Cerebral abscesses is, fortunately, a rare disease; but the very fact of its rarity makes the resemblance of the pain it causes to that of neuralgia the more likely to lead us into serious errors. We are apt to forget the possibility of suppuration of the brain on account of its infrequence.
Pain in the head is present as an early symptom of abscess in the brain in a large proportion of cases in which there is pain at all. [Of seventy-five cases of cerebral abscess analyzed by Gull and Sutton (Reynolds's "System of Medicine," vol. ii.), pain was a symptom in thirty-nine, and most frequently an early symptom.] Many cases are recorded in which it preceded every other morbid sign by a considerable period. It is usually more or less paroxysmal, often strikingly so; in the latter case, it bears a great similarity to neuralgia. On the other hand, it sometimes takes the shape of a fixed burning sensation, much less resembling neuralgia. The situation of the pain by no means always, nor even usually, corresponds to the situation of the cerebral abscess; on the contrary, abscess in the cerebellum has often caused pain referred to the anterior part of the head, and so on. So long as the disease remains characterized only by pain, more or less, of a paroxysmal character, the diagnosis must be very uncertain; but in the great majority of cases certain more distinctive symptoms soon become superadded; either convulsions (sometimes hemiplegic), vertigo, coma, paralysis, vomiting, or a combination of some of these.
In the stage in which there is as yet no conspicuous symptom but severe pain, the diagnosis of cerebral abscess from neuralgia must rest on the following points of contrast:
| Cerebral Abscess. | Neuralgia of Head. |
| Often occurs secondarily to caries of internal ear, and purulent discharge the result of scarlet fever, measles, etc., in childhood. | Rarely appears before puberty. |
| Frequently follows a blow or injury. | Comparatively seldom caused by blow, or other external injury or caries of bone. |
| No true "points douloureux." | If severe, soon presents, in most cases, the "points douloureux." |
| Usually the pain does not completely intermit. | Intermissions of pain complete, and of considerable length. |
| Pain often excruciating from a very early period. | Pain usually not very violent at first. |
| Pain often limited in situation, seems deep-seated, though, as often as not, it has no relation to the site of the abscess. | Pain superficial; follows distribution of recognizable nerve-branches belonging to the trigeminus or the great occipital. |
| No well localized vaso-motor or secretory complications. | Usually there are lachrymation, congestion of conjunctiva, or other vaso-motor and secretory complications, such as are described in Chapter III. |
| Very rare in old age; then usually traumatic. | Severe and intractable neuralgia is commonest in the degenerative period of life. |
| Relief from stimulant narcotics very transitory. | Relief from opium, etc., is much more considerable and permanent. |
The only case of cerebral abscess that I have personally seen, in which the above points of distinction would have been insufficient, was that of a boy of sixteen, in whom the only discoverable symptom, for nearly three months, was pain, very strongly resembling ordinary migraine, recurring not oftener than once in ten days or a fortnight, lasting for some hours at a time, and nearly always ending in vomiting, and disappearing after sleep. At the end of the three months, acute pain in the left ear set in, and this was followed, soon, by right hemiplegia, coma, and death. It was then discovered, although it had formerly been denied, that the boy had suffered from discharge from the left ear, following a febrile attack which had been marked by sore-throat, and followed by desquamation of the cuticle—evidently scarlet fever. In all cases of severe pain in the head, it is a golden rule to inquire most carefully as to the possible existence, present or past, of discharge from the ear, or other signs of caries of the temporal bone; and, even if no positive history of this kind be given, we should still regard with great suspicion any case in which there has been scarlet fever followed by deafness.
A very important class of pains, which are occasionally confounded with true neuralgias, are those which occur in certain forms of chronic alcoholism. The diagnosis of their true nature is a matter of the utmost consequence, and the failure to recognize them for what they are may have very disastrous results. It is a curious fact that this consequence of chronic alcoholic poisoning has been entirely overlooked by some of the best known writers on that affection; it has, however, been described by Mr. John Higginbottom, and also by M. Leudet.
It must be clearly understood that the pains of which we are now to speak are not among the common consequences of chronic excess in drink. The affections of sensation which most usually occur in alcoholism take the shape either of anæsthesia, or of this combined with anomalous feelings partaking more or less of the character of formication. Chronic drinking has also a tendency, in its later stages, when the nutrition of the nervous centres has been considerably impaired by the habit, to set up true neuralgia, of a formidable type, in subjects who are hereditarily predisposed to neuroses. But the affection of which I now speak may occur at any stage except the very earliest, and, though often severely painful, is essentially different both in its seat and in its general characters, from neuralgia proper.
The earliest symptoms from which the patient usually suffers in these cases are insomnia, and intense depression of spirits, which, however, is not incompatible, indeed is frequently combined, with a morbid activity and restlessness of thought. There is generally marked loss of appetite, but often there is none of the morning nausea so characteristic of the common forms of alcoholism. Nor is there, ordinarily, any special unsteadiness of the muscular system. The pains are usually first felt in the shoulder and down the spine; but as the case progresses they especially attack the wrist and ankles; and it is in these latter situations that I have found them to be most decidedly complained of. Their similarity to neuralgia consists (a) in their somewhat paroxysmal character; (b) in their frequently recurring at about the same hour of the day, most commonly toward night; and (c) in their special aggravation by bodily and mental fatigue.
Their differences from neuralgia are—(a) that they never follow the course of a recognizable single nerve; (b) that they are nearly always present in more than one limb, and usually in both halves of the body, at the same time; and (c) especially, that they are far less promptly and effectually relieved by hypodermic morphia than are the true neuralgias; indeed, opiates very frequently only slightly alleviate the pain, while they excite and agitate the patient and render sleep impossible. On the contrary, a large dose of wine or brandy will never fail to procure temporary comfort and induce sleep, at least until the patient reaches an advanced stage of the disorder, and is, in fact, on the verge of delirium tremens.
I am not quite sure that I am right in believing that there is a special physiognomy for this form of chronic alcoholism, and yet I am much inclined to believe that there is. All the patients whom I have seen suffering with it have presented a peculiar brown sallowness of face, and a general harsh dryness of the skin, which has usually lost its natural clearness, not only in the face, but even more remarkably in the hands, which are so dark-colored as to appear as if they were dirty. There is usually considerable leanness of the limbs, and, though the abdomen may be somewhat prominent, this does not seem to depend much on the presence of fat, but rather on relaxation of the abdominal muscles, and sometimes flatulent distention of the stomach and intestines. The hands are usually hot, sometimes quite startlingly so.
Some of the patients suffer, besides the pains in the limbs (which they often describe as resembling the feeling of a tight band pressing severely around the ankles or wrists), from frequent or occasional attacks of genuine hemicrania; such a combination is to me always a suspicious sign, and induces me immediately to direct my attention to the possibility of chronic alcoholic poisoning. Otherwise, the limb-pains are often spoken of as resembling rheumatism, but there is no swelling of joints, and usually no decided tenderness of the painful parts. The patient has usually a particular worn and haggard appearance, complains of intense fatigue after the most moderate muscular exertion, and is usually utterly indisposed to physical exercise even though the mind, as already said, may display a feverish activity.
So far as I have seen, the subjects of this affection are by far the most frequently women; and I am inclined to attribute this predisposition of the sex not to inherent peculiarities of female organization, but to the fact that a much larger proportion of intemperate women than of intemperate men indulge in secret excess. They never get drunk, probably, but they fly to the relief of alcohol upon every trivial occasion of bodily or mental distress; and this habit may have been going on for years before it comes to be suspected by their friends or their medical attendant. Meantime, they have been more or less looked upon, and have looked upon themselves as, "debilitated" and "neuralgic" subjects, and have come, either with or without mistaken medical advice, to consider free stimulation as the proper treatment for the very ailments which have been produced by their own unfortunate habits. I cannot avoid the expression of the misgiving, that imperfect diagnosis, and consequent erroneous prescription, have done great harm in many such cases. It has happened to me no less than three times within the last six months to be called to lady patients, all suffering from alcoholism induced by a habit of taking stimulants for the relief of so-called neuralgic pain; and in the most distressing of these the mischief had been greatly aggravated by a prescription of brandy, based on the erroneous idea that the pains were truly neuralgic. I have already protested against this kind of medication, even in cases that are truly neuralgic in character; but it is doubly mischievous where given for a state of things which actually depends on alcoholic excess.
It is undoubtedly very difficult, sometimes, to elicit the truth, even in cases where we may entertain considerable suspicion that alcoholic excesses are the real cause of the pains which the patient calls neuralgic; more especially where the patient is aware that he or she is taking an amount of alcohol which is seriously damaging to health. And it is therefore necessary to look out for every possible additional help to our diagnosis. Besides the cardinal features of the disease—the insomnia, loss of appetite, foul breath, haggard countenance, and pains encircling the limbs near the joints rather than running longitudinally down the extremities there are certain moral characteristics of the patient that often tells a significant tale. The drinker, especially if a woman, is shifty, voluble, and full of plausible theories to account for this and the other phenomenon. It will be well to try the effects of a somewhat sudden though not uncourteous remark, to the effect that the diet should be strictly unstimulating. If this be introduced with some abruptness, in the course of a conversation not apparently leading to it, the patient's manner will not unfrequently betray the truth; while, if our suspicions are groundless, we shall also probably perceive that, in the unconscious, or frankly surprised, expression of the countenance. We may sometimes derive crowning proof of the existence of alcoholic excess by cautious questions which at least reveal the fact that the patient suffers from spectral hallucinations; this is a far commoner occurrence in chronic alcoholism than is generally supposed; it needs to be inquired for with great tact, but, when established beyond doubt, and joined to insomnia and the peculiar foul breath, is of itself sufficient to establish a positive diagnosis of alcoholic poisoning.
The results of treatment, in true neuralgia and in alcoholic pains, respectively, establish an important difference between these affections. In the former malady, for instance, the hypodermic injection of morphia always produces striking palliative, and very often curative effects. In alcoholic pains this remedy either affords only trifling relief, or more commonly aggravates the malady by increasing the general nervous excitement; and the only true treatment is at once to suspend all use of stimulants, to administer quinine, and to insist upon a copious nutrition. If any hypnotic must be employed, let it be chloral, or bromide of potassium with cannabis Indica. It will be well also to put the patient upon a somewhat lengthened course of cod-liver oil. There is one special symptom from which the chronic alcoholist often suffers acutely, namely a hypersensitiveness to cold; for this I found the use of Turkish bath two or three times a week, for three or four weeks, very useful in one case that was under my care. It will be important to insist that the patient shall take the bath only after that shorter method which I have described in speaking of the prophylaxis of true neuralgia.
Syphilis, as has already been shown in Part I. of this work, may excite true neuralgia in subjects already predisposed to the latter. The case of Matilda W., previously given, is an example. The pains, however, which are now to be described, are those which occur in the ordinary course of a constitutional syphilitic infection, and have nothing to do with neuralgia proper, from which they should be carefully distinguished.
There are two varieties of syphilitic pains proper, which are quite distinct. The first kind is represented by the so-called dolores osteocopi, which occur in the early stages of the constitutional affection, coincidently with, or just before, the secondary skin-eruptions. The second kind are those which occur in the tertiary stage, and are the immediate precursors of the formation of periosteal nodes.
It is the first of these varieties of syphilitic pains which is least commonly confounded with neuralgia. The pain is referred to the superficial bones, of which those most frequently attacked are the forehead, sternum, clavicle, ulna, and tibia, pretty much those selected for the growth of nodes at a later stage of the disease. Besides the bones, the shoulders, elbows, and nape of the neck are attacked sometimes simultaneously, sometimes successively. The pains are readily controlled by proper treatment; if untreated, their course is very uncertain. When they manifest themselves at the outset of the disease, they usually cease when the cutaneous eruption is fairly out. Commonly, there is no swelling or heat at the painful places; but, when the pains are very severe, nodes now and then form at this early period.[52]
These early syphilitic pains, in their violent aching character, and their intermittence, occasionally resemble true neuralgia very closely; but they are usually distinguished from it by their symmetrical disposition and by their attacking several bones at once. Moreover, they nearly always show the peculiarity of being distinctly aggravated by the warmth and repose of bed even if they be not altogether absent (as is not unfrequently the case) when the patient is up and moving about. A typical case of this kind is not so likely to be confounded with neuralgia as with rheumatism; but we occasionally meet with cases in which the pains are localized in a manner much more resembling the former. Thus I have met with several instances in which a patient, entirely unconscious (or professing to be unconscious) of having been syphilized, complained of violent pain in one tibia, recurring every night at a certain hour, and at first undistinguishable from that variety of sciatica in which the pain is principally felt in this situation, especially as it was relieved by firm pressure, just as neuralgia is in the early stages. And in one remarkable case, which came under my care at Westminster Hospital, the resemblance to clavus was most misleading:
H. A., aged nineteen, worker in a laundry, presented herself on account of a violent pain in the right parietal region, recurring three times daily with great regularity. The first two attacks occurred in the day-time, the third, which was always the severest, woke her out of sleep about midnight; the pain of this last was so agonizing that on more than one occasion she had become delirious. The girl (whose respectable appearance was against the notion of syphilis) was very anæmic; not, however, with the tint either of anæmic from hæmorrhage, or with that of chlorosis, exactly. It was rather a dirty sallowness of skin; but the gums and the conjunctivæ were exceedingly bloodless, and she complained of almost constant noises in the head. Menses scanty but regular. There was a soft anæmic bruit with the first sound at the base of the heart. Having failed to make any impression on the pains with iron and with muriate of ammonia in large doses, I was led to observe the fact that there was no diffuse soreness of the scalp, such as very commonly occurs in clavus, in the intervals of the pains, and the mere fact that there was this unusual circumstance in the case led me to reconsider the diagnosis thoroughly. In order to be sure of not omitting a point, I inquired, though without any expectation of an affirmative answer, as to the possibility of syphilitic disease; the girl at once confessed to having had sores, and examination detected a papular rash about the shoulders and back and on both thighs. Small doses of mercury greatly relieved the pain within a week, and cured it in less than three weeks; and it was very remarkable that the anæmia, which had obstinately refused to yield to iron, improved at once as the mercury began to relieve the pains. The eruption disappeared simultaneously.
It is the later pains of syphilis, however, that are most frequently confounded with neuralgia, and occasionally with very disastrous results. These pains, which are the precursors of the formation of true nodes, frequent the same localities as those affected by the earlier pains; they may exist in considerable severity for days, or even for many weeks, before any node-formation can be detected. The situation in which, of all others, they are likely to be mistaken for neuralgia is the scalp or face, especially when a single spot is affected on one side, and in the situation of one of the usual foci of trigeminal or occipital neuralgia. I have personally known the mistake to be made with syphilitic affections causing pain, respectively, in the superciliary region, in the malar bone, the jaw near the mental foramen, and the parietal eminence.
The possibility of mistaking tertiary syphilitic pain for neuralgia is fraught with such grave dangers, that we ought to be constantly and most vigilantly on the watch against it. But most especially is this the case when the pain is situated in some part of the cranium, as the parietal or temporal eminences, the mastoid process, or the prominences of the occipital bone. For it must be remembered that the same process, which forms syphilitic nodes upon the external surface of bones, or within bony canals, can produce them on the lining membrane of the skull, with most serious consequences, should the symptoms be neglected or misunderstood.
The pains produced by nodes upon the internal surface of the cranium are usually of a very intense character, and are mostly continuous, though aggravated from time to time, especially at night. Where syphilitic inflammation is diffused over a considerable portion of the meninges, it is certain very quickly to produce symptoms which can hardly fail to apprise us of the gravity of the affection; there will be decided and rapidly increasing impairment of memory, and general cloudiness of intellect, tending toward complete imbecility, the special senses will be greatly interfered with or lost, and muscular paralysis will be developed. But in the case of a more limited syphilitic affection of the dura mater, pain, of the kind already described, may be for some days the only very noticeable symptom. The following is an instance:
J. E., aged forty-seven, a street and tavern singer, applied to me (November 14, 1861), on account of severe pain in the right temporal region, which had on the whole the character of neuralgia, though rather more continuous than such pain usually is. He said that it commenced on the 10th, without any particular provocation that he knew of, and that it had hardly left him at all from that moment. It kept him awake at night, and that circumstance seemed to account sufficiently for a very worn and depressed look which he presented; he was otherwise a robust-looking man, and at first denied having suffered from any previous illness. The pain always came to a climax about one o'clock, a. m., waking him out of his first sleep in agony, and allowing him little rest for the remainder of the night; toward morning he would drop to sleep for an hour or so. There was no particular tender point, corresponding to any recognized neuralgic focus, yet the pain was limited most strictly to a spot that might be covered with two finger-points. There was no lachrymation nor conjunctival congestion, and nothing to remark in any way about either eye. The patient was ordered quinine in large doses, in the belief that the pain was neuralgic. On the following day he reported himself a trifle better, though still suffering greatly; and on the afternoon of that day there was an almost complete intermission of the pain for several hours; but it returned severely at the usual nocturnal period. On the 16th, at 10 a. m., he came to my house looking exceedingly ill, but the only additional symptom that I could detect was a small droop of the right eyelid. He was subcutaneously injected with one-fourth of a grain of morphia and sent home, where he immediately fell into a heavy sleep that lasted till bedtime. He awoke, undressed himself without feeling much pain, and got to bed; after an hour or so of dozing he was awakened by the pain, which was exceedingly severe. On the 17th he called on me in the morning, and I at once perceived that the ptosis of the right eyelid was much greater, and the right pupil was much dilated and insensitive, and the external rectus was paralyzed; the man also wore a look of stupidity, and answered questions with an apparent mental effort. I now cross-questioned him more closely; and also explored the tibiæ and other superficial bones: on the sternum a distinct though not very advanced node was found. Upon this he was induced to confess that he had suffered from chancre three years and a half previously, and subsequently had "blotches" on the skin, which had quickly disappeared under treatment, of which all that could be learned was, that it was fluid medicine and did not make his mouth sore. He was immediately ordered to take two grains of calomel in pill, with a little opium, every four hours. He had only taken one dose when I was sent for to him, and found him in an epileptiform convulsion, in which the left side of the body was almost exclusively affected; the convulsions recurred several times during the next twenty-four hours, and in the intervals he remained almost completely unconscious. The mercurial treatment was pushed, in the form of calomel-powders placed on the tongue. On the evening of the 18th he began to recover consciousness, and then had a little natural sleep; the next morning, at 10 a. m., he was found to be fully conscious, had had no return of convulsions, but the left arm and leg, especially the latter, were almost entirely powerless; the parietal headache had vanished; the gums were slightly tender; the third and sixth nerves of right side were completely paralyzed. Mercurial treatment was very gently continued, so as to keep the patient on the borders of ptyalism for the next three or four days; and he was then put on full doses of iodide of potassium. The pain never recurred; the left extremities recovered power rapidly; but it was six weeks before the ocular paralyses were completely well.
Late in the autumn of 1865 I was sent for hastily one evening to see this same man, and found him totally unconscious and apparently again hemiplegic, but now on the right side. He was miserably wasted, and covered with a rupious eruption; I was informed that he had been leading a most debauched and drunken life for some time past, and that, after looking extremely ill, and apparently half imbecile for a week or two past, he had suddenly fallen down unconscious in the street a few hours before I saw him. He remained deeply comatose, and died the next morning; no post mortem could be obtained.
The true neuralgias in which syphilis only plays the part of secondary factor, and which have been referred to in Part I. of this work, may depend for their exciting cause on local syphilitic processes, affecting either the peripheral distribution, the main trunk or the central origin of a sensory nerve; but I have pointed out the fact that, whatever the reason may be, syphilis does but rarely attack the central portions of individual sensory nerves, in comparison, with the frequency with which it attacks individual motor (cranial) nerves. But without any neuralgic predisposition at all, and without any limitation of the syphilitic process to a particular sensory nerve, the latter may become neuralgic in consequence of being involved in extensive intracranial or intra-spinal syphilitic mischief. The trigeminus is liable to suffer in this way from spreading syphilitic processes about the base of the brain; and my own impression is, that the cause of the neuralgic pain in some such cases is the extension of the mischief to the vertebral artery of the affected side, leading to interfering with the nutrition of the trigeminal nucleus in the medulla. A very interesting case is reported by Dr. Hughlings Jackson (who has done so much to acquaint us with syphilitic affections of cerebral arteries) in vol. iv. of the "London Hospital Reports," pp. 318-321. The patient was a woman, aged twenty-seven, and the initial symptoms of the malady which destroyed her life were violent trigeminal neuralgic pains on the right side: subsequently she had complete paralysis of the fifth, and of the sixth, seventh, and eighth nerves of the right side. After death the right vertebral artery was found engaged in the mass of syphilitic deposit; it must be added, however, that the (superficial) origin of the fifth nerve was itself softened, opposite the pons. Another mode in which syphilitic disease very probably causes neuralgia of the fifth, in a certain number of cases, is by injuring the Gasserian ganglion, upon the integrity of which (according to Waller's general law concerning the ganglia of posterior nerve-roots) the nutrition of the sensory root of the trigeminus materially depends. I have seen an example (as I cannot but suppose) of this sequence of morbid events; the evidence appears sufficiently complete, although I was unable to obtain a post mortem examination:
W. M., a house painter, of extremely dissipated habits, but who had never suffered either from distinct symptoms of alcoholism, nor from any affection traceable to lead-poisoning. In March, 1867, he applied to me on account of neuralgic pain, affecting chiefly the right eyeball, but also darting along the course of the frontal nerve of that side; after a short time it extended also into the infra-orbital nerves. He bore several scars of tertiary ulcers about the nose and forehead, and made no secret of having suffered from chancre six or seven years before, and from subsequent secondary and tertiary symptoms. I was consequently not at all surprised at his developing severe iritis (right) after he had been a fortnight under my care, although I had from the first given large doses of iodide of potassium; but I was not prepared for the extensive processes of destruction which followed, notwithstanding that I immediately commenced mercurial treatment, and applied atropine. I remarked that while the inflammation of the iris proceeded with great violence, the cornea was also much more severely affected than is usually the case in syphilitic iritis; in fact, the changes closely resembled those which have been noted after section of the fifth at the Gasserian ganglion, and at the date of the patient's death (seventeen days from the commencement of the iritis) a corneal ulcer was on the point of perforating. For the first three or four days after the iritis set in, the neuralgic pains went on augmenting in intensity, and extended into all three divisions of the fifth; there was a copious discharge from the right nostril. Almost suddenly, on the fourth day, the pains abated and then ceased, and it was now evident that the whole surface of the right half of the face was completely anæsthetic. Two days later a dark-red patch appeared on the cheek, and in the course of the next two days this ulcerated, the ulcer presenting a somewhat livid appearance, and exuding a sanious discharge; at the same time, superficial ulcers appeared on the right side of the tongue, and coalesced to form one large sore. The sores both on cheek and tongue assumed more and more a gangrenous appearance, and on the sixteenth day from the commencement of iritis there was considerable loss of substance in both these situations. On the evening of this day (the patient having become extremely depressed and much emaciated) general epileptiform convulsions set in, and followed each other rapidly; in a few hours coma supervened, and the patient sank the next day. No post mortem could be obtained; but it seems extremely probable, from the above history, that the Gasserian ganglion was early involved in the syphilitic inflammation, and that the neuralgia and subsequent anæsthesia, the iritis, and the other trophic lesions, were due to the injury inflicted upon it.
The treatment of syphilitic pains will, in doubtful cases, often give us valuable assurance of the correctness of our diagnosis. Where the disease is extensively diffused, we may fail to do any good; but, in cases where the syphilitic mischief is limited to a small portion of the meninges, we may often arrest it. In all merely suspicious cases, where the pain is thus limited, it will be well to use iodide of potassium tentatively—forty to sixty grains daily. But, where the pains are very severe and continuous, and there is danger to the integrity of the eye, or threatenings of a paralytic attack are observed, it is better not to trust to anything short of mercury, used in such a manner as just to stop short of absolute ptyalism. In very bad cases, like the last one narrated, we may fail to produce any good effect, but, where the specific treatment is commenced in good time, we may not unfrequently succeed in arresting the symptoms with a rapidity that assures us of the correctness of the diagnosis of syphilis.
So firmly is the idea of an essential connection between rheumatism and neuralgia implanted in the popular mind, and, indeed, in the minds of a certain portion of the medical profession, that the two complaints are continually confounded. In the great majority of instances, the mistake made is that of calling neuralgia a "rheumatism." But the opposite error occasionally occurs, and a patient is styled "neuralgic" who is really suffering from chronic rheumatism.
As true neuralgia is an essentially localized disease, there can be no excuse for mistaking for it the more typical cases of chronic rheumatism, in which a number of different joints, muscles, or tendons, are affected, more especially in the advanced stages, when the characteristic fixed contractions of the limbs and extremities have occurred. But there are a few cases in which, either with or without a previous history of acute rheumatism, one, or perhaps two, joints begin to suffer vague pains, which after a little time begin to shoot down the course of the limb, and are aggravated from time to time in a manner which superficially much resembles neuralgia; and when the malady has reached a certain intensity the pains may be so much more severely felt in the longitudinal axis of the limb than in the immediate neighborhood of a joint, that the patient forgets that in reality they commenced either within a joint (as the elbow or hip), or in the fibrous structures immediately outside it. Certain localities are much more frequently the seat of this kind of affection than other parts of the body; thus it occurs, perhaps in nine-tenths of the cases, in the neighborhood either of the shoulder (especially involving the insertions of the deltoid and triceps muscles), of the elbow (particularly affecting the tendinous insertions of the muscles on the internal aspect of the forearm), or the hip (extending to the aponeuroses on the outer and back part of the thigh): in all these cases there is a considerable superficial resemblance to true neuralgic pains. Nevertheless, the diagnosis need not present any serious difficulties after the earliest stages; for there soon arises a very diffuse and acute tenderness of the parts, and usually an amount of generalized swelling, which, though it may not be readily detectable by the eye, is sensible enough to the touch. Movement of the parts is also very painful; but usually not with the acute and agonizing pain which occurs in myalgia.
It is, however, upon signs which are of a more general character that we ought chiefly to rely for diagnosis. The fact that the patient has previously experienced a genuine attack of acute rheumatism, though of some value, is by no means to be taken as a conclusive argument that the present attack is of a rheumatic nature. The really important matter is, that whether the patient has or has not suffered acute rheumatism before the occurrence of the subacute or chronic form, the latter will always be attended by more or less of the specific constitutional disturbance of rheumatism. I would carefully abstain from the assumption that rheumatism is originally dependent on a blood-poisoning, a theory which I believe to be most doubtful and very probably false; but there is, nevertheless, a truly specific character about the general phenomena in acute rheumatism, and I maintain that similar though less-marked phenomena are always to be seen even in the mildest and least acute forms of rheumatism. Thus there will be, invariably, more or less of the peculiar sallow anæmia, together with red flushing of the cheeks when the pain is at the worst; and there will be a certain amount of the oily perspiration which makes the faces of rheumatic patients look shiny and greasy. No doubt these characteristics will sometimes be very slightly developed, but I believe that attentive observation will always discover them in any case which is genuinely rheumatic. One case, in particular, which has been under my care, very strongly impresses me with the value of these diagnostic signs, where otherwise the symptoms are obscure:
L. P., aged thirty-one, single, a printer by trade, applied to me, January, 1863, suffering from what I at first decidedly thought was cervico-brachial neuralgia, the pain having followed exposure to cold and wet, situated in the lower part of the neck, the shoulder, elbow and inner side of the right arm, and existing nowhere else. The character of the pain was described as at least remittent, if not distinctly intermittent. The pulse was not more than 78; the tongue was thickly coated with white fur, but the man did not complain of thirst, and there were no evident signs of fever. As the pains had only existed for about a fortnight, it appeared an excellent case for cure by the hypodermic injection of morphia; and, accordingly this was used in quarter-grain doses twice a day. After about ten days an attempt was made to do without the morphia, but the pains returned, worse than before, and meantime the tongue had remained uniformly coated, and was now very yellow; the appetite was bad, and there was some increase in frequency of pulse. It now struck me, for the first time, that the man presented, in a slight degree, the sallow and red tint and oily features of a rheumatic patient; it was now found that sweat and urine were distinctly acid. Acting on this idea, I administered five grains of iodide of potassium, and thirty grains of bicarbonate of potassium, four times every twenty-four hours, after giving a moderate saline aperient. The result was manifest improvement within twenty-four hours, and almost complete relief of the pain within three or four days (the urine never becoming distinctly alkaline, however.) As the attack subsided, the oily appearance of the skin disappeared, and the rheumatic tint was replaced by mere ordinary pallor, which the patient lost after taking a short course of steel.
At the time this case occurred to me, I was not aware of the importance, in doubtful instances, of looking to the temperature; but subsequent experience has convinced me that in every truly rheumatic case, however limited in extent, there is a real, though it may be a small, rise of temperature. The thermometer will be found to mark from 99-1/4° to 100° Fahr., and this, joined with the appearances above mentioned, and a strong acidity of urine, will be sufficient to distinguish the complaint as rheumatic; and the striking effect of such remedies as iodide with bicarbonate of potash, followed up with sesquichloride of iron, in full doses, helps still further to distinguish the cases from true neuralgias. Since the introduction of the full doses of the iron-tincture in the treatment of acute rheumatism, I have had the opportunity of treating two of these cases of subacute rheumatism in the same manner, viz., with the iron from the first, and the results have been most satisfactory in every way. These cases were independent of a much larger number, treated in the same way, in which the symptoms of rheumatism were more generalized and more severe.
Pains which are connected with a chronic and more or less latent form of gout not unfrequently receive the designation "neuralgic," and are treated upon that erroneous theory of their pathology. I have already endeavored to show that there is by no means that intimate causal relation between gout and neuralgia which is very commonly assumed to exist: true neuralgia is, I believe, only caused in an indirect and secondary manner by the gouty condition setting up changes of the blood-vessels, which precipitate the occurrence of the neuralgic malady, to which the patient was otherwise predisposed from birth. But the common idea, both without and within the profession, seems to be that neuralgia is only one expression, and that a quite common one, of the gouty habit. Nevertheless, with strange inconsistence, the kind of truly gouty pains of which I am now speaking are constantly treated upon a special plan, upon the supposition that they are neuralgic.
There are six situations in which gouty pains are apt to be developed in a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2) more indefinitely within the cranium; (3) in the stomach, simulating gastralgia; (4) in the chest, simulating angina pectoris; (5) in the dorsum of the foot, simulating neuralgia of the anterior tibial nerve; (6) in a somewhat diffuse manner about the hip and back of thigh, simulating sciatica.
It is not really a common thing to find such cases very difficult of diagnosis, provided that the possibility of their occurrence has been carefully noted; for the gouty habit has a number of slight manifestations which are usually enough to discover it even when its more decided symptoms are entirely wanting.
Thus, in the first place, it will be almost invariably found, on inquiry, that the patient has always been intolerant of beer and of sweet wines. Also, he has been liable (either after a single large excess in eating or a prolonged course of a diet too highly animalized in proportion to the amount of exercise taken) to attacks of general malaise, with or without uneasiness, just short of decided pain, about the metacarpo-phalangeal joint of the great-toe, and ending after a few hours or days with a free discharge of uric acid. Less frequently, but still very often, it will be found that he has some deposit of lithate of soda (chalk-stone) in some situation where its presence does not necessarily arrest attention; Dr. Garrod has shown how often these little tophi are found in the cartilage of the ear. Careful examination will sometimes detect their presence in the sclerotic of the eye. But in doubtful cases it would be always well to make a cautious trial of colchicum, which, if the case be gouty, will nearly always produce an amount of relief sufficient to confirm the diagnosis of gout. At least, this rule holds goods for the external forms; but in the case of the supposed gouty pseudo-angina it is far best to trust to opium, as colchicum may prove too depressing to a heart which may quite possibly be already the subject of organic disease. My own impression is, that it was these cases of gouty heart-pain, which are not true angina at all, that procured for opium its high reputation for relieving the latter disease, a reputation which is by no means confirmed by my own experience, since I have found that drug enormously inferior to stimulants like ether in its power to relieve genuine angina.
Lastly, if there be no other possibility of making ourselves certain whether there is or is not a gouty taint at the bottom of the quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the serum of the blood to a search for uric acid (thread-test).
Colic, or painful half spasm, half paralysis of the large intestines, is the best example of a kind of spasmodic pains to which some authors accord the name of neuralgia, as it seems to me without good reason. They appear to be quite independent of the operation of the neurotic temperament, and to be caused entirely by the operation of some local irritant, or narcotic irritant, upon the muscular fibres of the viscus. In the case of colic this influence is most frequently and most powerfully exerted by lead, which undoubtedly becomes locally deposited in chronic poisoning with that metal; at other times it is produced by the irritation of indigestible food passing along the alimentary canal.
That there may be such a thing as enteralgia, of really neuralgic character, I do not deny; on the contrary, so far as regards the rectum, I have myself seen such a case. But true neuralgia of the large bowel is exceedingly uncommon; what goes by the name is usually either colic from local irritation of the viscus; or a mere hysterical hyperæsthesia of the lining membrane, which is one of the occasional phenomena of spinal irritation; or else it is a case of neuralgia of the abdominal wall, such as is included in the description of "lumbo-abdominal neuralgia," in Part I. of this work.
There is no occasion to describe minutely the symptoms of so familiar a disease as lead-colic, or as colic from irritation by indigestible food, when they occur in their typical forms. In the former case the marked constipation which ushers in the attack of pain, and the peculiar greenish-yellow sallowness nearly always seen in the countenance, ought to be sufficient to direct examination to the gums (for the blue line) and inquiry as to any possible impregnation of the system with lead, owing either to the nature of the patient's occupation, or to some accidental entry of the poison into the drinking-water, or its inhalation from the walls of newly-painted rooms, etc. In the latter case, the fact that the attack of colic was shortly preceded by a meal, either of obviously indigestible food, or too copious in quantity and heterogeneous in kind, or too hastily eaten without sufficient mastication, supplies a clew.
But there are a few cases representing minor degrees of either of these kinds of colic, that are much less easy to diagnose distinctly.
Lead-poison sometimes enters the system continuously, for a long period, but in proportions too minute to produce the effects which we identify as an attack of lead-colic. I believe that for the production of the latter complaint it is necessary that the poisoning shall be sufficiently intense completely to paralyze a considerable piece of bowel, thus altogether hindering peristalsis, or, rather, making the peristaltic acts of the non-paralyzed portions above worse than fruitless. But there is a minor degree in which it may happen that the local affection (owing, I believe, to a less extensive deposit of lead in the bowel) does not reach the decidedly paralytic stage; the state then is one of irregular and painful spasm of individual fibres (quite possibly intermingled with paralysis of a few others), and the practical result is irregularity of evacuation—now diarrhœa, and again constipation—and the frequent recurrence of twinges of pain that are easily mistaken for abdominal neuralgia. Such symptoms as these are nearly always found to have occurred, if proper inquiry be made, in those examples of chronic lead-poisoning in which the toxic process goes on to the development of epilepsy, or marked symmetrical paralysis of the wrist-extensors, without the patient having ever suffered an attack of ordinary colic. In these slow and insidious cases the constitutional affection may not have reached the height at which the complexion and general aspect of the patient suggests metallic poisoning: and the case may present very neuralgia-like features. The absence of the points douloureux is not, as we have seen, conclusive against neuralgia in its early stages. It is therefore an excellent rule, in all cases of chronic recurrent spasmodic pain in the abdomen, especially in men, to investigate the possibilities of lead-poisoning; and, if the slightest suspicious appearance of the gums be found, this track of inquiry must be followed up exhaustively before we abandon the idea. The absence of all special neurotic history in a patient's family should increase our suspicions respecting pains of this character that continue with an obstinacy which makes it unlikely they are due to improper food.
Pains of abdominal irritation are, however, without doubt produced in some cases by unsuspected faults of diet, and may even recur in such a quasi-periodic manner as to strongly suggest the idea of neuralgia in the lumbo-abdominal nerve. One special variety of this happens, I believe, much more often than is thought. A patient will habitually take considerable quantities of some article of food which he does not readily digest, but which is not at all acutely irritant: under these circumstances a simple accumulation is apt to take place in the colon, especially at the top of the ascending colon, the top of the descending colon, or just above the sigmoid flexure, or else in the cæcum. The result of accumulation in the last of these places is not unfrequently typhlitis and perityphlitis, this part of the bowel having (for some reason) a special tendency to inflammation. Deposits in the other localities named are rarely the cause of inflammation, but they very frequently give rise to violent pain, which is exceedingly apt to be taken for the pain either of gall-stone, of renal calculus, or else of some abdominal neuralgia. In cases, therefore, where there is any possibility that accumulation is the cause of pain, it is highly desirable to commence with a dose of castor-oil and laudanum, followed up, if needful, by the administration of a large warm-water enema, given through an O'Beirne's tube. The most violent and recurrent attacks of pain in the renal region, the flank, the abdomen, or the groin, will sometimes be instantly cured by such means, sufficiently proving the non-neuralgic character of the complaint.
I have elsewhere explained that the impaction of a renal or an hepatic calculus, in the ureter or the ductus choledochus, may set up a true neuralgia in persons with the requisite congenital predisposition. The passage of renal or hepatic calculi may give rise to symptoms falsely suggesting neuralgia, which require just to be mentioned here. But there is no need to dwell much upon the diagnosis, for the passage of renal or hepatic calculi has always attendant symptoms and features of constitutional history, which ought to preserve the physician from mistake. The sensation of constriction, of nausea and vomiting, the faintness approaching to collapse, the persistent and constantly increasing severity of the pain up to the moment at which mechanical relief occurs, to say nothing of other phenomena, are distinctive to the skilled observer, and, when taken in conjunction with the history of past attacks, if any, will always prevent mistakes. In the few cases which might still be doubtful it will be well to try the effect of a relaxing dose of chloroform, which, in the case of calculus, will often put an end to the paroxysm at once and finally.
A final word or two must be given to the distinction between neuralgia of the head and an affection so utterly different that it is surprising that they should be so frequently confounded. One constantly hears medical men speak of "sick headache" (migraine) as if it were the same thing as headache from indigestion; and, unfortunately, they often treat migraine upon this confused and erroneous notion, doing no little mischief thereby.
But, although migraine, already amply described, is entirely independent of the state of digestion, and its stomach-phenomena are purely secondary to the affection of the fifth nerve, there is a kind of headache really dependent on imperfect digestion. The sufferers from these headaches are dyspeptics whose stomach troubles are the result of chronic gastric catarrhal inflammation. (In the acute form of gastric catarrh there are even more severe headaches; but the general symptoms of the disorder are too marked to allow us to mistake the case for neuralgia complicated with secondary stomach disturbance.) The patients in question have frequently passed so gradually into the dyspeptic condition as to have become accustomed to it, and inclined to forget that the stomach was the organ which first gave them annoyance. The headaches, which occur from time to time, are either frontal or (more frequently) occipital in position, and they are usually quite evenly bilateral; still, there is not enough uniformity of difference between them and true migraine, in this respect, to enable us to establish a decided diagnosis upon it. This much may be said, however: that the pain is rarely or never seated in one parietal region, as is frequently the case with migraine and with clavus. The patient suffers very strikingly, in almost every case, from languor and a feeling of inability to exert himself; and has also much aching pain in the limbs, and usually a pain (sometimes very severe) in the scapular region. The tongue may vary a good deal in appearance, especially as regards the degree of general redness; but it always has enlarged papillæ, most prominent toward the tip, and more or less thick furring at the back, and reaching forward, in some cases, nearly to the tip, to which the "strawberry" aspect is then confined. The headache is frequently joined with nausea, but never with absolute vomiting, unless the stomach has been provoked with a meal that gives it more trouble than usual. The desponding frame of mind which this kind of dyspeptics always exhibit distinguishes them, in most cases, quite sufficiently (together with the unwholesome complexion, the appearance of the tongue, and the great complaints of general malaise and aching and feebleness of the limbs) from the victims of migraine, who are often persons of bright spirits and lively intelligence in the intervals of their attacks; but, above all, there is nothing of the regular and characteristic sequence of events which distinguishes the attacks of migraine. The attacks are not periodic, but nearly always depend on some chance dietary indiscretion, or other imprudence, which has visibly aggravated the stomach irritation. And, when the pain does come on, it has no uniform tendency to go on intensifying for some hours and culminate in vomiting, followed by sleep, after which the patient is free. On the contrary, the digestive disturbance is the provocation, and the pain itself is of a heavy character, with a sense of tension or fulness, and it does not go on intensifying in a regular manner, up to a climax, but hangs about in a dull, tormenting way, and frequently is just as bad after sleep as it was before. The diagnosis of these headaches from neuralgic headache is not really difficult; it only requires the use of a fair amount of caution in observation. It would, however, be exceedingly advantageous that the word "sick-headache" should be dropped altogether, and that migraine should always be called by that name (or "megrim," if you will), and that headaches really proceeding from chronic catarrhal disease of the stomach should be called "dyspeptic" headaches. The present state of nomenclature does much to perpetuate a confusion of ideas which ought not to exist any longer, and which leads to much practical mischief.