The secondary affections which may arise as complications of neuralgia form a deeply interesting chapter in nervous pathology, and one which has only been explored in quite recent years. The excellent treatises of Valleix and Romberg, written only thirty years ago, make but most cursory and superficial mention of these complications, and do not attempt to group them in a scientific manner. The reflex convulsive movement of the facial muscles in severe tic-douloureux had of course been long observed; and Valleix added the correct observation that gastric disturbance was often secondarily provoked in facial neuralgia, thus improving greatly on the old view, which supposed that, where trigeminal neuralgia andstomach disorder coexisted, the latter must have been the antecedent and the cause of the former. Still, he did not explain the pathological connection. And as regards certain other most interesting results of neuralgia, which he could not avoid meeting with from time to time,e. g., lachrymation, flux from the nostril, salivation, altered nutrition of the hair, he only speaks of these as occasional phenomena, and in no way classifies them, or explains their relation to the neuralgia itself.
There did exist, however, one too little known work of some years earlier date, which, though not dealing specifically with neuralgia, and though based upon the necessarily very imperfect knowledge of the functions of the nervous system prevalent in its day, had nevertheless done much to lay the foundation of a comprehensive view of the complications of neuralgia; we refer to the work of the brothers Griffin, on "Functional Affections of the Spinal Cord and Ganglionic System," published in 1834. In this most interesting treatise, the record of acute and extensive observations made in a quiet and unpretending way by two Irish practitioners, numerous examples are cited in which neuralgic affections were seen to be inseparably united with secondary affections of the most various organs, with which the neuralgic nerves could have no connection except through the centres, by reflex action. The authors, while firmly grasping the fact of the common connection of the nerve-pain and the other phenomena (convulsions, paralysis, altered special sensation, changes in secretion, changes even in the nutrition of particular tissues) with the central nerve system, were doubtless in error in thinking that they could detect the precise seat of the original malady, by discovering certain points of tenderness over the spinal column. But their facts were observed with the greatest care, and can now be interpreted more intelligently than was possible at the time. Here, for example, is a case which forestalls one of the most interesting pieces of information which more recent research has made generally known:
"Case XXIV.—Kitty Hanley, aged fourteen years, catamenia never appeared; about six months ago was attacked with pain in the right eye and brow, occurring only at night, and then so violently as to make her scream out and disturb every one in the house; it afterward occurred in the infra-orbital nerve, and along the lower jaw in the teeth, and there was inflammation of the cornea, with superficial ulceration and slight muddiness. Tenderness was found at the upper cervical vertebræ, pressure on any of them exciting severe pain in the vertex and brow; but none in the eye or jaws, where it is never felt except at night."
The above is a well-marked example of neuralgia of the trigeminus causing secondary inflammation and ulceration of the eye of a precisely similar kind to that which had been experimentallyproduced by Magendie by section of the fifth, at or posterior to its Gasserian ganglion. We shall see, hereafter, how extremely important are this and similar facts, not only in regard to the clinical history, but also to the pathology of neuralgia in general.
The first regular attempt, I believe, to classify the complications of neuralgia, was made by M. Notta, in a series of elaborate papers in the "Archives Generales de Medecine" for 1854. We may specially mention his analysis of a hundred and twenty-eight cases of trigeminal neuralgia, which is well fitted to impress on the mind the frequency, though, as we shall presently see, it does not adequately represent the seriousness, of these secondary disorders. As regards special senses, Notta says that the retina was completely or almost completely paralyzed in ten cases, and in nine others vision was interfered with, partly, probably, from impaired function of the retina, but partly, also, from dilatation of the pupil or other functional derangement independent of the optic nerve. The sense of hearing was impaired in four cases. The sense of taste was perverted in one case, and abolished in another. As regards secretion, lachrymation was observed in sixty-one cases, or nearly half the total number. Nasal secretion was repressed in one case, in ten others it was increased on the affected side. Unilateral sweating is spoken of more doubtfully, but is said to have been probably present in a considerable number of cases. In eight instances there was decided unilateral redness of the face, and five times this was attended with noticeable tumefaction. In one case the unilateral tumefaction and redness persisted, and were, in fact, accompanied by a general hypertrophy of the tissues. Dilatation of the conjunctival vessels was observed in thirty-four cases. Nutrition was affected as follows: In four cases there was unilateral hypertrophy of the tissues; in two, the hair was hypertrophied at the ends, and in several others it was observed to fall out or to turn gray. The tongue was greatly tumefied in one case. Muscular contractions, on the affected side, were noted in fifty-two cases. Permanent tonic spasm, not due to photophobia, was observed in the eyelid in four cases, in the muscles of mastication four times, in the muscles of the external ear once. Paralysis affected the motor oculi, causing prolapse of the upper eyelid, in six cases; in half of these there was also outward squint. In two instances the facial muscles were paralyzed in a purely reflex manner. The pupil was dilated in three cases, and contracted in two others, without any impairment of sight; in three others it was dilated, with considerable diminution of the visual power. Finally, with regard to common sensibility, M. Notta reports three cases in which anæsthesia was observed. Hyperæsthesia of the surface only occurred in the latter stages of the disease.
To Notta's list of complications of trigeminal neuralgia must be added the following, all of which have been witnessed, and several of them in a large number of instances: Iritis, glaucoma, corneal clouding, and even ulceration; periostitis, unilateral furring of the tongue, herpes unilateralis, etc. In writing on this subject three or four years ago, I mentioned that all these secondary affections had been seen by myself, except glaucoma. That is now no longer an exception; indeed, my attention has been so forcibly called to the connection between glaucoma and facial neuralgia, that I shall presently examine it at some length.
The trigeminus is, of all nerves in the body, that one whose affections are likely to cause secondary disturbances of wide extent and various nature, owing to its large peripheral expanse, the complex nature of its functions, and its extensive and close connections with other nerves. Moreover, its relations to so important and noticeable an organ as the eye tends to call our attention strongly to the phenomena that attend its perturbations. But there is every reason to think that all secondary complications which may attend trigeminal neuralgia are represented by analogous secondary affections in neuralgias in all kinds of situations; and we may classify them in the principal groups which correspond to disturbance of large sets of functions:
1. First, and on the whole, probably, the most common of all secondary affections, we may rank some degree of vaso-motor paralysis. It may be doubted if neuralgia ever reaches more than a very slight degree without involving more or less of this; for so-called points douloureux are themselves pretty certainly, for the most part, a phenomenon of vaso-motor palsy; and the more widely-diffused soreness, such as remains in the scalp, for instance, after attacks of pain, even at an earlier stage of trigeminal neuralgia than that in which permanently tender points are formed, is probably entirely due to a temporary skin-congestion. The phenomenon presents itself in a much more striking way in the condition of the conjunctiva seen in intense attacks of neuralgia affecting the ocular and peri-ocular branches of the fifth; one sometimes finds the whole conjunctiva deeply crimson; and, in one remarkable instance that I observed, the same shade of intense red colored the mucous membrane of the nostril of the same side. In several instances, I have seen a more than usually violent attack of sciatic pain followed by the development of a pale, rosy blush over the thinner parts of the skin of the leg, especially of the calf, which were then extremely tender, in a diffuse manner, for some time after spontaneous pain had ceased.
2. Not merely the circulation, however, but the nutrition of tissues, becomes positively affected, in a considerable numberof cases. It is difficult to judge, with any exactness, in what proportion of neuralgic cases this occurs, but its slighter degrees must be very common. It has very frequently happened to me, quite accidentally, in examining with some care the fixed painful points, which are so important in diagnosis, to be struck with the decided evidence to the finger of solid thickening, evidently dependent on hypertrophic development of tissue-elements; in severe and long-standing cases, I believe this condition will always be found. Probably the change is, more usually than not, sub-inflammatory; but it is certain, on the other hand, that there are great variations in the kind of tissue-changes complicating neuralgia, and that inflammation is no necessary element in them. This subject has greatly engaged my attention, and I find myself able to give what is probably a fuller account of the matter than any yet published connectedly.
The following tissues have been seen by myself to become altered under the influence of neuralgia in nerves distributed to them, or to the parts in their immediate neighborhood.
(a) The hair has changed in color in many cases. Of twenty-seven patients suffering from neuralgia of the ophthalmic division of the fifth, eleven had more or less decided localized grayness of hair on that side. The amount of this varied greatly, from mere patches of gray near the roots of the hair to decided grayness of the majority of the hairs over the larger part of half the head, nearly to the vertex; but in each case it was a change of color that did not exist on the other side of the head. In four of these cases there was also grayness of part of the eyebrow on the affected side. A very remarkable phenomenon, which I have sometimes identified, is fluctuation of the color, the grayness notably increasing during, and for some time after, an acute attack of pain, and the same hairs returning afterward more or less to their original color. My attention was first called to this curious occurrence in my own case. I have so often related this case [see, for instance, my article on Neuralgia in "Reynolds's System of Medicine," vol. ii.] that I shall merely recall the fact that, when pain attacks me severely, the hair of the eyebrow on the affected side displays a very distinct patch of gray (on some occasions it has been quite white) opposite the tissue of the supra-orbital nerve, and that the same hairs (which can be easily identified) return almost to the natural color when I am free from neuralgia. I must, however, add the very curious fact, which I observed accidentally in experimenting (as regards urinary elimination) on the effects of large doses of alcohol, that a dose sufficiently large to produce uncomfortably narcotic effects invariably caused the same temporary change of color in the hair of the same eyebrow, even when no decided pain was produced, but only general malaise.The subject will be again referred to under the heading of Pathology.
Change in the size and texture of the hairs, in neuralgia, has been noted by Romberg and Notta, and has been several times observed by myself. Occasionally the individual hairs near the distribution of the painful nerve become coarsely hypertrophied; at times the number of hairs appears to multiply, but I imagine this is only a case of more rapid and exuberant development of hairs that would be otherwise weak and small. In one very remarkable instance of sciatica this came under my observation; the whole front of the painful leg, from the knee nearly to the ankle, became clothed, in the course of about six months, with a dense fell of hair, which strongly reminded me of similar abnormal hair-growths that have been occasionally seen in connection with traumatic injuries to the spinal cord. More commonly, the effect of neuralgia upon hair is to make it brittle, and to cause it to fall out in considerable quantities; one young lady, who consulted me for a severe migraine, was seriously afraid of having a good head of hair completely ruined in this way, but the hair gradually grew again after the neuralgia had disappeared.
(b) The periosteum of bone and the fibrous fasciæ in the neighborhood of the painful points of neuralgic nerves not unfrequently take on a condition of subacute inflammation, with marked thickening and tenderness on pressure. The most striking instance of this that I have seen was in a lady suffering from severe cervico-brachial neuralgia. In the neighborhood of the emergence of the musculo-spiral nerve at the outer side of the arm, there was developed what looked for all the world like a large syphilitic node, except that the skin was brightly reddened over it; this disappeared altogether some little time after the neuralgia had been relieved by ordinary treatment. I must say that, but for the peculiar circumstances of the case, putting syphilis out of the question, I could not have avoided the suspicion, at first, that the swelling was specific. But I have several times seen similar, though less developed, swellings in neuralgia, and in one case I noticed the occurrence of such a swelling on the malar bone, in an old woman in whom the neuralgic pain was limited to the auriculo-temporal and the supra-orbital branches of the fifth.
A very important point is to be noted in connection with these sub-inflammatory swellings in connection with neuralgia. Pressure on them will, frequently, not merely excite the neuralgic pains in the branches of the affected nerve, but send a powerful reflex influence through the cord to distant organs, causing vomiting, for instance, or affecting the action of the heart in a very perceptible manner. I shall show, when I come to speak of the phenomena of so-called spinal irritation, that this circumstance has led to erroneous influences in manycases. These exquisitely tender points are often found where Trousseau places his neuralgicpoint apophysaire, namely, over, or very near, the spinous processes of the vertebræ. The tenderness is quite unlike that which is known as hysterical hyperæsthesia; it is much severer, and is limited to one, two, or three points, corresponding, in fact, to the superficial part of the posterior branches of as many spinal nerves.
(c) The nutrition of the skin over neuralgic nerves is sometimes notably affected even when the process does not reach the truly inflammatory stage, which will be more particularly mentioned presently. A certain coarseness of texture of the skin has struck me much, in several cases of long-standing facial neuralgia. And there is a most curious phenomenon (which will be especially considered hereafter in regard to the singular influence of the constant galvanic current upon it), the distribution of a greater or less amount of dark pigment to the skin near the painful part. This phenomenon is much more marked during the paroxysms, and in the slighter cases entirely disappears in the intervals, but in old-standing severe cases it becomes more or less permanent.
(d) The mucous membranes, in situations where we can observe them, not unfrequently show interesting changes, the nutrition of the epithelium of parts covering the painful nerve being exaggerated. It has been noted by various observers, in neuralgia affecting the second and third divisions of the trigeminus, that the half of the tongue corresponding to the painful nerve was covered with a dense fur. This is by no means universally the case, but I have seen it occur several times. In my own case, in which the neuralgia is limited for the most part to the ophthalmic division, and only rarely spreads even to the second division of the nerve, this does not usually occur, but I have noticed it on one or two occasions. And I once made the still more singular observation that a large narcotic dose of alcohol, which was sufficient to cause comparatively free elimination of unchanged alcohol in the urine, caused furring of the tongue, which was decidedly thicker on the side of the affected nerve than on the other half of the tongue.
(e) We come now to a group of complications of neuralgia which are exceedingly important, and by no means adequately appreciated as yet, viz., the acute inflammations which directly result from neuralgic affections in a certain percentage of cases, probably much larger than has been at all generally suspected.
The most familiar of the inflammatory complications of neuralgia is herpes zoster, the favorite seat of which is the skin which covers one or more of the intercostal spaces: the eruption, as occurring in this situation, is so well known that it would be waste of time to describe it. In young subjects zoster is commonly painless, at least the sensations are those ofheat, pricking, and irritation, rather than of acute pain; but from puberty onward there is an increasing tendency, especially in those otherwise predisposed to neuralgia, for zoster to be preceded, accompanied, or followed by neuralgia of the intercostal nerves corresponding to the distribution of the eruption. Most commonly, the eruptive period is, in my experience, nearly or quite free from neuralgia, but it often recurs, or breaks out for the first time, when the vesicles are drying up, but more especially if, as is sometimes the case, especially in elderly people, the scabs fall off and leave superficial ulcers. Neuralgia may last, after herpes zoster, for any time from a few days to many weeks, and I have known it so agonizingly severe and so persistent as actually to kill an aged woman from sheer exhaustion. In spite of sundry objections that have been raised to the theory of the nervous origin of zoster, it appears to me that the evidence in favor of it is overwhelming, more especially now that it is proved that the disease, with all the same characteristics presented by it when seen on the chest or abdomen, may occur on the face (following the branches of the trigeminus), or on the forearm (following the course of nerves from the brachial plexus). Two of the severest cases of neuralgia attending herpes that I have ever seen were in private patients (whose family history, unfortunately, I had no means of ascertaining) who were affected, respectively, in the facial and in the brachial nerve-territories.
A far more formidable occasional complication of neuralgia is inflammation affecting the eye. Mr. Jonathan Hutchinson records several cases in which neuralgic herpes zoster of the face was attended with iritis, with serious or even irremediable damage to the organ. For my own part, I have witnessed several instances in which neuralgia of the first and second divisions of the fifth has been attended with skin-inflammation, but only in one of these (just alluded to) did the inflammation present the characteristic appearances of herpes: in all the rest it far more closely resembled erysipelas. The skin was excessively reddened in an almost or quite continuous patch over the whole territory through which ran the painful nerves; by no means only linearly in the course of the nerves, though accurately limited to the district of the first or first and second divisions of the fifth. In the first case I saw (a woman, aged thirty-two), nothing could be more startling than the rapidity with which an irregular patch of the skin, including half of one cheek, the side of the nose, and a large part of the forehead and scalp on the same side, became converted into the dense, fiery-red, brawny tissue, with minute vesicles scattered over its surface, which looks so characteristic of erysipelas; this commenced immediately on the subsidence of severe neuralgic pain. During the erysipelatoid inflammation, though there was no spontaneous pain, the neuralgia could be instantlylighted up for a moment by pressure on the infra-orbital foramen, on the supra-orbital notch, or upon the malar bone, about its centre. Since that time I have seen several cases of a similar character; two of these, which were reported in theLancetfor 1866, I shall here reproduce: [Extensive inquiries convinced me that the tendency to erysipelatous complication of facial neuralgia is exceedingly common. Eulenburg expressly confirms my original statement to this effect, and extends it to all neuralgias.]
Case I.—A woman, aged sixty-three, presented herself in the out-patient room at Westminster Hospital, suffering from neuralgia of ten days' standing (which for the present, however, seemed to have abated considerably), but asking advice chiefly for an erysipelatoid inflammation which had come on a day or two before, and occupied the area of the painful nerve-district. The neuralgia had affected the supra-orbital nerve, running up toward the vortex, and the auriculo-temporal branch of the third division of the fifth; although there was no very acute pain present at this time, pressure over the supra-orbital notch, or at a point just in front of the ear, would at once cause a brief paroxysm of pain. It was curious to find that there was a thickened and tender spot over the malar bone (and corresponding to the exit of some nerve filaments from the bone) which had never been the seat of spontaneous neuralgia, but pressure here sent a dart of pain into the auriculo-temporal and supra-orbital nerves. The inflammation was markedly limited to the general area of distribution of the twigs of the auriculo-temporal and of the ophthalmic division; it was of a continuous deep-red color, and attended with much thickening of the skin. The conjunctiva was intensely congested, and there were lachrymation and very marked photophobia, but there were no signs of iritis, and no corneal clouding.
Case II.—M. W., a woman, aged forty-two, well-nourished and healthy-looking, married and had one child; had never suffered any serious ailment except once, about five years previously. She then had a decided attack of "erysipelas," very accurately limited to the right half of the face. Five months before coming to me she sustained a severe shock from being thrown out of a chaise, without suffering any external or visible damage. An hysterical tendency, which she had always possessed, became more marked; it revealed itself by palpitations, occasional dysphagia, and a disposition to weep causelessly. The menses were flowing at the time of the accident; they ceased abruptly soon after (they had been scanty for some time previously), and did not recur till four months later. The hysteric disturbance progressively increased during a fortnight, and then the patient was attacked with violent intermittent neuralgia, commencing in the eyeball and spreading over thedistrict supplied by the branches of the first and second divisions of the trigeminus. The pain was accompanied by intense conjunctival congestion and photophobia [Dr. Handfield Jones remarks that photophobia, in his experience, is only a rare accompaniment of facial neuralgia. I have latterly come to the same opinion. Redness of the eye and lachrymation are very common; true photophobia uncommon. Notta's experience would seem to have been similar]. It lasted on the first day fourteen hours, and returned daily for the next fifteen or sixteen days. An attack of erysipelas, strictly limited to the district of the painful nervous branches, then set in. From that moment the neuralgic attacks became less frequent and severe. A second similar onset of erysipelas occurred some three or four weeks after the first. Finally, the neuralgia disappeared about four months after its first occurrence, and the menses reappeared in tolerable abundance about the same time. About a fortnight before this the patient had discovered that her right eye was dim; as the photophobia had previously disabled her from opening the eye, she could not be sure how long this dimness had existed. At the time of her visit to me the cornea was blurred with a large patch of interstitial lymph, with the remains of a superficial ulcer in the centre; the iris was turbid and discolored, showing the traces of recent but past iritis; the pupil was regular in form and active to light; the conjunctiva was slightly congested. Ophthalmoscopic observation was attempted by a skilled observer, but could not be satisfactorily carried out, from the turbid state of the media. The conjunctiva was slightly congested. In place of the lachrymation that had prevailed during the neuralgic period, there was a remarkable insensibility of the lachrymal apparatus, for the patient had noticed that the smell of onions, which would make the other eye weep profusely, had no influence on the affected one.
The family history of this patient is a most remarkable one. All the members of her mother's family, for two generations back, had died at middle age, either from apoplexy or some disease involving hemiplegia. This case has, by a mistake, not been added to the list of twenty-two private cases in which the family history was carefully investigated, that will be found in the chapter on Pathology; this arose from the fact that the patient was not properly under my care, but was sent to me as a medical curiosity; the notes of her case were therefore taken in a different book from the others. The case certainly ought to be taken as a counterpoise to such a one as No. XVI. in the list, which is that of a gentleman who suffered from the most complicated neurotic maladies (asthma, angina pectoris, facial neuralgia, more than once attended with erysipelas), but whose family history, so far as it was known, presented no traces of tendency to neurotic disease.
To these two cases of inflammation, secondary to neuralgia, I shall add a third, which is even more interesting, and which came under my notice not long since.
Case III.—H. T., watchmaker's assistant, aged forty-two, suffered for about three weeks with very severe remittent abdominal pain, entirely unconnected with dyspepsia, constipation, or diarrhœa. It was intermittent in character, but observation soon showed that the times at which it came on were simply those at which the stomach had gone longest without food, especially the early morning, and that nourishment never failed to relieve it. The suffering was great, and the man failed considerably in general health, notwithstanding that his appetite and digestion were unimpaired. He had only been under my care about ten days when he presented himself one day at the hospital, and stated that the pains in the stomach had entirely left him, but that he suffered the most frightful pains in and around the right eye. I found a well-marked conjunctival congestion and lachrymation, but there were as yet no tender points; the neuralgia was felt most severely in the globe of the eye and in one tolerably straight line, darting up toward the vertex from the brow. The iris seemed clear and free, and the cornea was not cloudy. I gave the man a subcutaneous injection of one-sixth grain acetate of morphia, for present ease, and ordered him muriate of iron and small doses of strychnia three times a day. When he next appeared, four days later, I was alarmed to perceive that unmistakable iritis had fully developed itself, the iris was already turbid and discolored and the pupil irregular, from a serious amount of adhesions. By this time there were fully-developed tender points, supra-orbital and parietal; besides this, pressure on the globe caused paroxysms of pain, in all the branches of the ophthalmic division, but there was not much spontaneous pain. I dropped atropine in the eye, applied blistering fluid to the back of the neck, [the nape of the neck is the point most suitable for blistering which is intended to affect the eye, and the ophthalmic division of the fifth, generally,] and desired the man to come to see me at my own house next day, intending to take him to an ophthalmic surgeon. Unfortunately he failed to do this, and three days later, when he came to see me at the hospital, the cornea was studded with opacities, the pupil was almost closed with effused lymph, there was violent ocular pain, and a great and increasing sense of tension. I begged him to go without loss of time to the Eye Hospital, as my own ophthalmic colleague was not at Westminster that day; and I have never heard any more of the patient.
Glaucoma is a still more serious disease of the eye, which I think there is now sufficient evidence to show is sometimes entirely, and very often in considerable part, neuralgic in its origin. Since my attention was directed, some six years ago,to the frequent connection between the so-called rheumatic iritis and neuralgia, I have taken much interest in the subject of acute eye-affections; and the occurrence of one or two cases of glaucoma in personal friends of my own has made this interest even painfully strong. I am necessarily without the means of personally observing glaucoma on the large scale, but I have now seen two cases in which, if I possess any faculty of clinical observation whatever, the whole genesis of the disease was a neuralgic disorder of the trigeminus; and it was to me a melancholy reflection that nothing better than iridectomy in one case, and excision of the eyeball in the other, could be done in the present state of ophthalmic science. There are now a good many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell Carter, of St. George's, and the South London Ophthalmic Hospital, recently assured me that nervous aspect of some form of glaucoma presents itself the strongly to his mind, though he does not commit himself to any theory. Two cases were reported by Mr. Hutchinson, in Ophthalmic Hospital Reports IV. and V.; but the most complete and interesting cases that I have met with are recorded by Dr. Wegner;[15]they are two out of four that occurred within a very short time in the clinic of Prof. Horner at Zurich, and they form the basis of some researches by Wegner into the nature of the influence of the trigeminus upon ocular tension, which will be referred to, along with others, in the chapter on Pathology. The second of these cases is so important that I shall reproduce it in full.
A. Hediger, aged twenty-four, a moderately strongly-built young woman, seen first in August, 1860. From her own and her mother's account, it seemed she had long suffered from convulsive attacks that did not appear to have been truly epileptic. Some days previously her left eye became very painful, and the sight failed, without any inflammatory symptoms. On inspection the pupil was somewhat dilated, the eye somewhat hypermetropic, fundus normal; No. 5, Jager's type, was read with difficulty. Wegner could not explain the condition. At the end of October the eye was much worse; after severe paroxysms of pain, No. 16 type was the smallest legible, the field of vision was decidedly limited in all directions, but especially on the inner and upper portions. An unusually long hysteric attack was now observed. The patient was for twenty-four hours in a half-sleep, the extremities, meantime, were much jerked, the speech sometimes coherent and sometimes incoherent; she cried out to her friends, etc., but had no severe convulsion-fit with spasm of glottis. She was removed to the hospital, where she stayed six weeks. The hysteria improved under treatment with valerianand 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 (withhigh 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 voluntarypower 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 connectionwith 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 (videChapter 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 knownpoints 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 occupymore time and space. It will, however, be necessary to return to the consideration of the subject in connection with Pathology.
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 ofneuralgia, 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 mystificationas 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, andsuffered 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 shalltake 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.