Neuralgia and the Diseases That Resemble It. Francis Edmund Anstie
for a delicate girl, on complaint of some stitch of neuralgia or muscular pain in the side, to be immediately bled to a large extent, with the idea of checking an imaginary commencing pleurisy. The treatment, so far from curing the pain and the dyspepsia (which it produced), often aggravated them; whereupon the signs of inflammation were thought to be still more manifest, and more blood was taken. Under such circumstances the most complete anæmia was developed, and very often the patient became a martyr to clavus in its severest forms. One does not now very frequently meet with the victims of such mistaken practice; but I have seen one [since writing this I have seen another case (vide cardiac neuralgia, infra)] very severe case of clavus produced by loss of blood (in a subject who was doubtless predisposed to neuralgic affections, to judge from his family history). The case was that of a boy who accidentally divided his radial.
The middle period of life is not, according to my experience, fruitful in first attacks of trigeminal neuralgia. But, when the neuralgic tendency has once declared itself, there are many circumstances of middle adult life which tend to recall it. Over-exertion of the mind is one of the most frequent causes, especially when this is accompanied by anxiety and worry; indeed, the latter has a worse influence than the former. In women, the exhaustion of hæmorrhageal parturition, or of menorrhagia, and also the depression produced by over-suckling, are frequent causes of the recurrence of a migraine or clavus to which the patient had been subject when young. The middle period of life is very obnoxious to severe mental shocks, which are more injurious than in youth, because of the diminished elasticity of mind which now exists; and the same may be said of the influence of severe bodily accident of a kind to inflict damage on the central nervous system. Special mention ought to be made, in the case of women, of the disturbing influence of the series of changes which close the middle portion of their life, viz., the involution of the sexual organs. It would seem as if every evil impression which has ever been made on the nervous system hastens to revive, with all its disastrous effects, at this crisis. Latent tendencies to facial neuralgia are particularly apt to reassert their existence, and they are usually accompanied and aggravated by a tendency to vaso-motor disturbance, which not unfrequently seems to be the most distressing part of the malady. I have several times been consulted by women undergoing the "change," whose chief complaint was of disagreeable flushings and chills, especially of the face; and, on inquiring further, one has found that they were suffering from severe facial neuralgia, which, however, alarmed and distressed them less than did the vaso-motor disturbance, and the giddiness, etc., which were an evident consequence of it.
It is, however, the final or degenerative period of life which produces the most formidable varieties of facial neuralgia. Neuralgia of the fifth, which have previously attacked an individual, may recur at this time of life without any special character, except a certain increase of severity and obstinacy. But trigeminal neuralgias, which now appear for the first time, are usually intensely severe, and nearly or quite incurable. These cases correspond with the affection named by Trousseau tic epileptiforme, and it is of them, doubtless, that Romberg is speaking, when he says that the true neuralgias of the fifth rarely occur before the fortieth year of life. These neuralgias are distinguished by the intense severity of the pain, the lightning-like suddenness of its onset, and the almost total impossibility of effecting more than a temporary palliation of the symptoms. But they are also distinguished by another circumstance which too often escapes attention, namely, they are almost invariably connected with a strong family taint of insanity, and very often with strong melancholy and suicidal tendencies in the patient himself, which do not depend on, and are not commensurate with, the severity of the pain which he suffers. It may seem a strong view to take, but I must say that I regard a well-developed and typical neuralgia, of the type we are now speaking of, as an affection in which the mental centres are almost as deeply involved as in the fifth nerve itself; though, whether this is an original part of the disease, or a mere reflex effect of the affection of the trigeminal nerve, I am not prepared to say. Other reflex affections are common enough in this kind of facial neuralgia, and especially spasmodic contractions of the facial muscles, which, indeed, often form one of the most striking features of the malady, the attacks of pain being accompanied by hideous involuntary grimaces. Even in the earlier stages of the disease there is usually some degree of the same thing, as, for instance, spasmodic winking. In the great majority of cases, after a little time, exquisitely tender points are formed in the chief foci of pain; in the intervals between the spasms the least pressure on these points is sufficient to cause agony, and a mere breath of wind impinging on them will often reproduce the spasm. Yet, in the height of the acute paroxysm itself, the patient will often frantically rub these very parts in the vain attempt to produce ease; and it has often been noticed that such friction has completely rubbed off the hair or whisker on the affected side: this happens the more easily, because the neuralgic affection itself impairs the nutrition of the hair and makes it more brittle, as we shall have occasion to show more fully hereafter. The general appearance of a confirmed neuralgic of the type now described is very distressing, and the history of his case fully corresponds to it. He is moody and depressed, he dreads the least movement, and the least current of air; he hardly dares masticate food at all, more especially if the inferior maxillary division of the nerve be implicated (as is generally the case sooner or later), for this movement re-excites the pain with great violence. Nutrition is very commonly kept up by slops, and is thus very insufficiently maintained: this failure of nutrition is itself a decidedly powerful influence in aggravating the disease. And there is a still further calamity which is not unlikely to occur. The patient may fly to the stupefaction of drink as a relief to his sufferings, and, if he has once experienced the temporary comfort of drunken anæsthesia, is excessively likely to repeat the experiment. But this is another and one of the most fatally certain methods of hastening degeneration of nerve-centres, and the ultimate effect, therefore, is disastrous in every way.
Although the neuralgias of the degenerative period are thus fatally progressive, on the whole, there are some curious occasional anomalies. Many cases are recorded, and I have myself seen such, in which the attacks of pain, after reaching a very considerable degree of intensity, have ceased for many months, whether under the influence of remedies or not it is difficult to say with certainty, but probably far more from independent causes. Whatever may be the reason of these sudden arrests, however, certain it is that they are very seldom permanent, the pain returning sooner or later, like an inexorable fate.
(b) Cervico-occipital Neuralgia.—As Valleix has remarked, there are several nerves (in fact, the posterior branches of all the first four spinal pairs) which are more or less frequently the seat of this affection. But among them all there is none comparable to the great occipital, which arises from the second spinal pair, for the frequency and importance of its neuralgic affections. This nerve sends branches to the whole occipital and the posterior parietal region. On the other hand, the second and third spinal nerves help to make up the superficial cervical branch of the cervical plexus which is distributed to the triangle between the jaw, the median line of the neck, and the edge of the sterno-mastoid, and those to the lower part of the cheek. Then there is the auricular branch, which starts from the same two pairs, and supplies the face, the parotid region, and the back of the external ear. Then the small occipital, distributed to the ear and to the occiput. And, finally, superficial descending branches of the plexus. These, altogether, are the nerves which at various points, where they become more superficial, form the foci of cervico-occipital neuralgia.
The most typical example of this form of neuralgia which has fallen under my notice occurred (after exposure to cold wind) in a lady about sixty years of age, who had all her life been subject to neuralgic headache approaching the type of migraine, and who came of a family in which insanity, apoplexy, and other grave neuroses, had been frequent. The pain centred very decidedly in a focus corresponding to the occipital triangle of the neck; it recurred at irregular intervals, and in very severe paroxysms, lasting about a minute. It was interesting to follow the history of this case in one respect. It afforded a clear illustration of the manner in which local tenderness is developed; for during the first three or four days the patient, so far from complaining that the painful part was tender on pressure, experienced decided relief from pressure, although she experienced none from mere rest, however carefully the neck might be supported. But in the course of a few days an intensely painful spot developed itself in the occipital triangle, and the back of the ear became excessively tender. All manner of remedies had been tried in this