case of nervous headaches, which are often very greatly relieved by a
series of gentle, monotonous movements of the finger-tips, as well as
by the domestic remedy of gently and persistently combing or brushing
the patient's hair. A still more efficient application of a similar
kind is the regular vibration communicated by a large magnet or by the
instrument devised by Mortimer Granville. A thoroughly satisfactory
explanation of the action of this treatment is yet to be furnished.
There is no doubt that in the treatment of neuralgia a persistent and
thorough use of the remedies suggested is usually the key to success.
Nevertheless, special cases are sometimes reached by special means of
treatment, and the following are appended as occasionally useful:
Ammonio-sulphate of copper (grs. ij-vj, taken in divided doses in the
course of the day); salicylate of soda, in full doses; caffeine; tonka
(fluidrachm j of the fluid extract at repeated intervals of a few
hours); oil of turpentine; muriate of ammonia.
{1230} Special Forms of Neuralgia.[35]
[Footnote 35: Consult, in connection with this subject, the sections
on Symptomatology and Treatment.]
MIGRAINE AND PERIODICAL HEADACHE.—In many of the recent treatises upon
nervous disease migraine and headache are removed from the category of
the neuralgias and placed in that of the functional affections of the
sympathetic vaso-motor system of nerves. This classification is based
upon the fact that in many of these cases marked vascular
changes—congestion or anæmia, as the case may be—are observed in the
external tissues of the affected parts, while the sensations of the
patient often lead us to infer the presence of similar conditions
within the cranium. The pain and the other symptoms of the outbreak,
it is thought, are due to the changes in blood-tension in the cortex
cerebri or in the region of expansion of sensitive nerves, or, in
part, to the spasm of the muscular walls of the vessels themselves.
This theory is seductive from its appearance of pathological
simplicity and exactness, but the writer believes, with Anstie,
Latham, Allbutt, and other observers, that it is not borne out by
clinical experience, and that its adoption tends to cloak the wider
relationship that exists between the sensory neuroses.
Migraine, nervous headache, and the superficial and the visceral
neuralgias hardly differ more fundamentally from each other than
individual cases of either affection differ among themselves. It is
not improbable, as we have seen, that all the phenomena of some
neuralgic attacks are wholly or in part the expression of irritation
of the sensory nervous system from without; but in many cases, on the
other hand, the signs of the neurosal tendency are clearly marked, and
there is hardly one of the symptoms of a typical migraine of which the
analogue may not be found, though perhaps faintly pronounced, in one
or another form of superficial neuralgia, while the relation of both
to the whole family of the neuroses is still more clearly evident.
Migraine is a disease of youth and middle life, characterized, in its
most typical form, by attacks of severe headache of a few or many
hours' duration, of gradual onset and decline, ushered in by
well-marked auras involving one or more of the cerebral functions, and
terminating in nausea or vomiting or profuse secretion of pale urine,
or in some other critical nervous outbreak. The pain is usually, but
not invariably, deep-seated. It may be confined to one side of the
head, most often the left, or may involve both sides, either from the
outset or in the course of the attack. The forehead or temple is
usually the first part to become painful, but in severe or prolonged
seizures the parietal and occipital regions are prone to be affected
likewise.
The auras are manifold and important. On the day before an attack the
patient may feel remarkably well, or may complain only of such
sensations as thirst or giddiness. The attack itself is apt to be
ushered in by visual hallucinations of dazzling and vibrating points
or serrated images, sometimes with prismatic outlines, accompanied by
a loss or obscuration of vision over one-half or some other portion of
the field, which lasts half an hour or more, and sometimes clearing up
in one part while it advances in another. Simultaneously or
immediately after this there may be {1231} tingling and a sense of
numbness of the tongue, lips, hand, or one-half of the body, sometimes
followed by partial hemiparesis, and, if the right side be affected,
by more or less aphasia or mental confusion. Occasionally the other
special senses are affected. Sometimes the aura may constitute the
whole of the seizure.
The writer has observed a case in which migraine was represented
throughout boyhood by repeated attacks of subjective numbness and
tingling of the entire right side of the face, the right arm, and the
right half of the body, with aphasia and hemianopsia, followed during
many years by trifling headache or none at all; later in life by
severe pain. Here migraine as well as neuralgia in other forms was a
well-marked family disease.
These auras are especially worthy of notice, because they occasionally
point to epilepsy, an affection with which migraine is allied.
The pain may begin on the same side with these prodromal symptoms or
on the opposite side. Sometimes drowsiness is a marked symptom
throughout the attack, and this differs in significance from the
sound, refreshing sleep with which the paroxysm often comes to an end.
Sometimes the arteries of the affected side seem strongly contracted,
as shown by pallor and coldness of the face and dilatation of the
pupil (angio-tonic form); sometimes, on the other hand, they are
dilated and pulsate strongly, or the latter condition may follow the
former (angio-paralytic form). The radial pulse may show corresponding
modifications. These vascular phenomena are often, however, entirely
wanting.
Migraine appears to be slightly more common in women than in men. The
liability to the attacks often shows itself in extreme youth, usually
increases at puberty, and generally ceases at the age of forty or
fifty. The attacks sometimes recur at regular intervals of a week, a
month, etc., but, on the other hand, they may remain absent for years
unless brought on by some exciting cause.
ETIOLOGY AND CLINICAL RELATIONS.—Migraine is a directly inheritable
disease, and one which stands in a close relationship to the other
grave neuroses, as well as to the neuropathic temperament. Cases are
occasionally seen in which the migraine of youth gives place to
epilepsy in later years. It is often met with also in families and
individuals of neuralgic tendency, and in fact it shades off into
neuralgia of the fifth and occipital nerves on the one hand and into
periodic nervous headaches on the other. It frequently occurs in gouty
persons, and is thought to be related to the brow ague of malaria. The
attacks may be brought on by any of the causes which depress the
vitality of the nervous system, and by various special irritations,
among which errors of refraction are prominent.
The PROGNOSIS is unfavorable in well-marked cases, in which the habit
of regular recurrence is established, and where the neuropathic
predisposition is pronounced and no special exciting cause can be
found. On the other hand, there are many cases where the tendency is
less deeply rooted, and where with the removal of the exciting cause
or causes the outbreaks cease.
Finally, there is great probability that the disease will cease of
itself with advancing years, not always, however, without having left
its mark on the patient's mental and bodily vitality.
{1232} The TREATMENT should be directed first to the detection and
removal of special sources of irritation, whether in the eye, stomach,
uterus, or elsewhere. Causes of anxiety and mental strain should be as
far as possible avoided, and great caution enjoined in the use of
stimulants and narcotics. The nutrition should be maintained at its
highest level by tonics, and, if need be, by electricity, massage, and
hydropathy. Sometimes, besides this a special diet is advisable, for
it seems beyond question that some patients have fewer headaches if
they abandon all animal food, while others—whether because of a gouty
tendency is not clear—do best on a nitrogenous diet with exclusion of
sugar and starch.
Of the drugs used to control the liability to the attacks, the most
important is cannabis Indica, given in doses of about half a grain of
a good preparation of the extract several times daily for weeks or
months together. Valerianate of zinc and the iodide and bromide of
potassium in full doses are also recommended, but are less
efficacious.
In the treatment of the attack itself, besides absolute rest and
quiet, large and repeated doses of guarana or caffeine, either alone
or combined with drachm doses of bromide of potassium, are sometimes
of use if given at the very outset.
It is thought by some observers that ergot or ergotin is of value if
the vessels are dilated, and conversely nitrite of amyl or glonoine if
they are contracted. It must not be forgotten, however, in case of
doubt, that the throbbing due to the latter drugs may increase the
pain.
The writer has known a strong faradic current applied with the
moistened hand to the back of the neck to relieve an attack, and
prolonged but gentle manipulation of the painful area with the
finger-tips may have a like effect if the pain is not too severe; as,
for example, toward the end of a paroxysm.
Neuralgias of the Fifth Nerve.
Three varieties of these neuralgias may conveniently be distinguished:
1. Ordinary facial neuralgia, analogous to the neuralgias of the other
superficial nerves;
2. Intermittent supraorbital neuralgia, sometimes called brow ague,
though by no means always of malarial origin;
3. Epileptiform neuralgia (tic douloureux).
These varieties are of course closely allied, and have many features
and causes in common.
THE ORDINARY FACIAL NEURALGIA is a painful and obstinate malady,
although not so serious as the typical tic douloureux. The pain may
remain fixed in one position or it may shift from one part of the face
to another; and the latter is especially common in those forms which
occur in anæmic or ill-nourished persons. It associates itself readily
with occipital neuralgia, and sometimes also with neuralgia of the
pharynx and other parts. It occurs most often in persons of neurotic
tendencies or impaired nutrition, and may be provoked by disorders of
the ears, teeth, and even distant organs. The possibility of aneurisms
of the internal carotid or of cerebral tumor should also be borne in
mind, and signs of herpes zoster and locomotor ataxia carefully sought
for.
{1233} The relation of caries of the teeth to neuralgia of the fifth
pair forms a very important chapter, which is admirably treated by
J. Ferrier.[36] Opinions on this subject are conflicting and
unsatisfactory, and the fact that many patients have had nearly all
their teeth drawn in the vain attempt to get cured of one of the
severe forms of facial neuralgia often creates an impatience of
further investigation in the matter. Ferrier points out that as a rule
it is not the severest cases of epileptiform tic douloureux that arise
in this way, but, on the other hand, that it is a mistake to conclude,
because a neuralgia is benefited by medical treatment and made worse
by fatigue, exposure, etc., and because it occurs in a person of
neurotic temperament, that it is not likely to be due to this form of
irritation. The teeth need not themselves be the seat of pain, and the
disease in them may be detected only after diligent search.
[Footnote 36: _Les Névralgies reflexes d'Origine dentaires_, Paris,
1884.]
The most important lesions are said to be caries, exostosis, and other
affections involving the pulp-cavity, exposure of the sensitive
dentine, ulcerations of the gums, injuries caused in extraction, and
other diseases of the alveolar process. The wisdom tooth, by its
pressure on other roots and on the gums, is not infrequently the one
at fault.
Chronic inflammation of the mucous membrane of the nose or pharynx is
said to be an occasional cause of neuralgia of the face, as well as of
the upper portions of the body.
THE INTERMITTENT NEURALGIA OF THE SUPRAORBITAL is an interesting
affection to which too little attention has been paid. One variety
seems to bear a certain relationship to migraine, inasmuch as it
occurs under similar circumstances—_i.e._ in distinctly neuropathic
individuals and families, and in attacks of about the same duration
and periodicity of recurrence.
Another variety approaches the other neuralgias in the longer duration
of the attacks, but is characterized by a daily seizure which recurs
with absolute regularity, coming on usually at about nine in the
morning and increasing in severity for an hour or so, then persisting
unchanged until midday or later, when it gradually diminishes, finally
disappearing in the course of the afternoon. As a rule, it is brought
on by catarrh of the frontal sinuses, often following an acute attack
of coryza. A certain amount of neurosal predisposition is often found
in this form, and the first attacks may show themselves in early
youth, rarely in the decline of life. The writer has seen one family
in which a number of members in at least two generations have been
attacked in this way, the seizures having been brought on by
exhaustion or coryza, or both combined.
This form of neuralgia is often greatly controlled by quinine if given
in sufficiently large doses (15 to 20 or 25, or even 30, grains) and
as long as four hours before the attack.
Lange[37] thinks the action of galvanism is remarkably successful, but
the writer's experience does not fully bear this out.
[Footnote 37: Cited in the _Centralbl. für Nervenheilkunde, etc._,
1881, p. 10.]
Seeligmüller[38] speaks very highly of the effect of the nasal douche,
used for the sake of curing the catarrh of the frontal sinuses, and
potassic iodide may be useful by rendering the secretions more fluid.
[Footnote 38: _Centralbl. für Nervenheilkunde, etc._, June 1, 1880.]
THE EPILEPTIFORM FACIAL NEURALGIA, OR TIC DOULOUREUX, {1234} is a
chronic affliction, characterized by the suddenness of onset and the
severity of its paroxysms of pain, which may recur every few minutes
with lightning-like rapidity, either spontaneously or brought on by
motion of the jaw or the taking of food, and disappear again as
quickly. After a group of such paroxysms as this there may be an
intermission of some hours or days. During the attack the patient is
apt to rub the seat of pain with great violence. The path pursued by
the darts of pain may be either in the direction of the nerve-trunks
or in an irregularly inverse direction.
In spite of their sufferings, these patients may present an appearance
of health. In its worst forms, and especially in advanced life, this
variety of neuralgia may be incurable, and at the best it is sure to
tax the care and skill of the physician. Anstie thinks that it is apt
to be associated with a taint of insanity.
The best TREATMENT consists in the most painstaking attention to
hygiene, in the persistent use of galvanism, arsenic, cod-liver oil,
quinine, aconite (see under General Treatment), and phosphorus. Croton
chloral is occasionally of service.
As a last resort, surgical measures (see above) may be appealed to,
but it should be borne in mind that even when the prospect seems most
hopeless the relief under medicinal and hygienic treatment may really
be near at hand. Where section of nerves is without result, the
operation of tying the larger vessels, the carotid or vertebral, on
the affected side may be tried, and offers some chance of success.
OCCIPITAL AND CERVICO-OCCIPITAL NEURALGIAS are second only to
trigeminal neuralgia in severity, though, fortunately, less common,
and either is liable by extension to give rise to the other.
Neuralgic pains in the occipital region may attend Potts's disease of
the cervical vertebræ; and this is especially important to bear in
mind because the osseous deformity is often wanting for a long time.
The writer has known a persistent pain in this region to be due to
intracranial syphilitic disease, and to cease suddenly with the advent
of more serious cerebral symptoms.
CERVICO-BRACHIAL AND BRACHIAL NEURALGIAS are less often indicative of
the neuropathic taint than the facial neuralgias; and, on the other
hand, they are, like sciatica, relatively often due to neuritis set up
by injury, amputation, strains, enlarged cervical glands,
periarthritis of the shoulder,[39] etc., or associated with herpes
zoster. When not due to an unremovable cause the prognosis is
favorable. The treatment needs no special description.
[Footnote 39: See J. J. Putnam, “A Form of Painful Periarthritis of
the Shoulder,” _Boston Med. and Surg. Journ._, 1882.]
INTERCOSTAL NEURALGIA is a very important form, both on account of its
frequency and obstinacy, and because it is often associated both with
anæmia and chlorosis and with affections of the visceral organs,
especially the uterus. The distressing cardiac palpitation of
neurasthenic patients often associates itself with pain in the left
side, and there is an intimate connection between neuralgia of the
cardiac plexus (angina pectoris; see below) and neuralgia of the
intercostal and brachial nerves.
Pain in this region, often due to neuritis, may accompany acute and
chronic thoracic disorders, and may be the precursor of herpes zoster.
{1235} Caries of the vertebræ and meningitis should be thought of, and
cancer if the neuralgia is very persistent, even if it is paroxysmal
in character.
TREATMENT.—Besides the general indications for treatment referred to
above, it is worthy of special note that nerve-stretching has been
successfully tried for intercostal neuralgia. In one interesting case
seven nerves were stretched at one operation.[40] The reporter
discusses the surgical aspects of the operation, and points out that
the nerves should be sought for, not directly beneath the rib, but
behind and beneath it, and thinks that the failure to bear this fact
in mind might lead to puncturing the pleura.
[Footnote 40: Lesser, _Deutsch. Med. Wochenschr._, Sto. 20, 1884.]
MAMMILLARY NEURALGIA (irritable breast of Astley Cooper), though often
met with in company with intercostal neuralgia, may occur entirely
independently. It is sometimes bilateral, and is apt to be associated
with irregularity of the uterine functions. Cutaneous hyperæsthesia is
often present to a distressing degree, and small tumors of either
temporary or permanent duration may make their appearance (A. Cooper),
which, however, do not affect the prognosis.
There is no especially effective TREATMENT beyond what has been spoken
of. Surgical interference is not especially to be recommended, though
it has occasionally been useful.
LUMBO-ABDOMINAL NEURALGIA, or neuralgia of that part of the lumbar
plexus which supplies the flank and abdomen and the external genital
region. These neuralgias are apt to accompany those of the intercostal
nerves and share in their significance.
The most important facts with regard to them are that they are
intimately associated, in relation both of cause and of effect, with
affections of the abdominal and the pelvic organs and of the testis.
Neuralgias of the terminal branches of the lumbar plexus, the
obturator and anterior crural nerves, though well recognized, are
comparatively rare.
One of the chief respects in which they are important is in calling
attention to the possible presence of disease of the hip-joint or of
periarthritis of the hip, as well as of tumors or inflammation within
the pelvis.
NEURALGIA OF THE SCIATIC NERVE is one of the most severe and common
forms. While sharing in the common etiology and history of the other
neuralgias, it is peculiarly prone to be due to peripheral causes,
which give rise to thickening of interstitial and investing connective
tissue of the nerve. The distribution of the pain may be coextensive
with the whole distribution of the great and little sciatic nerve, but
far oftener the patient indicates certain regions as the seat of his
severest suffering; and these are especially the sacral region of one
side, the neighborhood of the sciatic notch, the popliteal space, the
calf, and the outer side of the foot and ankle. Not infrequently the
whole course of the sciatic nerve is traced out by the darts of pain;
and in this case it is the nerves which supply the sheath of the
sciatic itself which are supposed to be the seat of the neuralgic
process.
Sciatica is usually unilateral, but exceptionally bilateral, or
attacks the two sides alternately. The tender points most often met
with are at the sacro-iliac synchondrosis, the posterior border of the
great trochanter, just beneath the head of the peroneal bone, below
and behind the {1236} external malleolus, but numerous others are
likewise noted by Valleix. Sometimes no tender points can be found.
Sometimes, also, it is one or more of the collateral branches of the
sciatic plexus that are the seat of the neuralgia, and the
distribution of the pain and of the tender points varies accordingly.
It is in sciatica pre-eminently—in part, no doubt, because of the
frequency of neuritis—that disorders of sensibility of the skin are
noticed, as well as muscular paresis or spasm. This anæsthesia has
been studied with great care by Hubert-Valleroux and others, and it
has been shown that it is often confined to limited spots, a
centimeter or so in diameter, within which the loss of sensibility may
be nearly absolute. Nevertheless, their functional origin is proved by
the fact that under faradization they may rapidly disappear.
The duration of an attack of sciatica varies from a week or two to
months or even years, and it shows a marked liability to recur,
especially with changes of weather. First attacks occur pre-eminently,
though not exclusively, in middle life, and oftener in men than in
women, evidently because they are oftener exposed to mechanical injury
and, through their occupations, to sudden changes of temperature and
the like.
The occasional causes are numerous, and include sudden wrenches and
jars, even if not very severe, interpelvic pressure from tumors or
impacted feces, etc. Gout, syphilis, and diabetes may act as
predisposing and even exciting causes, and, it is said, gonorrhœa
likewise. Periarthritic inflammations of the hip-joint and varicose
veins frequently excite pains in the various sciatic nerve-branches
which simulate true sciatica.
As has been indicated, although sciatica may be a pure neuralgia (see
under Pathology), running its course without leading to any
appreciable change in the nerve, yet subacute and chronic neuritis is
very common, either as a primary condition or a complication, and its
presence puts a graver aspect upon the case. The pain of neuritis,
when severe, is relatively constant, remittent instead of
intermittent, dull rather than lancinating, increased by motion and
pressure; whereas the purely neuralgic pains are sometimes relieved by
movement. It is, however, doubtful whether an accurate differential
diagnosis is possible (see above). It is to this neuritis that the
muscular atrophy is due which is often so marked, and it may likewise
give rise to various cutaneous lesions of herpetic character. The
severe pain that accompanies typical herpes zoster of this region is
well known.