If we inquire a little further into the circumstances under which various kinds of pain occur, we gain some fresh suggestions. Among the neuralgias, those are the most acutely agonizing which occur under circumstances of impaired nutrition incident to the period of bodily decay, and strong reasons will be hereafter adduced for the belief that there is especial impairment of the nutrition of the central end of the painful nerves. To find a parallel to the severity of this kind of pains we must turn to the case of organic tumors, which, from their position, structure, and mode of growth, necessarily exercise continuous and severe pressure on the branches or the trunk of a nerve; or to the class of pains which attend severe cramp, or tonic contraction of muscles. Now, it can scarcely be doubted that in the latter instance there is an abnormally rapid and violent destruction of tissue going on; at the very least there is an extraordinarily violent and irregular manifestation of motor force. In any case the patent fact here is dynamic perturbation of a severe kind; and, in the instance of organic tumors exercising steady and continuously increasing pressure on nerves, one can scarcely doubt that a similar perturbation, less intense but more enduring, is necessarily set up. That which can be done in the way of producing severe pain by these severe affections of the peripheral portions of nerves, or of tissues lying outside them, we might a priori expect would be effected by slighter but continuous changes in the nutrition of the more important portion of the nerve itself – its central gray nucleus. One would say that a pathological process which continuously and progressively lowered the standard of nutrition here must interfere from hour to hour, certainly from day to day, with that regular and equable distribution of force which is the essence of unimpeded function.
Take, again, the case of the very severe pain which frequently attends inflammation of the pleura and of the peritoneum. Whatever theory of the causation of these pains we may adopt, it is certain that one most important element in their production and maintenance is the continual movement and friction of the affected parts. But there is little doubt that the moving muscles are involved in the inflammatory process, as Dr. Inman has correctly observed. It would seem plain that under these circumstances – an inflamed muscular structure forced to perform its ordinary contractions as well as it can – there must be powerful dynamic perturbation going on.
If perturbation of nerve-function – a disturbance quite different from mere exaltation of the normal development of nerve-force – be the essence of pain, how comes it that pains of the severest type may be produced by changes in structures which are usually described, for practical purposes, as lying outside the nervous system? We must, in the first place, remark that the externality of any bodily tissue to the nervous system is more apparent than real. Microscopic researches are constantly revealing nerve-fibres, in ever-increasing profusion, which penetrate to parts seemingly the least vitalized in the organism. But, in any case, the nerves are certainly the ultimate channel of communication between the suffering part and the sentient centre. It seems, therefore, the inevitable conclusion that a dynamic perturbation going on in the non-nervous tissue is continued along the nerves themselves: and that the severity of the pain perceived by the conscious centres is proportionate to the tumultuousness, the want of coordination, and the waste with which force is being evolved in the cramped muscle, or whatever structure it may be, in which the pain takes its source.
Not to pursue these topics further, we may sum up the considerations which have now been adduced, in the following general propositions, which will tend to simplify the examination of the various painful disorders which we are about to discuss:
1. Pain is not a true hyperæsthesia; on the contrary, it involves a lowering of true function.
2. Pain is due to a perturbation of nerve-force, originating in dynamic disturbance either within or without the nervous system.
3. The susceptibility to this perturbation is great in proportion to the physical imperfection of the nervous tissue, until this imperfection reaches to the extent of cutting off nervous communications (paralysis).
PART I.
ON NEURALGIA
CHAPTER I.
CLINICAL HISTORY
Neuralgia may be defined as a disease of the nervous system, manifesting itself by pains which, in the great majority of cases, are unilateral, and which appear to follow accurately the course of particular nerves, and ramify, sometimes into a few, sometimes into all, the terminal branches of those nerves. These pains are usually sudden in their onset, and of a darting, stabbing, boring, or burning character; they are at first unattended with any local change, or any general febrile excitement. They are always markedly intermittent, at any rate at first; the intermissions are sometimes regular, and sometimes irregular; the attacks commonly go on increasing in severity on each successive occasion. The intermissions are distinguished by complete, or almost complete, freedom from suffering, and in recent cases the patient appears to be quite well at these times; except that, for some short time after the attack, the parts through which the painful nerves ramify remain sore, and tender to the touch. In old-standing cases, however, persistent tenderness, and other signs of local mischief, are apt to be developed in the tissues around the peripheral twigs. Severe neuralgias are usually complicated with secondary affections of other nerves which are intimately connected with those that are the original seat of pain; and in this way congestions of blood vessels, hypersecretion or arrested secretion from glands, inflammation and ulceration of tissues, etc., are sometimes brought about.
The above is a general description of neuralgia which will identify the disease sufficiently for the purpose of introducing it the attention of the reader. We must now proceed to give a more accurate account of its
Clinical History and Symptoms.– These vary so greatly in different kinds of neuralgia that it will be necessary to discuss the greater part of this subject under the headings of the special varieties of the disease. There are certain common features, however, in all true neuralgias.
I. In the first place, it is universally the case that the condition of the patient, at the time of the first attack, is one of debility, either general or special. I make this assertion with confidence, notwithstanding that Valleix, and some other very able observers, have made a contrary statement. In the first place, it is certainly the case that the larger half of the total number of cases of neuralgia which come under my care are either decidedly anæmic, or else have recently undergone some exhausting illness or fatigue; and if other writers have failed to see so many neuralgic patients in whom these conditions were present, it must certainly be because they have limited the application of the term "neuralgia" within bounds which are too narrow to be justified by any logical argument; as will, indeed, be shown at a later stage. On the other hand, although a considerable number of neuralgic patients have an externally healthy appearance, as indicated by a ruddy complexion and a fair amount of muscular development, it cannot be admitted that these appearances exclude the possibility of debility, either structional or functional, of the nervous system. The commonest experience might teach us that, so far from the nervous system being invariably developed with a corresponding completeness and maintained with a corresponding vigor to those which distinguish the muscular system and the organs of vegetative life, there is often a very striking contrast between these in the same individual. What physician is there who has not seen epileptic patients, in whom mental habitude, a low cranial development, imperfect cutaneous sensibility, and other obvious marks of deficient innervation, were marked and striking features at, or even before, the first occurrence of convulsive symptoms, while the body was robust, the face well colored, and the muscular power up to or beyond the average? Now, it will invariably be found, on carefully sifting the history of apparently robust neuralgic patients, that they, too, have given previous indications of weakness of the nervous system: thus, women, who, after a severe confinement attended with great loss of blood, are attached with clavus hystericus or with migraine; will inform us that whenever, in earlier life, they suffered from headache, the pain was on the same side as that now affected, and chiefly or altogether confined to the site of the present neuralgia. In a considerable number of cases, also, in which I have been able to observe accurately the events which preceded an attack of neuralgia, it has been found that the skin supplied by the nerves about to become painful was anæsthesic to a remarkable degree; and it is very