Neuralgia

=Neuralgia= means simply “nerve pain.” The term neuralgia should be

restricted to such nerve pains as are not caused by structural changes

in the nerves. In cases where the pain is due to organic changes

in the nerves, the disease should not be classed as a neuralgia,

although it is practically impossible to draw an absolute line

between functional and organic disturbances for the one may gradually

progress (pathologically) into the other. In neuralgia there is always

=disturbance= of the =blood supply= to nervous tissue, which may be

of the character of congestive irritation, ischemia or altered states

of the blood wherein it contains toxic substances or is below normal

quality. It is well known that osteopathic lesions are very common

etiological factors.

=Osteopathic Etiology.=—Neuralgia is essentially a disease of adults.

It rarely occurs before puberty or late in life. Women are more prone

to neuralgia than men and the tendency may sometimes be hereditary.

Sufferers from neuralgia often present a peculiar “nervous temperament.”

The exciting causes of neuralgia are impairment of general health;

irritations of the nerve fiber or trunk by a displaced bone, ligament

or muscle, which may affect the nervous tissue directly by mechanical

irritation, or indirectly, by the disturbance of its blood supply,

or toxic agents; exposure to cold or damp; overwork and worry; toxic

influences of various diseases, as malaria, lead poisoning and

alcoholism; irritation from carious teeth, and various septic foci.

=Symptoms.=—Pain, which is spontaneous and paroxysmal, is the most

prominent symptom. It may be described as “darting,” “shooting,”

“burning,” “stabbing,” “boring,” etc. The pain is usually unilateral,

following the course of the sensory nerves, and there are generally

tender points along the course of the nerve. Especially are there

points of tenderness near the central end of the nerve, where the

displaced structures are irritating it. After the pain has continued

for some time the skin becomes tender, reddened and swollen. The

redness and edema are supposed to be due to vasomotor changes. Muscular

spasms, trophic disturbances, skin eruptions, herpes and grayness of

the hair are of rare occurrence. The duration of an attack varies from

a number of minutes to a few hours.

=Neuralgia of the Fifth Nerve.=—This is by far the most frequent

variety of neuralgia, and it is generally due to a displaced =atlas= or

=inferior maxilla=. The teeth sinuses, and other possible regions of

focal infections should be thoroughly investigated. Anemia and products

of metabolism may be underlying factors. All the branches of the fifth

nerve are rarely involved. The =ophthalmic division= is most often

affected; pain and tenderness being present about the supraorbital

notch or foramen, the palpebral branch at the outer part of the eyelid,

the nasal branch, and occasionally an ocular pain will be felt within

the eyeball. When the =infraorbital branch= is involved, pain and

tenderness are principally present at the infraorbital, nasal and malar

points. When the =third division= is affected, the chief tender places

are the inferior dental, temporal and parietal points. In nearly all

cases of neuralgia of the fifth nerve, there is extreme tenderness

in the region of the articulation of the atlas and the occipital,

particularly the side on which the fifth nerve is involved. This

tenderness in a few cases may be found as low as the second or third

cervical vertebra. The pain may be so severe as to cause edema along

the course of the affected nerve fibers, grayness of the eyebrows and

locks of hair chiefly in the temporal region, and convulsive twitching

of muscles.

=Tic Douloureux= is a vastly exaggerated neuralgia of the fifth nerve

and is supposed to be a primary affection of the Gasserian ganglion.

Starting in middle life from no apparent cause it increases in severity

until it becomes unbearable and suicide is not an infrequent result.

Many methods to relieve have been tried including destruction of the

ganglion but with various results.

Treatment should be the same as in the milder form of neuralgia but it

will require critical examination to determine the causes which are

liable to be obscure.

=Cervico-Occipital Neuralgia.=—This variety involves the =posterior

branches= of the =first four cervical= nerves, affecting the region of

the posterior part of the neck and head. The pain may extend as far

forward as the parietal eminence and the ear. The chief tender points

are about midway between the mastoid process and the spine, between

the sternomastoid and trapezius (branches of the cervical plexus), and

a point just above the parietal eminence. This form of neuralgia is

chiefly due to =subluxation= of the =upper four= or =five cervical=

vertebræ irritating the posterior branches of the spinal nerves. A

draught of air or exposure to cold are common exciting causes. The

pain is of a sharp lancinating nature or else it is heavy and tense.

Tuberculosis of the cervical spine may be an underlying cause.

=Cervico-Brachial and Brachial Neuralgia.=—In these forms of neuralgia

the pain is referred to the area supplied by the =four lower cervical=

and the =first dorsal= nerves. The tender points are in the axilla

along the course of the ulnar, the circumflex at the posterior part of

the deltoid and points at the lower and posterior part of the neck.

The =lesions= exciting this form of neuralgia are usually found in the

upper dorsal and upper cervical spines, but they may be as low as the

sixth dorsal or as high as the atlas. As far as neuralgia of the ulnar

nerve alone is concerned, it can be traced to the seventh and eighth

cervical and first dorsal, and the lesion may be found occasionally

at the fifth dorsal vertebra or rib. How a lesion as low as the fifth

dorsal affects the ulnar nerve, it is hard to say definitely. There

may be fibers directly to the ulnar nerve as low as this region, the

nerve may be reflexly affected, the vasomotor supply to the ulnar nerve

may be disturbed, or possibly the lesion interferes with fibers of the

deep layers of the back muscles and thus contraction of muscles for

some distance above the lesion would affect the ulnar and other nerves.

The scaleni may be affected and involve the plexus. A bursitis may be

present (See Painful Shoulders Part I). Focal infections are sometimes

factors.

=Trunk Neuralgia.=—This includes dorso-intercostal and lumbo-abdominal

neuralgia. The former, =dorso-intercostal= neuralgia, affects the

intercostal nerves from the =third= to =ninth dorsal=, and is

characterized by pain along the intercostal spaces, or in a few of

them. The pain may be bilateral and symmetrical, which usually shows

a vertebral lesion. Three points of tenderness are usually noted,

viz., near the median line in front, and midway between these two

points in the mid-axillary line. The pain is usually dull with acute

exacerbations. =Lesions= of the =vertebræ= and =ribs= in the locality

affected are by far the principal causes. Cold, exposure, strains,

etc., are exciting causes of every day occurrence. When the pain is

bilateral and symmetrical the lesion is usually in the vertebra; when

unilateral the rib alone may be involved. The most common lesion is

a crowding together of the ribs anteriorly at the fifth and sixth

interspaces. Carefully exclude a possible tuberculosis of the spine or

ribs, aneurism, etc.

The pain of =herpes zoster= is not neuralgic, but neuritic, involving

the posterior spinal ganglion. =Pleurodynia=, strictly speaking, is

neuralgia of the pleural nerves, and not of the intercostals, but a

deranged rib over the region of the pain is commonly the cause of the

pleurodynia.

=Lumbo-abdominal= neuralgia involves the posterior branches of the

=lumbar nerves=. Tender points are found near the vertebræ, middle

of the iliac crest, lower part of the rectus, and in the male

occassionally in the scrotum, in the female in the labia. These

are often bilateral and are usually of a constricting nature. The

ilioscrotal branch is the one most commonly affected.

=Subluxation= of the =vertebræ=, and other lesions, as contracted

muscles, are found along the lumbar vertebræ, and even as high as the

lower dorsal vertebræ. Also lesions are found at the lumbo-sacral

articulation. Pelvic disease is also a cause.

A downward displacement of the =lower ribs=, eleventh and twelfth, is a

common disorder and may be the cause of severe neuralgic pains in the

region of the iliac fossæ. It may simulate ovarian inflammation, renal

colic, or even appendicitis if on the right side. And septic kidney has

been wrongly diagnosed from these lesions. In fact it may be a cause of

inflammation of the deeper structures, such as the ovary and Fallopian

tube.

A subluxation of the vertebræ at the fourth and fifth dorsals may cause

severe neuralgic pains in the epigastrium.

=Neuralgia of the Spinal Column.=—According to medical writers this is

especially found in weakly women and after concussion of the spine;

that it is a troublesome symptom in hysteria, and in many cases it

is due to a reflex stimulus from diseased viscera. Most of this is

undoubtedly true, but they have not found out the real significance of

these neuralgic pains. The various =tender points= along the spinal

column are of paramount importance to the osteopath as a =guide= to his

=diagnosis=; not only in certain cases, but in nearly every case. The

tender points are not due, in nearly every instance, to reflex stimuli

from diseased organs, but these tender points are often the result of

a local lesion, and are many times the cause of the disorder to the

diseased viscus. The neuralgic pains are simply a symptom that a lesion

exists in the immediate locality.

=Neuralgia of the Sacral Region and Coccygodynia.=—This form involves

the nerves in the sacral and coccygeal regions. The nerves between the

bone and the skin are affected. The cause of the pain is generally due

to derangement of the articulation of the =lumbar= and =sacrum=, and

to severely contracted muscles over the sacral foramina; also to lower

lumbar lesions. It may be a reflex from various possible disorders

of the organs and tissues of the pelvis. In coccygeal neuralgia, the

=coccyx= is commonly displaced in any one of the various displacements

that are liable to occur. Special attention should be given to the

fibro-articulation of the coccyx, and to the status of the lumbo-sacral

and innominata. In adjusting the coccyx, place forefinger in rectum up

to proximal end of coccyx, and with thumb externally over the section,

exert traction until articulation is released; then adjust.

=Neuralgia of the Legs and Feet.=—This includes the =crural form=, in

which the front of the thigh is the seat of the pain; also the form

in which tender points are found along the course of the =sciatic=

nerve. The latter form is quite a common one, although sciatica

is rarely a neuralgia. It is a neuritis and will be found classed

under that heading. The tender points presented are the lumbar,

sacro-iliac, gluteal, peroneal, maleolar and external plantar. The

various neuralgic pains of the legs and feet are generally due to

=lesions= of the =lumbar=, =pelvic= and =thigh= regions, and to =weak

arches=. =Metatarsalgia= occurs when the fourth metatarso-phalangeal

articulation is partially dislocated. Neuralgia in the heel, ball of

the foot and toes may be due to local causes or to lesions higher up.

Aside from the above care should be taken that there are no toxic

factors that may be exciting causes.

=Visceral Neuralgia.=—This is a term applied to neuralgia of the

gastro-intestinal tract, the kidneys, and the various pelvic organs.

=Diagnosis and Prognosis of Neuralgia.=—Neuralgia is to be diagnosed

chiefly from neuritis, rheumatism, and the effects of severe pressure

upon the nerves. In =neuritis= there is oftentimes a symmetrical

affection, while in =neuralgia= there is a unilateral distribution and

there are many remissions and intermissions and a varying of the pain

from one place to another. In severe forms of neuritis, anesthesia

succeeds the hyperesthesia of the sensory nerves. In cases of severe

pressure upon nerves, the pain is continuous and neuritis will soon be

manifested. In =rheumatism= the pain is localized in muscles or groups

of muscles and does not follow the course of the nerve. The pain is

increased by motion.

The =prognosis= is generally favorable, no matter how severe the

attack. The prognosis is influenced only by the age of the patient and

the cause.

=Treatment of Neuralgia.=—Consists, first, in the control of the

paroxysm and, second, in the removal of its cause. In controlling

the paroxysm, frequently one will be able to remove the cause. In a

large majority of neuralgias the cause is directly due to a =displaced

tissue=, generally a bone or muscle in the locality affected; often

all that is necessary in order to perform a cure is to adjust the

disordered tissue and the pain will cease. This usually can be done

immediately, although there are cases which require several treatments

before an adjustment of the parts can be accomplished; besides, in

acute cases the involved region will be so tender that an attempt

to correct the tissues sufficiently to relieve the paroxysm will be

unbearable to the patient. In such instances when the cause cannot be

removed at once, firm pressure or inhibition over the involved nerves

for a few minutes and local application of hot packs generally disperse

the pain for the time being. The rules of hygiene should be observed in

all cases.

The best time to =remove= the =cause= of neuralgia is between the

attacks when the tissues are not as tender or contracted to such an

extent as during the paroxysm. A diagnosis can then be made much more

easily, and the tissues adjusted with less pain to the patient.

The details (as to the locality treated) for each form of neuralgia

will be found under the discussion of each variety. The general health

and diet should be considered. Peterson[115] says: “Morphine is,

among the alkaloids, the most frequent cause of insanity. It is a sad

commentary on the heedlessness of some medical men, but the family

physician is responsible, in almost every case, for the development

of the morphine habit and its far-reaching consequences. It should be

looked upon as a sin to give a dose of morphine for insomnia or for any

pain (such as neuralgia, dysmenorrhea, rheumatism) which is other than

extremely severe and transient.”