Part 2 (1/2)
In the inferior maxillary division the foci are: (1) The temporal, a point on the auriculo-temporal branch, a little in front of the ear; (2) the inferior dental point, opposite the emergence of the nerve of that name; (3) the lingual point, not a common one, on the side of the tongue; (4) the inferior l.a.b.i.al point, only rarely met with.
Besides these foci in relation with distinct branches of the trigeminus, there is one of especial frequency which corresponds to the inosculation of various branches. This is the parietal point, situated a little above the parietal eminence. It is small in size--the point of the little finger would cover it. It is the commonest focus of all.
Neuralgia may attack any one, or all, of the three divisions of the nerve; the latter event is comparatively rare. Valleix, indeed, holds a different opinion; but this seems to me to arise from the fact that his definition of neuralgia was too narrow to include a large number of the milder cases of neuralgia, which are, nevertheless I believe, decidedly of the same essential character with the severer affections. The most frequent occurrence is the limitation of the pain to the ophthalmic division, and incomparably the most frequent foci of pain are the supra-orbital and the parietal.
The most common variety of trigeminal neuralgia is migraine, or sick-headache, as it is often called. This is an affection which is entirely independent of digestive disturbances, in its primary origin, though it may be aggravated by their occurrence. It almost always first attacks individuals at some time during the period of bodily development. Under the influences proper to this vital epoch, and often of a further debility produced by a premature straining of the mental powers, the patient begins to suffer headache after any unusual fatigue or excitement, sometimes without any distinct cause of this kind. The unilateral character of this pain is not always detected at first; but, as the attacks increase in frequency and severity, it becomes obvious that the pain is limited to the supra-orbital and its twigs, with sometimes also the ocular branches. In rare cases, as in all forms of neuralgia, the nerves of both sides may be affected; I have already observed that this seems to be relatively more common in young children.
If the pain lasts for any considerable length of time, nausea, and at length vomiting, are induced. This is followed at the moment by an increase in the severity of the pain, apparently from the shock of the mechanical effect; but from this point the violence of the affection begins to subside, and the patient usually falls asleep. The history of the attacks negatives the idea that the vomiting is ordinarily remedial.
This symptom merely indicates the lowest point of nervous depression; but it may happen that a quant.i.ty of food which has been injudiciously taken, lying as it does undigested in the stomach, may of itself greatly aggravate the neuralgia, by irritation transmitted to the medulla oblongata. In such a case vomiting may directly relieve the nerve-pain.
When the patient awakes from sleep, the active pain is gone. But it is a common occurrence--indeed it always happens when the neuralgia has lasted a long time--that a tender condition of the superficial parts remains for some hours, perhaps for a day or two. This tenderness is usually somewhat diffused, and not limited with accuracy to the foci of greatest pain during the attacks.
Sick headache is not uncommonly ushered in by sighings, yawning, and shuddering--symptoms which remind us of the prodromata of certain graver neuroses, to which, as we shall hereafter see, it is probably related by hereditary descent. In its severer forms, migraine is a terrible infliction; the pain gradually spreads to every twig of the ophthalmic division; the eye of the affected side is deeply bloodshot, and streams with tears; the eyelid droops, or jerks convulsively; the sight is clouded, or even fails almost altogether for the time, and the darts of agony which shoot up to the vertex seem as if the head were being split down with an axe. The patient cannot bear the least glimmer of light, nor the least motion, but lies quite helpless, intensely chilly and depressed, the pulse at first slow, small and wiry, afterward more rapid and larger, but very compressible. The feet are generally actually, as well as subjectively, cold. Very often, toward the end of the attack, there is a large excretion of pale, limpid urine.
Another variety of trigeminal neuralgia which infests the period of bodily development is that known as clavus hystericus: clavus, from the fact that the pain is at once severe, and limited to one or two small definite points, as if a nail or nails were being driven into the skull.
These points correspond either to the supra-orbital or the parietal, or, as often happens, to both at once. But for the greater limitation of the area of pain in clavus, that affection would have little to distinguish it from migraine, for the former is also accompanied with nausea and vomiting when the pain continues long enough; and in both instances it is obvious that there is a reflex irritation propagated from the painful nerve. The adjective hystericus is an improper and inadequate definition of the circ.u.mstances under which clavus arises. The truth is, that the subjects of it are chiefly females who are pa.s.sing through the trying period of bodily development; but there is no evidence to show that uterine disorders give any special bias toward this complaint. Both migraine and clavus are often met with in persons who have long pa.s.sed their youth; but their first attacks have nearly always occurred during the period of development.
One circ.u.mstance in connection with well-marked clavus appears worth noting, as somewhat differentiating it from migraine. It is, I think, decidedly more frequently the immediate consequence of anaemia than they; but it does not appear, from my experience, that the chlorotic form of anaemia is any more provocative of it than is anaemia from any other cause. Some of the worst cases of clavus, probably, that have ever been seen were developed in the old days of phlebotomy. It was then very common for a delicate girl, on complaint of some st.i.tch of neuralgia or muscular pain in the side, to be immediately bled to a large extent, with the idea of checking an imaginary commencing pleurisy. The treatment, so far from curing the pain and the dyspepsia (which it produced), often aggravated them; whereupon the signs of inflammation were thought to be still more manifest, and more blood was taken. Under such circ.u.mstances the most complete anaemia was developed, and very often the patient became a martyr to clavus in its severest forms. One does not now very frequently meet with the victims of such mistaken practice; but I have seen one [since writing this I have seen another case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus produced by loss of blood (in a subject who was doubtless predisposed to neuralgic affections, to judge from his family history). The case was that of a boy who accidentally divided his radial.
The middle period of life is not, according to my experience, fruitful in first attacks of trigeminal neuralgia. But, when the neuralgic tendency has once declared itself, there are many circ.u.mstances of middle adult life which tend to recall it. Over-exertion of the mind is one of the most frequent causes, especially when this is accompanied by anxiety and worry; indeed, the latter has a worse influence than the former. In women, the exhaustion of haemorrhageal parturition, or of menorrhagia, and also the depression produced by over-suckling, are frequent causes of the recurrence of a migraine or clavus to which the patient had been subject when young. The middle period of life is very obnoxious to severe mental shocks, which are more injurious than in youth, because of the diminished elasticity of mind which now exists; and the same may be said of the influence of severe bodily accident of a kind to inflict damage on the central nervous system. Special mention ought to be made, in the case of women, of the disturbing influence of the series of changes which close the middle portion of their life, viz., the involution of the s.e.xual organs. It would seem as if every evil impression which has ever been made on the nervous system hastens to revive, with all its disastrous effects, at this crisis. Latent tendencies to facial neuralgia are particularly apt to rea.s.sert their existence, and they are usually accompanied and aggravated by a tendency to vaso-motor disturbance, which not unfrequently seems to be the most distressing part of the malady. I have several times been consulted by women undergoing the ”change,” whose chief complaint was of disagreeable flus.h.i.+ngs and chills, especially of the face; and, on inquiring further, one has found that they were suffering from severe facial neuralgia, which, however, alarmed and distressed them less than did the vaso-motor disturbance, and the giddiness, etc., which were an evident consequence of it.
It is, however, the final or degenerative period of life which produces the most formidable varieties of facial neuralgia. Neuralgia of the fifth, which have previously attacked an individual, may recur at this time of life without any special character, except a certain increase of severity and obstinacy. But trigeminal neuralgias, which now appear for the first time, are usually intensely severe, and nearly or quite incurable. These cases correspond with the affection named by Trousseau tic epileptiforme, and it is of them, doubtless, that Romberg is speaking, when he says that the true neuralgias of the fifth rarely occur before the fortieth year of life. These neuralgias are distinguished by the intense severity of the pain, the lightning-like suddenness of its onset, and the almost total impossibility of effecting more than a temporary palliation of the symptoms. But they are also distinguished by another circ.u.mstance which too often escapes attention, namely, they are almost invariably connected with a strong family taint of insanity, and very often with strong melancholy and suicidal tendencies in the patient himself, which do not depend on, and are not commensurate with, the severity of the pain which he suffers. It may seem a strong view to take, but I must say that I regard a well-developed and typical neuralgia, of the type we are now speaking of, as an affection in which the mental centres are almost as deeply involved as in the fifth nerve itself; though, whether this is an original part of the disease, or a mere reflex effect of the affection of the trigeminal nerve, I am not prepared to say. Other reflex affections are common enough in this kind of facial neuralgia, and especially spasmodic contractions of the facial muscles, which, indeed, often form one of the most striking features of the malady, the attacks of pain being accompanied by hideous involuntary grimaces. Even in the earlier stages of the disease there is usually some degree of the same thing, as, for instance, spasmodic winking. In the great majority of cases, after a little time, exquisitely tender points are formed in the chief foci of pain; in the intervals between the spasms the least pressure on these points is sufficient to cause agony, and a mere breath of wind impinging on them will often reproduce the spasm. Yet, in the height of the acute paroxysm itself, the patient will often frantically rub these very parts in the vain attempt to produce ease; and it has often been noticed that such friction has completely rubbed off the hair or whisker on the affected side: this happens the more easily, because the neuralgic affection itself impairs the nutrition of the hair and makes it more brittle, as we shall have occasion to show more fully hereafter. The general appearance of a confirmed neuralgic of the type now described is very distressing, and the history of his case fully corresponds to it. He is moody and depressed, he dreads the least movement, and the least current of air; he hardly dares masticate food at all, more especially if the inferior maxillary division of the nerve be implicated (as is generally the case sooner or later), for this movement re-excites the pain with great violence. Nutrition is very commonly kept up by slops, and is thus very insufficiently maintained: this failure of nutrition is itself a decidedly powerful influence in aggravating the disease. And there is a still further calamity which is not unlikely to occur. The patient may fly to the stupefaction of drink as a relief to his sufferings, and, if he has once experienced the temporary comfort of drunken anaesthesia, is excessively likely to repeat the experiment. But this is another and one of the most fatally certain methods of hastening degeneration of nerve-centres, and the ultimate effect, therefore, is disastrous in every way.
Although the neuralgias of the degenerative period are thus fatally progressive, on the whole, there are some curious occasional anomalies.
Many cases are recorded, and I have myself seen such, in which the attacks of pain, after reaching a very considerable degree of intensity, have ceased for many months, whether under the influence of remedies or not it is difficult to say with certainty, but probably far more from independent causes. Whatever may be the reason of these sudden arrests, however, certain it is that they are very seldom permanent, the pain returning sooner or later, like an inexorable fate.
(_b_) _Cervico-occipital Neuralgia._--As Valleix has remarked, there are several nerves (in fact, the posterior branches of all the first four spinal pairs) which are more or less frequently the seat of this affection. But among them all there is none comparable to the great occipital, which arises from the second spinal pair, for the frequency and importance of its neuralgic affections. This nerve sends branches to the whole occipital and the posterior parietal region. On the other hand, the second and third spinal nerves help to make up the superficial cervical branch of the cervical plexus which is distributed to the triangle between the jaw, the median line of the neck, and the edge of the sterno-mastoid, and those to the lower part of the cheek. Then there is the auricular branch, which starts from the same two pairs, and supplies the face, the parotid region, and the back of the external ear.
Then the small occipital, distributed to the ear and to the occiput.
And, finally, superficial descending branches of the plexus. These, altogether, are the nerves which at various points, where they become more superficial, form the foci of cervico-occipital neuralgia.
The most typical example of this form of neuralgia which has fallen under my notice occurred (after exposure to cold wind) in a lady about sixty years of age, who had all her life been subject to neuralgic headache approaching the type of migraine, and who came of a family in which insanity, apoplexy, and other grave neuroses, had been frequent.
The pain centred very decidedly in a focus corresponding to the occipital triangle of the neck; it recurred at irregular intervals, and in very severe paroxysms, lasting about a minute. It was interesting to follow the history of this case in one respect. It afforded a clear ill.u.s.tration of the manner in which local tenderness is developed; for during the first three or four days the patient, so far from complaining that the painful part was tender on pressure, experienced decided relief from pressure, although she experienced none from mere rest, however carefully the neck might be supported. But in the course of a few days an intensely painful spot developed itself in the occipital triangle, and the back of the ear became excessively tender. All manner of remedies had been tried in this case, without the slightest success and especially there was a large amount of speculative medication, on the theory of the probably ”rheumatic” or ”gouty” nature of the affection.
Nothing was doing the least good to the pain, and meantime the old lady's digestion and general health and spirits were suffering very severely. Blistering was now suggested, and the affection yielded at once. The relief afforded must have been very complete, to judge by the warm grat.i.tude which the patient expressed. The subsequent history of this patient ill.u.s.trates several points which will engage our attention under the section of Pathology. It may be just mentioned here, that she suffered, twelve months later, from a hemiplegic attack of paralysis.
The tendency of cervico-occipital neuralgias is to spread toward the lower portions of the face, as observed by Valleix; in this case they become, sometimes, undistinguishable from neuralgias of the third division of the trigeminus. In the early stages of the disease, if the physician had been lucky enough to witness them, the true place of the origin of the pain would have been easily recognizable; at a later date it sometimes needs great care, and a very strict interrogation of the patient, to discover the true history of the disease. Sometimes, even, a cervico-occipital neuralgia which spreads in this way causes great irritation and swelling of the submaxillary and cervical glands; and I have known a case of this kind mistaken for commencing glandular abscess. The pain and tension were so great in this case, and the const.i.tutional disturbance was so considerable, that the presence of deep-seated pus was strongly suspected, and the propriety of an incision (which would have been a hazardous proceeding) was seriously canva.s.sed.
Experience is too limited, to judge by what I have personally seen, and the recorded cases with which I am acquainted, to enable us to say anything with confidence of the conditions, as to age and general nutrition of the body, which specially favor the occurrence of cervico-occipital neuralgia. Apparently, however, there is much reason for thinking that the immediately exciting cause of it is most frequently external cold. I have known it produced several times in the same person, by sitting in a draught which blew strongly on the back of the neck. And I am inclined to think that it is seldom the first form of neuralgia which attacks a patient, but usually occurs in those who have previously suffered from neuralgic pains either of the trigeminus or of some other superficial nerve. I have known it once to occur in a person, thus predisposed to neuralgic affections, in consequence of reflex irritation from a carious tooth, as was proved by its cessation on the extraction of the latter, although there was no facial pain.
(_c_) _Cervico-brachial Neuralgia._--This group includes all the neuralgias which occur in nerves originating from the brachial plexus, or from the posterior branches of the four lower cervical nerves. The most important characteristic of the neuralgias of the upper extremity is the frequency, indeed almost constancy, with which they invade, simultaneously or successively, several of the nerves which are derived from the lower cervical pairs. The neuralgic affections of the small posterior branches (distributed to the skin of the lower and back part of the neck) are comparatively of small importance. But the ”solidarite,” which Valleix so well remarked, between the various branches of the brachial plexus, causes the neuralgias of the shoulder, arm, forearm, and hand to be extremely troublesome and severe, owing to the numerous foci of pain which usually exist. Perhaps Valleix's description of these foci is somewhat over-fanciful and minute; but the following among them which he mentions I have repeatedly identified; (1) An axillary point, corresponding to the brachial plexus itself; (2) a scapular point, corresponding to the angle of the scapula. (It is difficult to identify the peccant nerve here; the one to which it apparently corresponds, and to which Valleix refers it, is the subscapular; but we are accustomed to think of this as a motor nerve.
Still, it is certain that pressure on a painful point existing here will often cause acute pain in the nerves of the arm and forearm.); (3) A shoulder point, which corresponds to the emergence, through the deltoid muscle, of the cutaneous filets of the circ.u.mflex; (4) a median-cephalic point, at the bend of the elbow, where a branch of the musculo-cutaneous nerve lies immediately behind the median-cephalic vein; (5) an external humeral point, about three inches above the elbow, on the outer side, corresponding to the emergence of the cutaneous branches which the musculo-spiral nerve gives off as it lies in the groove of the humerus; (6) a superior ulnar point, corresponding to the course of the ulnar nerve between the olecranon and the epitrochlea; (7) an inferior ulnar point, where the ulnar nerve pa.s.ses in front of the annular ligament of the wrist; (8) a radial point, marking the place where the radial nerve becomes superficial, at the lower and external aspect of the forearm.
Besides these foci, there are sometimes, but more rarely, painful points developed by the side of the lower cervical vertebrae, corresponding to the posterior branches of the lower cervical pairs.
The most common seat of cervico-brachial neuralgia has been, in my experience, the ulnar nerve, the superior and inferior points above mentioned being the foci of greatest intensity; an axillary point has also been developed in one or two cases which I have seen. Rarely, however, does the neuralgia remain limited to the ulnar nerve; in the majority of cases it soon spreads to other nerves which emanate from the brachial plexus. A very common seat of neuralgia is also the shoulder, the affected nerves being the cutaneous branches of the circ.u.mflex. I am inclined to think, also, that affections of the musculo-spiral, and of the radial near the wrist, are rather common, and have found them very obstinate and difficult to deal with. One case has recently been under my care in which the foci of greatest intensity of the pain were an external humeral and a radial point; but besides these there was an exquisitely painful scapular point. In another case the pain commenced in an external humeral and a radial point, but subsequently the shoulder branches of the circ.u.mflex became involved. A most plentiful crop of herpes was an intercurrent phenomenon in this case, or rather, was plainly dependent on the same cause which produced the neuralgia.
Median cephalic neuralgia is an affection which used to be comparatively common in the days when phlebotomy was in fas.h.i.+on, the nerves being occasionally wounded in the operation. I have only seen it in connection with this cause, that is to say, as an independent affection. One such case has been under my care. But a slight degree of it is not uncommon, as a secondary symptom, in neuralgia affecting other nerves. The traumatic form is excessively obstinate and intractable.
In the neuralgias of the arm we begin to recognize the etiological characteristic which distinguishes most of the neuralgic affections of the limbs, namely, the frequency with which they are aggravated, and especially with which they are kept up and revived when apparently dying out, the muscular movements. In the case above referred to, of neuralgia of the subscapular, musculo-spiral (cutaneous branches), and radial, the act of playing on the piano for half an hour immediately revived the pains, in their fullest force, when convalescence had apparently been almost established.
There is a special cause of cervico-brachial neuralgias which is of more importance than, till quite lately, has ever been recognized, namely, reflex irritation from diseased teeth. The subject of these reflex affections from carious teeth has been specially brought forward by Mr.
James Salter, in a very able and interesting paper in the ”Guy's Hospital Reports” for 1867; and Mr. Salter informs me that he has been surprised by the number of cases of reflex affections, both paralytic and neuralgic, of the cervico-brachial nerves, produced by this kind of irritation, and that he agrees with me in thinking that a peculiar organization or disposition of the spinal centres of these nerves must be a.s.sumed in order to account for the fact.