Neuritis may be suspected, even if one or all of these signs are absent, in the prolonged neuralgias which follow wounds or strains of nerves or exposure to damp cold, or which occur in nerves which are in the immediate neighborhood of diseased organs; also where the pain is relieved by compression of the nerve above the painful part, or, on the other hand, where pressure on the nerve excites a pain which runs upward along the course of the nerve.
It may also be suspected in the large class of superficial neuralgias which follow a regular and protracted course with gradual onset and decline, and where the pain is felt not only in the region of distribution of a nerve, but also along its course—that is, in the nerve-fibres (either the recurrent nerves or the nervi nervorum) which are distributed in the sheath of the main trunk or the adjoining tissues.20
20See Cartaz,Des Névralgics envisagés au point de vue de la sensibilité récurrente, Paris, 1875.
It must be remembered that the study of neuritis, and especially of chronic neuritis, is still in its infancy, and that we are by no means in possession of its complete clinical history.21
21See Pitres and Vaillard,Arch. de Névrologie, 1883.
The presence of congestion of the sensory nerves or nerve-centres may be inferred with some degree of probability where neuralgic attacks of relatively sudden onset and short duration occur in parts which have been exposed to heat or cold, or in connection with suppression of the menstruation, or, it is said, as a result of intermittent fever. The exacerbations of pain which take place in cases of chronic neuritis under changes of weather and after fatigue are very likely due to this cause; and the same may be true of some of the fleeting pains which occur in chlorotic and neuropathic persons who are subject to fluctuations of the circulation of vaso-motor origin.
The same vaso-motor influences which cause congestion may also cause the correlative state of anæmia, which becomes thus a cause of transient and shifting though often severe attacks, which may be irregular in their distribution. General anæmia is also a predisposing cause of severe typical seizures, as has been pointed out above.
The pressure of new growths or of aneurisms is to be suspected when neuralgic attacks are unusually severe and prolonged, recur always in the same place, and occur in persons who are not predisposed to neuralgias. The pains from this cause are apt to be relatively continuous, but they may, on the other hand, be distinctly paroxysmal, and may occupy a part of the body far removed from the irritating cause.
Bilateral pains should also excite suspicion of organic disease, though they may be due to other causes, such as gout, diabetes, and metallic poisoning.
Neuralgic attacks may be supposed to be of neurosal origin when they are of sudden onset and short duration, or when they occur in persons of neuropathic constitution, and, by exclusion, when no other cause is found. These conditions are best fulfilled in the case of migraine and the visceral neuralgias. It must, however, be borne in mind that the neuropathic predisposition is sometimes well marked even in the case of the superficial neuralgias, especially the epileptiform neuralgia of the face.
GENERALTREATMENT.—To treat neuralgia with satisfaction it isnecessary to look beyond the relief of the particular attack and search out the causes by which it was provoked. As has already been remarked, these are usually multiple, and among them will be found, in the great majority of cases, some vice of nutrition or faulty manner of life.
It is safe to say that any dyscrasia occurring simultaneously with neuralgia, whether gout, phthisis, malaria, or diabetes, should receive its appropriate treatment, whatever theory we may hold as to the real connection between the two conditions.
In protracted neuralgias it is always proper to assume that neuritis may be present—i.e.to treat the nerve itself by galvanism and local applications. Local irritations, such as diseases of the eye, ear, teeth, nose, or uterus, should be sought out and removed; and attention may here be called again to the fact that a neuralgia may be due to some local condition which does not of itself attract the patient's attention.
Patients who are subject to pain at changes of weather or on exposure should be suitably protected by clothing, and should have their cutaneous regulatory apparatus strengthened by baths and friction. The best protection, however, is incapable of entirely warding off the effect of atmospheric changes upon the nervous centres. Vaso-motor changes of neurotic origin can be, in a measure, prevented by removing the patient from the influence of irregularity of life and emotional excitement and through an improved nutrition.
If the patient has been subjected to chronic fatigue or nervous strain, not only must these be avoided, but their action should be counteracted by the requisite rest and tonic treatment.
Long hours of sleep at night may often be supplemented to advantage by rest during certain hours of the daytime. If the patient cannot take active exercise, massage is indicated, and in some cases of anæmia this may advantageously be combined with the wet pack, in the manner described by Mary Putnam Jacobi.22
22Massage and Wet Pack in the Treatment of Anæmia.
Where these measures cannot be carried out, the writer has found it of much service in these, as in a large class of debilitated conditions, to let the patient rub himself toward the end of the forenoon in a warm room with a towel wet in cold or warm water, and then lie down for an hour or so or until the next meal. If acceptable, the same operation may be repeated in the afternoon.
Neuralgic patients are apt to be underfed, and even where this is not distinctly the case, a systematic course of over-feeding,23with nourishing and digestible food, such as milk, gruel, and eggs, given at short intervals, is often of great service if thoroughly carried out. The full benefit of this treatment cannot always be secured unless the patient is removed from home, and, if need be, put to bed and cared for by a competent nurse.
23See S. Weir Mitchell,Fat and Blood; and Nervous Diseases, especially of Women.
A change of climate, and especially the substitution of a dry and warm for a moist and cold climate, will sometimes break up the neuralgic habit, for the time at least. In making choice of climate or locality, however, the physician should keep distinctly in view the end that he desires to gain. Thus, the debility or anæmia which is the essential condition of many neuralgias may often be relieved by surroundings whichwould not be thought favorable to the neuralgic tendency as such. Oftentimes the sedative influence of quiet country life is all that is required.
Of the tonic drugs, cod-liver oil, iron, arsenic, and quinine are by far the most important, and it is often well to give them simultaneously. Iron may be used in large doses if well borne, for a short time at least. Quinine may be given in small doses as a tonic, or in larger doses to combat the neuralgic condition of the nervous system. This remedy has long been found to be of great value in the periodical neuralgias of the supraorbital branch of the fifth pair, but its usefulness is not limited to these cases. It may be of service in periodical neuralgias of every sort, and often even in non-periodical neuralgia.
When the attacks recur at stated intervals care should be taken to anticipate them with the quinine by about four hours, even if the patient has to be waked in the early morning for the purpose. Single doses of fifteen, twenty, or even thirty grains may check the attacks where smaller doses have failed. Such doses cannot, however, be long continued, and are not to be classed as tonic.
Of other remedies which directly influence the neuralgic condition, the following are the most important: opium, aconite, gelsemium, phosphorus, belladonna, chloride of ammonium, cannabis Indica, croton-chloral, electricity, hydropathy, massage, counter-irritation, subcutaneous injections of water, chloroform, osmic acid, etc.; surgical operations.
Opium is usually employed only for the momentary relief of pain, but it has also been claimed that in small and repeated doses it may exert a really curative action. This should not, however, be too much counted on. Opium should never be used continuously for the simple relief of pain unless under exceptional circumstances, the danger of inducing the opium habit is so much to be dreaded. Moreover, both patient and physician are less likely to seek more permanent means of cure if this temporary remedy can always be appealed to. It is best given by subcutaneous injections of the various salts of morphine. The dose should always be small at first (gr.1/12and upward), unless the idiosyncrasy of the patient is already known; and there is probably no advantage in making the injections at the seat of pain or in the immediate neighborhood of the nerve supplying the affected part, except such as might attend the injection of any fluid (see below).
Belladonna (atropia), which is so often given with morphine to diminish its unpleasant effects, seems at times, even when given alone, to have an effect on neuralgia out of proportion to its anæsthetizing action, which is very slight. It is considered to be especially useful in the visceralgias.
Aconite, given, if necessary, in doses large enough and repeated often enough to cause numbness and tingling of the lips and the extremities for some days, will sometimes break up an attack, especially of trigeminal neuralgia,24better than any other means; but its use is liable to depress the heart, and it is a dangerous remedy if not carefully watched. Some patients complain that it causes a marked sense of depression or faintness, and a feeling of coldness; and indeed its full therapeutic effect is sometimes not obtained until such symptoms as these are induced to some degree. The use of the crystallized alkaloid, aconitia, has the advantage of ensuring certainty of dose.
24See Seguin,Arch. of Med., vol. i., 1879; vol. vi., 1881.
The susceptibility of different persons to this drug is so different that the dose should first be as small as1/400gr., but this may be repeated every three hours, and gradually increased to1/100gr., or until its physiological effects are felt. Patients must sometimes be kept under its influence for weeks together.25It is, however, a remarkable fact that occasionally a few full doses will secure an immunity from pain for a long period. Although most useful in facial neuralgias, the writer has known it to be effective in brachial and mammillary neuralgia. Aconitia can now be had in granules of1/400gr., or can be given in alcoholic solution.
25See Seguin,Arch. of Med., vol. vi., 1881.
Gelsemium is also occasionally very useful in facial and even in intercostal neuralgia, and is said to be of special service in the neuralgia due to carious teeth. The commencing dose of the fluid extract is five minims, which may be gradually increased to twenty, or until a slight degree of muscular prostration, ptosis, or dilatation of the pupil is induced.
The use of phosphorus has been revived of late years, chiefly through the efforts of J. Ashburton Thompson, and it is at least occasionally of service. Success is said to be best obtained by full doses (about1/20gr. every three or four hours, up to1/5or1/4gr. daily for some days), watch being kept for signs of gastric irritation. The best preparation is an alcoholic solution (Thompson's), such as the following:
Electricity, if properly used, is capable of temporarily, and even radically, relieving the neuralgic state. The forms most often employed are faradic and galvanic electricity, though frictional electricity has also been coming into use of late, mainly as a substitute for faradism. The galvanic current is by far the most efficacious of all. This probably acts mainly by directly inducing better nutritive and better functional conditions in the nerves and nerve-centres, but the fact that it is often of use in cases of undoubted neuritis seems to indicate that it may also influence the grosser structural changes in the affected parts, if such are present. It is impossible to explain its action more exactly, and the teachings of physiological experiments do not lend us much aid.
It is probably not of much consequence which pole is used in the neighborhood of the affected nerve. It should be remembered that the peripheral nerve-trunks are so deeply buried that the electrodes cannot be directly applied to them, as they are to the exposed nerve of a frog in the laboratory, and, further, that instead of being isolated they are surrounded with tissues of good conducting power, into which the current must rapidly flow off. For these reasons the nerve near which either electrode is applied is virtually exposed to the action of both poles in almost equal degree; and although it is more customary to use the positive pole in the neighborhood of parts which are considered to be in a state of irritation, yet clinical experience has not justified the conversion of this custom into a rule. Neither is the direction of the current of material consequence.
It is, however, very important in acute cases to take care that the current-strength should not be rapidly changed; and for this reason the electrode should be drawn slowly to a distance from the nerve before it is removed, or left in situ while the current is gradually diminished by a suitable rheostat. As a rule, the former method is the more practicable.
In the treatment of acute cases moderate currents and short applications, frequently repeated, are the best. On the other hand, in cases of long standing, especially cases of sciatica, strong currents are sometimes more effective, and even interruptions and reversals of the current may be in place.
The choice of a battery is not a matter of indifference. Any stationary battery of high interior resistance will answer the purpose, but most of the portable (zinc-carbon) batteries in common use are objectionable,26for the reason that their interior resistance is so low in proportion to that of the body that it may almost be counted out as a factor in determining the strength of the current. The latter is liable to rise, therefore, quite suddenly as the resistance of the body—i.e.the vascularity of the skin—becomes modified. This objection is obviated if a large, constant resistance (water or graphite rheostat) is attached to the battery and kept always in the main circuit.
26Archives of Medicine, April, 1884.
Faradism probably owes its efficiency to the indirect effects of stimulation of the sensitive nerves of the skin. This may be produced either by the wire brush, which causes a sharp irritation and reddening, and is to be compared with the counter-irritants, or by the milder application of a moist or dry electrode or the hand of the operator. The latter procedure may be compared to the superficial manipulation which is sometimes so grateful, especially in nervous headaches.
The value of electricity as a general tonic should be remembered in this connection.
Hydropathy.—Douches and baths of various kinds have doubtless proved of much value in the treatment of neuralgia. The majority of them, however, are difficult of application for the general practitioner, and we confine ourselves to mentioning the tonic and soothing action of the wet pack and of the prolonged warm bath, which should be followed by sponging with cool water, and used under every possible precaution against exposure.
Long-continued local applications of gentle heat (bags of sand or salt, or hot water) are often temporarily grateful, and in the treatment of chronic cases the daily application of hot water or ice-bags to the spine is said to have a good effect. In acute and subacute neuritis, and in those forms of neuralgia in which neuritis plays a large part, such as sciatica, the persistent application of ice-bags along the course of the affected nerve, even for days together, is sometimes of great service. Even where we cannot be sure that neuritis is present, long-continued applications of ice may be of use, but alternations of cold and heat, on the other hand, are usually to be carefully avoided. This treatment is safer in chronic than in acute cases, though it may be useful in either.
Counter-irritation.—A spray of ether may be substituted for ice when only a temporary chilling is desired, for its counter-irritant effect. Thishas even been used on the face, the eye being protected by some suitable covering, and a good deal of benefit is to be hoped for both from this and from the similar use of chloride of methyl.
Debove27has found the chloride of methyl, used in this manner, singularly effective in the treatment of sciatica. A considerable and long-continued counter-irritation is thus made over a large surface and without great pain. The neuralgia is said to be greatly relieved and a rapid cure sometimes affected.
27Bulletin générale de Thérap., cited in theBoston Med. and Surg. Journ., vol. cxii. p. 210.
Counter-irritation is also practised by making applications of cutaneous irritants, such as blisters, mustard, turpentine, chloroform, or of the actual cautery carried in light superficial stripes over the skin, and repeated if necessary at short intervals. As a rule, the counter-irritation is more effective the larger the surface which is covered.
The use of the cautery and of blisters is in place in almost every form of neuralgia where the temporary disfigurement is of no consequence.
Of other cutaneous applications, aconite and chloroform liniments, menthol in substance or in alcoholic solution (drachm j or drachm ij to fluidounce j), aconite and veratrine ointments, are the most useful. A strong aconitine ointment, made with Duquesnet's aconitia and lard (drachm j to ounce j), has been recommended by Webber28to be used in portions of the size of half a split pea, but, though effective, it needs to be employed with great caution.
28Nervous Diseases, Boston, 1885.
These applications act in part as irritants, by keeping up a play of sensitive impressions in virtue of the lodgment which they effect in the skin, but also, no doubt, by reducing the sensitiveness of the cutaneous nerve-fibres, and thus removing one source of excitation of the diseased nervous centres. The remarkable temporary benefit sometimes obtained from the instillation of cocaine into the eye in cases of neuralgia of the ophthalmic division of the fifth nerve bears testimony in favor of this explanation.
Surgical operations for neuralgia are of three kinds—section (neurotomy), removal of a piece of nerve (neurectomy), and nerve-stretching. The two former operations are of course rarely practised, except upon the purely-sensitive fifth pair of nerves, the latter upon mixed nerves also.
Neurectomy is now almost always substituted for simple neurotomy, and sometimes still more effective means are taken to prevent the reunion of the nerve, such as doubling over the cut end, destroying the nerve throughout the length of the bony canal in which it lies, and even plugging the canal with cement.29
29Heustis (Med. News, Dec. 8, 1883) found that the infraorbital nerve could be readily drilled out with a piece of piano wire.
The inconvenience following nerve-section is as nothing compared to the pain of a severe and intractable neuralgia. It has rarely happened that the disease has been increased by the operation, and under proper antiseptic precautions the surgical risks are not great. There is some chance of permanent cure, and a much greater chance of securing an immunity from pain for a long period.
It is important to remember that when the neuralgia occupies the distribution of several branches of the fifth nerve, an operation on the one primarily or most severely affected may relieve the pain in all. On theother hand, the converse may be true,30inasmuch as the same district is supplied by recurrent fibres from several different sources. Before any operation is decided on it should be remembered that even in apparently desperate cases of trigeminal neuralgia the persistent and thorough use of tonic and other remedies may in the end be crowned with success, perhaps at the moment when it is least expected.
30Cartaz,Des névralgies envisagés au point de vue de la sensibilité récurrente.
During the past few years the operation of nerve-section has been to some degree superseded by that of nerve-stretching, as being less serious in its immediate (though not necessarily in its remote) consequences, and sometimes more efficacious. Hildebrandt, indeed, raises the question whether the traction which is apt to be exerted when a nerve is cut is not an important element in bringing about the result. On the other hand, cases are reported where neuralgia which had not been relieved by stretching was cured by resection.31
31Nocht,Ueber die Gefolge der Nerven-dehnung.
The best showing for the operation is in the treatment of sciatica, but most of the other superficial nerves, including the intercostals, have been successfully treated in the same manner.
On the other hand, this treatment is not without its dangers. Apart from the risks of the operation itself, cases have been reported in which the spinal cord has been injured, so that chronic myelitis has been set up, and a greater or less degree of paralysis—rarely permanent, it is true—may be induced by the direct injury to the nerve.
This means of treatment is therefore certainly to be thought of in serious and obstinate cases, but not lightly decided on.
A substitute operation for sciatica is the so-called bloodless stretching, in which, the patient having been etherized, the thigh is forcibly flexed on the pelvis, and then the leg extended on the thigh and the foot on the leg (dorsal flexion), and held for a short time in this position. A very material degree of stretching of the sciatic nerve is doubtless possible in this way, and a number of cures have been thus effected. But, though less dangerous than the stretching of the exposed nerve, this operation is not a trifling one.
In one case of sciatica the writer has seen a neuritis of some severity lighted up by this operation, perhaps because the disease was in too active a state, although it had lasted some months. The operation is probably most indicated in chronic cases.
The anatomical effects of nerve-stretching are manifold. Nerve-fibres are usually destroyed in greater or smaller number, and the conducting power of the nerve correspondingly impaired. Small blood-vessels are broken and the circulation and nutrition of the nerve-trunks altered, and it is probable that adhesions in and around the nerve-sheaths, where such exist, are severed. The nerve-fibres ramifying in the inflamed sheaths of the large trunks may also be ruptured, and it may be that the displacement of the fluid contents of the nerve brings about better nutritive conditions.32It is also probable that the operation either directly or indirectly affects the nutrition of the nerve-centres,33and although this is not without its dangers, the chances are in favor of a beneficial result.
32See “Die Rückenmarks-dehnung,” Hegar,Samml. klin. Vorträge, 239.
33Hegar,loc. cit.
Another means of directly acting on neuralgic nerves is by subcutaneous injections of water, chloroform, ether, osmic acid, nitrate of silver, and other substances. The deep injection of water over the affected nerve is attended with but little danger, and is occasionally successful. The similar use of chloroform, in doses of 15 to 30 minims, is much more often effective, but sometimes causes great pain, and even abscess. It has been mainly used in sciatica, also in other neuralgias, even those of the fifth pair. In this case the injection is best made through the buccal mucous membrane. This treatment is not without danger of causing collapse, or even death, probably due to the wounding of a small vein. In one case of sciatica treated by the writer the chloroform probably entered the nerve itself to some extent, as the injection was followed by very severe pain lasting for several hours, and eventually by some degree of muscular wasting. The neuralgic pain, which had continued obstinately for a long period, was, however, cured, and had not returned at the end of some days, when the patient was lost sight of.
Osmic acid has been used recently in the same way, and the reports show about an equal number of successes and failures. The dose is about 8 minims of a 1 per cent. solution, and the injection may be repeated at intervals of a few days. It has been used successfully in various parts of the body, including the face and the fingers. The injection causes no great pain, but occasionally, though rarely, excites abscess.
Under the general heading of massage a number of manipulations may be grouped which are of value in the treatment of neuralgia, even of long-standing cases of sciatica and the like.34When, as often happens in the case of sciatica, the nerve is the seat of congestion and exudation, strong and deep kneading along its course, with vigorous stroking upward in the direction of the lymph-vessels, is the important part of the treatment. Besides this, however, the prolonged and gentle manipulation of the painful region may greatly relieve the patient for a time, apparently by acting on the sensitive nerves and exerting a sort of inhibitory action, in which it is not at all impossible that an influence upon the attention analogous to that of Braidism plays a part.
34See Reibmayr,Die Massage, etc., Wien, 1883.
A striking instance of the effect of this treatment is seen in the case of nervous headaches, which are often very greatly relieved by a series of gentle, monotonous movements of the finger-tips, as well as by the domestic remedy of gently and persistently combing or brushing the patient's hair. A still more efficient application of a similar kind is the regular vibration communicated by a large magnet or by the instrument devised by Mortimer Granville. A thoroughly satisfactory explanation of the action of this treatment is yet to be furnished.
There is no doubt that in the treatment of neuralgia a persistent and thorough use of the remedies suggested is usually the key to success. Nevertheless, special cases are sometimes reached by special means of treatment, and the following are appended as occasionally useful: Ammonio-sulphate of copper (grs. ij-vj, taken in divided doses in the course of the day); salicylate of soda, in full doses; caffeine; tonka (fluidrachm j of the fluid extract at repeated intervals of a few hours); oil of turpentine; muriate of ammonia.
35Consult, in connection with this subject, the sections on Symptomatology and Treatment.
MIGRAINE ANDPERIODICALHEADACHE.—In many of the recent treatises upon nervous disease migraine and headache are removed from the category of the neuralgias and placed in that of the functional affections of the sympathetic vaso-motor system of nerves. This classification is based upon the fact that in many of these cases marked vascular changes—congestion or anæmia, as the case may be—are observed in the external tissues of the affected parts, while the sensations of the patient often lead us to infer the presence of similar conditions within the cranium. The pain and the other symptoms of the outbreak, it is thought, are due to the changes in blood-tension in the cortex cerebri or in the region of expansion of sensitive nerves, or, in part, to the spasm of the muscular walls of the vessels themselves. This theory is seductive from its appearance of pathological simplicity and exactness, but the writer believes, with Anstie, Latham, Allbutt, and other observers, that it is not borne out by clinical experience, and that its adoption tends to cloak the wider relationship that exists between the sensory neuroses.
Migraine, nervous headache, and the superficial and the visceral neuralgias hardly differ more fundamentally from each other than individual cases of either affection differ among themselves. It is not improbable, as we have seen, that all the phenomena of some neuralgic attacks are wholly or in part the expression of irritation of the sensory nervous system from without; but in many cases, on the other hand, the signs of the neurosal tendency are clearly marked, and there is hardly one of the symptoms of a typical migraine of which the analogue may not be found, though perhaps faintly pronounced, in one or another form of superficial neuralgia, while the relation of both to the whole family of the neuroses is still more clearly evident.
Migraine is a disease of youth and middle life, characterized, in its most typical form, by attacks of severe headache of a few or many hours' duration, of gradual onset and decline, ushered in by well-marked auras involving one or more of the cerebral functions, and terminating in nausea or vomiting or profuse secretion of pale urine, or in some other critical nervous outbreak. The pain is usually, but not invariably, deep-seated. It may be confined to one side of the head, most often the left, or may involve both sides, either from the outset or in the course of the attack. The forehead or temple is usually the first part to become painful, but in severe or prolonged seizures the parietal and occipital regions are prone to be affected likewise.
The auras are manifold and important. On the day before an attack the patient may feel remarkably well, or may complain only of such sensations as thirst or giddiness. The attack itself is apt to be ushered in by visual hallucinations of dazzling and vibrating points or serrated images, sometimes with prismatic outlines, accompanied by a loss or obscuration of vision over one-half or some other portion of the field, which lasts half an hour or more, and sometimes clearing up in one part while it advances in another. Simultaneously or immediately after this there may betingling and a sense of numbness of the tongue, lips, hand, or one-half of the body, sometimes followed by partial hemiparesis, and, if the right side be affected, by more or less aphasia or mental confusion. Occasionally the other special senses are affected. Sometimes the aura may constitute the whole of the seizure.
The writer has observed a case in which migraine was represented throughout boyhood by repeated attacks of subjective numbness and tingling of the entire right side of the face, the right arm, and the right half of the body, with aphasia and hemianopsia, followed during many years by trifling headache or none at all; later in life by severe pain. Here migraine as well as neuralgia in other forms was a well-marked family disease.
These auras are especially worthy of notice, because they occasionally point to epilepsy, an affection with which migraine is allied.
The pain may begin on the same side with these prodromal symptoms or on the opposite side. Sometimes drowsiness is a marked symptom throughout the attack, and this differs in significance from the sound, refreshing sleep with which the paroxysm often comes to an end. Sometimes the arteries of the affected side seem strongly contracted, as shown by pallor and coldness of the face and dilatation of the pupil (angio-tonic form); sometimes, on the other hand, they are dilated and pulsate strongly, or the latter condition may follow the former (angio-paralytic form). The radial pulse may show corresponding modifications. These vascular phenomena are often, however, entirely wanting.
Migraine appears to be slightly more common in women than in men. The liability to the attacks often shows itself in extreme youth, usually increases at puberty, and generally ceases at the age of forty or fifty. The attacks sometimes recur at regular intervals of a week, a month, etc., but, on the other hand, they may remain absent for years unless brought on by some exciting cause.
ETIOLOGY ANDCLINICALRELATIONS.—Migraine is a directly inheritable disease, and one which stands in a close relationship to the other grave neuroses, as well as to the neuropathic temperament. Cases are occasionally seen in which the migraine of youth gives place to epilepsy in later years. It is often met with also in families and individuals of neuralgic tendency, and in fact it shades off into neuralgia of the fifth and occipital nerves on the one hand and into periodic nervous headaches on the other. It frequently occurs in gouty persons, and is thought to be related to the brow ague of malaria. The attacks may be brought on by any of the causes which depress the vitality of the nervous system, and by various special irritations, among which errors of refraction are prominent.
ThePROGNOSISis unfavorable in well-marked cases, in which the habit of regular recurrence is established, and where the neuropathic predisposition is pronounced and no special exciting cause can be found. On the other hand, there are many cases where the tendency is less deeply rooted, and where with the removal of the exciting cause or causes the outbreaks cease.
Finally, there is great probability that the disease will cease of itself with advancing years, not always, however, without having left its mark on the patient's mental and bodily vitality.
TheTREATMENTshould be directed first to the detection and removal of special sources of irritation, whether in the eye, stomach, uterus, or elsewhere. Causes of anxiety and mental strain should be as far as possible avoided, and great caution enjoined in the use of stimulants and narcotics. The nutrition should be maintained at its highest level by tonics, and, if need be, by electricity, massage, and hydropathy. Sometimes, besides this a special diet is advisable, for it seems beyond question that some patients have fewer headaches if they abandon all animal food, while others—whether because of a gouty tendency is not clear—do best on a nitrogenous diet with exclusion of sugar and starch.
Of the drugs used to control the liability to the attacks, the most important is cannabis Indica, given in doses of about half a grain of a good preparation of the extract several times daily for weeks or months together. Valerianate of zinc and the iodide and bromide of potassium in full doses are also recommended, but are less efficacious.
In the treatment of the attack itself, besides absolute rest and quiet, large and repeated doses of guarana or caffeine, either alone or combined with drachm doses of bromide of potassium, are sometimes of use if given at the very outset.
It is thought by some observers that ergot or ergotin is of value if the vessels are dilated, and conversely nitrite of amyl or glonoine if they are contracted. It must not be forgotten, however, in case of doubt, that the throbbing due to the latter drugs may increase the pain.
The writer has known a strong faradic current applied with the moistened hand to the back of the neck to relieve an attack, and prolonged but gentle manipulation of the painful area with the finger-tips may have a like effect if the pain is not too severe; as, for example, toward the end of a paroxysm.
Three varieties of these neuralgias may conveniently be distinguished:
1. Ordinary facial neuralgia, analogous to the neuralgias of the other superficial nerves;
2. Intermittent supraorbital neuralgia, sometimes called brow ague, though by no means always of malarial origin;
3. Epileptiform neuralgia (tic douloureux).
These varieties are of course closely allied, and have many features and causes in common.
THEORDINARYFACIALNEURALGIAis a painful and obstinate malady, although not so serious as the typical tic douloureux. The pain may remain fixed in one position or it may shift from one part of the face to another; and the latter is especially common in those forms which occur in anæmic or ill-nourished persons. It associates itself readily with occipital neuralgia, and sometimes also with neuralgia of the pharynx and other parts. It occurs most often in persons of neurotic tendencies or impaired nutrition, and may be provoked by disorders of the ears, teeth, and even distant organs. The possibility of aneurisms of the internal carotid or of cerebral tumor should also be borne in mind, and signs of herpes zoster and locomotor ataxia carefully sought for.
The relation of caries of the teeth to neuralgia of the fifth pair forms a very important chapter, which is admirably treated by J. Ferrier.36Opinions on this subject are conflicting and unsatisfactory, and the fact that many patients have had nearly all their teeth drawn in the vain attempt to get cured of one of the severe forms of facial neuralgia often creates an impatience of further investigation in the matter. Ferrier points out that as a rule it is not the severest cases of epileptiform tic douloureux that arise in this way, but, on the other hand, that it is a mistake to conclude, because a neuralgia is benefited by medical treatment and made worse by fatigue, exposure, etc., and because it occurs in a person of neurotic temperament, that it is not likely to be due to this form of irritation. The teeth need not themselves be the seat of pain, and the disease in them may be detected only after diligent search.
36Les Névralgies reflexes d'Origine dentaires, Paris, 1884.
The most important lesions are said to be caries, exostosis, and other affections involving the pulp-cavity, exposure of the sensitive dentine, ulcerations of the gums, injuries caused in extraction, and other diseases of the alveolar process. The wisdom tooth, by its pressure on other roots and on the gums, is not infrequently the one at fault.
Chronic inflammation of the mucous membrane of the nose or pharynx is said to be an occasional cause of neuralgia of the face, as well as of the upper portions of the body.
THEINTERMITTENTNEURALGIA OF THESUPRAORBITALis an interesting affection to which too little attention has been paid. One variety seems to bear a certain relationship to migraine, inasmuch as it occurs under similar circumstances—i.e.in distinctly neuropathic individuals and families, and in attacks of about the same duration and periodicity of recurrence.
Another variety approaches the other neuralgias in the longer duration of the attacks, but is characterized by a daily seizure which recurs with absolute regularity, coming on usually at about nine in the morning and increasing in severity for an hour or so, then persisting unchanged until midday or later, when it gradually diminishes, finally disappearing in the course of the afternoon. As a rule, it is brought on by catarrh of the frontal sinuses, often following an acute attack of coryza. A certain amount of neurosal predisposition is often found in this form, and the first attacks may show themselves in early youth, rarely in the decline of life. The writer has seen one family in which a number of members in at least two generations have been attacked in this way, the seizures having been brought on by exhaustion or coryza, or both combined.
This form of neuralgia is often greatly controlled by quinine if given in sufficiently large doses (15 to 20 or 25, or even 30, grains) and as long as four hours before the attack.
Lange37thinks the action of galvanism is remarkably successful, but the writer's experience does not fully bear this out.
37Cited in theCentralbl. für Nervenheilkunde, etc., 1881, p. 10.
Seeligmüller38speaks very highly of the effect of the nasal douche, used for the sake of curing the catarrh of the frontal sinuses, and potassic iodide may be useful by rendering the secretions more fluid.
38Centralbl. für Nervenheilkunde, etc., June 1, 1880.
THEEPILEPTIFORMFACIALNEURALGIA,ORTICDOULOUREUX,is a chronic affliction, characterized by the suddenness of onset and the severity of its paroxysms of pain, which may recur every few minutes with lightning-like rapidity, either spontaneously or brought on by motion of the jaw or the taking of food, and disappear again as quickly. After a group of such paroxysms as this there may be an intermission of some hours or days. During the attack the patient is apt to rub the seat of pain with great violence. The path pursued by the darts of pain may be either in the direction of the nerve-trunks or in an irregularly inverse direction.
In spite of their sufferings, these patients may present an appearance of health. In its worst forms, and especially in advanced life, this variety of neuralgia may be incurable, and at the best it is sure to tax the care and skill of the physician. Anstie thinks that it is apt to be associated with a taint of insanity.
The bestTREATMENTconsists in the most painstaking attention to hygiene, in the persistent use of galvanism, arsenic, cod-liver oil, quinine, aconite (see under General Treatment), and phosphorus. Croton chloral is occasionally of service.
As a last resort, surgical measures (see above) may be appealed to, but it should be borne in mind that even when the prospect seems most hopeless the relief under medicinal and hygienic treatment may really be near at hand. Where section of nerves is without result, the operation of tying the larger vessels, the carotid or vertebral, on the affected side may be tried, and offers some chance of success.
OCCIPITAL ANDCERVICO-OCCIPITALNEURALGIASare second only to trigeminal neuralgia in severity, though, fortunately, less common, and either is liable by extension to give rise to the other.
Neuralgic pains in the occipital region may attend Potts's disease of the cervical vertebræ; and this is especially important to bear in mind because the osseous deformity is often wanting for a long time.
The writer has known a persistent pain in this region to be due to intracranial syphilitic disease, and to cease suddenly with the advent of more serious cerebral symptoms.
CERVICO-BRACHIAL ANDBRACHIALNEURALGIASare less often indicative of the neuropathic taint than the facial neuralgias; and, on the other hand, they are, like sciatica, relatively often due to neuritis set up by injury, amputation, strains, enlarged cervical glands, periarthritis of the shoulder,39etc., or associated with herpes zoster. When not due to an unremovable cause the prognosis is favorable. The treatment needs no special description.
39See J. J. Putnam, “A Form of Painful Periarthritis of the Shoulder,”Boston Med. and Surg. Journ., 1882.
INTERCOSTALNEURALGIAis a very important form, both on account of its frequency and obstinacy, and because it is often associated both with anæmia and chlorosis and with affections of the visceral organs, especially the uterus. The distressing cardiac palpitation of neurasthenic patients often associates itself with pain in the left side, and there is an intimate connection between neuralgia of the cardiac plexus (angina pectoris; see below) and neuralgia of the intercostal and brachial nerves.
Pain in this region, often due to neuritis, may accompany acute and chronic thoracic disorders, and may be the precursor of herpes zoster.Caries of the vertebræ and meningitis should be thought of, and cancer if the neuralgia is very persistent, even if it is paroxysmal in character.
TREATMENT.—Besides the general indications for treatment referred to above, it is worthy of special note that nerve-stretching has been successfully tried for intercostal neuralgia. In one interesting case seven nerves were stretched at one operation.40The reporter discusses the surgical aspects of the operation, and points out that the nerves should be sought for, not directly beneath the rib, but behind and beneath it, and thinks that the failure to bear this fact in mind might lead to puncturing the pleura.
40Lesser,Deutsch. Med. Wochenschr., Sto. 20, 1884.
MAMMILLARYNEURALGIA(irritable breast of Astley Cooper), though often met with in company with intercostal neuralgia, may occur entirely independently. It is sometimes bilateral, and is apt to be associated with irregularity of the uterine functions. Cutaneous hyperæsthesia is often present to a distressing degree, and small tumors of either temporary or permanent duration may make their appearance (A. Cooper), which, however, do not affect the prognosis.
There is no especially effectiveTREATMENTbeyond what has been spoken of. Surgical interference is not especially to be recommended, though it has occasionally been useful.
LUMBO-ABDOMINALNEURALGIA, or neuralgia of that part of the lumbar plexus which supplies the flank and abdomen and the external genital region. These neuralgias are apt to accompany those of the intercostal nerves and share in their significance.
The most important facts with regard to them are that they are intimately associated, in relation both of cause and of effect, with affections of the abdominal and the pelvic organs and of the testis. Neuralgias of the terminal branches of the lumbar plexus, the obturator and anterior crural nerves, though well recognized, are comparatively rare.
One of the chief respects in which they are important is in calling attention to the possible presence of disease of the hip-joint or of periarthritis of the hip, as well as of tumors or inflammation within the pelvis.
NEURALGIA OF THESCIATICNERVEis one of the most severe and common forms. While sharing in the common etiology and history of the other neuralgias, it is peculiarly prone to be due to peripheral causes, which give rise to thickening of interstitial and investing connective tissue of the nerve. The distribution of the pain may be coextensive with the whole distribution of the great and little sciatic nerve, but far oftener the patient indicates certain regions as the seat of his severest suffering; and these are especially the sacral region of one side, the neighborhood of the sciatic notch, the popliteal space, the calf, and the outer side of the foot and ankle. Not infrequently the whole course of the sciatic nerve is traced out by the darts of pain; and in this case it is the nerves which supply the sheath of the sciatic itself which are supposed to be the seat of the neuralgic process.
Sciatica is usually unilateral, but exceptionally bilateral, or attacks the two sides alternately. The tender points most often met with are at the sacro-iliac synchondrosis, the posterior border of the great trochanter, just beneath the head of the peroneal bone, below and behind theexternal malleolus, but numerous others are likewise noted by Valleix. Sometimes no tender points can be found. Sometimes, also, it is one or more of the collateral branches of the sciatic plexus that are the seat of the neuralgia, and the distribution of the pain and of the tender points varies accordingly.
It is in sciatica pre-eminently—in part, no doubt, because of the frequency of neuritis—that disorders of sensibility of the skin are noticed, as well as muscular paresis or spasm. This anæsthesia has been studied with great care by Hubert-Valleroux and others, and it has been shown that it is often confined to limited spots, a centimeter or so in diameter, within which the loss of sensibility may be nearly absolute. Nevertheless, their functional origin is proved by the fact that under faradization they may rapidly disappear.
The duration of an attack of sciatica varies from a week or two to months or even years, and it shows a marked liability to recur, especially with changes of weather. First attacks occur pre-eminently, though not exclusively, in middle life, and oftener in men than in women, evidently because they are oftener exposed to mechanical injury and, through their occupations, to sudden changes of temperature and the like.
The occasional causes are numerous, and include sudden wrenches and jars, even if not very severe, interpelvic pressure from tumors or impacted feces, etc. Gout, syphilis, and diabetes may act as predisposing and even exciting causes, and, it is said, gonorrhœa likewise. Periarthritic inflammations of the hip-joint and varicose veins frequently excite pains in the various sciatic nerve-branches which simulate true sciatica.
As has been indicated, although sciatica may be a pure neuralgia (see under Pathology), running its course without leading to any appreciable change in the nerve, yet subacute and chronic neuritis is very common, either as a primary condition or a complication, and its presence puts a graver aspect upon the case. The pain of neuritis, when severe, is relatively constant, remittent instead of intermittent, dull rather than lancinating, increased by motion and pressure; whereas the purely neuralgic pains are sometimes relieved by movement. It is, however, doubtful whether an accurate differential diagnosis is possible (see above). It is to this neuritis that the muscular atrophy is due which is often so marked, and it may likewise give rise to various cutaneous lesions of herpetic character. The severe pain that accompanies typical herpes zoster of this region is well known.
TheTREATMENTof sciatica must vary with the probable cause of the disease and its stage of progress. Diathetic taints are to be met if present, and the greatest measure of physical health secured that the circumstances possibly admit. It is a good precaution in all cases to secure free evacuation of the bowels and to guard against hemorrhoidal congestions.
As against the neuralgia itself, the proper means vary with the acuteness of the attack and the presence or absence of neuritis. For the acute stage absolute rest is almost always desirable as a prime condition. Quinine, belladonna, aconite, and turpentine in full doses should be thoroughly tried, and special reference had to the periodicity of the seizures.
Frequent and extensive but superficial counter-irritation (actualcautery, blistering, ether, or chloride of methyl) is in place in this stage, and galvanism (constant current) is often of great service. It is probable that for the acute stage the prolonged use of mild currents is the best, whereas in more chronic cases the stronger, even very strong, currents, brought to bear as accurately as possible upon the nerve itself, are sometimes more useful.
Hydropathic treatment is in great repute both for acute and chronic cases, but as success in this way demands care and knowledge, the reader is referred to the special treatises.
In cases of long standing the continued application of ice-bags along the length of the limb for days together is often of excellent service, but this method of treatment is not without its dangers and needs to be carefully watched.
In chronic cases deep injections are of service, and nerve-stretching (see above) is in place.
THEVISCERALNEURALGIAShave not received the attention which is due them both on account of their intrinsic importance and their constitutional significance. Not only are they found in common with the superficial neuralgias in the overtired and the underfed, but they point more strongly than the latter to the neuropathic diathesis, alternating with such symptoms as migraine, asthma, nervous dyspepsia, and insomnia. They occur also in the gouty and among the neuropathic descendants of the gouty, and as a result of functional and organic disorders of the viscera.
The pain of these neuralgias, though usually described as vague, ill-defined, dull, etc., yet often stirs the nervous system to its depths, causing nausea, faintness, sweating, prostration, reflex disorders of the secretions, and like symptoms.
ANGINAPECTORISis a neuralgia probably of the pneumogastric and sympathetic nervous apparatus of the heart. The pain, which is usually of a heavy, dull, oppressive, or tearing character, and capable of rising to intense agony, is usually deep-seated, and felt to the left of the sternum and beneath the breast, often involving the left arm and side, and occasionally the left side of the face and neck, and even the leg of the same side or the right arm. It may also, as the writer has seen, be confined to the sternal region. In the case referred to this pain recurred every afternoon and evening with great regularity. Sometimes instead of pain the arm may be the seat of a tingling numb sensation only.
During the attacks the action of the heart may continue unchanged, or it may become slow and feeble or intermittent, yet without necessarily being the seat of organic disease. The onset of anginic attacks is usually, but by no means always, sudden, and their duration is commonly short. All the features of the attack, however, are subject to considerable variation, and nervous symptoms of a variety of kinds, which it is not necessary to detail, may precede or attend the seizure. In severe attacks the patient's anguish and prostration are extreme; the face and extremities become pale and cold, and a cold sweat breaks out.
In a large proportion of cases, especially the severest ones, these neuralgic attacks are associated with organic disease of the heart or blood-vessels.
A variety of causes have been suggested to account for the seizures,prominent among which is a widespread contraction of the arterioles, bringing a sudden strain upon the left ventricle of the heart. This theory is especially noteworthy because of the success which has attended the treatment by nitrite of amyl, which brings on a rapid vascular relaxation. In other cases spasm of this kind is manifestly absent. Fraenkel41has recently defended the view that a momentary paralysis and over-distension of the left ventricle is the exciting cause. In other cases all sign of arterial or cardiac disease is and remains absent.
41Zeitschr. für klin. Med., 1882.
In this latter group the tendency to the attacks may cease under appropriate hygienic treatment. Thus, in an instance known to the writer a lady of usually good health suffered for several months from slight attacks of præcordial pain, with pain or a sense of numbness in the left arm, and often a feeling of breathlessness on very slight exertion. This condition had manifestly been brought about by prolonged physical and mental strain, and disappeared completely after a period of rest. Other such cases are described by Anstie, Allbutt,42and others.
42London Lancet, 1884, i.
In judging of the significance of anginic attacks in a given case the signs of circulatory disease should first be studiously sought, and especially, as more likely to escape notice, indications of cardiac enlargement or weakness, or of increased vascular tension, or of chronic nephritis.
Dull pains in the intervals of the attacks are also regarded as important, as indicating the presence of neuritis of the cardiac nerves, which without doubt often exists. On the other hand, as pointing rather to a neurotic origin of the symptoms, a tendency, individual or inherited, to neuralgias of other forms, to asthma, migraine, and the other neuroses, is to be looked for.
Heredity plays a certain part in the etiology, and among the special causes of the non-organic form abuse of tobacco is said to be important.
TheTREATMENTwould be likely, of course, to be widely different according to the nature of the case, being on the one hand addressed to the circulatory apparatus, on the other to the health of the nervous system, in both cases following well-known lines.
In the treatment of the individual attacks the diffusible stimulants and the narcotics are of value when there is time to employ them. With regard to nitrite of amyl and the longer-acting nitro-glycerin, which have given so much relief in some cases, it would be premature to confine their use to the cases of demonstrable vascular spasm or even organic disease, and they are fair agents for trial in the apparently non-organic cases as well.
A patient of Romberg's used to get great relief from swallowing pieces of ice.
When the attacks are long continued or frequent, electricity, either as galvanism or by the wire brush, is applicable, and also counter-irritation over the chest, even by vesication.
GASTRALGIA(syns. gastrodynia, cardialgia, gastric colic, cramp of the stomach, etc.) may be associated with organic disease of the stomach or may occur as an independent neurosis. It is met with in individuals and families in which asthma, migraine, gout, etc. are found. In general it is common in persons of nervous, mobile temperament, and is moreover apt to point to temporary exhaustion from some cause, though this is by nomeans always true. The writer has seen several sensory disorders of this class at the period of life of which the menopause is the chief feature. The pains of apparently hypochondriacal patients doubtless belong sometimes in this group.
The pain of gastralgia is felt primarily at the epigastrium, whence it may radiate upward and backward along the œsophagus and through into the back, as well as laterally in various directions. Allbutt says that it is sometimes associated with anginiform attacks.
Other associated symptoms are dyspnœa, prostration, faintness, coldness of the extremities, or reflex changes in the action of the heart, which may beat feebly, rapidly, and irregularly, or more slowly than normal.
Apropos of the relation of gastralgia to organic disease, it is important to recall the fact that some of the organic diseases of the stomach, notably chronic ulcer and cancer, may fail to reveal their presence by any physical sign. In a case seen by the writer a cancerous growth had invaded the entire stomach, causing an enormous thickening of its walls, yet no tumor was to be felt, and the most marked symptoms were gastralgia and exhaustion.
The relations of gastralgia to the other purely functional disorders of the stomach are interesting and peculiar. It is beyond a question that every variety of digestive disorder, from simply delayed and painful digestion to pyrosis, the formation of gas, and constant vomiting, is much more often of purely neurotic origin than has been supposed.
TheDIAGNOSISof catarrhal gastritis as distinguished from nervous dyspepsia is indeed often difficult or even impossible. Leube has recently recorded a case where the matter vomited during life contained fungoid growths, such as are usually considered pathognomonic of gastritis, and yet at the autopsy the mucous membrane appeared perfectly healthy.
With these nervous disorders of digestion, which are by no means confined to hysterical patients, gastralgia may be variously associated, or it may occur independently of them all, or vice versâ. On the other hand, digestion may be attended with a sense of discomfort, often amounting to severe pain, yet without regular outbreaks.43This symptom is classified by Allbutt as a hyperæsthesia of the stomach rather than as a neuralgia, but from this to true gastralgia there is only a sliding scale of difference. Sometimes a persistent neuralgic habit is set up by a local disorder which itself passes away entirely.
43Allbutt,loc. cit.
TREATMENT.—In acute attacks the aim is simply to relieve pain by whichever of the well-known methods promises the best. The real field for thought and care is in the treatment of the underlying states—first, those which, like gout, anæmia, syphilis, or nervous debility, predispose to the attacks; second, the local or special conditions which act as exciting causes. Sometimes it will be found that such patients have special idiosyncrasies with regard to the nature of food or time of meals.
In that condition of the system which is indicated by frequent or paroxysmal excess of uric acid in the urine a long-continued use of Vichy water or lithia is sometimes of service. If it be finally concluded that the stomach is in an hyperæsthetic, not in an inflamed, condition, it may not be advisable to diminish the amount of food, but, on the contrary, by one means or another, to increase it.