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 statement6 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.