shorter time, and awake free from pain.

(_d_) The use of bromide of potassium in neuralgia is a subject of great
importance, and which requires much attention and discrimination. In
common with, I dare say, many others, I made extensive trial of this
agent when it first began to be much talked of, but was so much
disappointed with its effects in neuralgias, that at one time I quite
discarded it in the treatment of those affections. Renewed experience
has taught me however, that, though its use is restricted, it is
extremely effective if given in appropriate cases and in the right
manner. For the great majority of neuralgias it is quite useless, and,
what is more, proves often so depressing as indirectly to aggravate the
susceptibility of the nervous system to pain. The conditions, _sine quis
non_, of its effective employment seem to be the following: The general
nervous power, as shown by activity of intelligence, and capacity of
muscular exertion and the effective performance of co-ordinated
movements, must be fairly good, find the circulation must be of at least
average vigor; the patient must not have entered on the period of
tissue-degeneration. Among neuralgics who answer to this description,
those who will benefit by the bromide are chiefly subjects--especially
women--in whom a certain restless hyperactivity of mind and perhaps of
body also, seems to be the expression of Nature's unconscious resentment
of the neglect of sexual functions. That unhappy class, the young men
and young women of high principle and high mental culture to whom
marriage is denied by Fate till long after the natural period for it,
are especial sufferers in this way and for them the bromide appears to
me a remedy of almost unique power. But I wish it to be clearly
understood that it is not to the sufferers from the effects of
masturbation that I think the remedy specially applicable: on the
contrary, it is rather to those who have kept themselves free from this
vice, at the expense of a perpetual and almost fierce activity of mind
and muscle. The effects of solitary vice are a trite and vulgar story;
there is something far more difficult to understand and at the same time
far more worth understanding in the unconscious struggles of the
organism of a pure minded person with the tyranny of a powerful and
unsatisfied sexual system. It is in such cases, which it heeds all the
physician's tact to appreciate, that it is sometimes possible to do
striking service with bromide of potassium; but it will be necessary to
accompany the treatment with strict orders as to generous diet, and,
very likely, with the administration of cod-liver oil.

Having decided that bromide of potassium is the proper remedy, we must
use it in sufficient doses. Not even epilepsy itself requires more
decidedly that bromide, to be useful, shall be given in large doses. It
is right to commence with moderate ones (ten to fifteen grains), because
we can never tell, beforehand, that our patient is not one of those
peculiar subjects in whom that very disagreeable phenomenon--bromic
acne--will follow the use of large doses. But we must not expect good
results till we reach something like ninety grains daily. Let me add
that it is not so far as I know, by reducing any "hyperæsthesia" of the
external genitals, of which the patient is aware, that the remedy acts;
I have not seen such a nexus of disease and remedy in these cases.

3. Local Measures.--The external remedies which may be applied for the
treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_)
paralyzers of peripheral sensory nerves; (_c_) remedies adapted to
diminish local congestion; (_d_) remedies adapted to diminish arterial
pulsation; (_e_) electricity; (_f_) mechanical means of protection.

(_a_) Among the skin-stimulants blisters hold the highest place as a
remedy for neuralgia; indeed the assertion of Valleix, that they are the
best of all remedies, is still not very wide of the truth. They are by
no means universally applicable, and the degree to which their action
should be carried varies materially in different forms of the disease,
but they are of the greatest possible service in a large number of
instances.

It is possible to view the action of blisters in neuralgia in more than
one way. When applied in such a manner as to vesicate decidedly, and
especially if kept open and suppurating for some time, they cause
considerable pain of a different kind from that of neuralgia itself and
the mental effect of this, operating as a diversion of the patient's
thoughts from his original trouble, may be thought to assist in breaking
the chain of nervous actions by which he is made to feel neuralgic pain.
There may be something in this, but I confess that I do not believe this
kind of effect goes for much in genuine neuralgia. It is rather in the
pain of hypochondriasis, and the so-called spinal irritation (to be
described in the second part of this work), that such an action of
blisters proves useful.

Another action of blisters, which some authors hold to be perhaps the
most effective portions of their agency, is that which is produced by
the drain of fluid, specially when they are kept open, by which means a
kind of depletion is set up, and the morbid irritation that causes the
nerve pain removed. I cannot at all assent to this view. In the first
place, I believe that any one who has large experience of blistering in
neuralgia will ultimately come, as Valleix did, to believe that
prolonged drain from a blister is rarely or never useful, and that a far
better plan is that of so-called flying blisters, renewed at intervals
if necessary. The most genuine successes that I have procured from
blistering have certainly been got in this way. But I should go further,
and say that the prolonged drain and the peculiar kind of chronic
irritation produced by a suppurating blistered surface can very
decidedly aggravate a neuralgia; this is more especially the case when
the blister is applied immediately over the focus pain.

The view which I am strongly convinced alone explains the beneficial
action of blisters is that which supposes them to act as true stimulants
of nerve-function. In order that this effect shall be produced, it will
be necessary that the skin-irritation be either produced at some
distance from the seat of the greatest pain, or that, if applied in that
spot, it shall be comparatively mild in degree. And accordingly, I have
been led, in my observations to apply the blister at some distance from
the focus of pain. An indifferent point, however, will not do--there
must be an intelligible channel of nervous communication between the
irritated portion of skin and the painful nerve. This object is
accomplished by placing the blister as close as may be to the
intervertebral foramen from which the painful nerve issues; the effect
of this is probably a stimulation of the superficial posterior branches,
which is carried inward to the central nucleus of the nerve. I must say
that the results which I have derived from this plan of treatment have
been far more satisfactory than those which I used to obtain when I
habitually applied the vesication as near as might be to the focus of
peripheral pain; and I think that this result tallies well with the idea
that the essential mischief in neuralgia consists in an enfeebled
vitality of the central end of the posterior root. An exceedingly
interesting confirmation of this idea as to its _modus operandi_ has
been afforded me by the fact that not merely neuralgic pain, but also
trophic and inflammatory complications attending it, have been sensibly
relieved, in several cases that I have seen, by this mode of reflex
stimulation. This has been particularly the case in herpes zoster, where
the process of inflammation and vesiculation has been very promptly
checked by the application of a tolerably powerful blister by the side
of the spine at the proper level; and I am gratified to mention that Dr.
J. K. Spender, of Bath, pointed out this fact[39] at a time when he had
only seen my statement that the pain could be relieved in this way. In
the case of the trigeminus, the same kind of reflex stimulation is most
effectively obtained by applying the blister over the branches of the
cervico-occipital, at the nape of the neck; and it is remarkable what
powerful effects are sometimes thus produced, even in cases that wear
the most unpromising aspect. For example, in the desperate epileptiform
tic of old age, I have more than once seen a complete cessation of
suffering, which lasted for a very long time--so long, in fact, as to
make me hope against hope that it might never return. I do not now
entertain any such expectations from this remedy; still, its value is
very great.

There are curious differences between the effects of blistering in
trigeminal or intercostal neuralgia and in sciatica. On the whole, it
would appear that blistering in the neighborhood of the spine is less
frequently effective in the latter, and we sometimes, after failing with
this method, obtain immediate success by two or three repetitions of the
flying blister, somewhere over the trunk of the nerve, especially just
outside the sciatic notch. I have one lady patient in whom this series
of phenomena has several times been observed; and I have seen it occur
in a particular attack, in other patients, in whom, nevertheless, on
another occasion the spinal blistering has been promptly effective.

I consider blistering of the posterior branches to be an important, and
usually an essential, element in the treatment of all cases of sciatica
in the middle period of life which have reached some severity and lasted
long enough to become complicated with decided secondary affections.

In all cases where blistering is employed it is advisable to adopt the
simultaneous use of hypodermic morphia or atropine; this combination of
remedies is exceedingly powerful.

Lastly, it must be said of blistering, that, on the whole, it is a
remedy not well fitted to be applied to aged subjects; and in its
severer forms it should never be applied to patients who are greatly
prostrated in strength. For it must be borne in mind that the remedy may
miss its aim of relieving the neuralgia, in which case it is necessary
to remember, more accurately than many practitioners appear to do, what
a very serious element of misery and prostration will be introduced into
the case by the vesication itself.

I am not convinced that any of the other forms of severe skin-irritation
(_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to
such a degree as to produce not the anæsthetic but the irritant effects)
are of any particular value; if blistering failed, I should not expect
to see them succeed.

A milder degree of skin-stimulation is represented by rubefacient
liniments of various kinds, which may be briskly rubbed into the skin
along the track of the painful nerve, without any danger of producing
vesication. Among this class I continue to prefer chloroform diluted,
with six or seven parts of chloroform, to any other; in the milder forms
of neuralgia, especially in young persons and first attacks, it is
surprising how frequently the paroxysm may be greatly relieved, if not
arrested. Still, this can only be regarded as the merest palliative; and
in severer cases such applications are useless. Occasionally, when
chloroform-liniment has failed, a mustard plaster will do good.

The mildest degree of skin-stimulation is represented by the continuous
application of moist warmth, which is best effected by the simple
application of moistened spongio-piline; so far as I have observed,
however, it is rather in cases of myalgia than in true neuralgia that
this does good; in the latter it is probably little more than a mere
protector against cold.

(_b_) A variety of agents can be employed with the object of temporarily
interrupting the conductivity of the painful nerve; by this means a
period of rest is obtained during which the centres--sensory and
psychical--have time to regain a juster equilibrium, and the habit of
pain is, _pro tanto_, broken through.

There is one agent of this class which for general purposes I do not
think is worth retaining on our list of sensory paralyses--namely, cold.
Cold, to be of any value, ought to be of the degree which is represented
by ice allowed to melt slowly in contact with the skin; and for the
majority of neuralgias this is decidedly inferior to other remedies that
can be applied by painting or inunction. The one case in which ice is
supremely useful is in neuralgia of the testis; here I make no doubt
that it is almost, if not quite, the most useful remedy we can employ,
although of course other means must be taken to modify the neuralgic
temperament. It should be applied the moment an attack comes on.

Far more useful, in neuralgias generally, is the external application of
aconite or of veratrine. Aconite may be employed in the milder or the
stronger form; in the former case, we simply paint the ordinary tincture
on the skin over the painful nerves (avoiding any cracks or sores); in
the latter, we rub in an ointment containing one grain of the best
hydrate of aconitine to the drachm of lard, about twice a day, and to
such an extent as to maintain complete numbness of the parts
continuously, for two, three, or four days. I do not believe that this
will ever, by itself, cure a true neuralgia of any considerable
severity; but I have more than once known its intervention, at a crisis
in treatment when it seemed that other remedies might fail, produce a
striking change in the progress even of a very bad case.

A milder, but still very useful form of the same kind of action, is
produced by veratrine-ointment. I would recommend, however, as a rule,
that it be employed, at any rate at first, of weaker strength than that
recommended in the Pharmacopoeia, for with some persons it is easy to
pass the anæsthetic, and to enter on the irritant, action of veratrine
upon the skin. This leads me to give a caution that should properly
have come earlier, when I was speaking of skin-stimulants. In aged
subjects, especially, we rather frequently meet, in neuralgia, with a
specially irritable state of the skin, even although there may be at the
same time some loss of common and tactile sensation; and the
practitioner must be warned against the danger of producing an amount of
skin-irritation which will fearfully annoy his patient. I speak
feelingly, having by such an indiscretion lost the richest patient who
ever favored my consulting-room with his presence!

The inunction of mild veratrine-ointment is extremely useful, as an
adjunct to other treatment, in migraine and supra-orbital neuralgias of
suckling women, and of chlorotic girls. I have also seen it do much good
in mammary neuralgia.

The last division of the subject of paralyzing agents in the treatment
of neuralgia includes the surgical operations for division or resection
of a painful nerve. Upon this question there is much difficulty in
speaking decidedly. I admit at once, of course, that surgical
interference is evidently indicated when, along with decided and
intractable neuralgic pain, there is plain evidence either of the
existence of a neuromatous tumor, or the presence of a foreign body
impacted, or a tight cicatrix pressing upon a nerve. I admit, also,
though with much greater qualifications, that carious teeth may need to
be extracted before we can cure a neuralgia; but even here I should put
in the decided caveat that we must consider whether the system is in a
state to bear the shock, and that in any case we probably ought to
mitigate the effects of the operation by performing it under chloroform.
And I need hardly tell any one, who is familiar, either practically or
from reading, with the subject, that thousands of carious teeth have
been extracted from the mouths of neuralgic patients, not only without
benefit, but with the effect of distinctly aggravating the disease. And
I am yet more doubtful as to the advisability of such surgical
procedures as the division or the resection of a piece of the painful
nerve. Theoretically, as the reader will understand from the strong
opinion I have given as to the mainly central origin of neuralgias, I
never could anticipate that such a procedure would be more than
temporarily successful; on the contrary, the mischief in the central end
of the nerve remaining, I should suppose that the trying process of the
reunion of the nerve (which always takes place) would be almost
certainly attended with a revival of the neuralgia, too probably in an
aggravated form. The only two cases of excision of a piece of the nerve,
that I have ever seen, completely answered to this anticipation. In
common fairness, however, I must admit that there is a large amount of
evidence on the other side. Neuralgias of the trigeminus are pretty
nearly the only cases in which the proposal of neurotomy or neurectomy
ought to be entertained; in mixed nerves the inconvenience of the
muscular paralyses that would follow would be usually too serious to
allow of our incurring them. But resection of painful branches of the
trigeminus has been performed in a great number of instances, more
especially by German surgeons, with results that merit our attention;
the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be
especially referred to. On the other hand, with the exception of simple
division of the nerve, which can be subcutaneously performed, and is a
trivial proceeding (but has very short-lived effects), these operations
are by no means without danger, especially when they are pushed to such
a length as the opening of bony canals, and the resection of
considerable portions of bone in order to get sufficiently far toward
the centre, and fatal results have in more than one case followed. Above
all, we can never too seriously reflect on the most interesting case of
Niemeyer's reported by Wiesner,[40] in which the most formidable
operations of this kind have been performed, in an apparently desperate
case of epileptiform facial tic, and in which, after all, the
application of the constant current painlessly effected an infinitely
greater amount of good than had been done by all those severe and
painful surgical manipulations. I think it is impossible, after this,
not to conclude that neurectomy ought never to be even thought of except
as a last resort, in cases of extreme severity, after other measures had
been patiently tried and had decisively failed.

(_c_) Of remedies that are intended to relieve local congestion, I must
speak with very doubtful approbation. Leeches or scarifications are, I
think, very seldom of value. The only remedy that has sometimes seemed
to do good is local compression, and, after all, it is quite as likely
that this acts by anæsthetizing the nerve as by reducing congestion.

(_d_) Remedies that interfere mechanically with arterial pulsation are
of considerable value where they can be effectively applied. I have
already pointed out the specially aggravating effect of the
momentarily-repeated shocks of arterial pulsation upon neuralgic pain.
Where, then, it is possible, effectively to control an artery pretty
near to the point where it divides into the branches that lie close to
the painful part of the nerve, it is always worth while to try the
experiment. But such a measure as the compression of the carotid in
trigeminal neuralgia is of very doubtful propriety; I suspect the
consequent anæmiation of the brain more than does away with any benefit
that might be mechanically produced. And any attempt to interfere with
the general arterial circulation by cardiac depressants is not to be
permitted for an instant.

(_e_) We enter now upon a most important subject, the treatment of
neuralgia by electricity. It is necessary to exercise much caution in
speaking upon this topic, and, as I shall have to express somewhat
decided opinions, I may be excused for referring to the circumstances
under which I have arrived at my present stand-point upon this question.
I can hardly be accused of having, with any very rash haste, espoused the
cause of medical electricity in the therapeutics of pain, as any one will
see who cares to turn to my article on Neuralgia[41] written only three
years ago. At that time I had already been studying the subject for a
considerable period, but was so convinced of the multitude of
opportunities for fallacy that beset the student of electro-therapeutics,
that I was unwilling to state more than the minimum of what I hoped and
believed might be affected by this mode of treatment. Since that time I
have become more fully acquainted with the researches of foreign
observers, and, with the help of their indications, have been able to
apply myself more fruitfully to my personal inquiries into the matter.
The result is, that I am now able to speak with far greater assurance of
the positive value of electricity as a remedy for neuralgic pain. I shall
make bold to say that nothing but the general ignorance of the facts can
account for the extraordinary supineness of the mass of English
practitioners with regard to this question.

In the first place, I have arrived at a decided conviction that Faradic
electricity is of little or no value in true neuralgias, and that the
cases which are apparently much benefited by it will invariably be
found, on more careful investigation, to belong to some other category.

On the effect of frictional electricity I have had such very small
experience that I cannot venture to speak with any confidence, and the
accounts that I have heard from others whose experience is much larger
have not led me to attribute much importance to this agent. If I am to
judge at all, I should say it merely acts as a skin-stimulant, and is,
in that capacity, inferior to many other simpler and more facile
applications.

Very different is the verdict of experience as regards the effects of
the constant current; here the results which I have obtained have been
so remarkable that even now I should distrust their accuracy, were it
not that they are in accord with the general result which (among minor
discrepancies) may be gathered, we may fairly say, from all the more
important researches that have lately been carried out in Germany. The
constant current, as I now estimate it, is a remedy for neuralgia
unapproached in power by any other, save only blistering and hypodermic
morphia, and even the latter is often surpassed by it in permanence of
affect; while it is also applicable in not a few cases where blistering
would be useless or worse.

The English medical profession has not as yet adequately appreciated the
necessity for great care in the choice of apparatus and the mode of
application of electricity. It is all-important, however, and especially
in the case of applying galvanism for the relief of pain. The first
quality that must be absolutely required in a battery, that is to be
used for this purpose, is that it shall deliver its current with as
little as possible variation of tension, in fact that it shall be
constant, and not merely continuous; a vast majority of all the various
galvanic apparatus that have been used have been merely the latter, and
have consequently been almost valueless for the relief of pain. Such are
Pulvermacher's chains, the voltaic piles made with elements of metallic
gauze, Cruickshank's battery, and many others that have been used. A
sufficiently constant current may be obtained from either of the
following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's.
For hospital use, the Daniell battery (in Muirhead's modification, or
with the form of cells introduced by Siemens-Halske) is perhaps the most
desirable; but for private practice it is worth while to sacrifice
something of the superior constancy which we gain in the Daniell battery
for the sake of comparative portability. All purposes which we aim at in
the electric treatment of neuralgia may be sufficiently obtained by the
use either of the Bunsen battery (zinc-carbon, excited by dilute
sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc
and platinized silver, excited by dilute sulphuric acid), as in the
highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It
must be remarked that, for the purpose of treating neuralgia, we shall
never need to employ more than fifteen, or at the utmost twenty, cells
of either of these batteries. Both the Stohrer's Bunsen and the modified
Smee of Weiss are made so that the elements are not immersed in the
exciting fluid until the moment when the battery is going to be used; a
simple mechanism at once throws the battery into or out of gear. In this
way, destruction of the elements is minimized; and either of these two
batteries may be used for from three to six months without any renewal,
supposing the average work done to be one or two daily seances. If the
battery is worked harder, it will require more frequent revivification.
I strongly recommend London practitioners to deliver themselves from all
care and trouble about the repair of their batteries, by making an
agreement with the manufacturers to inspect and set them in order at
stated intervals. The country practitioner, on the other hand, will do
well to familiarize himself with the process of renewing the acid, of
cleaning the plates, of amalgamating the zinc, etc.; in fact, to make
himself independent of the manufacturer in every thing short of an
actual renewal of the elements, when that becomes necessary. For all
further details respecting the above-named, and other batteries, I must
refer the reader to systematic works on medical electricity.[42] I must
now pass on to the various modes of application, and the cautions to be
observed.

It is, in the first place, necessary to say, that all the best observers
coincide in the statement that the use of a current intense enough to
produce actual pain or severe discomfort is never to be thought of in
the treatment of true neuralgias; such practice will infallibly do harm.
Only such a current is to be employed as produces merely a slight
tingling, and (on prolonged application) a slight burning sensation,
with a little reddening of the skin at the negative electrode. This
being the case, it is perhaps not unnatural for those who have not had
practical experience, to suspect that an application which causes so
little palpable perturbation is devoid of any positive influence at all.
Such skepticism will certainly not survive any tolerably lengthened
observation of the actual facts; but, as some persons may be deterred by
this _prima-facie_ view of the case from making any fair trial of the
current, it may be worth while, here, to allude to the unmistakable
physical effects which similarly painless constant currents are
repeatedly observed to produce in cases of motor-paralysis attended with
a wasted condition of muscles. Those who have had experience of the
treatment of such cases know that it is a by no means infrequent thing
to see both muscles and nerves aroused from a state of complete
torpidity, and brought into a condition in which the Faradic current,
quite powerless before, is again able to excite powerful contractions,
while, at the same time, the bulk of the muscles has increased most
sensibly. These, surely, are sufficient indications of a positive action
of the painless constant current; and such facts have now been recorded,
in multitudes, by most competent observers.

The next maxim of first-rate importance is that the applications of the
current should be made at regular intervals, and at least once daily; in
most instances, this is enough, but occasionally it will be found useful
to operate twice in the day. The matter of regularity is, I find, of
great consequence, and it will not do to intermit the galvanism
immediately on the occurrence of a break in the neuralgic attacks: it
should be continued for some days longer.

The length of sittings is a point as to which there is considerable
difference of opinion between various authorities; but my own
experience coincides with that of Eulenburg, that from five to ten, or,
at the utmost, fifteen minutes, is almost the range of time.

Closely connected with the question of the length of sittings, is that
of the continuity with which the current is to be applied. I have seen
the best results, on the whole, from passing a weak current, without any
breaks, for about five minutes. But, where there are several foci of
intense pain, it will often be advisable to apply the current to each of
these, successively, for three or four minutes.

The places to which the electrodes should be applied vary much according
to the nature of the case.

Benedikt's rule, that the application of electricity, to be useful, must
be made to the seat of the disease, is undoubtedly true; but it is
capable of being applied in a somewhat different manner from that which
he recommends in particular cases, the difference being due to the view
of the pathology of neuralgia which is taken in this work. That view is,
that the essential _locus morbi_ is always in the posterior nerve-root
(and usually in that portion of the root which is within the substance
of the cord), and that the peripheral source of irritation, if any, is
only of secondary--though sometimes of considerable--importance. Hence
the main object, in electrization, would seem to be to direct the
influence of the current upon the posterior nerve-root. This may,
however, be done in different ways, according to the situations in which
we place the electrodes, and the direction in which we send the current.

There are, as yet, very considerable differences of opinion among
electro-therapeutists as to the principles which should govern us, both
in the localization of the effect and the direction of the current.
Benedikt, for example, recommends that the current should be directed
toward the supposed seat of the mischief. Thus, if we suppose a
neuralgia to depend on morbid action within the spinal cord, then we may
galvanize the spine, taking care to make the current come out through
any vertebra over which we detect tenderness. If we suppose the seat of
the disease to be in the nerve-root in the mere ordinary sense of the
word, then we apply the positive pole to the vertebra opposite the
highest nerve-origin that can be concerned, and we stroke the negative
pole down by the side of the spinous processes, some forty times in
succession. The proportion of cases of idiopathic neuralgia in which
this treatment succeeds is, according to Benedikt, very large. In other
cases, he sends the current from the cord to the apparent seat of pain.

On the other hand, Althaus[43] tells us that, whether the application
be central or peripheral, it is the positive pole, alone, which should
be applied to the part which we intend to affect: and that the
application of the negative pole in this situation is rather likely to
do harm than good, as proving too exciting. Eulenburg, also, says that
in general the positive pole should be applied to the seat of the
disease, the negative on an indifferent spot, or on the peripheral
distribution of the nerve.

It is, however, very doubtful to me whether, in the majority of cases,
the direction of the current makes any considerable difference in its
effects, provided only that the stream is fairly directed so as to
include the _locus morbi_ in the circuit, and care is taken to apply it
with sufficient persistence and with not too great intensity. Upon this
point I am glad to be able to cite the authority of Dr. Reynolds, whose
experience is very large. This author, while admitting that in theory
the "direct" and the "inverse" currents would seem likely to have
different effects, declares that in practice this does not prove to be
the case, either in the instance of pain of nerve or of spasm of muscle.
Dr. Buzzard, also, in relating a very striking case (which I had the
advantage of personally observing) before the Clinical Society,
particularly mentioned that the direct and the inverse currents had a
precisely similar effect in relieving the pain. The patient suffered
from severe and probably incurable cervico-brachial neuralgia; the poles
were placed, respectively, on the nape of the neck and in the hand of
the affected limb, and whether the positive was on the nape and the
negative in the hand, or _vice versa_, the effect was the same. Very
striking remission of the pain was always produced, and the immunity
from suffering sometimes lasted for a considerable time, while no other
plan of treatment seemed to have more than the most momentary effect.

My own experience tells the same story very decidedly, for I have on
very many occasions obtained great benefit, both by the direct and by
the inverse currents, in the same patient. I shall here relate a few
instances:

CASE I.--A married woman, aged forty-eight, whose menstrual periods had
ceased quietly some six years previously. She was, on the whole, a
healthy person, but had suffered from migraine in her youth, and came of
a neurotic family. She was attacked with severe cervico-brachial
neuralgia, which resisted all treatment for nearly three months, and, on
her then trying a month's change of air and absence from medication,
became worse than ever. The constant current was applied, from ten (and
afterwards fifteen) cells of Weiss's battery, daily for twenty-four
days, the pain vanished finally at the end of thirteen days, and the
accompanying anæsthesia and partial paralysis disappeared before the
treatment was concluded. In this case the negative pole was applied by
the side of the three lower cervical vertebræ, and the positive was
applied, successively, to three or four different parts of the most
intense peripheral pain.

CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the
leg. Galvanization (twenty cells Daniell), from the anterior tibial
region to the spine was found invariably to cut short the pain. I now
reversed the current; the effect was the same. After ten sittings I
suspended the treatment, as there had been no attack for three days; but
a week later the neuralgia returned in full fury. I resumed
galvanization from periphery to spine; after twelve more sittings the
attacks had become rare and slight. I continued treatment for eight days
longer, during the whole of which time there was no pain. It had not
recurred when I saw her fifteen months afterward.

CASE III.--H. G., a footman, aged twenty-three, applied to me at
Westminster Hospital, with neuralgia of the first and second divisions
of the right trigeminus, of six weeks' standing. The right eye was
bloodshot and streaming with tears, the skin of the right side of the
nose and right cheek was anæsthetic, the right levator palpebræ was
partially paralyzed. Hypodermic injections of morphia proved only very
temporarily beneficial. After a fortnight's treatment with this and with
flying blisters to the nape of the neck and the mastoid process, I
commenced the use of the constant current daily (ten cells, Weiss). The
first application (positive on nape, negative on infra-orbital foramen)
stopped the pain, and procured fourteen hours' immunity. On the next day
I reversed the current; the pain stopped after three minutes'
galvanization; it did not recur for four days, during which time,
however, I continued the daily use of the direct current. On the sixth
day of treatment the patient came to me with a somewhat severe paroxysm,
almost limited to the ophthalmic division; it was accompanied by
spasmodic twitchings of the eyelid, and copious effusion of altered
Meibomian secretion, looking like pus. Galvanization from supra-orbital
foramen to nape stopped the pain in five minutes. The next day the
patient presented himself, quite free from pain, which had not returned;
the conjunctiva was clear, and there was no visible Meibomian secretion.
Inverse galvanization was continued for ten days; but no recurrence of
the pain took place. The cure was permanent three months later.

On the contrary, we sometimes see complete failure of the current to
affect any good whatever; and in these cases the reversal of the current
has not, so far, appeared to me to make any particular change in the
result. Such was the case with a patient whose history I detailed (along
with that of Case I.) to the Clinical Society. She was an ill-fed and
overworked unmarried needle woman, aged thirty; the neuralgia was a most
violent double occipital pain, with foci, on each side, where the great
occipital nerves become superficial. The current was passed daily, for
some days, from one focus to another (necessarily passing through the
nerve-roots and the spinal cord), and the positions of the conductors
were occasionally reversed; this not succeeding, the current was applied
altogether to the spine, the negative pole being placed on the highest
cervical vertebræ, but no good effect was produced after a treatment,
altogether, of sixteen days.

Notwithstanding these, and a good many similar facts that could be
adduced, I should hesitate to go so far as to say that there is never
any importance in the direction of the current. In old-standing cases,
where there are well-marked _points douloureux_ that are exceedingly
sensitive, I have found that the application of the positive pole,
successively, on the most tender points, the negative being placed on
the spine opposite the point of origin of the nerve, has had a more
beneficial effect than any other mode of application.

There are very considerable differences, both as to the best manner of
galvanization, and also as to the chances of doing good with it, in the
case of neuralgias of different nerves; and, on the whole, I find
Eulenburg's conclusions on this matter very just. He indicates sciatica
as the affection which is by far the most curable by the constant
current; he says that many cases are cured in from three to five
sittings, while others require as many weeks, or even months of
treatment; and that a total absence of benefit is only seen in rare
cases dependent on central causes, or on diseases which are irremovable
(like malignant pelvic tumors). On the other hand, he reports that
intercostal neuralgia has never been materially benefited by
galvanization in his hands. With regard to ordinary trigeminal
neuralgias, he speaks strongly of the current as a palliative, but very
doubtfully of its power to cure, in genuine and severe cases. In
cervico-brachial neuralgia he speaks of it as dividing with hypodermic
morphia the whole field of useful treatment, in the majority of cases.
In cervico-occipital neuralgia he says it rarely does much good. I shall
return to Eulenburg's estimate of its utility in migraine, presently.
Let me here say that I am inclined to indorse everything in the
above-detailed statements, excepting that I should place a considerably
higher estimate on the curative powers of the current in ordinary
trigeminal neuralgias. The remedy, like every other, will doubtless fail
in a considerable number of those very bad cases which occur in the
degenerative period of life; but if anyone desires to see the proof of
the power it sometimes exerts, even in extreme cases, he should study
the two most remarkable cases treated by Prof. Niemeyer, of Tubingen,
and reported by Dr. Wiesner.[44] The patients were respectively aged
sixty-four and seventy-four, and the duration of the neuralgia had been
respectively five and twenty-nine years; in both the pain was of the
severest type, and in both the success was most striking. In one of them
every possible variety of medication, and several distinct surgical
operations for excision of portions of the affected nerve, had been
quite vainly tried. The cases are altogether among the most interesting
facts in therapeutics that have ever been recorded. Dr. Russell Reynolds
has also told me of a case under his own care, in which a lady, who had
been the victim, for twenty years, of an extremely severe neuralgia of
the ophthalmic division of the fifth, which attacked her daily, and had
caused great injury to her general health and nutrition, was not merely
benefited, but the affection absolutely removed, at any rate for a long
period, by a single application of the current. I have personally seen
no such remarkable cases as these but I have had some extremely severe
cases under my care in which the effect of the current was to arrest the
pain in a few applications, and procure a remission for several days, or
even weeks. And I have had several slighter cases which were as much
cured, to all appearance, as any disease can be, by any remedy.

As a general rule, neuralgia of the limbs requires to be treated with a
more powerful current than neuralgia of the face (twenty cells instead
of ten). In the latter case, indeed, it is necessary to be exceedingly
cautious (commencing with five cells), since a current of high power has
been known to produce most serious effects upon the deeper-seated
organs; the retina has been permanently paralyzed, by too strong a
current applied on the face, and still graver dangers attend the
incautious use of galvanization of the brain or of the sympathetic, of
which we have now to speak.

Galvanization of the brain is a remedy chiefly employed in true
migraine, and is certainly very effective in that disease. I have not
found it useful to apply the current in the long axis of the cranium,
but transmitted from one mastoid process to the other it has proved most
useful; and I am glad to find that my experience on this point coincides
with that of Eulenburg. But the use of this remedy is highly perilous in
careless hands. In working with either Daniell's or Weiss's battery, it
is necessary to use at first only three or four cells, and to increase
the number only with the greatest caution. The sittings should never
last more than half a minute; but the slightest giddiness should make us
stop even sooner. On the other hand, the applications ought to be made
daily, and usually twice a day. Ten cells (Daniell or Weiss) is the
utmost that will ever be required, few patients will bear so much; and,
apart from the possibility of more serious mischief, there is nothing
which annoys and frightens patients more seriously than the sudden and
intense vertigo which over-galvanization of the brain may induce.

Even more ticklish than the galvanization of the cerebral mass is
galvanization of the sympathetic. I am not going to raise here the vexed
question in physiological electricity as to the possibility of a
galvanization the effects of which shall be accurately limited to the
sympathetic. The fact is unquestionable, that very powerful and peculiar
effects, utterly unprocurable in any other way, can be produced by
placing one pole on the superior cervical ganglion (just behind and
below the angle of the jaw) and the other on the manubrium sterni. This
is a mode of galvanization which has been highly praised, more
especially by Remak, and after him by Benedikt, but it has yielded
rather disappointing results in neuralgia in my hands. Either I have not
observed any distinct effect at all, or, if a current even a very little
too strong were applied, I have repeatedly seen most uncomfortable, and
sometimes very alarming, symptoms. I shall not easily forget a patient
who applied at the Westminster Hospital, suffering from a severe form of
facial neuralgia, and who was persuaded to come to my house and have his
sympathetic galvanized. I used only twenty cells of Daniell, but the
current had not been applied more than a few seconds when the patient
fell on the floor, and remained in a state of half swoon for a
considerable time. I allude to this and other less dangerous accidents
that I have seen follow galvanization of the sympathetic, not with the
view to prove that the method is useless in trigeminal neuralgia--I
should certainly hesitate to say that, considering the large amount of
respectable evidence in its favor--but I think that it is a procedure
requiring the utmost caution, and meantime I have not personally found
it nearly so useful as the methods already described.

There are sundry special applications of galvanism to particular forms
of neuralgia which require a few words of notice. Of electrical
treatment in regular angina pectoris I have had no experience; and in
the one case of intercostal neuralgia, complicated with quasi-anginal
attacks, in which I applied the constant current to the spine and the
cardiac region, in the direction of the affected intercostal nerve, no
effect was produced. I shall, however, mention the experience of
Eulenburg, as he is a sober and dispassionate writer on the effects of
electric treatment in general. He says he believes that in the proper
use of the constant current we shall discover the chief, possibly the
only direct, remedy for angina; and he describes the apparently
favorable results he has already obtained in three or four cases. The
current was from thirty cells; the positive pole was placed on the
sternum (broad electrode), the negative on the lower cervical vertebræ.
The alternative method which Eulenburg suggests, but has not, so far,
put in practice, is direct galvanization of the sympathetic and vagus
in the neck.

The application of the constant current in neuralgic affections of the
larynx and pharynx is of most indisputable service; the experience of
Tobold[45] upon this point is fully borne out by my own, as far as it
goes. In many cases it will be sufficient to place the positive pole
(from fifteen cells Weiss) on the pomum Adami, and the negative on the
nape of the neck, and to keep up a continuous current for five or ten
minutes daily; but in some cases the direct application of the current
to the pharynx or larynx may be required; in such, a modification of Dr.
Morell Kackenzie's laryngeal conductor will be found useful. [I shall
have occasion, in Part II., to notice the superior action of
Faradization in mere hysteric throat-pain, as distinguished from true
neuralgia.]

Neuralgia of the testicle can be best treated, if galvanism be thought
necessary, by immersing the whole scrotum in a basin of salt and water,
in which the positive pole is placed: the negative pole is to be placed
on the upper lumbar vertebræ; the current should be from fifteen cells
Weiss, and the application should last continuously for ten minutes. In
neuralgia of the urethra, I should be inclined to adopt a plan,
mentioned to me by Dr. Buzzard, of attaching one conductor to an
ordinary silver catheter introduced into the urethra, and placing the
other pole upon the perinæum.

Neuralgia of the neck of the bladder I have found to be materially
relieved by the constant current from twenty cells passed through from
pubis to perinæum; the sittings being rather long. I have also, on one
occasion, tried the introduction of a proper _porte-electricite_,
insulated, except at the tip; but the result was not superior to that
obtained in the other way.

As a general rule, it may be said that electricity, like other local
measures which tend to concentrate the patient's attention on the parts,
is only to be applied to the genital organs as a last resort. This is,
of course, especially true in the neuralgias of these organs in women.

In concluding what will doubtless seem to some English readers an
over-long and over-favorable estimate of the employment of galvanism in
neuralgias, I must carefully guard myself against the supposition that I
consider it a remedy to be applied in all cases, or likely to meet with
uniform success, even in the forms of the disease to which it is most
appropriate. It is a weapon which I seldom employ in the first instance,
for many reasons; the principal of which is the costliness of the
proceeding to the patient. Either the physician must personally
administer the remedy, daily, often for a considerable period, or he
must make the patient provide himself with an expensive battery; and in
the latter case there is, after all, the unsatisfactory consideration
that the application (even after the most careful directions have been
given) will perhaps be unskilfully and inefficiently made. On the other
hand, it is not desirable to delay the employment of galvanism too long,
if other remedies have been fairly tried; and the practitioner will do
well to remember the distinctions above laid down as to the varieties of
neuralgia in which it is specially likely to prove decidedly and quickly
beneficial. More especially in sciatica it would really, with our
present knowledge, be a decided neglect of duty were we to allow the
disease to run any considerable length without giving the constant
current a thorough trial. [I can only briefly refer, here, to the novel
mode of galvanization introduced by Dr. Radcliffe, and based upon his
ingenious theory, according to which the true effects of the voltaic
current upon nerve are the result of the charge of free electricity
which it sets up, and not of the current directly. The reader will find
the whole argument elaborately worked out in Dr. Radcliffe's recent work
on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be
enough to say, here, that the object to be attained, according to this
view, is to replace the neuralgic nerve in its healthy physiological
state, by charging it with free positive electricity. The manner in
which this is done is as follows: In a case, _e. g._, of
cervico-brachial neuralgia, we place the positive pole as near as may be
to the central origin of the affected nerve; the negative pole is held
in the hand of the same side, which is immersed in a basin of warm salt
and water. In this same basin is another electrode, the wire from which
is put in communication with the earth--most conveniently by putting it
in contact with a gas-pipe. The patient, and the battery, ought properly
to be insulated. The result of this arrangement is, that the free
negative electricity is carried off by the earth-wire, and the limb
remains charged with free positive electricity. I have had no sufficient
experience of this method to give any opinion of its merits, but the
inventor thinks it decidedly superior to the ordinary modes of applying
the constant current.]

(_f_) The last kind of local remedies for neuralgia of which we have to
speak are those by which we seek to mitigate the paroxysm by thoroughly
excluding the air from the site of apparent pain. These are chiefly of
value in those cases where a distinct inflammation (herpetic or
erysipelatoid), or an unusual degree of sensitiveness on pressure, etc.,
has become developed around the superficial branches of the neuralgic
nerve. Very much the best agent of this kind with which I am acquainted
is the flexible collodion; in neuralgic herpes and erysipelas the effect
of this application, conjoined with the hypodermic injection of morphia
(preferably in the immediate neighborhood), is of the greatest possible
service in mitigating the pain. In herpes it has this further special
advantage, that it prevents the occurrence of sores after the vesicles
fall, an accident which otherwise will sometimes happen, and which very
much increases the severity and intractability of the consecutive
neuralgic pain.

4. Lastly, we have to speak of prophylactic measures, which really ought
never to be thought of as a separate matter, but always as an essential
and most important part of the treatment of neuralgia. The prophylaxis
of neuralgia is divisible into (_a_) measures for preventing the
development of the neuralgic habit in those who may be supposed to have
a predisposition to it; (_b_) measures between the paroxysms; (_c_)
measures to be adopted after the attacks have ceased.

(_a_) The measures that should be taken to avert neuralgia, in those who
may be reasonably assumed to be predisposed to it, have scarcely
received any consideration at the hands of systematic writers; yet this
is a most important subject. The persons in question are children who
belong to families known to be infected with tendencies to neurotic
diseases, or persons whose daily occupations submit them to peculiarly
strong predisposing influences of an external kind. The hostile
influences that should be avoided, or at any rate compensated, are of
several kinds: (1) Psychical; (2) defects of nutrition; (3)
mismanagement of the muscular system; (4) sexual irregularities; (5)
over-fatigue of the special senses, and insufficiency of sleep,
especially the latter; (6) unhealthy atmosphere and climate.

(1) The psychical influences which must be especially avoided, if we
would avert the formation of the neuralgic habit, form a large and
somewhat indefinite group, which it is doubtless difficult to deal with
satisfactorily. The matter is, however, highly important, and the
attempt must be made. And there are, at any rate, some leading
principles that I feel justified in laying down with confidence.

We shall best commence the inquiry by directing our attention once more
to the fact, so often insisted upon in this work, that the large
majority of neuralgic patients carry in them the seeds of their malady
from their birth. It has been amply proved that every child born of a
family that has shown strong tendencies to insanity, epilepsy,
paralysis, etc., etc., ought to be looked on as a neurotic subject, and
as a potential sufferer from neuralgia. It has been shown that such
children will be exposed, even under favoring external circumstances, to
the danger of neuralgia at certain important stages of their
physiological history. The earliest of these critical periods is marked
by the occurrence of puberty; and it is not till this time that
psychical influences, as such, come to have any serious bearing on the
formation of the neuralgic habit. Mischief may, indeed, be done to the
brain and the general nervous system, by injudicious mental training, at
a far earlier period; but this mischief, serious or even fatal as it may
be, usually takes some other form than that of neuralgia. It will be
necessary, here, to reflect a little upon certain features of the
childish mind, in order that we may rightly estimate the kind of
influence which puberty exerts upon it.

A very young child is selfish, in the purely animal sense; it is
greedily acquisitive, and its selfishness is unchecked by any sense of
shame. With later childhood there comes a sense of right and wrong, and
a sensitiveness to shame, which check this tendency; still it is the
exception rather than the rule to find any great capacity of
self-abnegation in young school-boys. But a moderately healthy-minded
child, up to the age of puberty, is only acquisitively selfish; he is
not self-centered in the sense of dwelling upon his own mental state,
and reflecting upon the nature of his motives and feelings. It is with
the age of puberty that self-consciousness begins to be a feature in the
mind of the young, and its appearance marks the entrance of a dangerous
element into the character. It is an inevitable stage in mental growth,
and, if wisely dealt with, is ultimately productive, not of evil, but of
good; but it is more perilous to some children than to others, and it is
especially fraught with danger to those whose nervous centres are, by
inheritance, weak and unstable in whole or in parts. The mental antidote
to its possible evil effects is to be found in a vigorous (but not
excessive) training of the mind in studies which shall be as far as
possible external, and the discouragement of all tendencies to
introspection. I would venture to express the decided opinion that the
common idea, that close study injures the young, is only true in a
modified sense. It is, however, unquestionably the fact, that hasty and
imperfect cram-work does very seriously impair the stability of the
brain and the nervous system in young people; there is a spurious
excitement about this kind of learning (especially when it is mainly
competitive, and directed to the gaining of prizes and medals) which
must be injurious. But I think it is quite ridiculous to suppose that,
in this country, the actual amount of intellectual labor undergone by
boys and girls at school is sufficient to do harm, were it only regular
and systematic, and carried out in a conscientious manner; on the
contrary, though I think that the total daily period occupied in study
ought not to exceed some six or seven hours, I believe that the
insisting on strenuous diligence during school hours, and the
maintenance of a high standard as to the quality of the work exacted, is
all on the side of nervous health. But, an even more serious and
difficult matter than the regulation of the amount of intellectual work
to be done is, the question how we are to deal with the unfolding
emotional instincts of the boy or girl who has reached the age of
puberty. It is useless to ignore this side of the mental life; it will
assert itself either for good or for evil. At the risk of seeming to
meddle with matters that belong to the school-master rather than to the
physician, I would urge very strongly that a portion of the training be
deliberately directed to a serious study of one or other of the fine
arts--to that one, whether poetry, painting, sculpture, or music, to
which the boy or the girl instinctively leans. I am aware that there is
a prejudice among parents that the study of the fine arts renders young
people idle and indifferent to other branches of education and other
duties of life. I believe that this only applies to the miserably
inefficient way of teaching these subjects which prevails at present in
all but a few English schools; and that, in truth, a thorough knowledge
of the principles of either music or painting, and a real study of the
best masters, would be sure to prevent the development of that lazy,
conceited manner, and that neglect of other duties, which no doubt
unfavorably distinguish a good many of the young ladies and gentlemen
who dabble a little in music, or painting, or versification. We want the
German rather than the English type of training, we want the acquirement
of sound knowledge of the principles of music (at any rate) to be made
so common that the accidental possession of two pennyworth of
superficial accomplishment in that line shall not enable young ladies
and gentlemen to give themselves airs in society. The truth is, that the
young people who make music or painting an excuse for idleness
respecting other matters are invariably imposters even in that which is
their own supposed _forte_. On the other hand, the serious study of art,
a certain definite portion of time being set apart for it, and
thoroughness being insisted upon, is, I believe, an admirable vent for
the emotional effervescence of commencing sexual life; and I no less
firmly believe that the things that are usually substituted for it are
intensely pernicious. I have already, in the chapter on Pathology,
remarked on the mischief which is often done by the anxiety of religious
parents to make their children (usually somewhere about this perilous
time of puberty) experience the emotional struggle which is believed to
end in a change of heart and principles. I need, therefore, only now
repeat the expression of my intense conviction that the results of this
process, as seen by the physician to occur within that mental region
where the emotions and the organic nervous system come into closest
relations, are simply disastrous. It is not my business to suggest the
proper alternative to a mode of spiritual training which I think
deleterious; I can only intimate, in the most general way, my belief
that a calm and systematic training in the simplest principles of duty
and religion is greatly more suitable to the immature mind and brain of
youth than any strong emotional excitement on such topics. But if
ill-regulated spiritual emotion of a religious kind be a dangerous thing
for young persons in the most serious crisis of bodily development, far
more decidedly pernicious is the spurious excitement of feeling which is
directed to lower and often most unworthy objects. The increasing
precocity of boys and girls, in their familiarity with the most
objectionable aspects of passion and intrigue, is steadily fed, in the
present day, by a system that allows them, too often, unlimited access
to light literature which (as is strikingly the case with many novels of
our day) is at once devoid of true literary and artistic merit and at
the same time replete with sensational incident of a vulgarly exciting
kind. The same degrading tendency is very distinctly to be noted in the
character of the dramatic and other public exhibitions which are most
popular at the present day; the main characteristics being, bad art, and
thinly-veiled sensuality, all the more pernicious for being veiled at
all. It would be a hundred times better that a boy, or even a girl,
should study the frank and outspoken descriptions to be found in
Shakespeare or Fielding, with all their occasional coarseness, than that
they should enervate their minds with the sickly trash that is most
current and most popular at the present day, in theatre and circulating
library.

(2) The defects of nutrition that assist the development of the
neuralgic tendency are often the consequence of a system which, it is to
be hoped, is to a large extent becoming effete, but which, nevertheless,
survives in sufficient vigor and extent to demand express reprobation.
It was till lately the general, and it is still a too common practice,
to keep children and young persons on a very insufficient allowance of
the most important elements of food; the state of things in this
respect, both in public and private schools, in the first half of the
present century, is a lasting reproach to the medical practitioners of
those days, who scarcely lifted a finger to amend it, even when they did
not expressly approve it, under the influence of absurd theories about
the dangers of excessive "grossness of blood." It is indeed amazing
that, with the palpable fact staring them in the face, of the rapid and
incessant additions to tissues which are being made by children and
young people, medical men should have failed to perceive the necessity
for supplies of food practically unlimited except by the capacity of
digestion. Yet this seems hardly ever to have been thought of, and the
unfortunate results seem scarcely to have been noticed, except when they
led to emaciation or consumptive disease. But the effects were perhaps
even more disastrous where, with a maintenance of a fair amount of
muscular nutrition, there was only a little dyspepsia, and perhaps some
slight tendency to nervousness, to show that anything was wrong. The
children who were born of strong and healthy parents, may have suffered
comparatively little from this regimen as regards their nervous system,
but those who were born of neurotic ancestors undoubtedly suffered
extensively. The crisis of puberty was, in such ill-nourished children,
too frequently the signal for an explosion of epilepsy, chorea, or
neuralgia; and too often the mischief was yet further increased by a
most injudicious medical treatment, including a deterioration rather
than an improvement in the already insufficient dietary system. At the
present day, however, we may fairly hope that common sense is
prevailing, so as to put an end to this mischief as regards the children
of the upper and middle classes. Unfortunately, with the poor a similar
ill-nourishment of the young is too often inevitable, and the
consequences are constantly to be traced in enfeeblement of the nervous
system, of which neuralgia is a pretty common result.

It cannot be too frequently repeated that for those children, more
especially those who come of nervous families, any considerable error in
this direction has a fatal tendency to awaken the disposition to nervous
disease. At every step of the infancy, childhood, and youth of such
persons, the most generous allowance of the more nutritive elements of
food is of the first importance. At the same time I am entirely opposed
to the practice of giving stimulants to any considerable extent, or
indeed to any extent, save in exceptional instances. Good meat, bread,
milk, butter, fruit, and vegetables, are really the efficacious means of
fortifying the nervous system against the impending dangers. With
hospital out-patients, for whom we cannot command such diet, our best
course, whenever they show signs of deficient nutrition, will be the
steady administration of cod-liver oil for a long period.

(3) The true and proper training of the muscular system is among the
most important means of antagonizing the tendency to the development of
the neuralgic habit. It is a great mistake to suppose that over-training
in athletics of any kind is of use; but the systematic employment of
means which tend to make the muscular system hardy and efficient is of
very great benefit. The parents of children who may be supposed by
inheritance to possess a tendency to neuralgia would do well to study
such a methodical series of directions as those which are given by Mr.
Maclaren, in his excellent work on physical training. I suspect that the
benefit of judicious gymnastics is wrought in two ways: first, by its
improving circulation and general nutrition, including the nutrition of
the nervous centres; and, secondly, that it gives the nervous centres an
education, so to speak, by the variety of difficult co-ordinative
movements over which it trains those centres to preside. But
unquestionably the matter is a science, not a mere rude art, and
requires to be studied as such.

(4) Of unspeakable importance to the object of averting the formation
of the neuralgic habit is the prevention of sexual irregularities in the
young. Under this heading is included a large and various group of
influences; of these the first that requires notice is the prevention of
precocious sexual stimulation, whether by talk or by acts, which may
precipitate the occurrence of puberty at an unnaturally early age. I
know very well how difficult it is to devise any scheme which really
would effectively control and antagonize the worst mischief of schools;
but it is at least a duty to say here, that no experienced physician can
doubt that such a scheme must be found, if we are ever to hope for a
healthier race of children and of young men and women, and if we are to
break down one of the most potent of the influences that go to the
production and maintenance of the neurotic disposition. I would be
clearly understood not to suppose for a moment, either that this sort of
cause is usually at work in the production of neuralgia in the young, or
that of itself it is sufficient to produce the disease; but I would say,
for certain, that on children of nervous families such influences act
with disastrous energy; and, moreover, that where we see signs, in a
neuralgic young person, of that general form of bad health which is
connected with precocious puberty, we may be nearly certain that such
influences have actually been at work. At all cost, and by all
conceivable means, all children, but most especially the delicate and
nervous ones, ought to be shielded from the risk of this occurring.

Another form of sexual irregularity which can be counted as a
contributor to the formation of the neuralgic habit is menstrual
irregularity, especially at the commencement of sexual life. By far the
most mischievous in this way is menorrhagia of the young. I have seen
exceedingly severe and intractable neuralgia set up by it. As regards
the influence of simple amenorrhoea, I am by no means clear: it seems
pretty nearly as likely that the deficient excretion (when not dependent
on mechanical cause) is a mere sign of the general weakness which also
predisposes to the neuralgia, as that the neuralgia is in any way the
direct consequence of the amenorrhoea.

Leucorrhoea, especially when profuse and long-continued, is a much
more indisputable factor in many neuralgias. It is a point of real
importance to put an end promptly to such a discharge, if it exists, and
the usual remedies--cold bathing, mild astringent injections,
etc.--should be at once prescribed.

Dysmenorrhoea, a painful menstruation, when not dependent on a purely
mechanical cause, affords a strong example of neuralgia connected with
sexual difficulty; but there is every reason to think that the neuralgia
is the primary and not the secondary affection. The only effective
prophylaxis, therefore, is the adoption of such general measures as will
raise the whole tone of nervous health. It often happens that marriage
completely cures the tendency to these attacks.

(5) Insufficiency and irregularity as to the allowance of sleep are
potent influences in developing neuralgia in those who are hereditarily
predisposed. It is needless to say a single word to prove the imperative
need of the young for periodical and prolonged repose from the conscious
actions of the nervous system. Full ten hours of sleep in the
twenty-four, for boys and girls who are at or near the period of
puberty, is an absolute necessity if we would prevent any existing
irritability of the nervous system from developing into the fully-formed
neurotic temperament. Indeed, I believe that, for all young people (but
especially girls) up to the age of twenty-five, this allowance is not
the least beyond what is necessary: only the need is most pressing at,
and just before, the development of the sexual organs. Of course a much
larger allowance of sleep is necessary in actual infancy: from seven to
twelve we may be content if we get nine hours clear sleep; but during
the two or three years preceding puberty we should insist upon ten
hours, at any rate for children who possess the nervous temperament.

(6) Impurity of the atmosphere in which they habitually or daily reside
must be carefully shunned for young children, especially for the
nervous. The kind of dull and diffused headache which children often
complain of, after study for some time in a close, ill-ventilated
school-room, is very likely (if the bad influence be continued for a
number of years) to develop itself, at puberty, into a regular migraine.
Purity of air in the school-room must therefore be scrupulously provided
for; and the same thing must be attended to as regards the sleeping
rooms.

Of the climatic influences we may speak in a few words. Besides the
avoidance of distinctly malarial districts, and also of places where,
although there is no distinct ague, there is a prevalence of neuralgic
or even of so-called "rheumatic" complaints, it is necessary very
carefully to shun damp soils, and places where there is a great deal of
harsh and cold wind. Mere lowness of average temperature is not in
itself a strong predisposer to neuralgia, at any rate if guarded against
by abundant food and the use of such clothes as will prevent children
from ever feeling chilly and depressed. But damp and harsh winds are
actively bad; and when joined to habitual or frequent lowness of
temperature, they constitute very unfavorable surroundings for the
nervous systems of delicate children.

(_b_) We come now to the prophylaxis which is to be adopted in the
intervals of the paroxysms when neuralgia has been actually set up. This
consists essentially in three things: (1) Physiological rest, as perfect
as possible, of the affected parts; (2) protection from cold; (3)
protection from sunlight; (4) avoidance of injurious mental emotions.

(1) The maintenance of physiological rest, to the greatest extent that
is possible, is an absolute necessity, if we would shield a nerve, which
has lately been attacked with neuralgia, from fresh paroxysms. The most
evident illustrations of this fact are afforded by those neuralgic
affections in which it is most difficult to adopt this precaution. Thus
the greatest embarrassment from this cause is met with in the case of
sciatica; a mild case is often converted into one of great severity and
intractability because the patient, in the early stages, either cannot
or will not maintain the recumbent posture. So, too, though in less
marked degree, the cure of cervico-brachial neuralgia is often greatly
impeded by the difficulty of maintaining complete rest of the limb.
Again, in neuralgia affecting the third division of the fifth, the
movements of mastication and of speech are a terrible hinderance to the
progress of recovery; and it often becomes necessary, in severe cases,
to prescribe absolute silence, and even to feed the patient exclusively
with such liquid or semi-liquid food as shall require no efforts of
chewing.

(2) Preservation from external cold is highly important. When a nerve of
the arm, or leg, or trunk, is affected, warm flannel under-clothing
ought immediately to be adopted. The patient who has been suffering from
cervico-occipital neuralgia should for some time, in anything but quite
summer weather, never go out without wearing a warm comforter round the
neck. The sufferer from facial neuralgia should for some time after the
cessation of actual attacks never face wind without wearing a thick
veil.

(3) Exposure to bright light must be scrupulously avoided by sufferers
from ophthalmic neuralgia. The affection known as "snow-blindness" is
really a neuralgia, with vaso-motor complications, produced by the glare
of light reflected from snow; and one of the severest attacks of
neuralgia which I personally ever experienced was provoked in this way.
Even the comparatively slighter, but for an Englishman unusual, glare of
sunlight which one meets with during the first days of a Continental
holiday, in wandering about towns made up of clean white stone or
whitewashed houses, is enough to provoke an attack, unless the eyes are
carefully guarded with colored glasses.

(4) It is scarcely necessary, after what has been already said, to
insist upon the absolute necessity of mental quietude, as far as this
can be obtained. This precaution is more or less important in all
neuralgic affections; but in migraine and in other trigeminal neuralgias
it is almost of more consequence than any other prophylactic measure;
and in angina pectoris it is so essential that adoption or neglect of it
may easily turn the scale between life and death. All forms of abdominal
visceral neuralgia, also, are greatly affected by emotion, and passion
or strong excitement of any kind must be scrupulously shunned if the
neuralgic habit is to be broken through. Unfortunately, it too often
happens that the mental surroundings of the patient cannot be so changed
as to enable us to carry out this kind of prophylaxis effectually; and
neuralgic cases of this class are among the severest trials of the
physician's tact and skill, and too frequently defy his efforts.

(_c_) The precautionary measures which are to be adopted, after the
neuralgic habit has apparently been fairly broken through, in order to
prevent the patient from sliding again into the old vicious groove, can
hardly be defined with exactness though their general character will be
readily gathered from the picture of the clinical history and pathology
of the disease which has been exhibited at large in this work. They
mainly consist in the avoidance of severe, and especially of unequal,
strains upon bodily or mental powers; and in redoubled carefulness in
these respects at those natural crises in the life of the organism which
have been shown to exercise so important an influence upon the neuralgic
tendency. To a certain extent, also, but with much precaution, we may
attempt to modify the peripheral sensibility by what is commonly called
a hardening regimen. Thus, with great care, and proceeding in a very
gradual manner, we may by degrees accustom the patient to a larger
amount of exposure to free air, and even at last to rough weather, so
that in the end he may become less sensitive to some of the commonest
immediately exciting causes of neuralgia. If one were to construct an
advancing scale of such measures, one might arrange them something like
this: First, in-door gymnastics, and gentle horse-exercise for out-door
work, in fine weather only; then horse-exercise alternated with
pedestrianism, sea-bathing in warm weather; and, finally, we should try
to reach a stage at which the patient can well endure a ten or fifteen
miles' walk or ride every day, and be comparatively careless about the
weather. In reaching this latter stage I have seen some patients helped,
in an extraordinary degree, by the frequent use of the Turkish bath,
followed by douche. Upon this latter subject I beg to offer some
remarks, which are the result of pretty careful and extensive study of
the effects of the Turkish bath in a variety of chronic nervous
diseases. I believe it to be a very great mistake to suppose that,
either in rheumatism or in true neuralgia, the process of the bath
should be prolonged to such an extent as is commonly done. Instead of
the usual slow heating process, gradually carried to a point at which
excessive sweating occurs, I believe that the really scientific is the
following: The patient should as quickly as possible get into the
hottest atmosphere he intends to expose himself to, which should never
be more than about 170° Fahr. He should stay in this place just long
enough to get thoroughly hot, and, with the assistance of a glass or so
of water drunk, throw himself into a free but gentle perspiration. He
should then be rapidly shampooed, exposed to the spinal douche for two
or three minutes, and then pass to the cooling-room. Let him beware of
too long dawdling in the latter place, and let him avoid smoking there.
It is a positively dangerous thing to cool one's self quite down to the
normal heat, still more so to induce the slightest chilliness; the body
should be still in a universal glow when one issues into the street.
Over and over again I have proved upon myself that it is the beneficial
method, whereas the prolonged use of the bath, the production of very
copious sweating, and above all a lengthened cooling process, most
seriously exhaust the nervous energy.

There are certain special considerations as to the habits of life that
require a word or two. I need say nothing more to enforce the views
already put forward as to the necessity of copious supplies of food. I
need only refer to what I have already said about the decidedly
mischievous tendency of anything like habitual excess in the use of
alcohol, merely adding a special caution against such indulgence during,
and particularly toward, the end of the period of sexual activity. There
is one more topic upon which something must be said, namely, the extent
to which sexual intercourse should be allowed. Speaking of neuralgia
generally (excluding neuralgic affections of the sexual organs
themselves), it may decidedly be said that the regular and moderate
exercise of the function, during the natural period of sexual life, is
beneficial; but that excess is always dangerous, and that the
continuance of sexual intercourse, after the powers naturally begin to
wane, is extremely pernicious in its tendency to revive latent
tendencies to neuralgia. As regards neuralgias of the sexual organs, it
is very difficult to speak positively; and yet I believe that (once the
neuralgic habit broken through by other means) it is very desirable that
the patient should live according to the laws of normal physiological
life.


NOTE I.

ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE.

The following cases must be now added to those recorded in my list of
private patients whose family history has been ascertained with reliable
accuracy.

CASE I. is that of a gentleman, aged forty-seven, the subject of
lumbo-abdominal neuralgia: no history of nervous disease in the family;
his mother, however, was of a "nervous" temperament.

CASE II.--A gentleman, aged sixty-four, suffering from angina. His
family nervous history is fearful. On the father's side it is not
possible to get a clear account. But on the maternal side there has been
a strong tendency to insanity and suicide; and in the patient's own
generation one brother committed suicide from insanity, and one sister
is still alive, insane. An interesting fact is, that the mother's family
have shown an extraordinary proclivity to erysipelas.

CASE III.--The young gentleman, whose single but extremely severe attack
of angina is previously described, comes of a family in whom the
tendency to neuralgia is undoubtedly very strongly inherited. His father
is frequently and very severely _migraineux_, and in early life suffered
cardiac symptoms not unlike his son's. A brother was also liable to
attacks of true migraine between puberty and the age of twenty-one.

CASE IV.--On the other hand, a case of angina which I saw in the
country, last year, occurred in a gentleman, aged fifty, whose family
presented no traceable neurotic history. But the damage inflicted upon
his nervous system by various external influences was quite
extraordinary. In some way or other he got some attacks of migraine at
the age of fifteen or sixteen; for these he was treated with bleeding,
and with a most savage antiphlogisticism generally. From that time he
never got free of the neuralgic tendency. He used to have not only
facial, but intercostal neuralgia; for this last he was repeatedly bled,
under the idea that it was pleurisy. Added to all this he habitually did
an immense deal of brain-work in his study, and for years had performed
clerical duties of the most exacting and exhausting character. It is not
much wonder that these combined circumstances had sufficed to generate
the neurotic temperament.


NOTE II.

THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD.

In the present transitional state of opinion concerning the mode in
which the phenomena are produced that are popularly known under the name
of "reflex paralysis," I cannot pass without notice the doctrines of
these two observers. The reader will have perceived that, as regards the
secondary paralytic symptoms observed in neuralgias, I explain the
phenomena mainly on the theory of a process which is central, and not
peripheral, in origin. And, even where, as in some few instances, it
seems possible that the starting-point was an organic affection of some
viscus, we must always consider the possibility that the link between
this and the neuralgia and paralyses was a neuritis migrans travelling
inward to the sensory centre, and from that passing over to motor
centres and thus producing paralysis; or that, without the intervention
of any truly inflammatory process, the continual impressions streaming
in upon the cord from the original seat of organic disease may damage
the nutrition of the sensory nerve-root, producing a partial atrophy,
and that this process may extend to the motor root.

It remains, however, to inquire whether the influence of powerful
peripheral agencies may not, in a purely "functional" manner, disable
the nerve-centres for a time, causing paralysis with or without
neuralgia. The main supporters of such a doctrine are Dr. Handfield
Jones[46] and M. Jaccoud.[47]

Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to
spasm of the vessels in the nerve-centres, and we need not repeat his
arguments on that head, because it seems to be generally felt that the
vascular spasm theory will not account for the facts. Jones believes
that the state produced in the nerve-centre by the peripheral influence
is one of paresis from shock-depression, and that from the sensory
centre this state can communicate itself to motor and vaso-motor
centres, though commissural fibres. He does not believe in the existence
of a special inhibitory portion of the nervous system: he believes that
an impression may prove stimulating when it is mild, or paralyzing when
it is strong; and that any afferent nerve may convey either the one
influence or the other to the centres and thus produce secondary
stimulus or secondary paralyses in various efferent nerves. Jones has
the distinguished merit of being one of the first authors distinctly to
perceive that pain must rank on the same level with paralysis: hence he
sees nothing unintelligible in the communication of paralysis to a motor
centre from a sensory centre that was in the state which the mind
interprets as pain.

The _theorie d'epuisement_ of Jaccoud (Erschopfungs-theoric) also denies
the possibility of Brown-Sequard's idea of prolonged spasm of the
vessels of the centres. It imagines that powerful peripheral excitements
exhaust the irritability of the nerve, and through that of the centres,
and induce a state of unimpressibility--analogous to that which exists
in a nerve or nerve-centre, which is included in the circuit of a
constant current. The nervous force is wasted, and, until an opportunity
of repose is afforded to the centre, the faculty of impressibility
cannot again revive.

I must say that of these two theories I decidedly incline to that of
Handfield Jones (though I imagine that in reality the cases are
extremely rare, if there be any, in which the change in the centres is
really only functional and non-organic), I prefer the idea of
paralyzing shock to that of exhaustion from over-excitement, from a
consideration of the nature of that form of peripheral influence which
has been specially mentioned by authors as competent to produce this
sort of "reflex" affections, namely, intense and persistent cold. It
seems to me a mere abuse of words to speak of this as an agent that
could exhaust the nerve by over-stimulation; it must surely exhaust it
in a much more direct manner than this, namely by the direct physical
agency of withdrawing heat from the nerve, and spoiling its physical
texture, _pro tanto_. If such an effect as that which must thus be
produced on the nerve, and through it on the centre, is to be looked on
as a case of over-stimulated function, then, it seems to me, there is no
meaning in language, and no possibility of attaining to clear ideas on
the subject of nervous influence.


NOTE III.

ARSENICAL TREATMENT OF VISCERALGIÆ.

Since writing the above chapter on the Treatment of Neuralgia, I have
had two fresh and very striking examples, in private practice, of the
power of arsenic to break the morbid chain of nervous actions in angina
pectoris.

The first example was that of a medical man, aged seventy-five, in whom
a neuralgia, originally malarial in origin, and of some years' duration,
had fixed itself for some time in the fifth and sixth left intercostal
spaces, and of late had become complicated with anginoid attacks of an
unmistakable character, though not of the highest degree of severity.
The case certainly seemed very unpromising, looking at the patient's age
and the consequent high probability that there was much arterial
degeneration. However, the use of Fowler's solution (five minims three
times a day) was commenced and steadily pushed. The anginoid attacks
rapidly diminished in frequency and at the end of ten days' time were
entirely gone, and after one month of treatment he still had no return
of them, although they had previously been of daily occurrence. It is a
curious fact, whether a mere coincidence or not I cannot say, that, some
few days after the anginoid attacks ceased, he began to experience
somewhat severe pains, rheumatic in feeling, but unattended with heat or
swelling, in the elbows, wrists, and fingers, symmetrically. This has
nearly disappeared, but he is still free from angina. There is no
discoverable heart-lesion in this patient.

The other case was that of a fine old man of sixty-four, who, but for
some few slight attacks of gout, a few small calculi, and a troublesome
prostatic affection, had always enjoyed remarkably good health, until
about five months ago, when he began to notice tightness across the
chest, etc., when he walked uphill. About a fortnight before he came to
me, he was seized with very violent and alarming paroxysms of pain
across the chest and running down both arms, extreme intermittence
of pulse, and a sense of impending dissolution. The attack had recurred
daily, at the same hour (6 P. M.), ever since; besides which there was
an abiding sense of uneasiness in the cardiac region, and a
consciousness that the least excitement or exertion would bring on the
paroxysm. I put the patient on five minims of Fowler, three times a day,
with directions to take ether when the paroxysms came. At the end of the
first week there was already much improvement, the paroxysms having been
both less frequent and less severe. At the end of a fortnight's
treatment he reported that there had been nothing like a paroxysm for
the last eight days, although there was still a good deal of uneasiness
from time to time. The hour at which the attack was expected passed by
absolutely without a trace of angina. It remains to be seen how long
this improvement will last, but the altered state of things, and
particularly the suddenness of the change, cannot be overlooked, and has
very much struck the patient himself. It is now six weeks since he had
any paroxysm.

It becomes more and more apparent that arsenic is generally applicable
to neuroses of the vagus. In asthma, I have long held it to be the most
powerful prophylactic tonic that we possess. It is also an excellent
remedy in gastralgia; although I have rather dwelt (in the text of this
work) on the action of strychnia in this disease, I would not omit my
testimony to arsenic. Dr. Leared has related some exceedingly
interesting cases bearing on this point. (See _British Medical Journal_,
November 23 and 30, 1867.)


NOTE IV.

INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT.

Dr. Reynolds pointed out to me the exceedingly curious fact, which I have
several times verified, that the constant current, in relieving facial
neuralgia, not unfrequently disperses, almost instantaneously, the brown
skin-pigment that has collected in the painful region; _e. g._, near the
orbit.


NOTE V.

THE ACTUAL CAUTERY.

A remedy for inveterate neuralgia which of late years I had almost
discarded--the actual cautery--has quite recently yielded me very good
palliative results in two cases. Its omission from the text of the
chapter on Treatment was an accident due to the effect of habit in
making one, half unconsciously, reckon this remedy as a
"counter-irritant." The longer I practise, however, the more decidedly I
am convinced that the actual cautery, if properly applied, does not act
as an irritant at all; and this fact was sufficiently in my mind, when
writing of irritant remedies, to make me omit the cautery from that
section. I should have inserted it under the heading of remedies that
interrupt the conductivity of nerves, and thus give the centres
temporary rest. The only useful way to apply it is, to make an iron
white hot, and very lightly brush the skin over so as to make an eschar
not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is
the best for the purpose, but I have made the flat-iron cautery serve
very well.

FOOTNOTES:

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

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

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

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

[39] Practitioner, vol. iv.

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

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

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

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

[44] _Op. cit._

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

[46] _Op. cit._

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




PART II.

DISEASES THAT RESEMBLE NEURALGIA.




CHAPTER I.

MYALGIA.


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

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

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

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

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

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

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

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

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

          _Neuralgia._                        _Myalgia._

  Follows the distribution of a      Attacks a limited patch or
    recognizable nerve or nerves.      patches that can be identified
                                       with the tendon or aponeurosis
                                       of a muscle which, on inquiry,
                                       will be found to have been hardly
                                       worked.

  Goes along with an inherited or    As often as not occurs in persons
    acquired nervous temperament,      with no special neurotic
    which is obvious.                  tendency.

  Is much less aggravated,           Is inevitably, and very severely,
    usually, by movement than          aggravated by every movement of
    myalgia is.                        the part.

  Is at first accompanied by no      Distinguished from the first, by
    local tenderness.                  localized tenderness on pressure
                                       as well as on movement.

  Points douloureux, when            Tender points correspond to
    established at a later stage,      tendinous origins and insertions
    correspond to the emergence of     of muscles.
    nerves.

  Pain not materially relieved by    Pain usually completely and always
    any change of posture.             considerably relieved by full
                                       extension of the painful muscle
                                       or muscles.

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

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

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

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

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

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




CHAPTER II.

SPINAL IRRITATION.


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FOOTNOTE:

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




CHAPTER III.

THE PAINS OF HYPOCHONDRIASIS.


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

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

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

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

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

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

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

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

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




CHAPTER IV.

THE PAINS OF LOCOMOTOR ATAXY.


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

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

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

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

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

Frequent impairment of sight or hearing, one or both.

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

No very obvious paralysis of the bladder or lower bowel.

No necessary impairment of sexual power.

No tingling or kindred phenomenon.

No marked tremulous, convulsive, or spasmodic phenomena.

No marked impairment of muscular nutrition and irritability.

No impairment of the mental faculties.

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

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

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

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

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

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

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

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

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

FOOTNOTES:

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

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

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




CHAPTER V.

THE PAINS OF CEREBRAL ABSCESS.


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

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

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

       _Cerebral Abscess._                   _Neuralgia of Head._

  Often occurs secondarily to caries    Rarely appears before puberty.
    of internal ear, and purulent
    discharge the result of scarlet
    fever, measles, etc., in
    childhood.

  Frequently follows a blow or          Comparatively seldom caused by
    injury.                               blow, or other external
                                          injury or caries of bone.

  No true "points douloureux."          If severe, soon presents, in most
                                          cases, the "points douloureux."

  Usually the pain does not             Intermissions of pain complete,
    completely intermit.                  and of considerable length.

  Pain often excruciating from a        Pain usually not very violent at
    very early period.                    first.

  Pain often limited in situation,      Pain superficial; follows
    seems deep-seated, though, as         distribution of recognizable
    often as not, it has no relation      nerve-branches belonging to
    to the site of the abscess.           the trigeminus or the great
                                          occipital.

  No well localized vaso-motor or       Usually there are lachrymation,
    secretory complications.              congestion of conjunctiva, or
                                          other vaso-motor and secretory
                                          complications, such as are
                                          described in Chapter III.

  Very rare in old age; then            Severe and intractable neuralgia
  usually traumatic.                      is commonest in the
                                          degenerative period of life.

  Relief from stimulant narcotics       Relief from opium, etc., is much
    very transitory.                      more considerable and
                                          permanent.

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




CHAPTER VI.

PAINS OF ALCOHOLISM.


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

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

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

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

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

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

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

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

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




CHAPTER VII.

THE PAINS OF SYPHILIS.


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

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

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

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

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

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

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

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

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

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

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

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

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

FOOTNOTE:

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




CHAPTER VIII.

PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.


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

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

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

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

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




CHAPTER IX.

PAINS OF LATENT GOUT.


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

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

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

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

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




CHAPTER X.

COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.


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

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

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

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

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

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

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




CHAPTER XI.

DYSPEPTIC HEADACHE.


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

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

       *       *       *       *       *

Transcriber's Notes:

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

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

Table of Contents, Part 1, Chapter IV: original reads "DIAGNOSIS AND
PROGRESS OF NEURALGIA." "PROGRESS" has been corrected to "PROGNOSIS" as
shown in the Chapter heading.

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

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

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

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

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





End of the Project Gutenberg EBook of Neuralgia and the Diseases that
Resemble it, by Francis E. Anstie

*** END OF THIS PROJECT GUTENBERG EBOOK NEURALGIA, DISEASES THAT RESEMBLE IT ***

***** This file should be named 37592-8.txt or 37592-8.zip *****
This and all associated files of various formats will be found in:
        http://www.gutenberg.org/3/7/5/9/37592/

Produced by Bryan Ness, JoAnn Greenwood and the Online
Distributed Proofreading Team at http://www.pgdp.net (This
file was produced from images generously made available
by The Internet Archive/Canadian Libraries)


Updated editions will replace the previous one--the old editions
will be renamed.

Creating the works from public domain print editions means that no
one owns a United States copyright in these works, so the Foundation
(and you!) can copy and distribute it in the United States without
permission and without paying copyright royalties.  Special rules,
set forth in the General Terms of Use part of this license, apply to
copying and distributing Project Gutenberg-tm electronic works to
protect the PROJECT GUTENBERG-tm concept and trademark.  Project
Gutenberg is a registered trademark, and may not be used if you
charge for the eBooks, unless you receive specific permission.  If you
do not charge anything for copies of this eBook, complying with the
rules is very easy.  You may use this eBook for nearly any purpose
such as creation of derivative works, reports, performances and
research.  They may be modified and printed and given away--you may do
practically ANYTHING with public domain eBooks.  Redistribution is
subject to the trademark license, especially commercial
redistribution.



*** START: FULL LICENSE ***

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full Project
Gutenberg-tm License (available with this file or online at
http://gutenberg.net/license).


Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
electronic works

1.A.  By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement.  If you do not agree to abide by all
the terms of this agreement, you must cease using and return or destroy
all copies of Project Gutenberg-tm electronic works in your possession.
If you paid a fee for obtaining a copy of or access to a Project
Gutenberg-tm electronic work and you do not agree to be bound by the
terms of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B.  "Project Gutenberg" is a registered trademark.  It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement.  There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement.  See
paragraph 1.C below.  There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this agreement
and help preserve free future access to Project Gutenberg-tm electronic
works.  See paragraph 1.E below.

1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
or PGLAF), owns a compilation copyright in the collection of Project
Gutenberg-tm electronic works.  Nearly all the individual works in the
collection are in the public domain in the United States.  If an
individual work is in the public domain in the United States and you are
located in the United States, we do not claim a right to prevent you from
copying, distributing, performing, displaying or creating derivative
works based on the work as long as all references to Project Gutenberg
are removed.  Of course, we hope that you will support the Project
Gutenberg-tm mission of promoting free access to electronic works by
freely sharing Project Gutenberg-tm works in compliance with the terms of
this agreement for keeping the Project Gutenberg-tm name associated with
the work.  You can easily comply with the terms of this agreement by
keeping this work in the same format with its attached full Project
Gutenberg-tm License when you share it without charge with others.

1.D.  The copyright laws of the place where you are located also govern
what you can do with this work.  Copyright laws in most countries are in
a constant state of change.  If you are outside the United States, check
the laws of your country in addition to the terms of this agreement
before downloading, copying, displaying, performing, distributing or
creating derivative works based on this work or any other Project
Gutenberg-tm work.  The Foundation makes no representations concerning
the copyright status of any work in any country outside the United
States.

1.E.  Unless you have removed all references to Project Gutenberg:

1.E.1.  The following sentence, with active links to, or other immediate
access to, the full Project Gutenberg-tm License must appear prominently
whenever any copy of a Project Gutenberg-tm work (any work on which the
phrase "Project Gutenberg" appears, or with which the phrase "Project
Gutenberg" is associated) is accessed, displayed, performed, viewed,
copied or distributed:

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.net

1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
from the public domain (does not contain a notice indicating that it is
posted with permission of the copyright holder), the work can be copied
and distributed to anyone in the United States without paying any fees
or charges.  If you are redistributing or providing access to a work
with the phrase "Project Gutenberg" associated with or appearing on the
work, you must comply either with the requirements of paragraphs 1.E.1
through 1.E.7 or obtain permission for the use of the work and the
Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
1.E.9.

1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
terms imposed by the copyright holder.  Additional terms will be linked
to the Project Gutenberg-tm License for all works posted with the
permission of the copyright holder found at the beginning of this work.

1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5.  Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6.  You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including any
word processing or hypertext form.  However, if you provide access to or
distribute copies of a Project Gutenberg-tm work in a format other than
"Plain Vanilla ASCII" or other format used in the official version
posted on the official Project Gutenberg-tm web site (www.gutenberg.net),
you must, at no additional cost, fee or expense to the user, provide a
copy, a means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original "Plain Vanilla ASCII" or other
form.  Any alternate format must include the full Project Gutenberg-tm
License as specified in paragraph 1.E.1.

1.E.7.  Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8.  You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works provided
that

- You pay a royalty fee of 20% of the gross profits you derive from
     the use of Project Gutenberg-tm works calculated using the method
     you already use to calculate your applicable taxes.  The fee is
     owed to the owner of the Project Gutenberg-tm trademark, but he
     has agreed to donate royalties under this paragraph to the
     Project Gutenberg Literary Archive Foundation.  Royalty payments
     must be paid within 60 days following each date on which you
     prepare (or are legally required to prepare) your periodic tax
     returns.  Royalty payments should be clearly marked as such and
     sent to the Project Gutenberg Literary Archive Foundation at the
     address specified in Section 4, "Information about donations to
     the Project Gutenberg Literary Archive Foundation."

- You provide a full refund of any money paid by a user who notifies
     you in writing (or by e-mail) within 30 days of receipt that s/he
     does not agree to the terms of the full Project Gutenberg-tm
     License.  You must require such a user to return or
     destroy all copies of the works possessed in a physical medium
     and discontinue all use of and all access to other copies of
     Project Gutenberg-tm works.

- You provide, in accordance with paragraph 1.F.3, a full refund of any
     money paid for a work or a replacement copy, if a defect in the
     electronic work is discovered and reported to you within 90 days
     of receipt of the work.

- You comply with all other terms of this agreement for free
     distribution of Project Gutenberg-tm works.

1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
both the Project Gutenberg Literary Archive Foundation and Michael
Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
Foundation as set forth in Section 3 below.

1.F.

1.F.1.  Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
public domain works in creating the Project Gutenberg-tm
collection.  Despite these efforts, Project Gutenberg-tm electronic
works, and the medium on which they may be stored, may contain
"Defects," such as, but not limited to, incomplete, inaccurate or
corrupt data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be read by
your equipment.

1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3.  YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from.  If you
received the work on a physical medium, you must return the medium with
your written explanation.  The person or entity that provided you with
the defective work may elect to provide a replacement copy in lieu of a
refund.  If you received the work electronically, the person or entity
providing it to you may choose to give you a second opportunity to
receive the work electronically in lieu of a refund.  If the second copy
is also defective, you may demand a refund in writing without further
opportunities to fix the problem.

1.F.4.  Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS' WITH NO OTHER
WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.

1.F.5.  Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted by
the applicable state law.  The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.

1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in accordance
with this agreement, and any volunteers associated with the production,
promotion and distribution of Project Gutenberg-tm electronic works,
harmless from all liability, costs and expenses, including legal fees,
that arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project Gutenberg-tm
work, (b) alteration, modification, or additions or deletions to any
Project Gutenberg-tm work, and (c) any Defect you cause.


Section  2.  Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of computers
including obsolete, old, middle-aged and new computers.  It exists
because of the efforts of hundreds of volunteers and donations from
people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come.  In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future generations.
To learn more about the Project Gutenberg Literary Archive Foundation
and how your efforts and donations can help, see Sections 3 and 4
and the Foundation web page at http://www.pglaf.org.


Section 3.  Information about the Project Gutenberg Literary Archive
Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service.  The Foundation's EIN or federal tax identification
number is 64-6221541.  Its 501(c)(3) letter is posted at
http://pglaf.org/fundraising.  Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state's laws.

The Foundation's principal office is located at 4557 Melan Dr. S.
Fairbanks, AK, 99712., but its volunteers and employees are scattered
throughout numerous locations.  Its business office is located at
809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
business@pglaf.org.  Email contact links and up to date contact
information can be found at the Foundation's web site and official
page at http://pglaf.org

For additional contact information:
     Dr. Gregory B. Newby
     Chief Executive and Director
     gbnewby@pglaf.org


Section 4.  Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment.  Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States.  Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements.  We do not solicit donations in locations
where we have not received written confirmation of compliance.  To
SEND DONATIONS or determine the status of compliance for any
particular state visit http://pglaf.org

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States.  U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses.  Donations are accepted in a number of other
ways including including checks, online payments and credit card
donations.  To donate, please visit: http://pglaf.org/donate


Section 5.  General Information About Project Gutenberg-tm electronic
works.

Professor Michael S. Hart is the originator of the Project Gutenberg-tm
concept of a library of electronic works that could be freely shared
with anyone.  For thirty years, he produced and distributed Project
Gutenberg-tm eBooks with only a loose network of volunteer support.


Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as Public Domain in the U.S.
unless a copyright notice is included.  Thus, we do not necessarily
keep eBooks in compliance with any particular paper edition.


Most people start at our Web site which has the main PG search facility:

     http://www.gutenberg.net

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.