the nutritive changes observed by Mr. Jonathan Hutchinson in a number of cases of surgical injuries of nerves.5 The tendency of neuralgic pain accompanied by nutritive lesions of the skin and nails to seat itself in the hands and feet will be hereafter noted in connection with the subject of the pains of locomotor ataxy and of those produced by profound mercurial poisoning. And it will be seen in the section on Pathology, that very important conclusions are suggested by the coincidence.
Joined with the burning pains, and the altered skin-nutrition, in the cases of gunshot injury of nerves which we are considering, there is nearly always a marked alteration in the temperature of the parts, either in one direction or the other. In the great majority of instances of ordinary neuralgia after wounds, this alteration is a very considerable reduction of the temperature of the parts supplied by the painful nerves; a change which corresponds with what appears in the vast majority of all cases of division of sensitive nerves, whether pain be set up or not. But, in all examples of the burning pain after injury, Messrs. Mitchell, Moorehouse, and Keen found the temperature of the painful parts notably elevated.
It would appear that there is no form of neuralgia more dreadful, and scarcely any so hopeless, as this burning pain coming on as a sequel to severe nerve injuries. It exercises a profoundly depressing effect upon the whole nervous tone; the most robust men become timid and broken down, and their condition is compared by the American writers to that of hysterical women.
There is another peculiar nutritive affection, first recognized as an occasional consequence of nerve injuries by Messrs. Mitchell, Moorehouse, and Keen, namely, an inflammation of joints, and, although we have no concern here with this symptom, it will be referred to hereafter as throwing interesting light on certain questions of pathology. Certain lesions of secretion will also be specially referred to under the heading of Diagnosis.
II. Neuralgias of Intra-nervous Origin. – As regards the constitutional conditions with which the several varieties of neuralgia that arise independently of external violence, or disease of extra-nervous tissues, are respectively allied, the following preliminary subdivisions may be made:
1. Neuralgias of malarious origin.
2. Neuralgias of the period of bodily development.
3. Neuralgias of the middle period of life.
4. Neuralgias of the period of bodily decay.
5. Neuralgias associated with anæmia and mal-nutrition.
1. Neuralgias of malarious origin were formerly far more prevalent than they are at present, within the sphere of the English practitioner of medicine; with the general decline of malarial fevers, consequent on improved drainage and cultivation of lands, they have become constantly more scarce. The districts in which they still are found to prevail with any frequency are carefully specified in the interesting report of Dr. Whitley to the Medical Officer of the Privy Council, in the Blue-Book for 1863.
Of course, however, there are a considerable number of persons continually returning to England from countries where malarious diseases are common; and these often bear about with them the effects of paludal poisoning which occasionally exhibits itself in the form of neuralgia. Till very lately, however, I had not happened to come across such cases, although at one time and another I have seen and treated a good many persons returned from India and Africa, whence I judge that neuralgia with this special history is less common than many seem to think. In former times, on the contrary, malarioid neuralgias were so common that they forced themselves on the notice of every practitioner. The term "brow-ague," to this day applied by many medical men to every variety of supra-orbital neuralgia, is a relic of the older experience on this point, as is also the very common mistake of expecting all neuralgic affections to present a distinctly rhythmic recurrence of symptoms.
In the year 1864 I published the statement6 that, "in a fair sprinkling" of the cases of neuralgia which present themselves in hospital out-patient rooms, ague-poisoning may be suspected; but I was then speaking rather from hearsay than from my own experience, which, in fact, had yielded no clear cases of this sort of neuralgia, and was till just recently unable to reckon up more than two undoubted and one doubtful case of the affection, in all of which the fifth cranial nerve was unattacked. The periodicity in one of the genuine cases was regular tertian, in the other regular quotidian. A semi-algide condition always ushered in the attacks; but this was gradually exchanged, as the pain continued, for a condition in which the pulse was rapid and locomotive, but compressible, and the strength was further depressed. In both these cases there was unilateral flushing of the face, and congestion of the conjunctiva, to a slight degree, during the attack of pain. The pain became duller and more diffused contemporaneously with the lowering of arterial pressure; and, after the disappearance of active pain, moderate tenderness over a considerable tract round the course of the painful nerves remain for some time. There was no distinct development of painful points in the situations described by Valleix; but it should be remarked that the cases were rapidly cured with quinine, which very probably accounts for this circumstance.
Till lately I had not witnessed neuralgia as an after-consequence of tropical malaria-poisoning, although I have had many cases of other diseases, the relics of hot climates, under my care; but within the last year I have seen a case of extremely severe intercostal neuralgia of a perfectly periodic type occurring in a patient whose constitution had been thoroughly saturated with tropical marsh poison, and in whom the spleen was still much enlarged. The neuralgia was so terrible, and accompanied by such severe algide phenomena at the beginning of the attacks, and such a sense of throbbing as the pain developed, as to lead to serious suspicions of hepatic abscess, for the moment; but the course of events soon corrected this idea.
2. Neuralgias of the Period of Bodily Development.– By the "period of bodily development" is here understood the whole time from birth up to the twenty-fifth year, or there-abouts. This is the period during which the organs of vegetative and of the lower animal life are growing and consolidating. The central nervous system is more slow in reaching its fullest development, and the brain especially is many years later in acquiring its maximum of organic consistency and functional power.
That portion of the period of development which precedes puberty is comparatively free from neuralgic affections. At any rate, it is rare to meet in young children with well-defined unilateral neuralgia, except from some very special cause, such as the pressure of tumors, etc. Such neuralgias as do occur are commonly bilateral, and are connected either with the fifth cranial or the occipital nerves.
I must here mention an affection which was quite unknown to my experience, but was brought under my notice by the late Dr. Hillier, who kindly called my attention to the notes of two cases which were published in his interesting work on "Diseases of Children." The cases are those of two female children, aged nine and eleven respectively, in whom the principal symptom was violent and paroxysmal neuralgic headache. In both of these children the existence of cerebral tubercle was suspected, but this proved to be a mistake. In both there were intolerance of light, vomiting, tonic contraction of the muscles of the neck, and occasional double vision; but no impairment of intelligence, no amaurosis, and no paralysis or rigidity of the limbs. Each of these children died rather suddenly, after a violent paroxysm of pain. The main, indeed almost the only characteristic post-mortem change was a marked loss of consistence of tissue, in one case in the pons varolii, in the other in the pons, the medulla oblongata, and the cerebellum. These cases are of the highest possible interest, as are also several other instances of headache in children recorded by Dr. Hillier; notably one in which severe paroxysmal pains were attended with general impairment of brain-power, and, on the occurrence of death from exhaustion, the autopsy revealed an amount of degeneration in the cerebral arteries (as also in the general arterial system) which was astonishing, considering that the child was only ten and a half years old. This case, the full significance and interest of which will be better seen when we come to discuss the subject of pathology,
"London Hosp. Reports," 1866.
"Stimulants and Narcotics," Macmillan, 1854, p. 86.
