Page images
PDF
EPUB

these cases the pain was the result of actual changes in the nerves. The course of the fifth in the base of the skull through the membranes and bony foramina exposes it to damage from many morbid processes, and causes its fibres to suffer when there is any inflammatory swelling of the sheath.

Occasionally migratory pains are felt in various parts of the scalp, sometimes on one side, sometimes on the other, without any distinct relation to the nerve trunks. There may be tenderness of the skin during and after the paroxysms of pain. This form is sometimes more closely allied to rheumatism than ordinary neuralgia is. Rarely there is neuralgic pain over the whole scalp at the same time, so that, as one patient expressed it, there is "a cap of pain on the head." Pain at the vertex is a common form of headache sometimes closely allied to neuralgia, and it may alternate with characteristic neuralgic pains in other situations.

Cervico-Occipital Neuralgia.-The pain is felt in the region of the neck supplied by the first four cervical nerves and in the posterior portion of the head, chiefly along the course of the great occipital nerve. Thus the pain may extend over the greater part of the neck as well as over the head as far forward as the parietal eminence and the ear. It is occasionally confined to the posterior branches, extending over the back of the neck and occiput. The most important tender points are (1) about midway between the mastoid process and the spine at the point at which the great occipital nerve becomes superficial, (2) over the branches of the cervical plexus between the sterno-mastoid and trapezius, and (3) just above the parietal eminence, the focus common to occipital and trigeminal neuralgia. Fusion of these two forms of neuralgia occurs, so to speak, not only above but below where the distribution of the cervical nerves blends with that of the third division of the fifth over the lower jaw. A primary cervical neuralgia may extend into this region of the fifth; doubtless the centres blend as does the distribution. It is probable that cervico-occipital neuralgia is more often bilateral than any other form, especially when confined to the occipital region. I have known most severe bilateral neuralgia to be limited to the anterior cervical region from the jaw to the upper part of the thorax on each side. The pain in cervico-occipital neuralgia is rarely intermitting; there is more or less dull constant

pain with occasional exacerbations, less violent than in the trigeminal form. The scalp may become extremely tender, so that during the pain the patient cannot bear the hairs to be touched. This form of neuralgia is not common, and Anstie believes that it occurs especially in those who have suffered from other forms.

Cervico-brachial and brachial neuralgia includes those forms in which the pain is referred to the region supplied by the four lower cervical and the first dorsal nerves. The pain may be felt in the lower and posterior part of the neck or any part of the arm and hand, but is commonly most intense in the axilla at the brachial plexus and along the course of the ulnar nerve. The region of the last is a very frequent seat, but sometimes the pain is referred to other nerves.. It is commonly increased by movement and may render the arm almost useless. It is often excited by writing, and this may give rise to an erroneous impression that it is connected with the act of writing. Some severe forms of brachial neuralgia indeed have their origin in a sensory occupation neurosis. The most common tender points in brachial neuralgia are the axillary; the circumflex at the posterior border of the deltoid; a superior ulnar behind the elbow, and an inferior ulnar in front of the wrist. The latter is the most frequent of all the brachial foci. Others occasionally met with are the vertebral, by the side of the lower cervical spines; a scapular, at the inferior angle of that bone; an external humeral, on the outer side of the arm three inches above the condyle over the musculo-spiral nerve; and a radial, in the lower and outer part of the forearm. There is usually some constant pain in addition to the acute paroxysms. Occasionally it may radiate to the side of the chest, and then if on the left side may simulate angina pectoris. The pain is almost always intensified by movement. Trophic disturbance in the arm is very rare in cases of true neuralgia, and indeed probably always indicates neuritis. When the pain starts from the fingers it may begin with some sensation other than pain, such as tingling, which changes to pain as it passes up the arm. In some patients with brachial neuralgia the arm is peculiarly liable to be the seat of tingling at night. Brachial neuralgia is not often due to diathetic causes, with the exception of rheumatism, with which it is often associated even when there is no suspicion of

neuritis. On the other hand it is more frequently than any other as the result of injury. Probably many cases of supposed neuralgia are really cases of neuritis of the brachial plexus which may arise by migratory inflammation. But true neuralgia of the arm widely spread may be set up by a slight injury, as a blow which does not apparently cause neuritis. Brachial neuralgia is occasionally associated with neuralgia of the fifth, and this when there is no connecting pain in the neck.

Trunk Neuralgia.-Of the neuralgias of the trunk we have first the dorso-intercostal forms, which occupy the intercostal nerves from the third to the ninth, characterized by pain coursing along the intercostal spaces or parts of them. It is sometimes bilateral and symmetrical. There is usually a constant dull pain with acute stabbing exacerbations, but sometimes the continuous pain exists alone or the sharper pains are excited only by movement, respiratory or other. There are foci of intensity and tender points at the emergence of the three branches of the intercostal nerve-besides the vertebræ near the middle line in front and midway between these two points in the mid-axillary line. Intercostal neuralgia is most frequently due to cold or to injury, such as a contusion. It is sometimes extremely obstinate and of long duration.

The thoracic wall is also the seat of more trifling neuralgic pains; one of these is pleurodynia, which differs from true intercostal neuralgia in being usually localized at one spot not corresponding to the course or exit of the intercostal nerves. It appears to be a true neuralgia, distinguished from myalgia by the fact that it is local, very acute in character, and is excited by expansion of the thorax rather than by lateral movements of the trunk. The theory that it is a neuralgia of the pleural nerves has much probability. Another common neuralgic pain is the infra-mammary pain of anæmic women. Very limited in position it is more or less constant, and is rarely increased by respiration to such an extent as to interfere with the free expansion of the thorax. The relation between intercostal neuralgia and pulmonary trouble is a difficult subject on which satisfactory facts are difficult to obtain and few observers have ventured to corroborate the statement of Woillez that acute intercostal neuralgia is always accompanied by a secondary congestion of the lung. It is more

probable that, when this association exists the true relation is the reverse. The intercostal nerves are frequently the seat of herpetic neuralgia.

The neuralgias that occupy the lower half of the trunk have been grouped as lumbo-abdominal. The pain has a course similar to that of the intercostal form. Foci of pain and tender points are found at the back; beside the vertebræ over the posterior branches; at the middle of the iliac crest (iliac point); at the lower part of the rectus (hypogastric point), while sometimes there is in the male a scrotal and in the female a labial point. These pains are often bilateral and may change their position from time to time. They are generally acute pains, but now and then have a constricting character like the girdle pain of organic disease, but distinguished from them by their irritability. Lumbo-abdominal neuralgias seem to be sometimes secondary to disease of the pelvic organs, especially in the female. Neuralgia in the penis sometimes results from masturbation. It may also be due to lithæmia, and from this cause I have known it to be most severe and long continued.

The spinal column is a very common seat of neuralgic pain, especially in weakly women and after concussion of the spine. It constitutes one of the most troublesome of the many pains of hysteria, and one of the most enduring consequences of railway accidents. The pain is in most cases felt through a considerable vertical extent of the spine, and is specially intense in certain spots, commonly in more than one. The dorsal region is the most common seat, next the lower cervical, and least frequently the lumbar region. Sometimes the pain is localized on one side of the spine, close to it. The pain felt in the spine in cases of gastric ulcer seems to be a sort of reflex neuralgia. Often the pain seems to pass up to the back of the head. Spinal neuralgia may be associated with a similar pain in some other part of the trunk, shoulder, arm, or leg. It is usually accompanied by considerable tenderness, and is increased by fatigue, by use of the legs, by long sitting or standing, and also by vibration, such as the movement of a carriage. The latter point is often of considerable diagnostic importance, for it is far more marked in neuralgia than in spinal disease causing pain. On the other hand the pain is not increased by

slight movement, as is the pain of growths and caries. The pain is seldom distinctly paroxysmal, but as already mentioned in one case, paroxysms of pain in the cervical spine and vertex were most intense, and each was accompanied by opisthotonos. It is uncertain in what structure this spinal neuralgia is produced. It is often associated with neuralgia elsewhere, and also with rheumatism of the fibrous tissues, so that some cases seem to be of the nature of rheumatic neuralgia. It has been thought that the membranes are the seat of the pain, but there is no real evidence for or against the theory.

Another very common seat of neuralgia is the sacral region, no doubt in consequence of the plexus of nerves that lies between the bone and the skin. Pains of pelvic origin are often referred to this region, as those of parturition show. Occasionally the pain is felt chiefly about the coccyx-coccydynia it has been termed. It must be remembered that the fibrous tissues over the sacrum are sometimes the seat of acute rheumatism, such as higher up gives rise to lumbago.

Neuralgia of the Leg.-In the lower limb, neuralgia is rare in the region supplied from the lumbar plexus, although a crural form, in which the pain occupies chiefly the front of the thigh, is occasionally met with. In most instances pain in this region is of secondary origin, due to a lesion of the lumbar plexus, as, for instance, from the pressure of an abdominal tumor, or is due to the extension of neuritis from the sciatic up the lumbo-sacral cord.

The majority of neuralgic pains in the leg are in the region of the sciatic nerve, and are grouped under the designation of sciatica. The pain occupies especially the course of the nerve, but tender foci are met with in certain spots; lumbar, near the spine, just above the sacrum; sacro-iliac, at the articulation of the same name; a gluteal opposite the middle of the lower border of the gluteus; a series of spots varying in exact position, along the course of the nerve in the posterior aspect of the thigh; a peroneal behind the head of the fibula; and a malleolar behind the lower extremity of the fibula, and an external plantar at the outer border of the foot. It is, however, certain that sciatica is seldom a true neuralgia. Almost all severe cases are due to inflammation of the nerve trunk.

« PreviousContinue »