Chapter LXXXI: Introduction: This disease remained unnoticed until twenty years ago, (5)

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.

The TREATMENT of sciatica must vary with the probable cause of the 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.

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.

Vaso-dilators.—The action thus far considered has been wholly of a vaso-constrictor kind, and the dilatation which has been mentioned has been due to cessation of the constrictor energy normally passing outward. This may be termed a passive dilatation. It is the kind produced by division of any one of the sympathetic ganglia or cords. But further experiments have shown that another kind of dilatation may be produced, traceable not to a mere cessation of constrictor impulses, but to an impulse of a positive kind sent to the local ganglia and resulting in a sudden suspension of their activity. Such an impulse is really an inhibitory impulse arresting the action of the ganglia in spite of the continued stimulus sent to them from the central nervous system. Its result is a dilatation of the arteries, produced by the blood-pressure within them, which may be termed an active dilatation. Thus, Bernard {1245} found that irritation of the chorda tympani caused an immediate flow of blood to the submaxillary gland because of the dilatation of its vessels. And Dastre and Morat[2] have demonstrated a similar effect in the head and extremities after irritation of portions of the cervical sympathetic and of the peripheral nerves.

[Footnote 2: See _Archives de Physiologie_, “Vaso-dilateurs,” 1879, 1880, 1882; _Comptes rendus de l'Academie des Sciences_, 1880, pp. 393 and 441.]

Much confusion has arisen from the use of the term active dilatation, and many explanations of its mechanism have been offered. At first it was supposed that a system of longitudinal fibres in the vessel-wall acted as opponents to the circular constrictor fibres. This theory, originating with Stilling and Duchenne,[3] has been lately revived by Anrep and Cybulski.[4] They hold that since a vessel elongates as well as dilates with every heart-beat, its total distension is the result of two factors—viz. transverse and horizontal distension. If one of these is neutralized, they claim that the other will be increased. Longitudinal fibres in the wall by preventing elongation may thus allow the entire force of the heart to be expended in dilating the vessel. This theory has not, however, been accepted, and with that of Schiff, that contractile elements of the connective tissue surrounding the vessel-walls could pull outward the walls and thus dilate the vessel, has lapsed, because of lack of demonstration of the necessary anatomical structure in all arterioles. Another theoretical explanation, that dilatation of the arteries is caused by contraction of the veins damming back the blood, is disproved by the fact proven by Dastre and Morat, that blood-pressure increases instead of diminishing in the veins during vaso-dilator action. Legros[5] and Onimus,[6] noticing the normal occurrence of a peristaltic motion of centrifugal direction in the arteries of the retina, which if increased produced a certain degree of hyperæmia, attempted to explain the phenomena of dilatation by supposing a sudden increase of peristalsis. But Vulpian has proved that the peristalsis is both too slight and too slow in its effects to account for the rapid action of the vaso-dilators, and Dastre and Morat have shown that the peristalsis, not being synchronous with the heart-beat, really impedes the flow of blood. The last theory to be mentioned has a chemical basis, and is known as the theory of attraction (Brown-Séquard, Severini.) According to this, the organs, when active, manifest increased metabolism, to maintain which the blood is drawn toward them by the chemical changes in progress. This theory was based on the fact that irritation of the chorda tympani causes an increased secretion of saliva as well as a congestion of the submaxillary gland. It is now known, however, that these two acts are independent of each other, as either can be suspended while the other continues. Hence this theory too has lapsed.

[Footnote 3: Von Recklinghausen, _Handbuch der Pathologie des Kreislaufs und der Ernahrung_, 1883, where a full bibliography is to be found.]

[Footnote 4: _St. Petersburg Med. Wochenschrift_, 1884, i. 215.]

[Footnote 5: _Des Nerfs vaso-moteurs_, Thèse de Concours, Paris, 1873.]

[Footnote 6: _Des Congestions actives_, Paris, 1874.]

The view already stated, that vaso-dilators act by inhibiting local ganglia which cause contraction, is now accepted, especially since it is found that such inhibitory activity is constantly displayed by other parts of the nervous system, and is competent to explain the facts. The active dilatation produced by the inhibition of the action of the local ganglia is {1246} therefore to be clearly distinguished from the passive dilatation caused by the cessation of normal tonic impulses sent to them from higher centres. The former is a positive active vaso-dilator phenomenon. The latter is a negative paralytic vaso-constrictor phenomenon. The former is more effective, the dilatation being greater in degree and more permanent than the latter, and resembles exactly the dilatation produced experimentally by exhaustion of the activity of the local ganglia by over-stimulation of the constrictors.[7]

[Footnote 7: Goltz, _Arch. f. d. gesammt. Physiol._, xi. 92.]

An important point of contrast which has been established between vaso-constrictor and vaso-dilator impulses is that while the former are constant the latter are intermittent. Hence they cannot be regarded as opponents of one another. In a normal quiescent state vaso-constrictor energy is always being supplied to counteract the continued intravascular pressure ever renewed with the cardiac systole. The vaso-dilators are inactive. In an organ thrown into functional activity an increased flow of blood at once takes place, proportionate to the work being done by the organ. Such a functional hyperæmia might be produced either by a cessation of constrictor impulses or by an inhibition of their effects. It is by the latter means and through the vaso-dilators that it is produced, and it is probably the chief function of the vaso-dilator nerves to regulate the blood-supply in accordance with the need of a part. For this reason these nerves have been supposed to pass with the motor nerves to the muscles. As few organs exist without a possible use, it is probable that vaso-dilators pass to all parts of the body, as Vulpian asserts, though they have not been demonstrated in every organ or every part.

Like the vaso-constrictors, the vaso-dilators can be traced to the spinal cord, and their centres there are governed by a general centre in the medulla, which in turn may be affected by impulses from the cortex. A destructive lesion in any part of the vaso-dilator system does not produce as marked effects as one involving the vaso-constrictor system, since the symptoms of such a lesion will only appear when the vaso-dilators are called into play. When the vaso-dilator nerve to the submaxillary gland is cut, no change is observed until by some sapid substance put in the mouth its function should be excited, when the gland is no longer found to flush with blood as in the normal state. It is by means of the vaso-dilators that erectile organs become engorged with blood. Eckhard has shown the nervi erigentes of the penis to be vaso-dilator nerves. If they are destroyed, the organs will not respond to the wonted stimulus—a symptom which, however, would only be noticed at intervals. An irritative lesion of the vaso-dilator system may produce permanent congestion of an organ or part, but this seems to be rather more rare than a congestion from paralysis of the constrictors. It is seen in injuries of the peripheral nerves.

Origin of the Vaso-motor Nerves.—The exact course of the vaso-constrictor and vaso-dilator nerves has been traced from various parts into the central nervous system by the careful experiments of Dastre and Morat,[8] and more recently by Gaskell.[9] It is now established that they {1247} exist as separate nerves, although they often run together, and that they usually enter the spinal cord at different levels.

[Footnote 8: See _Comptes rendus Soc. de Biologie_, and _Arch. de Physiol._, 1879-84.]

[Footnote 9: W. H. Gaskell, “On the Structure and Function of the Nerves which Innervate the Vascular System,” _Journ. of Physiol._, Jan., 1886.]

If the various spinal nerves be cut singly from above downward, and the effects noted, and if the peripheral ends be irritated and the effects noted, and if with proper care the results be analyzed and compared, it will be found that the anatomical connections of the segments of the spinal cord with the sympathetic ganglia, which are so evident at each level, are not the ones by which physiological impulses pass out at that level. The vaso-constrictors of the head, which can be traced to the superior cervical ganglion, do not come from the upper cervical region of the cord, as might be supposed from the connections of that ganglion, but from the first three dorsal nerves. They reach the ganglion through the sympathetic cord in the neck, having traversed the inferior cervical ganglion on the way. There are vaso-constrictors in the cranial cavity which accompany the third, fifth, seventh, and twelfth nerves to the eye, face, and mouth. It is still undecided whether they originate in the cord and medulla, issue in the spinal accessory nerve, and with it enter the cranium (Gaskell), or reach those nerves by way of the carotid and vertebral plexus from the inferior cervical ganglion (Dastre and Morat). The vaso-constrictors of the arm, which can be traced to the inferior cervical and upper thoracic ganglia and to the thoracic sympathetic cord, are derived from the seven upper dorsal nerves. It is true that division of the roots of the brachial plexus causes a slight dilatation of the vessels of the arm, but this is so much increased when the dorsal nerve-roots are divided that it is evident that it is through them that the constrictor fibres chiefly pass. The vaso-constrictors of the leg, which can be traced into the second and third lumbar ganglia and lumbar sympathetic cord, are derived from the five lower dorsal and first lumbar nerves, and only join the crural and sciatic nerves after passing through the abdominal sympathetic. The thoracic viscera are probably supplied partly through the branches of the inferior cervical and thoracic ganglia, and partly through the pneumogastric, the latter statement being disputed by Gaskell. The abdominal viscera are supplied partly through the splanchnic nerves, which are made up of fibres issuing from the cord in the fifth to the twelfth dorsal nerves inclusive, and partly through the pneumogastric. Thus the dorsal region of the cord is the origin of the majority of vaso-constrictor fibres in the body.