Neuralgia and the Diseases That Resemble It. Francis Edmund Anstie
permanent good, and he passed out of my sight, being at that time in a condition of wretched feebleness, and with symptoms of threatened dementia. Of the female subjects, one was a married woman, who accused her husband of impotence, and from her account it would certainly appear that effective connection had never taken place; the hymen was completely destroyed, however. The neuralgic pains recurred nightly in several paroxysms, and were especially severe about the time of the monthly periods. In this case the patient was, she stated, induced to give up her malpractices; at any rate, the pain subsided in a manner which could not be well accounted for by any direct influence of the medicinal treatment. The other female patient was a widow in whom the morbid habit was suspected from her general appearance, and from the existence of enlarged clitoris and other signs of irritation about the external parts: she became rather rapidly phthisical, and suffered severely from neuralgic headaches.
Neuralgia of the bladder has been specially described by various writers; the pain is usually spoken of as seated at the neck of the bladder, and as accompanied by frequent desire to micturate. I have seen two cases, both in women: the first was eventually discovered to be an instance of malignant disease of the fundus of the bladder; the other was apparently the result of a long-continued menorrhœal flux, which had greatly impaired the health, and produced extreme anæmia. In neither of these instances was the pain referred to the external meatus, as in the female patients above mentioned who were suffering from urethral neuralgia. I have never seen the extreme examples of vesical neuralgia described by some writers, in which actual paralysis of the coats of the bladder was secondarily produced; but the reflex influence of the neuralgic affection in both the examples just mentioned appeared to produce great weakening of the muscular power of the rectum, occasioning most obstinate and troublesome constipation.
It would appear, from recorded cases, that both the bladder and the uterus are liable to be affected with neuralgia from malarious influences; but I have never chanced to see any such cases.
Neuralgia of the kidney is spoken of by several writers, and I suppose there is no doubt that it may exist as a special neurotic disease with obvious organic cause. For my own part, I cannot say that I have ever seen it except in instances where there was either the certainty, or a very strong suspicion, that the cause was the mechanical pressure and irritation of a calculus within the kidney. The diagnosis of the simple functional disorder must be excessively perplexing; for in the first place there is the greatest difficulty in making sure that the pain is not external, and seated either in the muscles of the back, or in the superficial dorsal or lumbar nerves, and certainly I am strongly inclined to suspect that this has been really the case in many examples of so-called renal neuralgia. That neuralgia of the kidney may arise secondarily, as a reflex extension of pelvic neuralgia, does, however, appear probable enough; for it is almost certain that in the latter affection at least, the vaso-motor nerves of the kidneys must be strongly influenced in a reflex manner; since the crisis or acme of a paroxysm of pelvic pain is not unfrequently attended with a copious secretion of pale urine.
Neuralgia of the rectum has been carefully described by Mr. Ashton, but is probably not often seen except by practitioners who possess special opportunities of observing rectal diseases. In the one pure case which has fallen under my notice the patient complained of acute paroxysmal cutting pains extending about one inch within the anus, and, as these were greatly increased by defecation I suspected the existence of fissure. Nothing of the kind, however, was found on examination; and the pain ultimately yielded to repeated subcutaneous injections of atropine. This patient had got wet through, and had sat in his damp clothes, getting thoroughly chilled; the pain came on with great suddenness and severity, and the tenderness which has been mentioned was developed very quickly. Probably the influence of cold and wet is among the commonest causes of the complaint. Mr. Ashton also reckons as causes, reflex irritation from other parts of the alimentary canal, and the influence of malaria. He observes that the subjects of the affection are most frequently anæmic, and of a generally excitable and deranged susceptibility, and that females, who, from menorrhagia, or frequent child-bearing with much hæmorrhage, have lost a great deal of blood, are specially predisposed.
Neuralgia of the testis (as an independent affection and not a mere extension of lumbo-abdominal neuralgia) is fortunately a much less common malady than the corresponding affection of the ovary; as might indeed be expected, from the much less degree of functional perturbation to which, in ordinary physiological circumstances, the former organ is exposed than the latter. Except from actual growths within the testis, of which it was a mere symptom, I have never seen neuralgia of the testis save from one of three causes. In one remarkable example it was produced as a reflex effect of severe herpes preputialis. Secondly, it is sometimes observed as a symptom of calculus descending the ureter. And, thirdly, I have seen it several times undoubtedly produced by excessive self abuse.
The occurrence of testicular neuralgia, in one case of epilepsy, as to the cause of which I had been previously much puzzled, led to the discovery of the real origin of the fits. I should observe here that I do not believe that self-abuse is ever more than an immediately exciting cause of epilepsy, a predisposition to the disease having previously existed in all cases. In the patient just referred to, there was a family history of epilepsy, but it was difficult to explain the exciting cause until this was suggested by the occurrence of neuralgic pain in the testicle. The patient relinquished his habit, and both the pain and the epilepsy ceased, and, for some twelve months during which I had him under observation, had not recurred at all. A medical friend has informed me of an instance in which the same habit had produced a neuralgia of the testis so severe as to strongly tempt the patient to castrate himself, and he would probably have done so but that he was too much of a coward with regard to physical pain. The attacks of pain were so severe as frequently to produce vomiting and the greatest prostration.
Hepatic Neuralgia.—It must be allowed that the evidence even for the existence of neuralgia of the liver is at present in an unsatisfactory state. At the same time, there are carefully-recorded cases, by Trousseau and other[7] writers of unquestionable authority, which leave no doubt in my mind, corroborated as they are by a certain amount of experience of my own, that such a form of neuralgia really exists. I must, of course, be understood to refer to something altogether different from the spasmodic pain which is produced by the difficult passage of a gall-stone toward the bowel. I have now seen several cases in which, as it appeared to me, there was sufficient evidence of neuralgic pain seated in the liver itself, and not dependent either on gall-stone or any so-called organic diseases of the viscus.
The subjects of hepatalgia are probably never troubled only by pain in the liver; they are persons of a nervous temperament, in whom a slight shock to, or fatigue of, the nervous system, habitually provokes neuralgic attacks; the pain localizing itself sometimes in the branches of the trigeminal, sometimes in those of the sciatic, sometimes in the intercostal nerves, etc. In one instance which has been under my observation, the attacks of hepatalgia alternated with cardiac neuralgia assuming the type of a rather severe angina pectoris. In another case the patient, a man aged sixty-seven, was very liable to attacks of intermittent abdominal agony, in which one could hardly doubt that the pain was located in the colon, and was attended with paralytic distention of the bowel; the peculiar feature of the case being the sudden way in which the symptoms would appear and depart, independently of any recognizable provocation or the use of any remedies. On two separate occasions this patient was attacked with pain of a precisely similar kind, but limited to the right hypochondrium, attended with great depression of spirits, and followed by a well-pronounced jaundice. So remarkable was the conjunction of symptoms in these two attacks that a strong suspicion of biliary calculus was raised, but not the slightest confirmation of this idea could be obtained; and indeed one symptom—vomiting—which nearly always attends the painful passage of a biliary calculus, was altogether absent.
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