PART VIII.

SYMPTOMATIC DISORDERS.

THERE are a number of symptomatic disorders very commonly met with in nervous maladies and essentially nervous in character that nearly reach the dignity of diseases. Headache, vertigo, insomnia, and neuralgia are the most important. Headache and vertigo have been specifically emphasized whenever they had a special relation to diseases of the nervous apparatus, and can be easily followed from the index. Neuralgia and sleep disorders require further study.

CHAPTER I.

NEURALGIA.

NEURALGIA (nerve pain) is always a symptom. Difficulty arises from the fact that intense neuralgic affections have often been confused with their most prominent painful symptoms. Neuritis and neuralgia have been differentiated only in recent years. Even now there are many who fail to discriminate between trifacial, brachial, and sciatic neuritides, and neuralgias of similar location. It also appears proven that an irritation at first producing neuralgia may, by its persistence, set up a neuritis, and it is certainly clear that neuralgia is one of the symptoms of neuritis. The distinction, therefore, is not always easy. Neuralgia may be an expression of disturbance acting (1) locally, or (2) systemically, or (3) in both ways at once. Neuralgias may be visceral or peripheral, and many visceral diseases have their corresponding peripheral or somatic neuralgias. In this relation the reader is referred to the section on Pain and the Referred Pains of Visceral Disorders as outlined by Head (p. 55, et seq). Many neuralgias-such as angina pectoris in cardiac disease, intercostal neuralgia in gastrohepatic disease, testicular neuralgia in kidney disease, pleurodynia, gastrodynia, and coccygodynia -are very clearly symptomatic and secondary. There are certain condi

tions favoring the appearance of neuralgia, and there are a few localized neuralgias that require individual consideration.

Conditions Favoring Neuralgias.-Intense neuralgic conditions are rare in early life and in old age, but when they appear after sixty, they usually have an irremediable organic basis and are correspondingly intractable. Women suffer in this way more than men. In some instances there is a marked hereditary tendency, and, as a rule, the "nervous" and neurotic, the possessors of unstable nerve-cells, are most prone to neuralgic conditions. This shows out strongly in the clinical histories of hysteria and neurasthenia. Arthritism in its broadest sense is a congener.

The inciting causes of disturbance marked by neuralgic features are very numerous. Any impairment of health, any debilitating influence, any continuous fatigue, anemia, emotion, concussion, may be symptomatized by neuralgia. Exposure to cold, peripheral local irritations, and any cause of neuritis, as well as every form of neuritis, may set up neuralgic pains. Nearly all toxic influences may induce neuralgia. Those toxic causes which are so active in the etiology of neuritis may induce neuralgic pain. Lead, alcohol, diabetes, auto-intoxication, malaria, and acute infections may all have neuralgic symptoms. The root pain of tabes, the peripheral pains of cortical brain disease, and the nerve pains of neuromata are easily understood.

Characters of Neuralgic Pains.-Neuralgic pains are commonly unilateral, and confined to the distribution of a part or the whole of a single nerve, or of several nerves. The pain is inconstant and usually paroxysmal, with complete freedom in the intervals, or with a dull ache between the severe pains. They are usually described as darting, stabbing, tearing, ripping, lightning-like, as if shot, and by other words or phrases expressing their sudden, instantaneous character. They may be repeated rapidly during a few minutes, or occur singly at longer intervals. The pain is located deeply in the parts, but often is attended by great superficial hypersensitiveness. At the same time deep pressure may give relief. During the painful attacks, motion of the muscles of the parts, a touch, even a breath of air in severe cases, may renew the stabbing pains. Heat, cold, and alcoholics may intensify or diminish the pain in various cases.

Neuralgic areas during the pains and between the paroxysms usually present nerve tenderness. This is most prominent at certain points where the nerve is superficial, overlies bone, or is inclosed by fascia or other rigid tissue. They correspond to the "maxima" of Head and constitute the "tender points" of Valleix.

In some cases the pain has a tendency to radiate into other branches of the same nerve or into related nerves. In the same way irritation of one branch of a nerve, especially of the trifacial, may induce neuralgia in another division. Neuralgic pains are often very fugaceous, appearing now here, now there, especially when arising from systemic causes.

The associated muscles may act spasmodically in the pain storms. This is rather common in the trifacial form, but it is difficult to tell whether the grimace is volitional or not. In the same way a sharp

leg neuralgia may be attended by a drawing up of the limb, and, if the patient is walking, he may suddenly fall.

Very often the parts subject to neuralgia show vasomotor disturbance and trophic changes. The vessels, at first constricted, usually dilate, and flushing follows. Edema, local sweating, erythema, scaliness, loss of hair, blanching of the hair, herpes, and pigmentation may attend upon neuralgia that is symptomatic of a neuritis. Localized hypertrophy, due to the continued congestive features of neuralgia, may be encountered.

Pathology. The mechanism of neuralgic pains has been a fruitful theme of discussions, into which we need not enter. The following facts indicate the interposition of the spinal apparatus in neuralgic pains: (1) The pain may occupy the areas related to several spinal segments, and not closely follow the distribution of nerves. In shingles, for instance, the herpetic and painful area on the upper trunk is bounded by horizontal planes, and not by the intercostal furrows; (2) irritation of one branch of the nerve may be radiated into another, which it could only reach by way of the nuclear cells; (3) the pain may develop exclusively in another region than the one irritated; (4) division of the posterior nerve-root, as has been done, especially by Abbé and others, or separation of the afferent path anywhere between the cord and lesion, immediately stops the neuralgia; (5) irritation of the proximal stumps of a divided nerve gives rise to pain referred to the periphery to which that nerve is anatomically related. This is seen in amputation neuromata and in anesthesia dolorosa.

By this conception we are able to understand how systemic poisoning, as by alcohol or malaria, may so predispose the spinal ganglia that pain is occasioned by a peripheral disturbance, perhaps insignificant in itself. It also explains the ability of an intense or protracted peripheral irritation to set up localized pain, which may long persist after the irritant condition has subsided.

Varieties of Neuralgic Pains.-An enumeration of the common varieties of neuralgic pains is all that need be attempted. They are classified (1) as to location, and (2) as to cause.

Varieties Depending upon Location.-Trifacial, cervico-occipital, cervicobrachial, brachial, dorso-intercostal, intercostal, lumbo-abdominal, spinal, sacral, coccygeal, sciatic, crural, metatarsalgia, etc. Visceral forms: Pleurodynia, angina pectoris, cardialgia, gastralgia, gastrodynia, hepatalgia, enteralgia, nephralgia, ovaralgia, testicular neuralgia, etc.

Varieties Depending on Cause or Association.-Epileptiform neuralgia, really a neuralgic facial tic; reflex sympathetic neuralgia, one in which the pain appears at a distance from its irritant source; traumatic neuralgias, really traumatic neuritis; occupation neuralgias, a part of occupation or fatigue neuroses; herpetic neuralgias, the neuralgic pains attending zoster; hysterical neuralgias, really stigmata of the neurosis; rheumatic, gouty, diabetic, anemic, and malarial neuralgias, associated with, and often due to, the respective systemic states; syphilitic neuralgia, very rare, and due to the syphilitic cachexia. Pains in syphilis are ordinarily due to neoplastic infiltration of the nerves and other tis

sues; degeneration neuralgia appears in the aged, and is due to involutional changes in the organism.

Trifacial Neuralgia. Of all varieties of neuralgia, that occurring in the trifacial is the most important. It often is extremely persistent and intractable. The constant exposure of the fifth pair in the face and nasopharynx to injury and infection of the periphery, the course traversed by the nerve through bony channels and over resisting structures, and its very extensive distribution territory, lay it especially liable to irritating and traumatic conditions. Its association with other cranial nerves sometimes causes it to be reflexly affected, as from the motor oculi and pneumogastric. It is affected about equally often on either side, and very rarely bilaterally. Exceptionally, all three branches are painful, but more commonly the neuralgia is confined to one or two of them.

When the first branch is affected, the pain is supraorbital, radiating from the supraorbital foramen over the corresponding side of the brow, or even to the vertex. The eyeball is frequently tender, or may be the seat of neuralgic pains. Tender points are usually found at the notch, on the upper lid, and over the lower margin of the nasal bone. When the second division is affected, the pain is located over the cheek, between the orbit and the mouth, spreading onto the wing of the nose. The tender points are at the lower border of the nasal bone, over the malar prominence, at the infraorbital foramen, on the gum above the canine tooth, and sometimes on the hard palate. In neuralgia of the third division, pain traverses the lower jaw and tongue and the corresponding portion of the face, extending, by the auricular branches, to the zygomatic, and even to the parietal region. The tender points are over the inferior dental foramen, in the temple, and in the parietal regions.

The pain is usually intense, lancinating, shock-like, and may cause the most excruciating torture. The attacks, if at all severe, usually cause vasomotor and secretory disturbance. Lacrimation, salivation, and mucous discharge from the nose may be encountered. The brow, or lip, or tongue, or the entire side of the face, may be swollen and edematous. The hyperalgesia is often intense, so that wiping the nose or eye, taking liquids into the mouth, and mastication are attended by great suffering, and often provoke a repetition of the neuralgic pains. Herpes possibly only occurs when histological changes in the nerve or its nucleus have taken place.

The neuralgias of the brachial, intercostal, and sciatic nerves are often intense, and present similar tender points and superficial hyperalgesia. The location of both have been described on page 55, et seq.

Treatment. The treatment of a symptom is necessarily the treatment of the underlying disease. Local and constitutional conditions capable of determining neuralgic pains must be carefully sought, and local conditions capable of producing neuralgia at a distance must not be overlooked. In order to specialize the matter we may consider the treatment of trifacial neuralgia in detail. With proper variations the same considerations and measures apply to other neuralgias.

Treatment of Trifacial Neuralgia.-In the treatment of a tri

facial neuralgia a careful search for local irritation is first to be made. In many cases pressure upon a given point will check or inhibit the pain. If such an inhibiting point can be found, it is a source of great relief to the patient. If the pain is intense and the hyperalgesia severe, the use of morphin or cocain may be required to make the examination. This should commence at the vertex. The scalp and brow should be carefully palpated, the orbit investigated, the eye examined for refractive errors, local inflammation, and glaucoma. The nasal fossæ, the antra, the nasopharynx, the mouth, and especially the jaws, must be thoroughly scrutinized. It is useless to sacrifice teeth unless a competent dentist finds them diseased. As a rule, a careful dental overhauling is a necessary measure in protracted cases, even where the pain is not located in the dental branches.

The general systemic state is of equal importance. The facial neuralgias of infections, grip, malaria, and eye-strain commonly involve the ophthalmic division. Dental and maxillary disease is most common in the middle branch. Compression of the nerve in the dental canal often causes neuralgia of the third branch. In elderly people who have lost their teeth the resulting greater elevation of the chin stretches the dental branch of the third, and may cause a neuralgia that can be readily relieved by the use of dental plates of proper vertical proportions to prevent the tug upon the affected nerve. Anemias, cachectic states, and conditions of auto-intoxication from the kidneys, stomach, or intestines, must be corrected. Neoplasms in the cranial cavity, or facial fossæ, jaws, and antra, may impinge upon the nerve and set up neuralgic pains.

In the management of these cases it is usually necessary to maintain complete rest. Many cases, otherwise rebellious, improve very rapidly under the Mitchell rest system. Food must usually be taken in a liquid form, and in very severe cases the nasal tube must be employed. Mastication ordinarily provokes the pains. Directed against the pain we have in malarial cases to employ large doses of quinin, or Warburg's tincture, or both, for several days, and follow them with arsenic, iron, and quinin in moderate doses for weeks. The purpose is to cinchonize the patient and maintain a saturation of the blood with quinin. A preparatory calomel purge is of importance. In other cases we have to resort to sedatives, and are usually reduced finally to the use of morphin. The reliable aconitia of Duquesnel, in doses of of a grain, several times a day, is sometimes of great service, and may be increased if well borne. Slight numbness of the lips, tongue, and fingers may be expected, and this amount of action can not safely be exceeded. Cocain, by local hypodermatic administration or anodal diffusion, is not reliable, and often acts badly. Morphin should only be given by the physician or a competent nurse. It is well if the patient can be kept in ignorance of the nature of the drug, owing to the tendency which is especially strong in these neurotic cases to the acquirement of the opium-habit. The use of electricity is more often disappointing than otherwise. The positive pole to the tender area, with three to ten milliamperes uninterrupted current for ten minutes, sometimes allays the pain. The current should