Neuralgia and the Diseases that Resemble it

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.