disease and its stage of progress. Diathetic taints are to be met if
present, and the greatest measure of physical health secured that the
circumstances possibly admit. It is a good precaution in all cases to
secure free evacuation of the bowels and to guard against hemorrhoidal
congestions.
As against the neuralgia itself, the proper means vary with the
acuteness of the attack and the presence or absence of neuritis. For
the acute stage absolute rest is almost always desirable as a prime
condition. Quinine, belladonna, aconite, and turpentine in full doses
should be thoroughly tried, and special reference had to the
periodicity of the seizures.
Frequent and extensive but superficial counter-irritation (actual
{1237} cautery, blistering, ether, or chloride of methyl) is in place
in this stage, and galvanism (constant current) is often of great
service. It is probable that for the acute stage the prolonged use of
mild currents is the best, whereas in more chronic cases the stronger,
even very strong, currents, brought to bear as accurately as possible
upon the nerve itself, are sometimes more useful.
Hydropathic treatment is in great repute both for acute and chronic
cases, but as success in this way demands care and knowledge, the
reader is referred to the special treatises.
In cases of long standing the continued application of ice-bags along
the length of the limb for days together is often of excellent
service, but this method of treatment is not without its dangers and
needs to be carefully watched.
In chronic cases deep injections are of service, and nerve-stretching
(see above) is in place.
THE VISCERAL NEURALGIAS have not received the attention which is due
them both on account of their intrinsic importance and their
constitutional significance. Not only are they found in common with
the superficial neuralgias in the overtired and the underfed, but they
point more strongly than the latter to the neuropathic diathesis,
alternating with such symptoms as migraine, asthma, nervous dyspepsia,
and insomnia. They occur also in the gouty and among the neuropathic
descendants of the gouty, and as a result of functional and organic
disorders of the viscera.
The pain of these neuralgias, though usually described as vague,
ill-defined, dull, etc., yet often stirs the nervous system to its
depths, causing nausea, faintness, sweating, prostration, reflex
disorders of the secretions, and like symptoms.
ANGINA PECTORIS is a neuralgia probably of the pneumogastric and
sympathetic nervous apparatus of the heart. The pain, which is usually
of a heavy, dull, oppressive, or tearing character, and capable of
rising to intense agony, is usually deep-seated, and felt to the left
of the sternum and beneath the breast, often involving the left arm
and side, and occasionally the left side of the face and neck, and
even the leg of the same side or the right arm. It may also, as the
writer has seen, be confined to the sternal region. In the case
referred to this pain recurred every afternoon and evening with great
regularity. Sometimes instead of pain the arm may be the seat of a
tingling numb sensation only.
During the attacks the action of the heart may continue unchanged, or
it may become slow and feeble or intermittent, yet without necessarily
being the seat of organic disease. The onset of anginic attacks is
usually, but by no means always, sudden, and their duration is
commonly short. All the features of the attack, however, are subject
to considerable variation, and nervous symptoms of a variety of kinds,
which it is not necessary to detail, may precede or attend the
seizure. In severe attacks the patient's anguish and prostration are
extreme; the face and extremities become pale and cold, and a cold
sweat breaks out.
In a large proportion of cases, especially the severest ones, these
neuralgic attacks are associated with organic disease of the heart or
blood-vessels.
A variety of causes have been suggested to account for the seizures,
{1238} prominent among which is a widespread contraction of the
arterioles, bringing a sudden strain upon the left ventricle of the
heart. This theory is especially noteworthy because of the success
which has attended the treatment by nitrite of amyl, which brings on a
rapid vascular relaxation. In other cases spasm of this kind is
manifestly absent. Fraenkel[41] has recently defended the view that a
momentary paralysis and over-distension of the left ventricle is the
exciting cause. In other cases all sign of arterial or cardiac disease
is and remains absent.
[Footnote 41: _Zeitschr. für klin. Med._, 1882.]
In this latter group the tendency to the attacks may cease under
appropriate hygienic treatment. Thus, in an instance known to the
writer a lady of usually good health suffered for several months from
slight attacks of præcordial pain, with pain or a sense of numbness in
the left arm, and often a feeling of breathlessness on very slight
exertion. This condition had manifestly been brought about by
prolonged physical and mental strain, and disappeared completely after
a period of rest. Other such cases are described by Anstie,
Allbutt,[42] and others.
[Footnote 42: _London Lancet_, 1884, i.]
In judging of the significance of anginic attacks in a given case the
signs of circulatory disease should first be studiously sought, and
especially, as more likely to escape notice, indications of cardiac
enlargement or weakness, or of increased vascular tension, or of
chronic nephritis.
Dull pains in the intervals of the attacks are also regarded as
important, as indicating the presence of neuritis of the cardiac
nerves, which without doubt often exists. On the other hand, as
pointing rather to a neurotic origin of the symptoms, a tendency,
individual or inherited, to neuralgias of other forms, to asthma,
migraine, and the other neuroses, is to be looked for.
Heredity plays a certain part in the etiology, and among the special
causes of the non-organic form abuse of tobacco is said to be
important.
The TREATMENT would be likely, of course, to be widely different
according to the nature of the case, being on the one hand addressed
to the circulatory apparatus, on the other to the health of the
nervous system, in both cases following well-known lines.
In the treatment of the individual attacks the diffusible stimulants
and the narcotics are of value when there is time to employ them. With
regard to nitrite of amyl and the longer-acting nitro-glycerin, which
have given so much relief in some cases, it would be premature to
confine their use to the cases of demonstrable vascular spasm or even
organic disease, and they are fair agents for trial in the apparently
non-organic cases as well.
A patient of Romberg's used to get great relief from swallowing pieces
of ice.
When the attacks are long continued or frequent, electricity, either
as galvanism or by the wire brush, is applicable, and also
counter-irritation over the chest, even by vesication.
GASTRALGIA (syns. gastrodynia, cardialgia, gastric colic, cramp of the
stomach, etc.) may be associated with organic disease of the stomach
or may occur as an independent neurosis. It is met with in individuals
and families in which asthma, migraine, gout, etc. are found. In
general it is common in persons of nervous, mobile temperament, and is
moreover apt to point to temporary exhaustion from some cause, though
this is by no {1239} means always true. The writer has seen several
sensory disorders of this class at the period of life of which the
menopause is the chief feature. The pains of apparently
hypochondriacal patients doubtless belong sometimes in this group.
The pain of gastralgia is felt primarily at the epigastrium, whence it
may radiate upward and backward along the œsophagus and through into
the back, as well as laterally in various directions. Allbutt says
that it is sometimes associated with anginiform attacks.
Other associated symptoms are dyspnœa, prostration, faintness,
coldness of the extremities, or reflex changes in the action of the
heart, which may beat feebly, rapidly, and irregularly, or more slowly
than normal.
Apropos of the relation of gastralgia to organic disease, it is
important to recall the fact that some of the organic diseases of the
stomach, notably chronic ulcer and cancer, may fail to reveal their
presence by any physical sign. In a case seen by the writer a
cancerous growth had invaded the entire stomach, causing an enormous
thickening of its walls, yet no tumor was to be felt, and the most
marked symptoms were gastralgia and exhaustion.
The relations of gastralgia to the other purely functional disorders
of the stomach are interesting and peculiar. It is beyond a question
that every variety of digestive disorder, from simply delayed and
painful digestion to pyrosis, the formation of gas, and constant
vomiting, is much more often of purely neurotic origin than has been
supposed.
The DIAGNOSIS of catarrhal gastritis as distinguished from nervous
dyspepsia is indeed often difficult or even impossible. Leube has
recently recorded a case where the matter vomited during life
contained fungoid growths, such as are usually considered
pathognomonic of gastritis, and yet at the autopsy the mucous membrane
appeared perfectly healthy.
With these nervous disorders of digestion, which are by no means
confined to hysterical patients, gastralgia may be variously
associated, or it may occur independently of them all, or vice versâ.
On the other hand, digestion may be attended with a sense of
discomfort, often amounting to severe pain, yet without regular
outbreaks.[43] This symptom is classified by Allbutt as a
hyperæsthesia of the stomach rather than as a neuralgia, but from this
to true gastralgia there is only a sliding scale of difference.
Sometimes a persistent neuralgic habit is set up by a local disorder
which itself passes away entirely.
[Footnote 43: Allbutt, _loc. cit._]
TREATMENT.—In acute attacks the aim is simply to relieve pain by
whichever of the well-known methods promises the best. The real field
for thought and care is in the treatment of the underlying
states—first, those which, like gout, anæmia, syphilis, or nervous
debility, predispose to the attacks; second, the local or special
conditions which act as exciting causes. Sometimes it will be found
that such patients have special idiosyncrasies with regard to the
nature of food or time of meals.
In that condition of the system which is indicated by frequent or
paroxysmal excess of uric acid in the urine a long-continued use of
Vichy water or lithia is sometimes of service. If it be finally
concluded that the stomach is in an hyperæsthetic, not in an inflamed,
condition, it may not be advisable to diminish the amount of food,
but, on the contrary, by one means or another, to increase it.
{1240} NEURALGIA OF THE UTERUS AND OVARIES.—Attention has repeatedly
been called to the fact that affections of these organs may excite
neuralgias in distant parts of the body or in the lumbo-abdominal
nerves; but besides these the uterine and ovarian nerves themselves
sometimes are the seat of neuralgia, and it is claimed that
menorrhagia and metrorrhagia may occur as a consequence.
The other abdominal organs and the testis are occasionally the seat of
neuralgic pains, and attacks which involve the liver may be followed
by swelling of the liver and by jaundice.
It is not always easy to assert with confidence whether an attack of
abdominal neuralgia affects the external or the visceral nerves.
NEURALGIA OF THE ANUS AND RECTUM is a well-marked and painful
affection, and the tendency to it may be hereditary. The seizures
themselves may come on spontaneously, especially after fatigue, or may
be excited by slight irritations, such as the passage of hardened
feces, or may follow seminal emissions. The pain may be accompanied by
quick, clonic spasm of the perineal muscles.
The rapid injection of hot water into the rectum often at once
relieves the attack.
* * * * *
We have not space to discuss at length the neuralgiform affections of
the joints and muscles and those due to the metallic poisons and other
causes which do not follow the course and distribution of special
nerves.
In accordance with the belief which we have expressed, that neuralgic
attacks are not always of the same nature, but are the manifestations
of many different conditions, we should be inclined to include many of
these irregular affections under the neuralgias instead of classifying
them apart, as Anstie and most writers have done. Thus, a patient of
the writer, a gentleman of middle life, who has had migraine since
childhood and belongs to a neuropathic family, suffers on the
slightest exertion from violent pain in both thighs, which comes on
very gradually, beginning at the knees and spreading upward,
eventually passing away after a night's rest. One might diagnosticate
this as myalgia if he confined himself to topographical
considerations, but the history of the patient and the regular march
of the attacks point to a different conclusion.
{1241}
VASO-MOTOR AND TROPHIC NEUROSES.
BY M. ALLEN STARR, M.D., PH.D.
DEFINITION.—In the term vaso-motor and trophic neuroses it is intended
to include a number of forms of disturbance of circulation and
nutrition which are caused by disorders of the nervous system. Such
disturbances may occur in any part of the body. They are not to be
regarded as distinct diseases, but rather as symptoms of lesions in
the peripheral or central nervous system. They may present themselves
in various forms, as hyperæmia or anæmia or instability of vascular
tone, as atrophy or hypertrophy or disintegration of normal tissue.
Their consideration cannot, however, be assigned to any previous
department of this volume nor relegated to various divisions of it;
partly because in some cases they are to be traced to lesions of the
sympathetic system, not elsewhere considered; partly because of our
ignorance as to the exact location in many cases of the lesion of
which they are manifestations.
It is probable that at a future time this chapter will disappear from
a system of medicine, as the chapter on ascites has disappeared, and
that the symptoms under consideration will be distributed among
various departments as symptoms of ascertained lesions in various
organs. For the present, however, they demand a separate discussion.
It is not possible to distinguish accurately in all cases between the
vaso-motor and the trophic neuroses, for while in many features they
are distinct, in a large proportion of cases they occur together. But
it is not possible to ascribe all trophic changes to vascular
disturbance, nor all vaso-motor changes to a defect or excess of
trophic action. Hence a separate consideration of these allied
subjects must be given. It is always to be remembered, however, that
each may give rise to the other, and that in their pathology they are
closely connected. Vaso-motor disturbances manifest themselves (1) by
a dilatation of the vessels, producing redness, heat, and rapid
metabolism in the part affected; or (2) by a contraction of the
vessels, causing pallor, coldness, and malnutrition; or (3) by an
alternation of these conditions and consequent temporary disturbance
of function. Trophic disturbances may occur in consequence of such
increase or decrease of blood-supply, or independently of any vascular
change, causing (1) an abnormal production of tissue in an organ, or
(2) a decrease in the size and number of its constituent cells, or (3)
an actual degeneration of the elements which make it up, after which
their place may be taken by another kind of tissue. Under all these
circumstances the function of the part affected will be disturbed, and
symptoms will be produced which will vary with the tissue or organ
involved. Hence a {1242} general consideration of these symptoms must
be given. Before proceeding to a detailed consideration of these
neuroses it is necessary to review the physiology of the vaso-motor
and trophic systems, in order to make clear the manner in which they
perform their functions. And inasmuch as the pathology of these
affections is best understood by comparison with experimental lesions
made by physiologists in investigating their function, it will be
treated together with their physiology.
Vaso-motor Neuroses.
[Illustration: FIG. 56. Vaso-motor Nerves and Ganglia accompanying the
Arterioles in a Frog (Gimbert): _C_, arterioles; _N_, vaso-motor
nerve; _G_, ganglion, from which nerves issue, situated at the point
of anastomosis of several capillaries; _R_, fibre of Remak.]
PHYSIOLOGY.—Local Vascular Tone.—Since changes in the force and
frequency of the heart's action, and variations in the total amount of
blood in the body, affect the body as a whole, the state of
circulation in any one organ or part must be dependent upon the degree
of contraction or dilatation of its own vessels. This is known as the
local vascular tone. It is under the control of a system of
nerve-ganglia with their subservient fibres which are found in the
middle coat of all arterioles (Fig. 56). The energy expended by these
ganglia is manifested by a constant moderate contraction of the
circular muscular coat of the artery—a contraction which is as
constantly opposed by the dilating force of the blood-pressure within
the vessel. An exact equipoise between these two forces never occurs,
since each varies constantly, but in a state of health one never
becomes permanently excessive. Considerable variations, however, in
the local {1243} vascular tone are frequently observed. Thus each
organ is influenced to a certain degree by every other, since an
increase of blood in one part must involve a decrease in all other
parts, the total amount of blood in the vessels being constant.
Alteration in the heart's action is felt more quickly in some organs
than in others, and thus the general blood-pressure by its variations
may cause secondarily a disturbance of local vascular tone. The
variations now under consideration, however, are not of this kind.
They are such as are produced by influences acting directly upon the
ganglia in the vessel-walls.
Local irritation is such an influence, and it may excite the ganglia
to increased activity, so producing a contraction of the vessel and
consequent pallor; or it may suspend the action of the ganglia, so
producing a dilatation of the vessel and consequent flushing.
Another influence is irritation acting from a distance and conveyed to
the local ganglia by nerve-fibres. These nerve-fibres can be
distinguished from all others by their structure, being
non-medullated, and by the fact that they have an indirect course,
passing from the central nervous system to the sympathetic ganglia,
and from these to the local ganglia in the vessels. The impulses sent
along these nerves may affect the local ganglia in one of two ways,
and either cause contraction by exciting the ganglia, or dilatation by
inhibiting the action of the ganglia. The result produced has
determined the names given to the impulse, to the fibre transmitting
it, and to the centre whence the impulse proceeds, and hence
vaso-constrictors and vaso-dilators are distinguished from one
another.
The history of the development of the sympathetic nervous system,[1]
as well as its gross anatomy, affords distinct proof that it is not an
independent system, as Bichat supposed, but is closely connected in
its physiological action with the spinal cord and brain. Impulses
which reach the sympathetic ganglia from a distance along the
vaso-constrictor or vaso-dilator fibres originate in the central
nervous system. The nervous mechanism which controls the local
vascular tone is therefore a complex one, consisting not only of the
set of local ganglia connected with larger sympathetic ganglia, but
also of centres in the spinal cord connected with higher centres in
the brain. The brain-centres in turn are complex, consisting of an
automatic mechanism in the medulla regulating the action of all the
subordinate parts below it, and of a series of cortical centres whose
function it is to stimulate or inhibit the medullary mechanism. It
therefore becomes evident that local vascular tone may be modified by
local causes acting on the ganglia in the vessels—_e.g._ cold or heat;
by changes in the sympathetic ganglia—_e.g._ the hyperæmia of the face
in lesions of the cervical ganglia; by reflex action through the
spinal cord—_e.g._ pallor produced by pain; by reflex action through
the medulla oblongata—_e.g._ glycosuria following sciatica; or by
conscious or unconscious impulses coming from the cortex—_e.g._ the
blush of shame, the vaso-motor paralysis of hemiplegia.
[Footnote 1: W. R. Birdsall, “Embryogeny of the Sympathetic System,”
_Arch. of Med._, vol. i. where a bibliography of the subject is to be
found.]
Vaso-constrictors.—Such a mechanism, however complex in structure,
would be easily comprehended if the constant manifestation of energy
in the maintenance of arterial tone had its only source in the action
of the local ganglia in the vessels, and was affected only
occasionally by impulses {1244} from a distance, as has been thus far
supposed. This, however, is not the case, as has been demonstrated by
a series of experiments beginning with the brilliant researches of
Claude Bernard. The classical experiments of the French physiologist
were made upon the sympathetic cord in the neck of a rabbit. Division
of this was found to produce a dilatation of the vessels of the ear.
Irritation of the peripheral end of the divided cord produced a
contraction of the vessels. Division of the spinal nerves connected
with the cervical sympathetic and of their anterior roots, or
irritation of the cut ends, produced effects similar in character to
those caused by division or irritation of the cervical sympathetic.
Destruction of the spinal cord in the lower cervical region, or
division of the cord at any higher level up to the medulla, was
followed by dilatation of the vessels. If the segment of the divided
cord just below the section was irritated the vessels contracted.
Destruction of the medulla at the calamus scriptorius and above it for
three centimeters produced a general dilatation of all the vessels in
the body, but division above this level had no effect. The initial
congestion produced by these various experiments was accompanied by a
rise of temperature in the part. It was followed after a time by a
partial recovery of vascular tone, which was more complete the farther
the division from the local ganglia. These facts warranted the
conclusion that the energy expended by the local ganglia in holding
the vessels in a state of constant moderate contraction is derived
from the central nervous system, primarily from the automatic centre
in the medulla, which in turn is reinforced by each of the secondary
centres in the spinal cord and sympathetic ganglia; and also that
while the medullary centres control the entire body, the cord and
sympathetic centres control only those parts with which they are
especially related. In order, therefore, to the maintenance of normal
vascular tone the local ganglia must be intact, and they must be in
connection with the sympathetic ganglia; these must be active, and
must be connected with the spinal cord; the cord must be normal, and
its tracts from the medulla must be capable of conduction; the
medullary centre must be active, and not hindered or spurred by
cortical impulses of a conscious or unconscious nature. Any injury to
one or more of these parts will produce a vascular dilatation by
interfering with the transmission of vaso-constrictor impulses from
within outward, and any irritation of one or more of these parts may
cause a contraction of the vessels by increasing the normal stimulus
sent to the local ganglia by the vaso-constrictors.