SPINAL IRRITATION.
I retain this phrase, not because it is an absolutely good one, but
because it has become so familiar that it is difficult to dispense with
it. We have taken a useful step, however, in separating the true
neuralgias from the somewhat indefinite group of diseases to which this
title has been given. I think the reader who has carefully studied Part
I. of this work will not deny that the latter disorders present a very
clear and definite common outline which distinguishes them essentially
from the vaguer affections to be described under the present heading.
Spinal irritation, in my sense, includes all those conditions in which,
without any special mental affection, and without any single nerve being
definitely affected, there are sensations varying between mere cutaneous
tenderness, often of a large and irregular surface, and acute pain
approaching neuralgia in character, together with fixed tenderness of
certain vertebrae on deep pressure. A very large majority of the
phenomena are such as would be popularly included (now that they are
known not to be of an inflammatory character) under the term
"hysterical." That unhappy word crosses our path at every turn in a most
embarrassing manner, and yet it can hardly at present be said that we
could afford to do without it.
The more typical cases of so-called "hysterical hyperaesthesia" present
the following phenomena: Along with the general symptoms of the
hysterical temperament (tendency to causeless depression, variable
spirits, sensation of globus, semi-convulsive attacks terminated by the
discharge of a great quantity of pale, limpid urine) there is commonly a
marked superficial tenderness of the surface everywhere, and an
exaggeration of reflex irritability. The general tenderness is so far
merely cutaneous that deep pressure is ordinarily borne better than the
lightest finger-touch. But besides this there are usually one or several
spots in which the tenderness is more profound and genuine. There is
almost sure to be some point in the spinal column where firm pressure
not merely evokes a complaint of pain, but also induces secondary
objective phenomena connected with distant organs, such as nausea and
vomiting when the cervical vertebrae are tender, severe gastric pain when
the dorsal vertebrae are tender, etc. In such cases there is not only
spinal tenderness, but very usually also a well-marked tenderness in the
epigastrium and the left hypochondrium, the _trepied hysterique_ of
Briquet. The reader must, however, be warned that the whole of these
three tender points may be merely myalgic, and it is necessary very
carefully to observe whether local movements do or do not seriously
aggravate the pain in them. And, on the other hand, the spinal tender
point may be merely the "point apophysaire" of a true neuralgia which
exhibits no other symptoms of the so-called hysteric constitution.
The kind of hysteria that is joined with the existence of fixed tender
spots in definite points of the vertebral column is not commonly
distinguished by the occurrence of cutaneous anaesthesia; but those
writers are certainly wrong in saying that such a combination never
takes place. I have seen examples of the most marked union of the two
classes of symptoms in the same person.
These cases of so-called spinal irritation with general hysteric
manifestations are very commonly attended with paroxysmal pains that
approach true neuralgia in character. Nor is it to be denied that we
sometimes meet with the combination of general hysteria, spinal
tenderness in definite points (with secondary spasmodic or paralytic
phenomena always following pressure exerted on the latter), and true
neuralgia limited to one nerve. But the more typical spinal irritation
cases are merely complicated with a tendency to vague pains which are
shifting both in character and position, not with definite unilateral
neuralgia always haunting the same nerve and exhibiting more or less of
the same type. In fact, as far as one can judge in the absence of any
precise information as to the condition of the nervous centres in such
cases, it would seem likely that the ordinary cases of spinal irritation
differ from the true neuralgias chiefly in this--that the injury, or
inherited weakness of organization, or both, which is at the root of the
malady, is at once slighter in degree, and spread over a larger tract of
the nervous centres, than that which produces a true neuralgia. I
believe that Dr. Radcliffe is right in supposing it to be probable that
a blow or other injury to the back producing general spinal shock, is
the original but unsuspected cause of a large proportion of these cases.
One of the most perfect examples of spinal irritation that I have ever
seen (and which also contrasts keenly with the commoner hysteric
affections on the one hand, and the true neuralgiae on the other) was
that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds,
and Dr. Bridge. This young lady was a most intelligent person, and not
in the slightest degree inclined to the apathy and idleness so often
seen in hysterical people. She had received what was thought at the time
to be a very slight contusion in a railway collision, in which, however,
her sister, who was in the same carriage, had been severely injured. She
nursed this sister assiduously, and it was not till three or four months
later that her own health began to fail seriously; but she then became
anaemic and extremely depressed. About six months after the accident it
was quite casually discovered that there was a spot over the lowest
cervical vertebra, pressure on which gave her exquisite pain and a
sensation of extreme nausea; and the very curious observation was made
that such pressure instantaneously produced extinction of the right
pulse, the left pulse remaining unaltered. In this case it cannot be
doubted that a serious shock had been communicated to a lateral segment
of the cord involving chiefly the vaso-motor nerve fibres, in which
probably some decided material lesion had been gradually set up; and
besides this there was probably slighter damage to the spinal cord
generally, as there was great general feebleness of movement, though no
actual paralysis of the limbs.
Along with the phenomena of fixed spinal tenderness, without distinct
neuralgia of any particular nerve, we not unfrequently observe the
development of more or less decided tenderness of some of the internal
surfaces of the body. I have recently had under my care a young woman in
whom a very tender point was developed over the second cervical
vertebra, and who suffered from such persistent tenderness of the whole
posterior part of the pharynx, that I was for some time seriously
apprehensive of the existence of spinal caries and post-pharyngeal
abscess. The general character of her symptoms, however, induced me to
hope that the case was one of spinal irritation merely, and the event
proved that this was the case, for under the use of iron and small doses
of strychnia she recovered completely in about three weeks. In another
patient who came under my care about twelve months ago, there was
extraordinary sensitiveness of the gastric mucous membrane, causing
exquisite pain after she had eaten almost any thing: there was only
occasional vomiting, however, and there had never been any haemorrhage,
so that the evidence for gastric ulcer, which I otherwise inclined to
think existed, was insufficient. I discovered that pressure on the third
or the fourth dorsal vertebra gave great pain, and produced a strong
inclination to vomit; this made it probable that the affection was
spinal, and accordingly all treatment addressed to the stomach was
abandoned. Flying blisters to the neighborhood of the painful spinal
points quickly relieved all the symptoms.
Another distressing class of symptoms, which is very commonly observed
in connection with these cases of spinal irritation, is that of abnormal
arterial pulsations: I am not sure whether even severe neuralgia
produces more distress than does this pulsation. I have repeatedly seen
abnormal pulsation of the carotids in connection with fixed
tender-points over the cervical or the upper dorsal vertebrae; and still
more commonly pulsation of the abdominal aorta in connection with
tenderness over one or two of the upper dorsal vertebrae. Spasmodic cough
and spasmodic dyspnoea frequently accompany tenderness of points in
the upper half of the spinal column; and in one instance I have seen
pressure on the lowest cervical vertebrae produce a paroxysm which looked
alarmingly like angina pectoris. A case of singularly prolonged and
obstinate spasmodic hiccough which came under my notice was
distinguished by the presence of a fixed tender spot over the third
dorsal vertebra.
Prolonged spastic contraction of voluntary muscles, going on, sometimes
for weeks, and even months, is a phenomenon that has often been
observed; it may attack the arm only, or may affect all the limbs, and
the muscles of the trunk and of the neck: it is for the most part
symmetrical, but is occasionally unilateral. It begins in the
extremities, and is very commonly limited to them; it is much more
gentle than tetanic spasm, and is also painless, or nearly so; but the
contraction is often strong enough to resist very vigorous efforts at
artificial extension.
Paralyses, both of bowel and bladder, have been recorded among the
occasional phenomena of spinal irritation with fixed tender points; but
I cannot say that I have ever seen such an occurrence. On the whole, I
must say that by far the most frequent phenomena of spinal irritation
that I have seen have been somewhat diffuse cutaneous or mucous
tenderness and irritability (without acute pain) and the presence of
tormenting arterial throbbings; also a marked tendency to aggravation of
some symptoms, especially the gastric, when firm pressure is made upon
the tender spinal points. For a further and fuller account of the
phenomena of spinal irritation I may refer the reader to the able
article of Dr. Radcliffe,[48] and the work of the brothers Griffin,
already quoted; adding the suggestion, however, that both these
authorities, and especially the Griffins, appear to me not to draw a
sufficiently clear distinction between the class of cases that I have
been attempting to describe and the true neuralgias.
After what has been said, there is no need to draw out a formal list of
the points of diagnosis between spinal irritation and neuralgia. It must
be admitted, moreover, that the two forms of diseases have a strong
connection in the fact that they are each of them most frequently
developed in the descendants of neurotic families. It is by the more
generalized character of the symptoms, and the absence of the tendency
to perpetual recurrence of paroxysmal pain in one definite nerve, that
spinal irritation is mainly distinguishable from true neuralgia. I may
add that there is a marked distinction, also, in the results of
treatment.
The treatment of spinal irritation is, it must be confessed still in an
unsatisfactory position; and I believe that a good deal of unnecessary
discouragement has been occasioned to physicians by their failures to
cure supposed neuralgias which really belonged to the spinal irritation
class. I would assuredly by no means assert that genuine neuralgia is
not frequently intractable, or even incurable; but it is certainly much
more curable than spinal irritation; and for this reason, mainly as I
believe--that there is much more possibility of aiming our remedies at
the actual seat of the disease. On the other hand, in spinal irritation
we are confused and distracted with a variety of phenomena for which
even the most subtle analysis will frequently fail to trace a common
origin. It is true that the existence of definite tender spots in the
spine apparently suggests a strictly local application of remedies; and
it true also that medication based upon this fact is sometimes very
effective; but this is, in my experience, only an occasional result, and
the practitioner who trusts to local measures will frequently be
disappointed. And, on the other hand, the general tonic treatment, and
the use of special medicines, like quinine and arsenic, or the
hypodermic injection of morphia oratropia, have nothing like the
extensive utility in the treatment of spinal irritation that they
possess in that of true neuralgia. Of internal remedies, by far the most
useful in my hands have been sesquichloride of iron with small doses of
strychnia, and the milder vegetable bitters, especially calumba.
There is one special phase, however, of spinal irritation which is very
amenable to the direct, treatment, viz., cutaneous and mucous
tenderness. Whatever the "hyperaesthetic" part is within reach, so that
we can apply Faradization, we can almost certainly eradicate the morbid
sensibility very quickly. The secondary current of an electro-magnetic
or volta-electric induction apparatus is to be employed; the conductors
should be of dry metal and the negative one, which is to be applied to
the painful surface, should be in the form of the wire brush. The
positive pole is to be placed on some indifferent spot, and the negative
is to be stroked briskly backward and forward over the sensitive skin, a
pretty strong current being employed. The process is painful so much so
that it will often be advisable, with delicate patients, either to
administer chloroform or to inject morphia subcutaneously before the
Faradization. A very few daily sittings of four or five minutes length
will generally remove the morbid tenderness completely. Where the tender
part is within one of the cavities, at the rectum, bladder, vagina, or
pharynx, we must of course use a solid negative conductor of appropriate
form, and must content ourselves with applying it steadily to one point
after another of the sensitive surface.
The fact that Faradization proves so remarkably useful, in these cases
of spinal irritation with diffuse cutaneous or mucous tenderness, is in
itself a strong diagnostic between this sort of affection and the true
neuralgiae, which, as I have stated are seldom benefited, and are often
made worse, by the interrupted current, though the constant current
frequently mitigates or cures them.
Sometimes where it is not possible to apply the remedy directly to the
sensitive surface, we may nevertheless do great good by sending the
interrupted current through it. Thus, in gastric sensitiveness connected
with spinal tenderness in the upper dorsal region, I have seen very
great relief afforded by sending a current from the positive pole,
placed on the tender vertebrae, to a broad, negative conductor placed on
the epigastrium. And similarly, I have seen an acutely sensitive
condition of the neck of the bladder greatly soothed by the passage of a
current from a painful lumbar vertebra to the perinaeum immediately
behind the scrotum.
Undoubtedly, however, the more serious cases of spinal irritation will
yield only (if they yield at all) to a prolonged treatment in which very
skilful use is made of general hygienic measures, and especially of
morbal influences. As the brothers Griffin long ago pointed out,
although rest is useful in the early stages of this malady, if the
disease does not quickly yield to this and to appropriate tonic
medication, and perhaps local applications to the spine, it will not do
to keep the patient recumbent and confined to the house; on the contrary
at whatever cost of immediate discomfort, he (or she for these patients
are by far the most frequently females) must be roused up, and persuaded
or compelled to take out-door exercise, and if possible to travel, and
divert the mind by complete change of scene. When such expensive
remedies are out of the question, it seems better that patients, even
seemingly very feeble, should take to their ordinary avocations in life
again, and fight down the tendency to invalidism. But of course, the
decision on such a point must rest with the tact and judgment of the
practitioner in each individual case, for there are, doubtless,
instances in which the attempt to carry out such a plan, even
moderately, would break down the remaining strength, and make matters
worse than they were before.
In the worse case of spinal irritation that I ever saw, that of a young
lady, aged twenty-eight, there were pronounced anaemia and general
feebleness, the true hysteric _trepied_ of tender points, painful
irritability of the stomach, which baffled all medical advisers and
resisted almost every possible form of tonic and nervine medicines,
counter-irritation to the spine, and, in fact every thing that one dared
attempt with so feeble-looking a patient, but at once cleared up and was
quite cured after marriage. And there can be no question that a very
large proportion of these cases in single women (who form by far the
greater number of subjects of spinal irritation) are due to this
conscious or unconscious irritation kept up by an unsatisfied sexual
want. In some patients there cannot be a doubt that this condition of
things is indefinitely aggravated by the practice of self abuse; but it
would be most unjust to think that this is a necessary element in the
causation; on the contrary, it is certain that very many young persons
(women more especially) are tormented by the irritability of the sexual
organs without having the least consciousness of sensual desire, and
present the sad spectacle of a _vie manquee_ without ever knowing the
true source of the misery which incapacitates them for all the active
duties of life. It is a singular fact, that in occasional instances one
may even see two sisters inheriting the same kind of nervous
organization, both tormented with the symptoms of spinal irritation, and
both probably suffering from repressed sexual function, but of whom one
shall be pure-minded and entirely unconscious of the real source of her
troubles, while the other is a victim to conscious and fruitless sexual
irritation.
I have already causally alluded to the danger of mistaking mere myalgia
for spinal irritation and must again enforce this consideration upon the
reader. Myalgic tender points in the region of the spine are common
enough; and it would be easy without careful attention, to mistake them
for the deeper-seated vertebral tenderness which is truly characteristic
of spinal irritation. Hence the utmost care must be taken to ascertain
the true history of the commencement of the disorder whether it
succeeded to great and long continued fatigue of particular sets of
muscles, and whether it is specially aggravated by contractions of those
muscles, and relieved by their full extension. The differences of
treatment which depend on the diagnosis are too obvious to need dwelling
upon.
The question of administering remedies with the direct intention of
procuring sleep, for patients suffering from spinal irritation, often
becomes an important and a very difficult one. It is, for the most part,
highly objectionable to commence the use of such remedies; and yet
sleeplessness is a very distressing symptom with many patients, and is,
of course in itself exhausting and deleterious. For as long as we
possibly can, we should content ourselves with efforts to produce sleep
by the timely administration of nourishment. The same general rule of a
very generous (though not very stimulating) diet to be enforced as
carefully as in the case of sufferers from neuralgia. But it is
especially advisable in spinal irritation; that the patient should take
some food shortly before bedtime; and it is well, also to place food
within reach at the bedside, so that if he wakes up he may take some.
If, however, we are absolutely driven to employ hypnotics, we must
commence with the very mildest. The popular remedy of a pillow stuffed
with hops will sometimes suffice; and a better way of administering the
volatile principle of hops is to scatter a few hops on hot water in an
inhaler, and let the patient breathe the steam. Hot foot-baths, with
mustard, are also very useful. If these fail, chloral, in moderate doses
is probably the best and safest remedy, and, with care not to give too
much, we may go on using the same dose without increase for a good many
times.
FOOTNOTE:
[48] Reynolds's "System of Medicine," vol. ii., Art. "Spinal
Irritation."