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                 NEURALGIA
                    AND
       THE DISEASES THAT RESEMBLE IT.

                    BY

      FRANCIS E. ANSTIE, M.D., LONDON,

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; HONORARY FELLOW OF KING'S
COLLEGE, LONDON; SENIOR ASSISTANT PHYSICIAN TO WESTMINSTER HOSPITAL;
LECTURER ON MEDICINE IN WESTMINSTER HOSPITAL SCHOOL; PHYSICIAN TO THE
BELGRAVE HOSPITAL FOR CHILDREN.

              [Illustration]

                NEW YORK:
      BERMINGHAM & CO., UNION SQUARE.
                  1882.

           W. L. MERSHON & CO.,
   _Printers, Electrotypers and Binders_,
              RAHWAY, N. J.




PREFACE.


I believe it will not be disputed that there was considerable need for
an English treatise dealing rather fully with the subject of Neuralgia,
and therefore I hope that the profession will be willing to give me a
hearing. The present work, moreover, does not profess to be a mere
compilation of standard authorities corrected down to the present time,
but puts forward a substantially new view of the subject--at least, a
view that has been only briefly sketched by me in an article that
appeared, three years ago, in Reynolds's "System of Medicine." My
principal object, in writing this volume, was to vindicate for Neuralgia
that distinct and independent position which I have long been convinced
it really holds, and to prove that it is not a mere offshoot of the
Gouty or Rheumatic diatheses, still less a mere chance symptom of a
score of different and incongruous diseases. In order to set the
diagnosis of true Neuralgia from its counterfeits in the clearest light,
it seemed advisable to draw separate pictures of each of the latter (at
least of as many as are of real importance) and present them separately,
as a kind of gallery of spurious neuralgias, and this I have done in the
second part of the volume. No one who had not tried to do it would
imagine how difficult this latter kind of work is. It was necessary for
the sketches to be very brief (unless my book was to become unmanageably
large), and yet to be as truthfully characteristic as possible; and it
was necessary also that only those diseases which so much resemble
Neuralgia as practically to lead medical men astray in diagnosis, should
be dealt with. The selection of the subjects, and the execution of this
part, took a long time, though it only covers about fifty pages. Then,
as regards Neuralgia itself, it became necessary to completely recast
the chapters on "Pathology" and on "Complications," on account of some
of the polite criticisms which Dr. Eulenburg directed (in his recent
"Lehrbuch der Nervenkrankheiten") to my argument in the article above
referred to, since it was obvious that a too brief statement of my views
had caused them to be partially misunderstood by the German physician.
These chapters (Part I., Chapters II. and III.) are certainly the most
important portion of my book, and I would particularly direct attention
to them, in order that their contents may be affirmed or corrected: the
reader will at any time find that they contain a kind of investigation
never before systematically carried out with regard to Neuralgia. The
causes above mentioned, together with others over which I had no
control, have kept back the appearance of this work so long beyond the
date for which it was originally announced, that I feel I ought to
apologize for an amount of delay that would seem hardly justified by the
moderate size of the volume.

16 WIMPOLE STREET, LONDON, _October_ 1, 1871.




CONTENTS.


    INTRODUCTION--ON PAIN IN GENERAL                7


                 PART I.

             _ON NEURALGIA._

    CHAP.                                        PAGE

       I.--CLINICAL HISTORY                        12

      II.--COMPLICATIONS OF NEURALGIA              79

     III.--PATHOLOGY AND ETIOLOGY OF NEURALGIA     96

      IV.--DIAGNOSIS AND PROGNOSIS OF NEURALGIA   142

       V.--TREATMENT OF NEURALGIA                 149


                 PART II.

     _DISEASES THAT RESEMBLE NEURALGIA._

    CHAP.

       I.--MYALGIA                                196

      II.--SPINAL IRRITATION                      200

     III.--THE PAINS OF HYPOCHONDRIASIS           207

      IV.--THE PAINS OF LOCOMOTOR ATAXY           210

       V.--THE PAINS OF CEREBRAL ABSCESS          213

      VI.--THE PAINS OF ALCOHOLISM                215

     VII.--THE PAINS OF SYPHILIS                  218

    VIII.--THE PAINS OF SUBACUTE AND CHRONIC
              RHEUMATISM                          225

      IX.--THE PAINS OF LATENT GOUT               227

       X.--COLIC, AND OTHER PAINS OF PERIPHERAL
              IRRITATION                          229

      XI.--DYSPEPTIC HEADACHE                     231




INTRODUCTION.

ON PAIN IN GENERAL.


Although it is, in a general way, unadvisable to introduce abstract
discussions into a treatise which should be strictly practical, it is
almost impossible to avoid some few general reflections on the
physiological import of Pain, as a preliminary to the discussion of the
maladies which form the subject of this volume. This whole group of
disorders is linked together by the fact that pain is their most
prominent feature; and, with regard to most of them, the relief of the
pain is the one thing required of the physician. It seems, therefore,
very important that we should ascertain, at least approximately, in what
the immediate state consists, which consciousness interprets as pain. It
is not necessary to enter at this stage into any inquiry as to the
pathological causes of the phenomenon; what we know of these, and it is
unfortunately too little, will be discussed in detail under the headings
of the several affections which I shall have to describe.

The question before us now is this: What is that functional state of the
nerves which consciousness interprets as pain? Is it, or is it not, an
exaltation of the ordinary function of sensation?

The latter question is generally answered affirmatively, without much
thought, by those to whom it casually occurs; but indeed there is plenty
of prescriptive authority for so dealing with it. Pain has been
described by some of the most distinguished writers on nervous diseases
as a hyperaesthesia. Yet there is really little difficulty in convincing
ourselves, if we institute a thorough inquiry into the matter, that pain
is certainly not a hyperaesthesia, or excess of ordinary sensory
function, but something which, if not the exact opposite of this, is
very nearly so.

The leading fallacy in the common view is the confusion which is
perpetually being made between function and action. Now, the function of
individual nerves is very nearly a constant quantity, at least, it
varies only within narrow limits; while the action of the same nerves
may be almost any thing. The function of the nerve is that kind of work
for which it is fit when its molecular structure is healthy; it is the
series of dynamic reactions which are necessarily produced in
nerve-tissue by the external influences which surround and impinge upon
it in the conditions of ordinary existence. The action of nerves, under
the pressure of extraordinary influences, may include all manner of
vagaries which really have nothing in common with the effects of
ordinary functional stimulation; which are, in fact, nothing but
perturbation. No one can suppose, for instance, that the explosive
disturbances of nerve-force which give rise to the convulsions of
tetanus are any mere exaggerated degree of the orderly and symmetrical
action by which the healthy nerve responds to the stimulus of volition
ordering a given set of muscles to contract; they are something quite
different in kind. And so it is with the sensory nerves. The functions
of these conductors, in health, is to convey to the perceptive centres
the sensations, varying only within a most limited range, which
correspond to a state of well-being of the organs, and which excite only
those reflex actions that are necessary to life. Thus the large surface
of sensitive nerve terminals which is represented by the collective
peripheral branches of the fifth cranial conveys to the medulla
oblongata an impression, derived from the temperature and movement of
the surrounding air, when the latter is neither too hot nor too cold,
which imparts to the brain a perception of comfortable sensations, and
excites in return the reflex action of breathing, which is necessary to
life. But the impression produced on this same peripheral expanse of
nerve-branches by prolonged exposure to cold wind may, and often does,
convey to the centres sensations which are quite different and provokes
reflex movements which are altogether abnormal. Pain is the product in
one direction; sneezing, perhaps, in the other. It seems absurd to say
that sneezing is any part of the function of those motor nerves whose
action regulates the performance of expiration. And it appears to me not
less absurd to say that pain is the function of the sensitive fibres of
the trigeminus. But the best way, perhaps, to illustrate the looseness
and incorrectness of applying the term "hyperaesthesia" (implying exalted
function) to the state of sensitive nerves when suffering pain, is to
examine the condition of distinctive perception in the very same parts
to which the painful nerves are distributed. It will invariably be
found, as we shall have occasion to see more fully proved hereafter,
that, in parts which are acutely painful, a marked bluntness of the
tactile perceptions can be detected. The tactile perceptions are, no
doubt, conveyed by an independent set of fibres from those which convey
the sense of pain.[1] Yet it is surely impossible to believe the effect
of the same influence, in functional power can be different--much more
than it can be exactly opposite--in the two cases.

If pain be not a heightening of ordinary sensation, then we seem to be
shut up to the idea that it is a perversion owing to a molecular change
of some part of the machinery of sensation which frustrates function.
For it is to be observed that, while the sensations conveyed by the
healthy nerve are correct in the indications which they afford to the
percipient brain, the indications given by pain are vague and
untrustworthy, and often seriously misleading. Not to speak of the
nerves of special sense, or of the fibres which convey the sensations of
muscular movement, even the nerves of common sensation do carry to the
internal perception, in health, a distinct impression of the well-being
of the organs to which they are distributed. Mr. Bain[2] has well
pointed out the positive character of this feeling, which is so often
incorrectly referred to as if it were a mere negation of feeling. It is
a sensation of equable and diffused comfort, if I may be allowed to use
the expression, which streams in from all parts of the organism; and
there is no possibility of comparing it, in any scale of less or more,
with the sensation of pain; for the latter commonly conveys no correct
information as to the organ from which it proceeds, or appears to
proceed. Especially is this the case in the neuralgias, for more
commonly than not the apparent seat of the pain is widely removed from
the actual seat of the mischief which causes it.

If we inquire a little further into the circumstances under which
various kinds of pain occur, we gain some fresh suggestions. Among the
neuralgias, those are the most acutely agonizing which occur under
circumstances of impaired nutrition incident to the period of bodily
decay, and strong reasons will be hereafter adduced for the belief that
there is especial impairment of the nutrition of the central end of the
painful nerves. To find a parallel to the severity of this kind of pains
we must turn to the case of organic tumors, which, from their position,
structure, and mode of growth, necessarily exercise continuous and
severe pressure on the branches or the trunk of a nerve; or to the class
of pains which attend severe cramp, or tonic contraction of muscles.
Now, it can scarcely be doubted that in the latter instance there is an
abnormally rapid and violent destruction of tissue going on; at the very
least there is an extraordinarily violent and irregular manifestation of
motor force. In any case the patent fact here is dynamic perturbation
of a severe kind; and, in the instance of organic tumors exercising
steady and continuously increasing pressure on nerves, one can scarcely
doubt that a similar perturbation, less intense but more enduring, is
necessarily set up. That which can be done in the way of producing
severe pain by these severe affections of the peripheral portions of
nerves, or of tissues lying outside them, we might _a priori_ expect
would be effected by slighter but continuous changes in the nutrition of
the more important portion of the nerve itself--its central gray
nucleus. One would say that a pathological process which continuously
and progressively lowered the standard of nutrition here must interfere
from hour to hour, certainly from day to day, with that regular and
equable distribution of force which is the essence of unimpeded
function.

Take, again, the case of the very severe pain which frequently attends
inflammation of the pleura and of the peritoneum. Whatever theory of the
causation of these pains we may adopt, it is certain that one most
important element in their production and maintenance is the continual
movement and friction of the affected parts. But there is little doubt
that the moving muscles are involved in the inflammatory process, as Dr.
Inman has correctly observed. It would seem plain that under these
circumstances--an inflamed muscular structure forced to perform its
ordinary contractions as well as it can--there must be powerful dynamic
perturbation going on.

If perturbation of nerve-function--a disturbance quite different from
mere exaltation of the normal development of nerve-force--be the essence
of pain, how comes it that pains of the severest type may be produced by
changes in structures which are usually described, for practical
purposes, as lying outside the nervous system? We must, in the first
place, remark that the externality of any bodily tissue to the nervous
system is more apparent than real. Microscopic researches are constantly
revealing nerve-fibres, in ever-increasing profusion, which penetrate to
parts seemingly the least vitalized in the organism. But, in any case,
the nerves are certainly the ultimate channel of communication between
the suffering part and the sentient centre. It seems, therefore, the
inevitable conclusion that a dynamic perturbation going on in the
non-nervous tissue is continued along the nerves themselves: and that
the severity of the pain perceived by the conscious centres is
proportionate to the tumultuousness, the want of coordination, and the
waste with which force is being evolved in the cramped muscle, or
whatever structure it may be, in which the pain takes its source.

Not to pursue these topics further, we may sum up the considerations
which have now been adduced, in the following general propositions,
which will tend to simplify the examination of the various painful
disorders which we are about to discuss:

1. Pain is not a true hyperaesthesia; on the contrary, it involves a
lowering of true function.

2. Pain is due to a perturbation of nerve-force, originating in dynamic
disturbance either within or without the nervous system.

3. The susceptibility to this perturbation is great in proportion to the
physical imperfection of the nervous tissue, until this imperfection
reaches to the extent of cutting off nervous communications
(paralysis).

FOOTNOTES:

[1] See, on this subject, some remarks, in my work on "Stimulants and
Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception
and Common Sensation."

A very distinct and careful statement of the distinction between pain
and hyperaesthesia will be found in a prize essay "On Neuralgia" by M. C.
Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.

[2] "Senses and Intellect."




PART I.

ON NEURALGIA.




CHAPTER I.

CLINICAL HISTORY.


Neuralgia may be defined as a disease of the nervous system, manifesting
itself by pains which, in the great majority of cases, are unilateral,
and which appear to follow accurately the course of particular nerves,
and ramify, sometimes into a few, sometimes into all, the terminal
branches of those nerves. These pains are usually sudden in their onset,
and of a darting, stabbing, boring, or burning character; they are at
first unattended with any local change, or any general febrile
excitement. They are always markedly intermittent, at any rate at first;
the intermissions are sometimes regular, and sometimes irregular; the
attacks commonly go on increasing in severity on each successive
occasion. The intermissions are distinguished by complete, or almost
complete, freedom from suffering, and in recent cases the patient
appears to be quite well at these times; except that, for some short
time after the attack, the parts through which the painful nerves ramify
remain sore, and tender to the touch. In old-standing cases, however,
persistent tenderness, and other signs of local mischief, are apt to be
developed in the tissues around the peripheral twigs. Severe neuralgias
are usually complicated with secondary affections of other nerves which
are intimately connected with those that are the original seat of pain;
and in this way congestions of blood vessels, hypersecretion or arrested
secretion from glands, inflammation and ulceration of tissues, etc., are
sometimes brought about.

The above is a general description of neuralgia which will identify the
disease sufficiently for the purpose of introducing it the attention of
the reader. We must now proceed to give a more accurate account of its

_Clinical History and Symptoms._--These vary so greatly in different
kinds of neuralgia that it will be necessary