effort to remove its cause. If syphilis is suspected, mercury and
iodide of potassium must be freely used. If the cause is an affection
of the middle ear, this must be treated. Wounds or traumatic injuries
must receive the necessary surgical attention. In addition, in such
cases electricity {1207} must be employed in the manner presently to
be described. In cases of rheumatic facial paralysis the treatment
will vary with their gravity. In the lighter form in which the nerve
is affected outside of the Fallopian canal, recovery takes place in a
comparatively short time, even without treatment, but is hastened by
the use of the faradic or galvanic current daily along the branches of
the nerve. In the severe form we must open the treatment by an attempt
to combat the condition of inflammation—of inflammatory
exudation—which we suppose exists within the Fallopian canal. Local
blood-letting by leeching upon the mastoid process may be
appropriately used in the very first outset of the paralysis. Iodide
of potassium, given persistently in large doses during the earlier
period of the disease, appears to act beneficially independently of
any syphilitic taint. Electricity is the remedy, however, on which
most reliance is to be placed in the treatment of rheumatic facial
paralysis, and the manner of its application may be taken as a model
of how it should be employed in all cases of peripheral paralysis. The
galvanic current, on account of its power of penetrating to the deeper
parts and its catalytic action, is to be preferred for the direct
electrical treatment of the nerve which should be instituted in recent
cases. Its action is best obtained by placing the positive pole behind
the ear on the affected side, the cathode behind the opposite ear, and
passing a moderate current across the base of the skull (the affected
nerve being thus in the course of the current) for one or two minutes.
Occasionally the position of the poles may be reversed. Besides this
direct application of galvanism to the point of lesion, it is
necessary to make a peripheral application of electricity to the
branches of the nerve and to the paralyzed muscles. For this we use
both the faradic and galvanic currents. The galvanic current is used
by applying the positive pole stationary behind the ear, while the
negative pole, with an electrode of suitable size, is stroked over
each branch of the nerve and applied to each muscle, a current being
used sufficiently strong to produce decided contractions. This
peripheral application should be made once daily, the time of
application being from two to five minutes. The application of the
faradic current is made by simply placing one electrode upon an
indifferent spot, and moving the other over the face, with a current
strong enough to cause contractions if the muscles still respond to
it, or if they do not of such strength as the patient can bear without
discomfort. Without doubt, one of the beneficial effects of peripheral
electrization is the reflex excitement of the facial above the point
of lesion through the irritation of the terminations of the fifth
nerve in the skin. A certain advantage derived from it is that it
maintains the tone of the paralyzed muscles, which in the case of the
orbicularis palpebrarum is of great importance in preventing the
eversion of the lower lid and the overflow of the tears. As it is
impossible during the first days succeeding the paralysis to
distinguish severe cases from those of the middle form, it is best to
begin the treatment of all cases in the manner above described. The
use of strychnia in rheumatic facial paralysis, both internally and by
hypodermic injection, may be mentioned on account of the widespread
preposession in its favor, and to point out distinctly its utter
futility.
Mechanical appliances and manipulation are used with advantage in the
treatment of facial paralysis to prevent the paralyzed muscles about
{1208} the mouth and cheek from being drawn out of place and
over-stretched by the action of the sound ones of the opposite side,
thus having their tonicity and nutrition impaired.
Contractions and rigidity of muscles receive little benefit from the
use of electricity, and must be treated by mechanical procedures, such
as stretching, massage, etc.
Neuromata.
The term neuromata was applied to all tumors involving the
nerve-trunks at a time when their histological differences had not
been studied and they were all supposed to be composed of
nerve-tissue; and even yet the name is conveniently retained, because,
although differing widely histologically, tumors situated upon the
nerves have a very similar clinical history.
Neuromas must be divided into true and false, the true consisting of
nerve-tissue, the false, or pseudo-neuromas, being composed of many
varieties, having this only in common, that they are seated upon the
nerves.
The true neuromas are again subdivided into those in which the
nerve-tissue composing them resembles exactly the fibres of the
peripheral nerves, showing with the microscope the double-contoured
white substance of Schwann surrounding an axis-cylinder, and those in
which the tumor is made up of fibres which Virchow has shown to be
non-medullated nerve-fibres—_i.e._ the axis-cylinder without the white
substance of Schwann. These two forms have been distinguished by the
names myelinic and non-myelinic. The true neuromas are non-malignant,
although showing the tendency to recur after extirpation, are of slow
growth, and as a rule do not increase to a very great size. The best
type of the myelinic neuromas is found in the spherical or
spindle-shaped enlargements at the cut ends of nerves, particularly in
the stumps of amputated limbs, where they are found oftenest
intimately connected with the cicatricial tissue, though sometimes
lying free. They consist of true medullated fibres mixed with some
fibrous tissue. The fibres composing them are derived partly from
splitting up and proliferation of the fibres of the nerve itself,
partly are of new formation, the appearances strongly recalling the
process of regeneration in nerves. Myelinic neuromas consist of fibres
and nuclei so closely resembling in microscopic appearance the
fibromas that they have hitherto been confounded with them; and there
is a difference among the highest authorities as to the certainty of
their diagnosis, and, in consequence, of the frequency of their
occurrence. The true neuromas may include in their structure all of
the fibres of the nerve-trunk or only a portion of them (partial
neuroma)—a fact of importance in their symptomatology. Of the false
neuromas, the fibromas are by far the most frequently met with. They
appear as knots, more or less hard, upon the course of the
nerve-trunk, which they may involve completely or partially. They are
often excessively painful to the touch or spontaneously, most of the
so-called tubercula dolorosa belonging to the fibro-neuromas. Fibromas
sometimes occur along the trunk and branches of a nerve, forming a
plexus of knotted cords (plexiform neuroma). Fibro-sarcomas are not an
infrequent form of neuroma.
{1209} Myxomas often occur upon the peripheral nerves, and are
frequently multiple, their points of predilection being the larger
trunks, as the sciatic, ulnar, etc. They show their characteristic
soft structure, and are usually spindle-shape, assuming a rounder form
as they attain a large size. The various forms of sarcoma occasionally
form tumors upon the nerves, attacking generally the large trunks.
Carcinomatous tumors beginning upon the nerves sometimes occur, but as
a rule these growths involve the nerve by extension to it from
adjacent parts.
Syphilitic gummata have been found almost exclusively upon the
intracranial portion of the cranial nerves.
Gliomas appear to affect only the optic and acoustic nerves. Lepra
nervorum (lepra anæsthetica) produces usually a spindle-form
thickening upon the nerve-trunks, but sometimes there are more
distinct knots, which may be felt beneath the skin, bead-like, along
the course of the nerves of the extremities.
Like the true neuromas, the false neuromas, developing from the
neurilemma and perineurium, may involve the whole or only a part of
the fibres of a nerve, or the nerve-fibres may run at the side of the
tumor—different conditions, which may alter materially the effects
produced upon the nerve.
Neuromas, both false and true, may occur not only singly, but often in
large numbers, many hundreds having been counted upon an individual.
Sometimes they are numerous upon a single nerve-trunk and its
branches, and again they may appear scattered over nearly all of the
nerves of the body, even to the cauda equina and roots of the nerves.
According to Erb,[9] isolated neuromas are more frequent in females,
while multiple neuromas are found almost exclusively in men. Neuromas
vary greatly in size, as we might expect from the very great
difference of their nature and structure; sometimes no larger than a
pea, they may attain the size of a child's head.
[Footnote 9: _Ziemssen's Handbuch_.]
ETIOLOGY.—In cases of multiple neuromata it would seem as if there was
a constitutional condition or diathesis as the foundation of the
affection. This we may the more readily believe as there appears good
evidence to show that the tendency to the formation of these
nerve-tumors is sometimes hereditary, and some of them are congenital.
Idiots and cretins have been observed to suffer in undue proportion
with multiple neuromas. We find a direct exciting cause of neuromas in
mechanical injuries of nerves, wounds, blows, pressure, etc. Thus, as
has been already seen, true neuromas occur in the divided ends of the
nerves after amputations or otherwise where a nerve-trunk has been
divided (cicatricial neuroma). As such neuromas are in some degree the
result of inflammation, it is probable that they may sometimes be
caused by chronic neuritis.
For a large number of neuromas no cause can be assigned, and we must
at present consider them as originating spontaneously.
SYMPTOMS.—The position and connections of neuromas being so different,
sometimes simply in contact with the nerve; sometimes situated in the
thickness of the nerve-trunk, the fibres being pressed aside and
spread out upon the surface of the tumor; sometimes involving in their
tissue a part or the whole of the nerve-fibres,—we cannot but expect a
{1210} very marked difference in their clinical history. Not a few
cases occur in which the presence of neuromas, even in large numbers,
gives rise to no symptoms during life, and their existence has been
revealed only upon a post-mortem examination.
The symptom most common to neuromas, and one to be expected from their
mechanical interference with the nerves, is neuralgic pain—sometimes
extreme, local or shooting along the course of the nerves, stubborn,
and hardly to be alleviated by remedies. It is paroxysmal,
notwithstanding the unvarying character of its cause, in consonance
with the tendency to periodical activity which prevails in the nervous
system. Sometimes the pain is increased notably by atmospheric
changes. The pain may sometimes be arrested by firm pressure upon the
nerve above the seat of the tumor. In some cases pressure upon the
neuroma, or even handling it, causes great pain. The intensity of the
pain does not depend upon the size of the tumor, some of the smallest
having earned the appropriate name of tubercula dolorosa. The
continued irritation of a neuroma sometimes produces a condition of
general nervous excitability, which shows itself in hysterical and
even in true epileptic convulsions. Occasionally there are abnormal
sensations (paræsthesiæ), formication, numbness, etc., in the
distribution of the nerve affected, and when from pressure or
histological changes the fibres are destroyed anæsthesia results.
The interference with the conductivity of the motor fibres, which
occurs less frequently than alterations of sensation, shows itself in
cramps, tumors, paresis, and paralysis, according to its degree.
Neuromas may destroy life by the continued excessive pain, which wears
down the strength and depresses the vitality. Death may be caused by
their peculiar situation; as, for instance, upon the cauda equina,
where they produce paraplegia, paralysis of the sphincter and bladder,
and trophic changes.
The DIAGNOSIS of neuromas can only be made when they are sufficiently
superficial to be recognized by the touch, and along with the symptoms
above detailed the tumor is situated upon the known course of a nerve,
to which, moreover, its attachment allows a lateral movement.
The only TREATMENT available for neuromas is extirpation, which must
be conducted with a view to sparing any fibres of the nerve not
involved in the tumor. Where it is necessary to divide the nerve in
the removal of the tumor, as small a portion as possible must be
excised, with the hope of a regeneration and reuniting of the cut
ends. The success of extirpation depends largely upon the nature of
the neuroma. The true neuromas, while they often show a strong
tendency to recur after removal, are benign and show no metastasis.
For the false neuromas the prognosis will be in accordance with their
benign or malignant character.
{1211}
NEURALGIA.
BY J. J. PUTNAM, M.D.
DEFINITION.—It is customary to describe as neuralgic those pains for
which no adequate cause can be assigned in any irritation of the
sensory nerves from outside, which recur paroxysmally, are unattended
by fever, and are distributed along the course of one or more nerves
or nerve-branches.
The general use of the term neuralgia further implies the common
belief that there is a disease or neurosis, not covered by any other
designation, of which these pains are the characteristic symptom. Of
the pathological anatomy of such a disease, however, nothing is known;
and if it could be shown for any given group of cases that the
symptoms which they present could be explained by referring them to
pathological conditions with which we are already familiar, these
cases would no longer properly be classified under the head of
neuralgia.
The attempt has frequently been made, and on good grounds, in
obedience to this reasoning, to cut down the list of the neuralgias,
strictly so called, and to account for many of the groups of symptoms
usually classified under that head by referring them to anæmia or
congestion of the sensory nerves, to neuritis, etc.
One of the best and most recent statements of this view is that of
Hallopeau,[1] who, although he does not wholly deny the existence of a
neurosis which may manifest itself as neuralgia, goes so far as to
maintain that the gradual onset and decline and more or less
protracted course so common in the superficial neuralgias, such as
sciatica, suggest rather the phases of an inflammatory process than
the transitions of a functional neurotic outbreak, and that, in
general terms, a number of distinct affections are often included
under the name of neuralgia which are really of different origin, one
from the other, and resemble each other only superficially. This
subject will be discussed in the section on Pathology, and until then
we shall, for convenience' sake, treat of the various neuralgic
attacks as if they were modifications of one and the same disease.
[Footnote 1: _Nouveau Dict. de Méd. et de Chir. pratiques_, art.
“Névalgies.”]
GENERAL SYMPTOMATOLOGY.—The neuralgias may be conveniently divided
into—1, external or superficial; 2, visceral; 3, migraine and the
migrainoid headaches.
Superficial Neuralgia.
The most prominent symptom of a neuralgic attack of the superficial
{1212} nerves is of course the pain, and sometimes, from first to
last, no other sign of disease is present. In an acute attack the pain
is usually ushered in by a sense of discomfort, which the patient
vainly tries to shake off, or by a feeling of weight and pressure or
of numbness and prickling, or of itching. Sometimes, though far less
often than in the case of migraine, there are prodromal signs of a
more general character, such as a feeling of thirst[2] or of mental
depression or drowsiness.
[Footnote 2: Spoken of by Mitchell's patient with neuralgia of the
stump (see below).]
A dart of pain may then be felt, which soon disappears, but again
returns, covering this time a wider area or occupying a new spot as
well as the old. The intensity, extension, and frequency of the
paroxysms then increase with greater or less rapidity, but, as a rule,
certain spots remain as foci of pain, which radiates from them in
various directions, principally up or down in the track of the
nerve-trunk mainly implicated. The pain rarely or never occupies the
whole course and region of distribution of a large nerve or plexus,
but only certain portions, which may be nearly isolated from one
another.
In an acute attack the affected parts may at first look pale and feel
chilly, and later they frequently become congested and throb. Mucous
surfaces or glandular organs in the neighborhood often secrete
profusely, sometimes after passing through a preliminary stage of
dryness.
The skin often becomes acutely sensitive to the touch, even though
firm, deep pressure may relieve the suffering. Movement of the painful
parts, whether active or passive, is apt to increase the pain. When
the attack is at its height, the pain is apt to be felt over a larger
area than at an earlier or a later period, and may involve other
nerves than those first attacked. Thus, a brachial becomes a
cervico-brachial neuralgia or involves also the mammary or intercostal
nerves. A peculiarly close relationship exists between the neuralgias
of the trigeminal and of the occipital nerves. It is said that when
the attack is severe the corresponding nerves of the opposite side may
become the seat of pain. This is perhaps remotely analogous to the
complete transference of the pain from one side to the other which is
so characteristic of periodical neuralgic headaches, especially if
they last more than one day.
Some cutaneous neuralgias pass away after a few hours' or a night's
rest, after the manner of a migraine or a headache, and patients in
whom this takes place are, as a rule, constitutionally subject to
neuralgia or other neuroses. Toward the end of such an attack there is
often a copious secretion of pale, limpid urine. In a large class of
cases, on the other hand, the attack is of several days' or weeks', or
even months' or years', duration, with remissions or intermissions and
exacerbations, which may be either periodical or irregular.
The most marked periodicity of recurrence is seen with the neuralgias
of malarial origin, which may take on any one of the typical forms of
that disease.
These malarial neuralgias affect pre-eminently, though not
exclusively, the supraorbital branch of the fifth nerve; but it should
not be forgotten that there is also a typically periodical
supraorbital neuralgia of non-malarial origin, of which the writer has
seen several pronounced examples, the pain usually recurring regularly
every morning at eight or nine o'clock and passing away early in the
afternoon. The same periodicity {1213} is seen, though less often, in
other neuralgias. Thus, Trousseau[3] speaks of neuralgic attacks from
cancer of the uterus in a young woman, which recurred daily at exactly
the same hour. Some of the traumatic neuralgias show the same
peculiarity to a marked degree.
[Footnote 3: _Clin. Méd._]
In many neuralgias, on the other hand, the exacerbations are worse at
night, like the pains of neuritis. In the intervals between the
attacks the pain may be wholly absent, or may persist, usually as a
dull aching.
After a neuralgia has lasted a few days—sometimes, indeed, from the
outset if the attack is severe—it is usually found that definite spots
of tenderness have made their appearance at certain limited points on
the course of the nerve. These are the famous points douloureux which
Valleix described with such minute accuracy, believing them to be
invariably present in true neuralgias. This is certainly not strictly
the case, though they are very common. They are not necessarily
coincident with the foci of spontaneous pain, as Valleix supposed, but
do correspond in general to the points at which the affected nerve
emerges from its bony canal or from deep muscles and fascia, and to
portions of its area of distribution in the skin. The spinous process
corresponding to an affected spinal nerve may also become tender, but
this is probably to be looked on, like the same symptom in so-called
spinal irritation, not as a sign of local disease, but as due to a
general reaction on the part of the nervous system, and as a fact of a
different order from the tenderness along the nerve.
The termination of an acute neuralgic attack is usually gradual, like
its onset, although in some cases of headache, and in other neuralgias
to a less degree, there comes a moment when the patient suddenly
declares that he is free from pain.
Neuralgic attacks are usually characterized, besides the pain, by a
highly-interesting series of symptoms, which are in part transitory
and functional, and in part due to structural changes in the
tissues.[4]
[Footnote 4: See Notta, _Arch. gén. de Méd._, 1854; Anstie, _Neuralgia
and its Counterfeits_.]
The spasm and subsequent dilatation of blood-vessels in the affected
area have already been alluded to. A disturbance of secreting organs
in the neighborhood of the painful region, the lachrymal gland, the
skin, the mucous membranes, the salivary glands, is of equally common
occurrence, and is probably in great measure due to direct irritation
of the glandular nerves, since the increased secretion is said to
occur sometimes unattended by congestion.
The hair may become dry and brittle and inclined to fall out, or may
lose its color rapidly, regaining it after the attack has passed.
The increased secretion of urine already alluded to attends not only
renal neuralgias, but those of the fifth pair, intercostal, and other
nerves. There may be unilateral furring of the tongue (Anstie).
The muscles supplied by the branches of the affected nerve or of
related nerves may be the seat of spasm, or, on the other hand, may
become paretic; and this is true even of the large muscles of the
extremities.
Vision may be temporarily obscured or lost in the eye of the affected
side in neuralgia of the fifth pair, and hearing, taste, and smell are
likewise deranged, though more rarely. I am not aware that distinct
{1214} hemianopsia is observed except in cases of true migraine, where
it forms an important prodromal symptom.
In connection with these disorders of the special senses the
occasional occurrence of typical anæsthesia of the skin of one-half of
the body should be noted, which several observers have found in
connection with sciatica. The writer has seen a cutaneous
hyperæsthesia of one entire half of the body in a case of
cervico-occipital neuralgia of long standing. These symptoms are
probably analogous to the hemianæsthesia which comes on after
epileptic or other acute nervous seizures, or after concussion
accidents, as has lately been observed both in this country and in
Europe, and it is perhaps distantly related to the hemianæsthesia of
hysteria. Local disorders of the sensibility in the neuralgic area are
far more common than this, and, in fact, are usually present in some
degree. The skin is at first hyperæsthetic, but becomes after a time
anæsthetic; and this anæsthesia offers several interesting
peculiarities. When this loss of sensibility is well marked, areas
within which the anæsthesia is found are apt to be sharply defined,
but they may be either of large size or so small as only to be
discovered by careful searching (Hubert-Valleroux). The sensibility
within these areas may be almost wanting, but in spite of this fact it
can often be restored by cutaneous faradization around their margins,
and the functional or neurosal origin of the anæsthesia is thus made
apparent. Where the anæsthesia is due, as sometimes happens, to the
neuritis with which the neuralgia is so often complicated, it is more
lasting, but usually less profound and less sharply defined.
These changes may be transient, or, if a neuralgia is long continued
and severe, they may pass into a series of more lasting and deeper
affections of the nutrition.
The skin and subjacent tissues, including the periosteum, from being
simply swelled or œdematous may become thickened and hypertrophied.
The writer has known a case of supraorbital neuralgia, at first
typically intermittent, to lead to a thickening of the periosteum or
bone over the orbit, which even at the end of several years had not
wholly disappeared.
Neuralgias of the fifth pair, which are as remarkable in their outward
results as they are in their severity and their relation to other
neuroses, are said to give rise to clouding and ulceration of the
cornea, to iritis, and even to glaucoma.
Herpetic eruptions on the skin sometimes occur, of which herpes zoster
is the most familiar instance.
Muscular atrophy is very common, especially in sciatica, and in some
cases this occurs early and goes on rapidly, while in others it may be
only slight and proportioned to the disease and relaxation of the
muscles, even where the neuralgia has lasted for weeks or months.
Neuritis of the affected nerve is a common result or attendant of
neuralgia, and may remain behind for an indefinite period after the
acute pain has gone, manifesting itself by subjective and objective
disorders of sensibility, by occasional eruptions on the skin, or by
muscular atrophy.
It is plain that in this list of symptoms a variety of conditions have
been described which would never all be met with in the same case, and
which, as will be shown in the section on Pathology, are probably due
to different pathological causes.
{1215} Neuralgia of the Viscera.
These neuralgias are less definitely localized by the sensations of
the patient than those of the superficial nerves, and it is not
definitely known what set of nerves are at fault.
They are deep-seated and are referred to the general neighborhood of
the larynx, œsophagus, heart, or one of the abdominal or genital
organs, as the case may be.
The pain is usually of an intense, boring character, and does not dart
like the pain of superficial neuralgia, but is either constant or
comes in waves, which swell steadily to a maximum and then die away,
often leaving the patient in a state of profound temporary
prostration.
Deep pressure often brings relief. A patient of the writer, who is
subject to attacks of this kind in the right hypochondrium, will bear
with her whole weight on some hard object as each paroxysm comes on,
or insist that some one shall press with his fists into the painful
neighborhood with such force that the skin is often found bruised and
discolored.