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 often the case that a more moderate amount of blunted sensation was perceptible in these parts during the intervals between attacks of pain. A somewhat delusive appearance of general nervous vigor is often conveyed to the observer of neuralgic patients, by reason of the intellectual and emotional characteristics of the latter. Both ideation and emotion are, indeed, very often quick and active in the victims of neuralgia, who in this respect differ strikingly from the majority of epileptics. But this mobility of the higher centres of the nervous system is itself no sign of general nervous strength; which last can never be possessed except by those in whom a certain balance of the various nervous functions is maintained. Much more will be said on this topic when we come to discuss the etiology of neuralgia. Meantime I may content myself with repeating the fact which is indubitably taught by careful observation – that neuralgics are invariably marked by some original weakness of the nervous system; though in some cases this defect is confined strictly to that part of the sensory system which ultimately becomes the seat of neuralgic pain.
Another circumstance is common to all neuralgias of superficial nerves; and, as a large majority of all neuralgias are superficial in situation, this is, for practical purposes, a general characteristic of the disease. I refer to the gradual formation of tender spots at various points where the affected nerves pass from a deeper to a more superficial level, and particularly where they emerge from bony canals, or pierce fibrous fasciæ. So general is this characteristic of inveterate neuralgias, that Valleix founded his diagnosis of the genuine neuralgias on the presence of these painful points. Herein he appears to me to be decidedly in error. I have watched a great many cases (of all sorts of varieties as to the situation of the pain), and I have uniformly observed that in the early stages firm pressure may be made on the painful nerve without any aggravation of the pain; indeed, very often with the effect of assuaging it. The formation of tender spots is a subsequent affair: they develop in those situations which have been the foci, or severest points, of the neuralgic pain. There is however, a point which, though not always, nor often, the seat of spontaneous pain, is nevertheless very generally tender. Trousseau, who criticises unfavorably the statement of Valleix as to the situation of the points douloureux, insists that this tender spot, which is over the spinous processes of the vertebræ corresponding to the origin of the painful nerve, and which he calls the points apophysaire, is more universally present than any of those pointed out by Valleix. I shall hereafter endeavor to show that these spinal points are by no means characteristic of neuralgia; they are present in a variety of affections which were ably described, under the heading of "Spinal Irritation," many years ago, by the brothers Griffin. ["Observations on the Functional Affections of the Spinal Cord," by William and Daniel Griffin. London, 1834] and they are also present with misleading frequency in cases of mere myalgia, such as I shall have to describe at a later stage.
Another characteristic of neuralgic patients in general is, I believe, a certain mobility of the vaso-motor nervous system and of the cardiac motor nerves; but I insist less on this than on the above-named features, because a more extended experience is necessary to establish the fact with certainty. Within my own experience it has always seemed to be the case that persons who are liable to neuralgia are specially prone to sudden changes of vascular tension, under emotional and other influences which operate strongly on the nervous system. The observation of this fact has been made accidentally, without any previous bias on my part, in the course of a large number of experiments made upon individuals free from manifest disease at the time, with Marey's sphygmograph.
Neuralgic attacks are always intermittent, or at the least remittent, in every stage of the disease.
The manner in which neuralgic pain commences is characteristic and important. There is always a degree of suddenness in its outset. When produced by a violent shock, it may, and often does, spring into full development and severity at once, of which, perhaps, the most striking example is the sudden and violent neuralgic pain of the eyebrow which some persons experience from swallowing a lump of undissolved ice. Usually, however, the first warning is a sudden, not very severe, and altogether transient dart of pain. The patient has probably been suffering from some degree of general fatigue and malaise, and the skin of the affected part has been somewhat numb, when a sudden slight stitch of pain darts into the nerve at some point which corresponds to one of the foci hereafter to be particularized. It ceases immediately, but in a few seconds or minutes returns; and these darts of pain recur more and more frequently, till at last they blend themselves together in such a manner that the patient suffers continuous and violent pain for a minute or so, then experiences a short intermission, and then the pain returns again, and so on. These intermittent spasms of pain go on recurring for one or several hours; then the intermissions become longer, the pain slighter, and at last the attack wears itself out. Such is generally the history of first attacks, especially in subjects who are not past the middle age, nor particularly debilitated from any special cause.
A point of interest in connection with the natural history of the neuralgic access is the condition of the circulation. The commencement of pain is generally preceded by paleness of skin and sensations of chilliness. At the commencement of the painful paroxysm, sphygmographic observation shows that the arterial tension is much increased, owing, in all probability, to spasm of the small vessels. This condition is gradually replaced by an opposite state, the pulse becoming large, soft, and bounding, though very unresisting, and giving a sphygmographic trace which exhibits marked dicrotism. Simultaneously with this the skin becomes warmer, sometimes even uncomfortably warm, and there is frequently considerable flushing of the face.
The final characteristic common to all neuralgias is that fatigue, and every other depressing influence, directly predispose to an attack, and aggravate it when already existing.
Varieties.– It is possible to classify neuralgias upon either of two systems: first (a), according to the constitutional state of the patient; and, secondly (b), according to the situation of the affected nerves. It will be necessary to follow both these lines of classification, avoiding all needless repetition.
(a) In considering the influence of constitutional states upon the typical development of neuralgia, it will be convenient to commence with the group of cases in which the general condition of the organism produces the least effect. This is the case when the pain is the result of direct injury to a nerve-trunk, whether by external violence, by the mechanical pressure of a tumor, or by the involvement of a nerve in inflammatory or ulcerative processes originating in a neighboring part. As regards the development of symptoms, the important matters are, that the pain in these cases commences comparatively gradually, that the intermissions are usually more or less complete, and that the pain is far less amenable to relief from remedies, than in other forms of neuralgia. The little that can be said about the form which is dependent upon progressively increasing pressure, or involvement of a nerve in malignant ulcerations, caries of bones or teeth, etc., falls under the heads of Diagnosis and Treatment, and need not detain us here. The clinical history of neuralgia from external violence, however, requires separate discussion:
1. Neuralgia from external shock may be produced by a physical cause (as by a fall, a railway collision, etc.), which gives a jar to the central nervous system; or by severe mental emotion, operating upon the same part of the organism. Under either of these circumstances the development of the affection may occur at once, but by far the most frequently it ensues after a variable interval, during which the patient shows signs of general depression, with loss of appetite and strength. Sometimes vomiting, and in other instances paralysis, of a partial and temporary kind, occur. When once developed, the neuralgic attacks do not differ from those which proceed from causes internal to the organism. In the greater number of instances, so far as my experience goes, it is the fifth cranial nerve which
