Part 6 (1/2)

CASE I.--A woman, aged sixty-three, presented herself in the out-patient room at Westminster Hospital, suffering from neuralgia of ten days'

standing (which for the present, however, seemed to have abated considerably), but asking advice chiefly for an erysipelatoid inflammation which had come on a day or two before, and occupied the area of the painful nerve-district. The neuralgia had affected the supra-orbital nerve, running up toward the vortex, and the auriculo-temporal branch of the third division of the fifth; although there was no very acute pain present at this time, pressure over the supra-orbital notch, or at a point just in front of the ear, would at once cause a brief paroxysm of pain. It was curious to find that there was a thickened and tender spot over the malar bone (and corresponding to the exit of some nerve filaments from the bone) which had never been the seat of spontaneous neuralgia, but pressure here sent a dart of pain into the auriculo-temporal and supra-orbital nerves. The inflammation was markedly limited to the general area of distribution of the twigs of the auriculo-temporal and of the ophthalmic division; it was of a continuous deep-red color, and attended with much thickening of the skin. The conjunctiva was intensely congested, and there were lachrymation and very marked photophobia, but there were no signs of iritis, and no corneal clouding.

CASE II.--M. W., a woman, aged forty-two, well-nourished and healthy-looking, married and had one child; had never suffered any serious ailment except once, about five years previously. She then had a decided attack of ”erysipelas,” very accurately limited to the right half of the face. Five months before coming to me she sustained a severe shock from being thrown out of a chaise, without suffering any external or visible damage. An hysterical tendency, which she had always possessed, became more marked; it revealed itself by palpitations, occasional dysphagia, and a disposition to weep causelessly. The menses were flowing at the time of the accident; they ceased abruptly soon after (they had been scanty for some time previously), and did not recur till four months later. The hysteric disturbance progressively increased during a fortnight, and then the patient was attacked with violent intermittent neuralgia, commencing in the eyeball and spreading over the district supplied by the branches of the first and second divisions of the trigeminus. The pain was accompanied by intense conjunctival congestion and photophobia [Dr. Handfield Jones remarks that photophobia, in his experience, is only a rare accompaniment of facial neuralgia. I have latterly come to the same opinion. Redness of the eye and lachrymation are very common; true photophobia uncommon. Notta's experience would seem to have been similar]. It lasted on the first day fourteen hours, and returned daily for the next fifteen or sixteen days.

An attack of erysipelas, strictly limited to the district of the painful nervous branches, then set in. From that moment the neuralgic attacks became less frequent and severe. A second similar onset of erysipelas occurred some three or four weeks after the first. Finally, the neuralgia disappeared about four months after its first occurrence, and the menses reappeared in tolerable abundance about the same time. About a fortnight before this the patient had discovered that her right eye was dim; as the photophobia had previously disabled her from opening the eye, she could not be sure how long this dimness had existed. At the time of her visit to me the cornea was blurred with a large patch of interst.i.tial lymph, with the remains of a superficial ulcer in the centre; the iris was turbid and discolored, showing the traces of recent but past iritis; the pupil was regular in form and active to light; the conjunctiva was slightly congested. Ophthalmoscopic observation was attempted by a skilled observer, but could not be satisfactorily carried out, from the turbid state of the media. The conjunctiva was slightly congested. In place of the lachrymation that had prevailed during the neuralgic period, there was a remarkable insensibility of the lachrymal apparatus, for the patient had noticed that the smell of onions, which would make the other eye weep profusely, had no influence on the affected one.

The family history of this patient is a most remarkable one. All the members of her mother's family, for two generations back, had died at middle age, either from apoplexy or some disease involving hemiplegia.

This case has, by a mistake, not been added to the list of twenty-two private cases in which the family history was carefully investigated, that will be found in the chapter on Pathology; this arose from the fact that the patient was not properly under my care, but was sent to me as a medical curiosity; the notes of her case were therefore taken in a different book from the others. The case certainly ought to be taken as a counterpoise to such a one as No. XVI. in the list, which is that of a gentleman who suffered from the most complicated neurotic maladies (asthma, angina pectoris, facial neuralgia, more than once attended with erysipelas), but whose family history, so far as it was known, presented no traces of tendency to neurotic disease.

To these two cases of inflammation, secondary to neuralgia, I shall add a third, which is even more interesting, and which came under my notice not long since.

CASE III.--H. T., watchmaker's a.s.sistant, aged forty-two, suffered for about three weeks with very severe remittent abdominal pain, entirely unconnected with dyspepsia, constipation, or diarrhoea. It was intermittent in character, but observation soon showed that the times at which it came on were simply those at which the stomach had gone longest without food, especially the early morning, and that nourishment never failed to relieve it. The suffering was great, and the man failed considerably in general health, notwithstanding that his appet.i.te and digestion were unimpaired. He had only been under my care about ten days when he presented himself one day at the hospital, and stated that the pains in the stomach had entirely left him, but that he suffered the most frightful pains in and around the right eye. I found a well-marked conjunctival congestion and lachrymation, but there were as yet no tender points; the neuralgia was felt most severely in the globe of the eye and in one tolerably straight line, darting up toward the vertex from the brow. The iris seemed clear and free, and the cornea was not cloudy. I gave the man a subcutaneous injection of one-sixth grain acetate of morphia, for present ease, and ordered him muriate of iron and small doses of strychnia three times a day. When he next appeared, four days later, I was alarmed to perceive that unmistakable iritis had fully developed itself, the iris was already turbid and discolored and the pupil irregular, from a serious amount of adhesions. By this time there were fully-developed tender points, supra-orbital and parietal; besides this, pressure on the globe caused paroxysms of pain, in all the branches of the ophthalmic division, but there was not much spontaneous pain. I dropped atropine in the eye, applied blistering fluid to the back of the neck, [the nape of the neck is the point most suitable for blistering which is intended to affect the eye, and the ophthalmic division of the fifth, generally,] and desired the man to come to see me at my own house next day, intending to take him to an ophthalmic surgeon. Unfortunately he failed to do this, and three days later, when he came to see me at the hospital, the cornea was studded with opacities, the pupil was almost closed with effused lymph, there was violent ocular pain, and a great and increasing sense of tension. I begged him to go without loss of time to the Eye Hospital, as my own ophthalmic colleague was not at Westminster that day; and I have never heard any more of the patient.

Glaucoma is a still more serious disease of the eye, which I think there is now sufficient evidence to show is sometimes entirely, and very often in considerable part, neuralgic in its origin. Since my attention was directed, some six years ago, to the frequent connection between the so-called rheumatic iritis and neuralgia, I have taken much interest in the subject of acute eye-affections; and the occurrence of one or two cases of glaucoma in personal friends of my own has made this interest even painfully strong. I am necessarily without the means of personally observing glaucoma on the large scale, but I have now seen two cases in which, if I possess any faculty of clinical observation whatever, the whole genesis of the disease was a neuralgic disorder of the trigeminus; and it was to me a melancholy reflection that nothing better than iridectomy in one case, and excision of the eyeball in the other, could be done in the present state of ophthalmic science. There are now a good many recorded instances of neuralgic glaucoma, and Mr. R. Brudenell Carter, of St. George's, and the South London Ophthalmic Hospital, recently a.s.sured me that nervous aspect of some form of glaucoma presents itself the strongly to his mind, though he does not commit himself to any theory. Two cases were reported by Mr. Hutchinson, in Ophthalmic Hospital Reports IV. and V.; but the most complete and interesting cases that I have met with are recorded by Dr. Wegner;[15]

they are two out of four that occurred within a very short time in the clinic of Prof. Horner at Zurich, and they form the basis of some researches by Wegner into the nature of the influence of the trigeminus upon ocular tension, which will be referred to, along with others, in the chapter on Pathology. The second of these cases is so important that I shall reproduce it in full.

A. Hediger, aged twenty-four, a moderately strongly-built young woman, seen first in August, 1860. From her own and her mother's account, it seemed she had long suffered from convulsive attacks that did not appear to have been truly epileptic. Some days previously her left eye became very painful, and the sight failed, without any inflammatory symptoms.

On inspection the pupil was somewhat dilated, the eye somewhat hypermetropic, fundus normal; No. 5, Jager's type, was read with difficulty. Wegner could not explain the condition. At the end of October the eye was much worse; after severe paroxysms of pain, No. 16 type was the smallest legible, the field of vision was decidedly limited in all directions, but especially on the inner and upper portions. An unusually long hysteric attack was now observed. The patient was for twenty-four hours in a half-sleep, the extremities, meantime, were much jerked, the speech sometimes coherent and sometimes incoherent; she cried out to her friends, etc., but had no severe convulsion-fit with spasm of glottis. She was removed to the hospital, where she stayed six weeks. The hysteria improved under treatment with valerian and morphia (Prof. Greisinger had confirmed the opinion that there was no true lesion of the centres), but the neuralgia of the globe was extraordinarily severe, both day and night. From January to June, 1861, Wegner saw her occasionally. The visual power of the left eye fluctuated between 15 and 19 Jager. Field of vision very limited. Pupil very dilated and insensitive, the globe painful to the touch, and injected.

The right eye weakly hypermetropic; normal field of vision, normal pupil, no pain. The scene suddenly changed on the 29th of June. She was attacked with fearful pain, and an enormous mydriasis with extreme amblyopia of the right eye; the fingers could hardly be counted when placed quite close. The optic disc appeared somewhat cloudy, with very evident venous pulsation. The mydriasis, amblyopia, and neuralgia lasted some time, while simultaneously the left eye could only read 19-17 type, but was painless. The pathology seemed quite obscure, and the surgeon remained almost pa.s.sive till August, when he performed paracentesis on the left eye. The patient could distinguish fingers at that time at a foot's distance with the right eye; with the left read No. 11, but suffered fearful pains. These diminished after the puncture; the eye could read No. 20 next day, and improved after that to 19; the pains recurred in the next day, but for the first time ceased to disturb sleep. The scene again changed in the most surprising manner on the 27th of August. The most frightful pain again attacked the left eye. The pupil was dilated to the maximum (far beyond what occurs in oculo-motor paralysis); the globe was extremely painful on touch, visual power fallen to 19 Jager. On the other hand, the right eye had a normal pupil, was painless, and could read No. 12. Paracentesis of the left eye improved its vision and diminished pain, but only temporarily, so that it had to be repeated at short intervals. The condition was so far stationary toward the end of October that the right eye continually gained visual power, but the left stood still and fluctuated from worse to better, with the greater or less severity of the neuralgic paroxysms.

Pupils always in extreme dilatation. In the end of October and beginning of November (the patient had worn a large seton for a month) remarkable changes occurred; the neuralgia of the left globe diminished steadily, the pupil got smaller, the visual power increased, the neuralgia now was only on the lower lid, which was slightly red and painful to the touch, and had continual spontaneous pain. Visual power of right eye No. 3, of left eye No. 5. Visual field intact; with full illumination by weak light there is a peripheral torpor, but only in a narrow zone. The hyperaemia now extended more and more over the lower lid and the upper part of the cheek; this was apparent during the paroxysms, which were very severe, and destroyed sleep; it did not allow the skin to be touched; the color was deep (with high temperature) and extended to the angle of the mouth. This phenomenon lasted till the beginning of December, when neuralgia again attacked the left globe, with strong mydriasis and diminution of visual power (15 to 20 Jager), till at last the movements of the hand could hardly be distinguished, and this state of things continued with fluctuations up to the end of the month. The seton had been taken off just before the new outbreak; it was put in again on December 31st. In January the pains continued severe in the eye, with only one remission (from the 17th to the 20th), when the hyperaemia recurred in the cheek. On the 26th the pupil was very dilated, and fingers could not be seen at half a foot's distance. Visual field very limited, globe hard. A large upper iridectomy was made. After this the pupil was contracted, the pains diminished, visual power 10 Jager, field seven inches. In the middle of February the hysterical attacks recurred with great force; the patient was unconscious half the day; she was clear enough in senses when awake, but complained of buzzing in her head, as if a c.o.c.k-chafer were inside it. From this till the middle of March, the left eye did not alter, the impairment of vision remained, with normal pupil and no pain in the globe, and the iridectomy seemed at least to have done good in one direction; but on the 13th of March the operated eye was again attacked with pain, visual power fell to No. 17, pupil became dilated, and after a few days the swelling, heat, and tenderness of the cheek recurred. During the years 1862 and 1863 the condition remained pretty much the same; _i. e._, the right eye sound, the left painful (in spite of the iridectomy) with dilated pupil, concentrically narrowed visual field, visual power fluctuating between No. 15 and mere finger-counting without any ophthalmoscopic appearances.

A number of paracentesis and subcutaneous injections of morphia (which last were the more indicated as the supra-orbitalis was tender on pressure) always brought relief merely for a few hours. On the 19th of April, 1864, vision being complete in right eye, and No. 19 in left, Wegner punctured the latter. On the 2d of May the eye read No. 10 slowly, the pains had gone and not returned, the pupil became smaller.

On the 31st of March, 1865, the patient was p.r.o.nounced well; the eye was painless, the pupil somewhat larger than the other; the finest type could be read when looked at very close.

3. The next group of affections secondary to neuralgia are the paralysis of muscles. These are pretty common; I find them in twenty-eight of the hundred cases which have been referred to. But of these twenty-eight instances of paralytic affections no less than twelve were connected with neuralgia of the trigeminus, and in most of these it was one or more of the muscles connected with the eye that were affected. Sciatica is nearly always attended with much weakening of voluntary power of the muscles of the thigh and leg; and in some instances this reaches to decided or even complete paralysis. In looking for this phenomenon we must be very careful that we do not mistake the mere reluctance to move the limb, on account of the painfulness of all movements, for true paralytic weakness of nerve and muscle. And it is also necessary to bear in mind, in prolonged cases, the probability that much of the weakness may have been caused by degeneration of the muscles owing to forced inaction. Still, there is a cla.s.s of secondary paralyses that are in no way to be confounded with such effects as these: for instance, it occasionally happens, almost in the very first onset of severe sciatic pain, that the limb hangs absolutely helpless; and in one such case lately, being struck with the completeness of the loss of power, I tested the Faradic irritability by directing a sharp current on comparatively exposed portions of the painful nerve (_e. g._, in the popliteal s.p.a.ce, and behind the head of the fibula), and elicited only the most feeble contractions, entirely unlike what the same current evoked in the opposite limb. I regret that I have as yet found it impossible to carry out a regular inquiry as to the sensibility to the different currents of motor nerves which are centrally connected with neuralgic sensory nerves.

Muscular viscera which are composed of unstriped fibre, like the intestines, or of a mixture of striped and unstriped, like the heart, are probably very liable to a secondary paralytic influence from certain special neuralgiae. It is ascertained that the pain of a certain degree of severity in the branches of the fifth may absolutely stop the heart's action for a moment--an effect which is succeeded, usually, by violent and disorderly pulsations. I have myself once known the operation of ”pivoting” a tooth, which gave frightful pain, cause instantaneous and most alarming arrest of the heart's motion, which for a minute or two seemed as if it were going to be fatal. But the variety of visceral paralysis which is probably far the most frequent is secondary paralysis of the bladder, from neuralgia in one or other of the pelvic organs, or of the external genitalia; and next to this comes paralytic distension of the caec.u.m, colon, or r.e.c.t.u.m, secondary to various abdominal and pelvic neuralgic affections. In one instance of acute ovarian neuralgia that I saw, the paralytic distention of the colon was by far the most remarkable circ.u.mstance, so enormously was it developed; and for some days after the neuralgia had ceased, and when the flatulence had nearly disappeared, the intestine remained absolutely torpid.

4. Convulsive actions of muscles, as every one knows, are very common complications of neuralgia. In trigeminal neuralgias these may be observed (according to the division or divisions of the nerve that are affected) in the proper muscles of the eye, or in those supplied by the fourth and sixth nerves, or (perhaps only when two or three divisions of the fifth are neuralgic at once) by the portio dura. It is curious, however, that those formidable spasmodic affections of the face which belong to the same order as torticollis and writer's cramp, are not frequently, if ever, directly a.s.sociated with trigeminal neuralgia. The only connection between them seems to be that these peculiar spasmodic affections are only developed in highly-neurotic families, some of whose members are almost sure to be found suffering from some form of regular neuralgia. In severe sciatica it has several times happened to me to see convulsive action of the flexors, bending the leg spasmodically upon the thigh. And in a very large proportion of all neuralgias, wherever situated, attentive observation of the patient during the paroxysms will detect the existence of local twitching or local spasm of muscles, though these may be slight in degree.

Among the convulsive affections must be reckoned convulsive movements and tonic spasms of various portions of the alimentary ca.n.a.l. Vomiting is a common example of this; in migraine it is the regular and necessary climax of attacks which last with severity for a certain time; indeed, any severe attack of neuralgia involving the ophthalmic division of the fifth may excite vomiting. Convulsive action of the pharyngeal muscles, as a complication of pharyngeal or laryngeal neuralgia, occasionally occurs to such an extent as to render deglut.i.tion difficult or impossible for the time. And I have seen what I do not doubt to have been a spasmodic condition of the r.e.c.t.u.m induced by peri-uterine neuralgia. The genito-urinary organs are also not unfrequently affected spasmodically in consequence of a neuralgic affection either peri-uterine or pudendal. I have seen spasmodic stricture of the male urethra thus produced, and likewise v.a.g.i.n.al spasm.

5. Impairments of sensation, both common and special, are very frequent attendants of neuralgia. As regards the special sensations, we may first mention that of touch; this is almost constantly impaired, immediately before, during, and some little time after a neuralgic paroxysm, in the skin supplied by the painful nerves. I was first led to make this observation by my own experience; the skin all round the inner angle of my right eye is permanently less sensitive to distinctive impressions than that of the opposite side, and this impairment is always decidedly greater, and spreads over a larger surface, before, during, and for some time after, the attacks of pain. More extended observation has convinced me that a certain amount of bluntness of distinctive skin-sensation accompanies nearly every neuralgia. As regards the sense of taste, I have found this decidedly perverted, at the time of an attack, even in my own case, although the neuralgia never extends into the third branch of the nerve. It is interesting to notice, in connection with this, that the epithelium of my tongue has been seen, on one occasion, to be exaggerated on the side of the neuralgic affection, showing a probability that there is perturbed function, at any rate of certain fibres, of the third division. But I have seen much more decided alteration, indeed temporary entire abeyance of the power to distinguish between the tastes of different substances, with the affected side of the tongue, in a case of severe epileptiform tic in which the third division was strongly affected with neuralgia; and Notta records a similar instance. As regards vision, besides minor perversions and disturbances, I have observed more or less complete amaurosis in several instances of ophthalmic neuralgia; in one case it was absolute, and lasted, with but slight improvement in the intervals between the paroxysms, for nearly a month, but disappeared entirely, though somewhat gradually, after the final cessation of the neuralgia. As regards hearing, I have noticed serious impairment only in five cases, all of them of a severe type of trigeminal neuralgia, involving all three divisions of the nerve. Smell, I have never observed to be more than doubtfully impaired, except in one case (_vide_ Chapter III), where it was completely destroyed.

Common sensation was reported by Notta as affected in only three cases out of a hundred and twenty-eight; but my own experience has afforded a much larger proportion of instances in trigeminal neuralgia. Indeed, in all situations neuralgia appears to me to involve this effect, in the larger number of instances, in the early stages; later, it is supplanted in part by great tenderness on pressure in the well known _points douloureux_, and sometimes the tenderness becomes diffused over a considerable surface. I agree with Eulenburg in thinking that anaesthesia is more frequent in sciatica than in other neuralgias.

6. Secretion is often very notably affected in neuralgia; the phenomena are necessarily more easily observed in connection with affections of the trigeminal than of other nerves. In the great majority of cases the affection is in the direction of increase; at least, the watery elements of secretion are often poured out in profusion. Thus, profuse lachrymation is exceedingly common in ophthalmic neuralgia; in a large number of cases there is also copious thin nasal flux on the affected side; sometimes, however, the secretion, though copious, is semi-purulent, or b.l.o.o.d.y. Increased salivation has been noticed, by a large number of observers, in neuralgia involving the lower division of the fifth. In a smaller number of instances, the secondary effect on secretion is precisely opposite; thus both Notta and myself have observed complete dryness on the nostril on the affected side in ophthalmic neuralgia.

I might expand this chapter on the complications of neuralgia to a very much greater length; but, as regards the clinical history of these affections, it is perhaps better not to occupy more time and s.p.a.ce. It will, however, be necessary to return to the consideration of the subject in connection with Pathology.

FOOTNOTE:

[15] Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.

CHAPTER III.

PATHOLOGY AND ETIOLOGY OF NEURALGIA.