Neuralgia and the Diseases That Resemble It. Francis Edmund Anstie
without the slightest success and especially there was a large amount of speculative medication, on the theory of the probably "rheumatic" or "gouty" nature of the affection. Nothing was doing the least good to the pain, and meantime the old lady's digestion and general health and spirits were suffering very severely. Blistering was now suggested, and the affection yielded at once. The relief afforded must have been very complete, to judge by the warm gratitude which the patient expressed. The subsequent history of this patient illustrates several points which will engage our attention under the section of Pathology. It may be just mentioned here, that she suffered, twelve months later, from a hemiplegic attack of paralysis.
The tendency of cervico-occipital neuralgias is to spread toward the lower portions of the face, as observed by Valleix; in this case they become, sometimes, undistinguishable from neuralgias of the third division of the trigeminus. In the early stages of the disease, if the physician had been lucky enough to witness them, the true place of the origin of the pain would have been easily recognizable; at a later date it sometimes needs great care, and a very strict interrogation of the patient, to discover the true history of the disease. Sometimes, even, a cervico-occipital neuralgia which spreads in this way causes great irritation and swelling of the submaxillary and cervical glands; and I have known a case of this kind mistaken for commencing glandular abscess. The pain and tension were so great in this case, and the constitutional disturbance was so considerable, that the presence of deep-seated pus was strongly suspected, and the propriety of an incision (which would have been a hazardous proceeding) was seriously canvassed.
Experience is too limited, to judge by what I have personally seen, and the recorded cases with which I am acquainted, to enable us to say anything with confidence of the conditions, as to age and general nutrition of the body, which specially favor the occurrence of cervico-occipital neuralgia. Apparently, however, there is much reason for thinking that the immediately exciting cause of it is most frequently external cold. I have known it produced several times in the same person, by sitting in a draught which blew strongly on the back of the neck. And I am inclined to think that it is seldom the first form of neuralgia which attacks a patient, but usually occurs in those who have previously suffered from neuralgic pains either of the trigeminus or of some other superficial nerve. I have known it once to occur in a person, thus predisposed to neuralgic affections, in consequence of reflex irritation from a carious tooth, as was proved by its cessation on the extraction of the latter, although there was no facial pain.
(c) Cervico-brachial Neuralgia.—This group includes all the neuralgias which occur in nerves originating from the brachial plexus, or from the posterior branches of the four lower cervical nerves. The most important characteristic of the neuralgias of the upper extremity is the frequency, indeed almost constancy, with which they invade, simultaneously or successively, several of the nerves which are derived from the lower cervical pairs. The neuralgic affections of the small posterior branches (distributed to the skin of the lower and back part of the neck) are comparatively of small importance. But the "solidarite," which Valleix so well remarked, between the various branches of the brachial plexus, causes the neuralgias of the shoulder, arm, forearm, and hand to be extremely troublesome and severe, owing to the numerous foci of pain which usually exist. Perhaps Valleix's description of these foci is somewhat over-fanciful and minute; but the following among them which he mentions I have repeatedly identified; (1) An axillary point, corresponding to the brachial plexus itself; (2) a scapular point, corresponding to the angle of the scapula. (It is difficult to identify the peccant nerve here; the one to which it apparently corresponds, and to which Valleix refers it, is the subscapular; but we are accustomed to think of this as a motor nerve. Still, it is certain that pressure on a painful point existing here will often cause acute pain in the nerves of the arm and forearm.); (3) A shoulder point, which corresponds to the emergence, through the deltoid muscle, of the cutaneous filets of the circumflex; (4) a median-cephalic point, at the bend of the elbow, where a branch of the musculo-cutaneous nerve lies immediately behind the median-cephalic vein; (5) an external humeral point, about three inches above the elbow, on the outer side, corresponding to the emergence of the cutaneous branches which the musculo-spiral nerve gives off as it lies in the groove of the humerus; (6) a superior ulnar point, corresponding to the course of the ulnar nerve between the olecranon and the epitrochlea; (7) an inferior ulnar point, where the ulnar nerve passes in front of the annular ligament of the wrist; (8) a radial point, marking the place where the radial nerve becomes superficial, at the lower and external aspect of the forearm. Besides these foci, there are sometimes, but more rarely, painful points developed by the side of the lower cervical vertebræ, corresponding to the posterior branches of the lower cervical pairs.
The most common seat of cervico-brachial neuralgia has been, in my experience, the ulnar nerve, the superior and inferior points above mentioned being the foci of greatest intensity; an axillary point has also been developed in one or two cases which I have seen. Rarely, however, does the neuralgia remain limited to the ulnar nerve; in the majority of cases it soon spreads to other nerves which emanate from the brachial plexus. A very common seat of neuralgia is also the shoulder, the affected nerves being the cutaneous branches of the circumflex. I am inclined to think, also, that affections of the musculo-spiral, and of the radial near the wrist, are rather common, and have found them very obstinate and difficult to deal with. One case has recently been under my care in which the foci of greatest intensity of the pain were an external humeral and a radial point; but besides these there was an exquisitely painful scapular point. In another case the pain commenced in an external humeral and a radial point, but subsequently the shoulder branches of the circumflex became involved. A most plentiful crop of herpes was an intercurrent phenomenon in this case, or rather, was plainly dependent on the same cause which produced the neuralgia.
Median cephalic neuralgia is an affection which used to be comparatively common in the days when phlebotomy was in fashion, the nerves being occasionally wounded in the operation. I have only seen it in connection with this cause, that is to say, as an independent affection. One such case has been under my care. But a slight degree of it is not uncommon, as a secondary symptom, in neuralgia affecting other nerves. The traumatic form is excessively obstinate and intractable.
In the neuralgias of the arm we begin to recognize the etiological characteristic which distinguishes most of the neuralgic affections of the limbs, namely, the frequency with which they are aggravated, and especially with which they are kept up and revived when apparently dying out, the muscular movements. In the case above referred to, of neuralgia of the subscapular, musculo-spiral (cutaneous branches), and radial, the act of playing on the piano for half an hour immediately revived the pains, in their fullest force, when convalescence had apparently been almost established.
There is a special cause of cervico-brachial neuralgias which is of more importance than, till quite lately, has ever been recognized, namely, reflex irritation from diseased teeth. The subject of these reflex affections from carious teeth has been specially brought forward by Mr. James Salter, in a very able and interesting paper in the "Guy's Hospital Reports" for 1867; and Mr. Salter informs me that he has been surprised by the number of cases of reflex affections, both paralytic and neuralgic, of the cervico-brachial nerves, produced by this kind of irritation, and that he agrees with me in thinking that a peculiar organization or disposition of the spinal centres of these nerves must be assumed in order to account for the fact.
The liability of particular nerves in the upper extremity to neuralgia from external injuries requires a few words. The nerve which is probably most exposed to this is the ulnar. Blows on what is vulgarly called the funny-bone are not uncommon exciting causes of neuralgia in predisposed persons, and cutting wounds of the ulnar a little above the wrist are rather frequent causes. The deltoid branches of the circumflex and the humeral cutaneous branches of the musculo-spiral are much exposed to bruises and to cutting wounds. So far as I know, it is only when a nerve trunk of some size has been wounded that neuralgia is a probable result. Wounds of the small nervous branches in the fingers, for instance, are very seldom followed by neuralgia. I have no statistics to guide me as to the effect of long-continued irritation applied to one of these small peripheral branches, but it is probable that that might be more capable of inducing neuralgia. As far as my own experience goes, however, it would appear that a more common result is convulsion of some kind, from reflex irritation of the cord.
(d) Dorso-intercostal