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.
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 diarrhœa. 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.
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.