XVI. Angina pectoris (neurotic); spasmodic asthma, twenty years; facial neuralgia and erysipelas; in a gentleman, aged fifty.

Family medical history scanty and imperfect; but, as far as it goes, entirely without evidence of either phthisis or neuroses.

XVII. Neuralgia of testis, immediately caused by local irritation.

Father died of phthisis; paternal uncle epileptic and insane.

XVIII. Ovarian neuralgia; in a girl, aged twenty-six, liable to occasional migraine. Mother has suffered sciatica; brother died of phthisis.

XIX. Gastralgia; in a man, aged twenty-seven; highly intellectual and nervous. Family history very free from neuroses; but some evidence of phthisis, in two previous generations, on mother's side.

XX. Sciatica; in a lady, aged sixty; second attack. Ancestors, on both sides, for some generations, clever, and in several instances decidedly eccentric, if not insane; much neuralgia in the family.

XXI. Migraine; in a young lady, aged seventeen; menstrual difficulties. No neurotic nor phthisical family history.

XXII. Sciatica; in a married lady, aged twenty-seven; first pregnancy; had rheumatic fever and subsequent ch.o.r.ea in childhood. Paternal uncle epileptic; mother had rheumatic fever and cardiac disease; paternal grandfather suffered from sciatica late in life.

No one, I think, can look down the above list and fail to be struck with the great preponderance of cases in which the general neurotic temperament plainly existed in the patients' families; and let me add that, in not a few of these cases, the neuralgia in the individual under observation might have been easily set down as dependent merely upon peripheral irritation, which, indeed, plainly did act as a concurrent cause.

Fortunately, however, I am not dependent upon my own evidence alone, for the proofs of the proposition that neuralgia is eminently a development of hereditary neuroses. The great French alienists, Morel and Moreau of Tours, some years ago laid the foundations of the doctrine of hereditary neurosis. They enforced this chiefly with reference to the manner in which insanity is transmitted through a chain of variously-neurotic members of a family stock; and Moreau laid special stress on the deeply interesting connection of the phthisical with the neurotic tendency.

Since then various observers have insisted on the same thing. Of late, Dr. Maudsley has worked out this subject with great ability, in his work "On the Physiology and Pathology of Mind," and in his recent "Gulstonian Lectures;" and Dr. Blandford dwells on it with emphasis in his interesting "Lectures on Insanity." [Dr. Blandford does not, however, admit that the phthisical diathesis has any such close and causal relation with neuroses as has been imagined by some recent pathologists; and, on the other hand, he points out that phthisis in neurotic subjects, _e. g._, the insane, must, in a large measure, be considered the product of the accidentally unhealthy circ.u.mstances in which they pa.s.s their lives. In the latter opinion I entirely agree.] Indeed, it may be taken as a recognized fact, among the more advanced students of nervous diseases, that hereditary neurosis is an important antecedent of neuralgia, in at least a very large number of instances. I shall conclude this part of the argument by stating the general results of my inquiries respecting sixty-one hospital patients. Of these cases, twenty-two were migraine, or some other affection of the ophthalmic division of the fifth nerve; seven were sciatica; two were epileptiform facial tic; ten were neuralgias affecting chiefly the second and third divisions of the fifth nerve; three were intercostal neuralgias pure; one was intercostal neuralgia plus anginoid pain; seven were intercostal neuralgias with zoster; three were brachial neuralgias; and five were abdominal neuralgias (hepatic, gastric, mesenteric, etc.) Of eighty-three hospital and private patients [It must be understood that the respective numbers do not indicate with any accuracy the relative frequency of the different neuralgias as seen in my practice. (Sciatica, _e. g._, was proportionally more frequent.) They represent but a small part of the neuralgic patients whom I have seen during fourteen years of dispensary, hospital, and private practice, and they were selected for inquiry merely because I happened to be able to give the time for the necessary questions. Every one who knows out-patient practice will understand how seldom this happened.] I obtained evidence of the presence, among blood-relations, of the following diseases: Epilepsy, fourteen cases (eight were examples of migraine); hemiplegia or paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen cases; "consumption," eighteen cases; "St. Vitus's dance," four cases.

I am well aware that these figures must be taken with caution, and that considerable doubt must rest on the accuracy of some of these details, more especially with regard to "epilepsy," as it was impossible, with the greatest care, to be sure that this was not given, by mistake, for hysteria in some cases; and the same may apply to the statement that relations had suffered from "consumption." The facts are given for what they are worth, and with the express reservation that their total reliability is far less than that of the accounts obtained respecting private patients belonging to the more educated cla.s.ses. But, in one respect, viz., as regards drunken habits, it is possible that a truer estimate is gained from the statements of hospital patients than from those of private patients, who would usually be more p.r.o.ne to reticence on such a topic.

The evidence as to the hereditary character of neuralgia a.s.sumes a yet higher importance when supplemented by the facts respecting the alternations of neuralgia with other neuroses as the same individuals.

Every pract.i.tioner must be aware how frequent is the latter occurrence.

Nothing is more common, for example, than to see insanity developed as the climax of minor nervous troubles, especially of neuralgia. And there is one form of neuralgia, the true epileptiform tic, which is intimately bound up with a mental condition of the nature of melancholia, and even with the markedly suicidal form of the latter affection. I have lately had under my care a lady in whom the prodromata of a severe facial neuralgia were mental; the disturbance commenced with frightful dreams, and there was great mental agitation even before the pain broke out; this disturbance of mind, however, continued during the whole period of the neuralgia, and was relieved simultaneously with the cessation of the attacks of pain. This is contrary to what happens in some cases; thus, Dr. Maudsley quotes the case of an able divine who was liable to alternations of neuralgia and insanity, the one affection disappearing when the other prevailed. Dr. Blandford has met with several instances in which neuralgia has been followed by insanity, the pain vanishing during the mental disturbance, and reappearing as the latter pa.s.sed away. And he remarks that, in the transition of a neuralgia (to mental affection), we may well believe that the neurotic affection is merely changed from one centre to another, from the centres of sensation to those of mind. He says that the ultimate prognosis of such cases is bad; a point to which we shall have to refer again.

The prominent place which quasi-neuralgic pains hold in the earlier history of locomotor ataxy is a fact that cannot but engage attention.

In this volume we have not treated these pains as belonging to the truly neuralgic cla.s.s, for the very practical reason that they are but incidents in a most important organic disease, and that in a diagnostic and prognostic point of view it is necessary to dwell on their connection with that disease. But, in considering the pathological relations of neuralgia, it would be improper to omit the consideration of the pains of locomotor ataxy, which bear a striking semblance to neuralgic pains. The fact that they are an almost if not quite constant feature of a disease which is from first to last an atrophic affection (mainly of the posterior columns of the cord), in which the posterior roots of the nerves are almost always deeply involved, has a bearing on our present inquiry too obvious to need further remark.

Equally important to our investigation is the fact that pains, closely resembling neuralgia, are not very uncommonly a part of the phenomena of commencing, and more frequently of receding, spinal paralysis. I have the notes of three cases of partial recovery from paraplegia, in all of which the patients remained for years, in one case for nearly twenty years (ending with death), the victims to a singularly intractable neuralgia of both lower extremities. In the worst of the cases the patient was the victim of excessive and continuous labor at literary work of a kind which hardly exercised the mental powers, but was extremely exhausting to the general power of the nervous system; he broke down at about the age of fifty, but dragged on a painful existence for the long period above mentioned.

We are also certainly ent.i.tled to adduce the example of the so-called neuralgic form of chronic alcoholism as an instance of the close relationship of neuralgia to other central neuroses. I refer to those cases, more common perhaps than is generally admitted, in which pains in the extremities, often quite resembling neuralgia in their intermittence, are either superadded to or take the place of the muscular tremors and general restlessness that are more popularly considered as the essential nervous phenomena of chronic alcoholic poisoning. That the pains are usually bilateral, and more diffuse in their character than those of ordinary neuralgia, is a fact which it is not difficult to explain by the _modus operandi_ of the cause; but we shall have more to say on the general relations of alcoholic excess to neuralgia presently. The pains themselves will be fully described in the second part of this book, which treats of the affections that simulate neuralgia; here we need only remark that it is not uncommon for them to occur interchangeably with true neuralgia in the same person.

The occasional interchangeability of migraine with epilepsy is a well-known fact; every pract.i.tioner who has seen much of the latter disease will have seen some cases in which the patient had been liable, at some point of his medical history, to "sick-headaches" of a truly neuralgic kind; although it is quite true, as Dr. Reynolds points out, that the kind of sensorial disorder specially premonitory of the attacks consists rather in indefinable distressing sensations, than in actual pain. The genealogical connection between migraine and epilepsy is, as I have already stated, apparently very close. Such instances as one mentioned by Eulenburg are rightly explained by him; it is the case of a girl who suffered at an unusually early age (nine) from migraine; her mother had been a migraineuse, and her sister was epileptic; the strong neurotic family tendency is believed by Eulenburg to account for the appearance of migraine at such a period of life.

This seems the fitting place to introduce some special remarks on migraine in its relations to other neuralgias of the head, because Eulenburg has mentioned and combated my view, according to which migraine is a mere variety of neuralgia of the ophthalmic division of the fifth nerve. I call it my view, because, though several other authors had previously expressed it, I was first lead to entertain it by observations made before I had studied their works, and especially by the impressive teaching of my own case, as to which more will be presently said. Eulenburg, though he fully allows that migraine is a neuralgia, urges a series of objections to the identification of migraine with ophthalmic neuralgias; of which objections one, based on the doctrine of Du Bois Reymond as to the action of the sympathetic in migraine, must be reserved for consideration when we discuss the general pathology of the vaso-motor complications of neuralgia. The other grounds of distinction that he urges are the following: In the first place, he remarks that the site of the pain is by far less distinctly referred to definite foci on the outside of the skull than in trigeminal neuralgia; the patient's sensations very usually lead him to declare that the pain is in the brain itself. Secondly, he says that the points douloureux (in Valleix's sense) are almost constantly absent in true migraine. Thirdly, he specifies the character of the pain in migraine--dull, boring, straining, etc.--as differing from that of trigeminal neuralgia, which is ordinarily much more acute and darting.

Fourthly, he notes the long duration of individual attacks of migraine, and the long intervals (very commonly three or four weeks) between them.

Fifthly, he dwells on the frequent prodromata of migraine referable to the organs of sense (flashes before the eyes, noises in the ears), or to the stomach (nausea), or more generally to the reflex functions of the medulla oblongata (_e. g._, convulsive rigors, excessive yawning, etc.)

Now, I should have nothing to say against the accuracy of this description, did it apply merely to the distinctions between highly-typical cases of the "sick-headache" of the period of bodily development, and highly-typical cases of the ophthalmic neuralgias which are commonest in the middle and later periods of life; nor indeed should I greatly care if it were finally decided that migraine and clavus should be separated from the true trigeminal neuralgiae, provided the following points were well impressed on the minds of pract.i.tioners. In the first place, I must insist that in my own experience the great majority of undoubtedly neuralgic headaches, which subordinate stomach disturbance, are far less sharply separated than the above description would allow from the unmistakable trigeminal neuralgias; it is only a minority of cases that wear this extreme type, and a far larger number shade imperceptibly away toward the type of ophthalmic neuralgia pure and simple. And so, again, of the so-called clavus there is every variety, from a form bordering closely on the migraine type to another, differing in nothing from an unusually severe ocular and frontal neuralgia of the fifth, except in the presence of a tremendously painful parietal focus. But the fact on which I would most particularly insist is one that was first taught me by my personal experience, viz., that migraine is, with extraordinary frequency, the primary or youthful type of a neuralgia which, in later years, entirely loses the special characters of sick-headache, and a.s.sumes those of ordinary frontal neuralgia, with or without complications. In my own case, the "sick-headache" character of the affection was strongly marked during the first two or three years, after which time it gradually but steadily lost all tendencies to stomach complications, and, what is more, the type of the recurrence became entirely changed. Yet it is quite impossible to believe that the malady is now a different one, in any essential pathological point, from what it was at first; if any disproof of this were needed, it might be remarked that the singular series of secondary trophic changes which have complicated my case have been impartially distributed between the respective periods when the affection was frankly migraineuse, when it was mixed, and when it was simply ophthalmic neuralgia (as it is at present;) indeed, some of the most decided of these trophic complications (orbital periost.i.tis, corneal ulceration, fibrous obstruction of the nasal duct) occurred within the period in which every attack of pain, unless I succeeded in getting to sleep very shortly, ended in violent vomiting. The experience thus gained has made me very attentive to the past history of those who, in later life, complain of frontal neuralgia without stomach complication, and it is surprising to find in how many cases patients, who at first declare that they never had neuralgia before, on reflection will recall the fact that they were often "bilious" in their youth; which "biliousness" turns out to have been regularly preceded by one-sided headache, and to have been severe in proportion to the severity and duration of that previous headache.

I ask the reader to dwell with fixed attention on this fact of the exclusiveness, or almost exclusiveness, with which the neuralgias of the anterior part of the head are represented during the period of bodily development, and especially in the years just succeeding p.u.b.erty, by migraine or by clavus. When this fact has thoroughly entered the mind, we can hardly help joining with it that other and most important fact already noticed, of the close connection between the predisposition to migraine and the predisposition to epilepsy, and reflecting further on the strong tendency which epilepsy likewise shows to infest the earlier years of s.e.xual life. In view of these things, it is difficult to avoid the inference that both the epileptic and the neuralgic affections of this critical period of life are the expression of a morbid condition of the medulla oblongata, in which the sensory root of the trigeminus has its origin; and further, that this morbid condition (tending to explosive and atactic manifestations of nerve-force) must have its basis in defective nutrition. For, be it remembered, the epoch of s.e.xual development is one in which an enormous addition is being made to the expenditure of vital energy; besides the continuous processes of the growth of the tissues and organs generally, the s.e.xual apparatus, with its nervous supply, is making by its development heavy demands upon the nutritive powers of the organism; and, it is scarcely possible but that portions of the nervous centres, not directly connected with it, should proportionally suffer in their nutrition, probably through defective blood-supply. When we add to this the abnormal strain that is being put on the brain, in many cases, by a forcing plan of mental education, we shall perceive a source not merely of exhaustive expenditure of nervous power, but of secondary irritation of centres like the medulla oblongata, that are probably already somewhat lowered in power of vital resistance, and proportionably irritable. Let us suppose, then, that to all these unfavorable conditions there was added the circ.u.mstance that the structure of the medulla oblongata, or of parts of it, was congenitally weak and imperfect; then surely it would be scarcely possible for these loci minimae resistentiae to escape being thrown into that state of weak and disorderly commotion which eminently favors pain in the sensory, and convulsion in the motor apparatus.

2. We have so far been mainly considering the relations to the production of neuralgia of certain conditions of the central nervous system which indisputably are inherent from birth. Let us now pa.s.s quite to the other extreme, and consider a cla.s.s of momenta which take a decided part in producing many neuralgiae, but which are altogether accidental and fact.i.tious, and cannot be included among the necessary hostile conditions of life. To push the contrast to the utmost, let us inquire first, what amount of influence in the production of neuralgia can be given by such a purely "functional" influence as educational misdirection of intellect and emotion?

It is somewhat strange, though every one accepts as a mere truism the maxim that sudden emotional shock may produce almost any degree or variety of nervous disorder, the slower but far surer influence of long-continued mental habit is often practically ignored. It cannot, indeed, be left out of sight as a cause of disorders of the mind itself, nor are there many who would deny that such diseases as cerebral softening are, in a considerable number of cases, the premature ending to a life that has been broken down by hara.s.sing work and anxiety. But what is far less appreciated is the tendency of certain unfortunate mental surroundings and modes of mental life to produce a generally neurotic condition, which may express itself in a variety of functional disorders, among which not the least common is neuralgia.

I may fairly hope to be acquitted of any predisposition to lay exaggerated stress on this kind of influence in the production of neuralgia, considering all that I have said of the importance of that inevitable cause, the neurotic inheritance, and all that I shall have to say presently as to the effects of a variety of external influences of a totally different kind. But I confess that, with me, the result of close attention given to the pathology of neuralgia has been the ever-growing conviction that, next to the influence of neurotic inheritance, there is no such frequently powerful factor in the construction of the neuralgic habit as mental warp of a certain kind, the product of an unwise education. This work is not intended as a treatise either on religion or psychology, and yet it is impossible for me to avoid some few words that may seem to trench on the province of each: for I believe that there are certain emotional and spiritual and intellectual grooves into which it is only too easy to direct the minds of young children, and which conduct them too often to a condition of general nervous weakness, and not unfrequently to the special miseries of neuralgia. As regards the working of the intellect, it is easier to speak in a free and unembarra.s.sed manner than respecting the other matters. There can be no doubt that, of intellectual work, that sort which exhausts and hara.s.ses the nervous system is the forced, the premature, and the unreal kind; and this it is which predisposes, among other nervous maladies, to neuralgia. It is more difficult to speak the truth about emotional influences generally, and especially about those which are concerned with the highest spiritual matters; but I should do wrong were I to suppress the statement of my convictions on this point. I believe that a most unfortunate, a positively poisonous influence upon the nervous system, especially in youth, is the direct result of efforts, dictated often by the highest motives, to train the emotions and aspirations to a high ideal, especially to a high religious ideal. It is not the object that is bad, but the machinery by which it is sought to be attained. In modern society there are two princ.i.p.al methods which are popularly employed for this purpose; I shall describe them, by two epithets which are selected with no offensive intention, as the Conventual and the Puritan methods of spiritual training. By the former is meant that kind of education which deliberately dwarfs the nervous energy, with the hope of preserving the mind from the contamination of unbelief and of sinful pa.s.sion. It is a system which is not peculiar to the Roman Church, nor even to the Christian religion, and it need the less detain our attention, as its effects, so far as they are evil, are mainly seen in general nervous and mental enfeeblement, rather than in the outbreak of explosive nervous disorders, such as convulsion, insanity, or neuralgia.

There are doubtless exceptions to the rule; but that is the rule. It is far otherwise with the spiritual education which is here called Puritan, but which is confined to no party in the Church. This is a system which seeks to purify and exalt the mind, not by enforcing obedience to a series of spiritual rules for which another mind is responsible, but by compelling it to a perpetual introspection directed to the object of discovering whether it comes up to a self-erected spiritual standard.

The reader will understand that I have not the remotest intention to depreciate either a true and manly self-restraint in obedience to the direction of "pastors and masters," or an honest watchfulness over one's own conduct and thoughts. But the lessons which our psychologists are rapidly learning, as to the evil effects on the brain of an education that promotes self-consciousness, are sorely needed to be applied to the pathology of nervous diseases generally, and of neuralgia among the rest. Common sense and common humanity, when united with the physician's knowledge, cry out against the system under which religious parents and teachers subject the feeble and highly mobile nervous systems of the young to the tremendous strain of spiritual self-questioning upon the most momentous topics. More especially is such a practice to be condemned in the case of boys and girls who are pa.s.sing through the terrible ordeal of s.e.xual development--an epoch which, as we have already seen, is peculiarly favorable to the formation of the neurotic habit, and I must emphatically state my belief that among the seriously-minded English middle cla.s.ses, more especially, whose life is necessarily colorless and monotonous, the mischief thus worked is both grave and widely spread.

Perhaps the maximum of damage that can be inflicted through the mind upon the sensory nervous centres is effected when to the kind of self-consciousness that is generated by an excessive spiritual introspection there is added the incessant toil of a life spent in sedentary brain-work, and checkered with many anxieties, and many griefs which strike through the affections. Doubtless, such a combination of morbid mental influences is sufficient of itself to generate the neuralgic disposition in its severest forms, without any hereditary neurotic influence, and without any other peripheral irritations; I have more than one such instance in my mind at this moment. But, if they can do this, much more can such influences arouse inherent tendencies to neuralgia; to persons who are predisposed in this manner they are most highly deleterious.

3. We come now to the peripheral influences which in a more obvious manner become factors in the production of neuralgia. Of such influences there are an immense variety, and the only common quality that can be predicated of all is the tendency directly to depress the life of the sentient centre upon which their action impinges.

If we search among the external influences which contribute to the production of neuralgia for one that is apparently trivial as to the amount of material disturbance which it can cause, and yet is very frequently effective, we may select the agency of cold. The effect of a continuous cold draught of air impinging on the naked skin for some time is comparatively frequently seen in the provocation of neuralgic attack: we say comparatively, because this influence is more frequently effective than blows, wounds, or temporary irritations of any kind, applied to the peripheral ends of sensory nerves. But if neuralgia be a more frequent consequence of cold than of these other influences, a moment's reflection will show that it is by no means an absolutely common result. One has only to think of the numerous omnibus-drivers, engine-drivers, cab-drivers, etc., etc., who pa.s.s their whole working lives in presenting the (more or less) naked expanse of their trigeminal and their cervico-occipital nerves to every variety of wind, to perceive that, were this sort of influence very potent in itself, male neuralgic patients should swarm as thick as bees in our hospital and dispensary out-patient rooms; which is notoriously quite contrary to the fact. The same remarks, in both directions, may be applied to the direct influence of atmospheric moisture, either with or without the effect of wind (of course I am not speaking of the more recondite effects of damp soil on the persons who live about it). [Among the hundred patients who formed the basis of the inquiries mentioned in this work, forty-one accused external cold of producing the attack, but many of these produced insufficient evidence that such was the case.] In short, the direct effects of atmospheric cold would seem to be these. Mere lowness of temperature goes for something, but not much; [The most marked instance of the effect of cold, _per se_, that I have seen, was exhibited by a young lady who was under my care during the past severe winter (1870-'71). During much of the time she was confined to a carefully-warmed apartment, on penalty of a violent paroxysm if she left it.] for about as much, perhaps, as it does in the way of aggravating all neurotic tendencies. Cold joined with wind is much more powerful.

And the maximum of ill-effect seems reached by very cold wind mingled with sleet or driving rain, which keeps the skin sodden. But the conclusion at which I long ago arrived is, that none of these influences ever take more than a small (though it is sometimes an important) part in the production of neuralgia; and that in the majority of cases there is no pretence for supposing that they had the slightest share in its causation.

A word or two must be said as to the _modus operandi_ of cold and cold wind, as these are the most frequent of external, so-called "exciting"

causes. The popular use of such phrases as the latter has an extraordinary influence in disguising the plain fact, which is, that these influences operate wholly in the direction of robbing the nerves of force. The continuous abstraction of heat from the surface, which of course is materially aided by rapid movement of the air, must necessitate a readjustment of the distribution of energy, the only result of which must be to drain the sensory nervous centre of its reserve of force. But, in fact, there is an experiment, ready performed to our hands, which may amply satisfy us as to the kind of influence exerted by cold on superficial nerves, viz., the sensations experienced in recovering from frost-bite, which has been severe enough to paralyze the nerves without causing actual gangrene of the tissues. The pa.s.sage of the nerves back from temporary death to full functional life is marked by a half-way stage in which there is agonizing pain.

4. We must next consider the effects of a cla.s.s of peripheral influences which act, where they exist, in a more constant manner than any others; viz., those in which the trunk or periphery of a sensory nerve either receives a severe injury, or becomes more or less engaged in inflammatory processes, or compressed or otherwise damaged by the growth of tumors or the spread of destructive ulcerations.

With regard to ordinary nerve-wounds as a cause of neuralgia, we have already said (_vide_ Chapter II.) nearly as much as it is necessary to say; we need only here point out that, like the influence of cold applied to superficial nerves, that of wounds must necessarily be a depressing one to the centre with which the wounded nerve is connected, and the resulting neuralgia must be regarded as an expression of impeded and imperfect nerve-energy, not of heightened nerve-function. The pain is set up during the process of nerve-healing; that is to say, at a stage intermediate between those of abolished function and completely restored function; and there can be little doubt that the obstinacy with which it is often protracted is due to the slowness with which a wounded nerve recovers its full functional activity; when once the latter is completely restored there is an end of neuralgic pain. It is exactly a.n.a.logous to the course of events in recovery from freezing.

There remain for consideration, however, (a) a small cla.s.s of cases of nerve-wounds in which the healing process is not simple; but the lesion is followed by the development of a tumor of the kind denominated true neuroma. The process consists of hyperplastic changes in the nerve-fibres; its commonest examples are seen in the extraordinarily painful swellings that occur on the ends of nerves left in stumps after amputations; but, in fact, a neuroma of this kind may occur after any kind of severe nerve-injury, as, _e. g._, a cut from broken gla.s.s, the impaction of foreign bodies, etc. The true neuromata are composed mainly of nerve-tissue, with a relatively small element of connective tissue: the nerve-fibres can be traced directly to the nerve-tumor. Besides the traumatic neuromata which form permanent tumors, incapable of being got rid of except by actual excision, a minor variety of the same kind of change has in several cases been known to take place in consequence of an abiding local irritation from the impaction of a foreign body, on the removal of which the neuromatoid enlargement completely disappeared. (b) There are likewise a certain number of cases in which a tumor is developed from the neurilemma, and does not consist of nervous tissue; these are distinguished as false neuromata, and may be of various kinds, the fibromatous and gliomatous being far the most common, but cysts and cystic tumors also sometimes occurring.

The case of the neuromata is well worth reflecting upon, in the course of our endeavors to clear up the Pathology and Etiology of Neuralgia. If ever we could find a merely peripheral influence which would of itself be invariably competent to excite neuralgic pains, it would surely be found in neuroma; but the case is not merely not so, it is strikingly contrary. Just as wounded and inflamed nerves frequently go through the whole processes of disease and recovery without once eliciting a neuralgic pang, so is it with neuromata; they are not unfrequently quite indolent, and neither excite neuralgia, nor are themselves at all particularly tender to the touch. And what is most remarkable is, that, as Eulenburg correctly remarks, among the pseudo-neuromata the kind of tumor which is most frequently a.s.sociated with neuralgia is by no means the dense fibroma or glioma, which might be expected by its mechanical pressure to excite inevitable neuralgic pain, but the far softer and more yielding cystic tumors. I do not know how the facts may affect the reader, but to me they suggest the strongest possible arguments against the belief that peripheral irritation can of itself produce neuralgia without the intervention of some centric change. The tendency to such change (from inherent const.i.tution) in the sensory root of the nerve must surely be the reason why neuroma causes neuralgia in a given number of subjects, instead of letting them go scot-free, as it does other persons.

The same remarks apply to the result of observations on the effect of tumors commencing in tissues altogether unconnected with the nerve, and merely coming to involve it, secondarily, in pressure. It has been often noted that, among these tumors, fluid-containing cysts and soft medullary cancers are far more frequently the cause of decided and distressing neuralgia than the denser and less yielding neoplasms. Of kinds of tumors that are specially apt to produce severe and even intolerable neuralgia by the pressure on nerves, it has been remarked that aneurisms are among the worst: here every pulsation often sends a dart of agony through the nerve. There is a reason here, however, which is often left out of sight; not merely is the perpetually varying pressure specially hara.s.sing and exhausting to the nerve, but in many of these cases there is general arterial degeneration, and the sensory root of the nerve is exceedingly likely to be very badly nourished. [This result will be more directly brought about when the aneurism happens to press on the ganglion of a posterior root.] We pa.s.s now to the consideration of the influence exerted by other great series of peripheral impressions in the production of neuralgia. These impressions are connected chiefly with the functions of the digestive and of the genito-urinary organs, the functions of the eye, and the nutrition of the teeth.

To take the least important of these first, I may surprise some readers by the statement, which I nevertheless make with much confidence, that irritation of any part of the alimentary ca.n.a.l is, on the whole, a rare concurrent cause, even in the production of neuralgia. There are, as has been already fully explained, cases of neuralgia seated in these viscera themselves (or the plexuses in their immediate neighborhood), although their number is immensely smaller than that of the neuralgias of superficial nerves. But it is not at all common--it is even exceedingly rare--for irritation conveyed from the alimentary ca.n.a.l to take any important part in setting up neuralgia of a distant nerve, even when that nerve has close connections, through the centres, with those coming from the irritated portion of the alimentary ca.n.a.l. Valleix had the great merit to perceive this, even in the case of neuralgias of the head, where appearances are so likely to lead the observer to a contrary opinion. And it is not a little remarkable that this should be the case, when we consider the close central connections which the vagus, the great sensory nerve of a large portion of the alimentary ca.n.a.l, has with the sensory root of the trigeminus. In fact, however, there are certain peculiar forms of gastric irritation which do react upon the trigeminus; for instance, a lump of unmelted ice, suddenly swallowed, almost invariably produces acute pain in the supra-orbital branch of the fifth, on one side or the other, and occasionally (as in a case cited by Sir Thomas Watson) in other nerves. But that common dyspeptic troubles at all frequently or importantly contribute to the production of neuralgia, I do not for a moment believe: it needs some very powerful irritation, such as that just mentioned, or as impaction of great ma.s.ses of scybalae in the intestines, or severe irritation from worms, to produce such an effect.

It is far otherwise with the genito-urinary apparatus; in a large number of cases, irritations proceeding from these organs do undoubtedly contribute to the production of neuralgia, though by no means in the important degree which many authors seem to have a.s.sumed. There can be no doubt, for example, that the irritation of a calculus, either within the kidney itself, in the ureter, or in the bladder, may set up violent neuralgia, which for the most part is localized in the branches of the lumbo-abdominal nerves. The instance of the eloquent Robert Hall is an example of renal calculus acting in this way: he suffered the most excruciating agony for years, and was obliged to take enormous quant.i.ties of opium in order to make life endurable. An instance of calculus impacted in the ureter, in a gentleman somewhat past middle age, occurred in my own practice; the lumbo-abdominal neuralgia occurred in frequent paroxysms of dreadful severity; and another case, already referred to was that of a woman, in whom ovarian neuralgia was undoubtedly in great part due to the irritation of an impacted calculus in the ureter. These cases, however, are very rare in comparison with others in which the peripheral source of the neuralgia is either the uterus or ovary, or the external genitals. I have no means of ascertaining, with anything like accuracy, the frequency with which the internal s.e.xual organs are the starting-point of neuralgia, because the majority of such cases pa.s.s, naturally, to the care of physicians who practice chiefly in the diseases of women, and consequently not adequately represented either in my hospital or my private practice; still, I have seen a good many of these affections, and, though I speak with the reserve necessitated by the circ.u.mstances just named, I am much inclined to believe that even such powerful centripetal influences as those of the states of commencing p.u.b.erty, of pregnancy, of the change of life, and uterine diseases generally, are very rarely the cause of true unilateral neuralgia, except in subjects with congenital tendencies to neuralgia. But in predisposed subjects there can be no doubt that these influences a.s.sist most powerfully in producing the malady.

Of the power of irritation of the external genitalia to act as a so-called "exciting cause" of neuralgia, there is abundant evidence. I would especially call attention to the remarkable monograph of M.

Mauriac, ["_Etude sur les Nevralgies Reflexes symptomatiques de l'Orchi-epididymite blenorrhagique_" Par C. Mauriac, Medecin de l'Hospital du Midi. Paris, 1870.] on the neuralgias consecutive to blenorrhagic orchi-epididymitis, as ill.u.s.trating this with a force that was to me, for one, surprising. I shall, perhaps, have further occasion to these researches; here it will be enough to mention that M. Mauriac's enormous experience of blenorrhoea and orchitis at the Midi has shown that, in an exceedingly large number of cases, certainly not less than four per cent., this combination is followed by reflex neuralgias, of which a large number are not seated in the genital apparatus, but affect the track of some distant sensory nerve, through the intermediation of the spinal centres; and that with these reflex pains there is often profound general disturbance, including very often an extremely profound general anaemia. The most frequent kind of these neuralgias is rachialgia, _i. e._, pain in the superficial posterior branches of spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and crural, visceralgic (abdominal), etc.; and besides all these there are numerous instances of neuralgia in the testis. As to the nervous "reflection," more hereafter.

It has surprised me, somewhat, that while M. Mauriac has seen so many reflex neuralgias set up by orchi-epididymitis, he does not appear to have noticed cases of trigeminal neuralgia from this source; because, in the very a.n.a.logous instance of the peripheral irritation produced by excessive masturbation, we undoubtedly do frequently get a development of the tendency to migraine, and also to other forms of neuralgia of the fifth: moreover the effect of such local irritation can be occasionally traced with much distinctness in the trigemini, by a tendency to certain forms of eye-disease without positive neuralgia. This was remarkably exemplified in a case which was under my care some years ago, and in which both eyes were greatly damaged by vaso-motor and trophic changes; partial insanity also supervened with hallucinations of sight and hearing.

We come now to one of the most powerful sources of peripheral irritation tending to set up neuralgia; viz., functional abuse of the eye. This is one of the very few peripheral influences which occasionally we see producing neuralgia unaided by hereditary predisposition, or any other observable cause whatever, and in a far larger number producing it with the sole aid of more or less defective general nutrition. The latter occurrence is well exemplified by a case which Mr. Carter sent me the other day, and which also ill.u.s.trates (second attack) the effect of the superaddition of syphilitic taint:

Matilda W----, aged thirty-three, married, and has three very healthy children. Comes of a remarkably healthy family, of which she told me the entire history for three generations, with unusual intelligence and clearness. No neuroses, properly so-called, in any of her relatives during all this time. She herself was a very strong and hearty girl until the age of seventeen; between this date and her marriage, three years later, she was obliged to work tremendously hard at fine sewing, by which means she gained a very scanty livelihood. After a comparatively short period of this work she began to suffer from typical attacks of migraine, very severe, and recurring every three or four weeks, but in no particular connection with the menstrual function, which was normal. On her marrying and ceasing to do needle-work, the migraine entirely disappeared, and she retained perfect health till the commencement of 1871. At this time she had suckled a very hearty baby for ten months, and was not able to furnish such good living as usual.

She was attacked early in January, with violent neuralgia affecting all three branches of the right fifth, and she the more readily applied for advice because she soon found that the neuralgia was becoming complicated with dimness of vision in the eye of the affected side, "as if she was going to have a cast." Was quite unconscious of ever having had syphilis. The medical man encouraged to believe that the whole malady was nervous, and would soon disappear under appropriate remedies, and gave her quinine, under which treatment she declares that she was rapidly improving, both as to pain and vision, but that her resources came to an end, and she could no longer pay for the medicine. She then neglected herself, and rapidly got worse in all regards, till at last she was compelled to apply to the South London Ophthalmic Hospital, whence Mr. Carter sent her to me, on the 6th of April. At this time the paroxysms were excessively violent and frequent, though brief. On examination, tender points were found at the supra-orbital notch, at the infra-orbital foramen; in front of the ear; in the temporal region; in the parietal region, and the inferior dental region. There was strongly marked anaesthesia of the skin of the right half of the face, of the gums, and of the side of the tongue. The teeth were absolutely perfect: not one spot of caries could be seen. Taste was completely destroyed in left half of anterior part of the tongue. Smell was totally lost on both sides, and had been so, the woman declared, from a very early period in the illness. The right eye showed complete paralysis of the levator palpebrae and of the external rectus; nearly complete paralysis of the superior and inferior rectus, rather less marked paralysis of the internal rectus. Pupil normal, conjunctiva moderately congested, lachrymation profuse, photophobia partial. The functions of the retina were perfect. Accommodation was affected in the following degree and manner. The vision of the affected eye was perfect at long distances, very imperfect at short distances. With both eyes open she saw every thing double, but could still count all the bricks in a whitewashed wall at sixteen feet distant. There was no secondary disturbance of the stomach whatever. On the first visit she a.s.suredly had no visible signs, in skin or throat, of syphilis; the perfect health of her children, and absence of abortions, made syphilis the less probable. But on her second visit she complained of sore throat, and a week later a palpably specific sore appeared on the soft palate. She declared, with apparent sincerity, that it was the first symptom of the kind she had ever had. The neuralgia rapidly disappeared under thirty grains of iodide of pota.s.sium daily. The lesions of taste and smell disappeared exactly pari pa.s.sua with the trigeminal pains. The ocular paralysis threaten to be much slower in departing. I think we must believe that this woman contracted syphilis after the birth of her last child. It is at any rate certain that the migraine of her youth was perfectly unconnected with syphilis, being as unlike the pains evoked by the latter as it is possible for two kinds of pain to be. In all probability she was infected during her last lactation.

Last among the peripheral influences of sufficient importance to be specially mentioned as effective factors in the production of neuralgia, must be mentioned caries of the teeth, and the comparatively rare accident of the mal-position or abnormal growth of a "wisdom-tooth." It is an undoubted fact that these things may cause neuralgia even of a very serious type, and attended with extensive complications; as in Mr.

Salter's cases, already mentioned, of reflex cervico-brachial neuralgia from carious teeth. Looking to the extreme frequency of caries, however, as compared with the rarity of true neuralgia (not mere toothache) as a consequence of it, it is impossible not to suppose that the share of the carious teeth in the production of such neuralgia must be very small, compared with that of other influences.

5. The next influence which we shall mention as undoubtedly very effective in a.s.sisting the production of neuralgia in certain cases is that of anaemia and mal-nutrition generally; but it is not necessary to dwell on this at any length. The fact is notorious that severe loss of blood is always followed by headache; and if there be the least predisposition to neuralgia, this headache will very commonly take the form of the severest clavus. And, in like manner, chronic states of anaemia and of mal-nutrition undoubtedly aggravate every existing neuralgia, and bring out lurking tendencies to the disease. But I do not believe that anaemia, or starvation pure and simple, ever generates true neuralgia by its sole influence.

6. The question how far, and in what way, the neuralgic tendency is helped by certain const.i.tutional diatheses, such as rheumatism and gout, and by certain toxaemiae, such as malaria, alcoholism, lead-poisoning, etc., is a very much more difficult one than might be supposed from the off-hand manner in which many writers speak of the "rheumatic," the "gouty," or the "alcoholic" forms of "neuralgia." We may, however, simplify it a good deal. In the first place, it seems obvious to me that the only manner in which alcohol helps the production of true neuralgia is by its tendency, after long abuse, to produce degeneration of the nervous centres: it will therefore be considered, shortly, under another division of the present subject. Lead-poisoning, again, only produces so highly special a form of neuralgia (if colic be neuralgia at all) that it need not detain us here. The influence of malaria is, for the most part, an utter mystery to us, but by so much as we can see it appears plain that one of the most important features in the disease is a powerful disturbance of the spinal vaso-motor centres. But the most interesting consideration that we have to deal with is the question of the supposed relations of the rheumatic and the gouty diatheses, and the syphilitic dyscrasia, to the neuralgic tendency. On this point I am obliged to disagree _in toto_ with the popular view that a.s.signs these diatheses among the most frequent predisposing causes of neuralgia.

To take the case of rheumatism first, I am willing to allow that there are a number of facts which superficially appear to countenance the idea of a close connection of this disease with neuralgia. But of these facts a considerable proportion consist only of examples of inflammation of the nerve-sheath, with a certain amount of effusion within and around it, occurring in persons who have never shown any symptoms which warrant the a.s.sumption of a general rheumatic diathesis; and these local phenomena really differ in nothing from many trophic and vaso-motor changes which have been already described as plainly secondary to ordinary neuralgia in which there could be no pretence of a rheumatic pathology except on the slender foundation of a suspicion that the affection was immediately excited by the influence of cold, which is really no argument at all. Such patients will be found to have exhibited, not special rheumatic, but special neuralgic tendencies in their past history. On the other hand, there undoubtedly are a certain number of patients who, having previously given signs of a tendency to generalized rheumatic inflammation of fibrous membranes, are, on some particular occasion, attacked with similar inflammation extending over a more or less considerable tract (not a small limited spot) of a nerve sheath. But so far from agreeing with those who think that this is a frequent case, my experience teaches me that it is quite exceptional; nor do I believe that the common opinion could ever have arisen had it not been for the rage that exists for connecting every disease with a special diathesis which the profession flatters itself that it understands. Few persons have taken more pains than myself to ascertain the frequency with which neuralgic patients show a history of previous rheumatism, whether in the so-called "fibrous," or in the synovial form; but it is remarkable how seldom I have found this to be the case--a result which surprised me, because it happened that I, a neuralgic subject, had suffered in youth from regular acute rheumatism, and had fancied that I should discover a close connection between rheumatism and neuralgia. Eulenburg states that neuralgia caused by cold more frequently attacks the sciatic nerve than any other, and thinks that the tendency to sciatica is characteristic of the relations of rheumatism to sensory nerves. For my own part, I see no reason to call in the rheumatic diathesis as a _deus ex machina_ to explain the frequency with which sciatica follows comparatively trifling peripheral impressions like that of cold. The true reason I believe to be, that what would have been a slight and trivial neuralgia elsewhere, becomes a serious affection in the instance of the sciatic nerve, by reason of the strong muscular pressure end dragging which are always going on in the thigh in locomotion. I shall return to this subject when speaking of Treatment.

As regards the relations, of gout to neuralgia, I can hardly express my own view better than by quoting the words of Eulenburg:[17] "Much more doubtful is the influence of gout, which in rare cases, perhaps, produces neuralgia directly, by means of neuritis, or by the deposit of tophus-like calcareous concretions in the nerve-trunks. Gout has been reckoned as a great influence among the causes of superficial neuralgias (sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but this influence is more probably only an indirect one, operating through circulation changes which are often produced by chronic liver-diseases or by diseases of the heart and vessels, (_e. g._ Valvular diseases and narrowing of the coronary arteries in angina)." To which I will add this argument against any close connection of gout with neuralgia, that it is exceedingly seldom that colchic.u.m effects any decided good, a fact which is as unlike the relations of colchic.u.m to true gout as any thing could be. For, whatever may be thought of the advantages or disadvantages, on the whole, of employing colchic.u.m against gout, at least no one with any experience will deny that in the immense majority of cases of true gouty pain, it gives rapid relief to the acute suffering. I doubt if it ever[18] acts in that way in real neuralgia, though I have occasionally seen it apparently useful in a more limited way, as will be said hereafter.

As regards the relation of the syphilitic dyscrasia to neuralgia, I agree in general with Eulenburg. "Syphilis," he says, "may be the direct cause of neuralgia, either by the development of specific gummata in the nerve-trunks or in the centres, or by arousing chronic irritative processes in the nerve sheaths, the membranes of the brain and spinal cord, or, especially, in the bones and periosteum (syphilitic osteitis and periost.i.tis)." The case of periost.i.tis, however, is a doubtful one: it may be questioned whether this affection (which will be among the diseases discussed in Part II. of this work) ever give rise to true neuralgia. Persons who are, by inheritance, highly predisposed to neuralgia, may from the mere general lowering of their health produced by const.i.tutional syphilis, become truly neuralgic simultaneously with, or subsequently to, the appearance of painful nodes on their bones. And as regards the whole relations of syphilis to neuralgia, I must, from my experience, conclude that the former is, after all, but rarely concerned in the production of the latter. Syphilis has a strong specialty for producing limited motor paralyses, but a much weaker one for producing limited affections of the sensory system.

7. We now come to the discussion of a group of momenta whose influence in the production of neuralgia is at once very powerful, and of the highest significance as regards the general pathology of the disease.

These are the degenerative changes of the arterial and capillary systems which are a part of the normal phenomena of old age, but may occur at earlier periods of life, in consequence either of certain const.i.tutional diseases, especially gout, or of special toxic influences on nutrition, of which persistent alcoholic excess is very far the most important.