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Lastly, it should be mentioned that in rare cases neuralgic pains are felt almost everywhere, in the limbs, trunk, and head, and apparently constitute a sort of universal neuralgia. The few cases I have seen have been in adult men, and associated with hypochondriasis.

VARIETIES DEPENDING ON CHARACTER.

Epileptiform Neuralgia.-The term is applied (according to the example of Trousseau) to an intractable form, in which each attack of pain comes on very suddenly, with intense severity, and lasts usually less than a minute, sometimes only a few seconds, rarely for two or three minutes. The frequency with which the attacks recur varies in different cases; the daily number may be one or hundreds. The pain is most intense, so that the patient stamps about the room in agony, or tries to get relief by violent rubbing or by pressure. Trousseau relates the case of a lady whose malar bone was atrophied in consequence of the pressure, repeated every few minutes for years. The sufferers from this terrible form are usually in the second half of life. The pain is invariably in the region of the fifth nerve, sometimes in the whole, sometimes in part only, but rarely confined to a single branch. Convulsive spasm in the face may accompany the pain (convulsive epileptiform neuralgia).

Reflex or sympathetic neuralgias are those in which the pain is felt in another nerve region than that in which its cause exists. The radiation of neuralgic pain must, as already stated, be ascribed to the extension of the central discharge to adjacent centres, but the term "reflex neuralgia" is not applied to these cases, but to those either in which the pain exists only at a distance from its cause, or in which the distant neuralgia has no sensory continuity with the primary pain. The pain of a carious tooth may be associated with a distant and apparently disconnected pain in some other part of the fifth nerve, or such disease may cause only distant neuralgia, and no local pain. The proneness of the fifth nerve to be affected in neuralgia renders it a common seat of the reflex form. For instance, neuralgia limited to the fifth has been produced by injury to the ulnar nerve, and to the occipital nerve (Anstie). Nevertheless, the converse relation is some

times observed; carious teeth are said occasionally to cause neuralgia in other parts, as, for instance, in the cervico-brachial region (Salter). When no local pain is felt, we must assume that the centre to which the afferent impressions directly come is not thus excitable to painful activity, or even so as to influence consciousness, but that it is in connection with another centre which, by natural or acquired susceptibility, is disposed to excessive action. Curious cases are on record in which the act of micturition invariably caused a pain in the region of the arm supplied by the ulnar nerve. (Several such cases are given by Vanlair ["Les Nevralgies," p. 330]; one of them comes from a curious source-the autobiography of Clarendon, Chancellor to Charles II. See p. 8.)

The cause and seat of reflex neuralgia may be most varied. When due to causes acting on the cerebro-spinal nerves, the pain is usually felt on the same side, and rarely far distant. A most inportant class of reflex pains are those which are produced by disease of the internal viscera, such as the spinal pain in ulcer of the stomach, the sacral pain in uterine disease, the scapular pain in affections of the liver, the pain in the testicle in renal colic, and pain in the front of the thigh and spine in gonorrhoeal orchitis (Mauriac). Many of these are rather reflex pains than neuralgias properly so-called, but they occasionally persist when their cause is removed, or assume disproportionate intensity. They are of very great practical importance on account of the readiness with which their cause may escape attention.

Traumatic neuralgias are those that are excited by injury to nerves-by contusion, and by punctured, lacerated, or incised wounds. In some instances the pain is the result of a neuritis, set up by the injury, which may ascend the nerves and pass, at a junction, to other trunks. But neuralgia may also be set up when there is no more than the local and transient inflammation at the spot injured. Such neuralgia may follow nerve lesions in any part of the body, but is especially frequent in the arm, the nerves of which are much exposed to injury. In the days of venesection, a common form of neuralgia resulted from injury to a cutaneous nerve in the operation. It may follow wounds of both large and small nerves, and by some observers has been thought to be more frequently due to the latter, but it must be remembered that small nerves

are more often wounded than larger trunks. Anstie believes that neuralgia is more common from partial injuries than when the nerves are completely divided. It is a frequent consequence of gunshot injuries of nerves. In some cases the disease is apparently due to the implication of nerves in a cicatrix, or to the morbid enlargement of the nerve ends after amputation, which goes by the name of "bulbous nerves."

The pain may commence a few hours or days after the injury, but more frequently not until after an interval of some weeks or months. It generally begins in the point injured, but is rarely limited to this, or even to the part supplied by the wounded branch. It usually radiates to adjacent regions, and sometimes to parts supplied by other nerve trunks. For instance, a woman received a blow on the thorax, probably contusing an intercostal nerve. The early pain of the injury ceased, but two months later neuralgic pains commenced at the spot and gradually spread over the whole region supplied by the cervical and brachial plexus (Ollivier). The pain may be less intense at the seat of the injury than it is elsewhere, and it may even be absent at the seat of injury, and then is of the purely reflex variety, instances of which have been already mentioned. These facts, and also the circumstance that the pain is not always influenced by excision of the injured nerve, show clearly that it is to a large extent of central origin, the expression of a disturbance which, though excited by the nerve injury, is to a considerable extent independent of it, and doubtless due, not only to the excitant, but also to a predisposition, such as is concerned in the production of other neuralgias. The same fact is seen even more clearly in cases in which some injury leaves a slight local weakness or disability, and years. afterward the part may become the seat of neuralgic pain, under the influence of a constitutional tendency.

The pain is usually intermitting in character, but often most intense in degree and causes profound depression of the general system. It may excite muscular spasm, and, especially at the onset soon after the injury, other reflex symptoms, such as vomiting. Vaso-motor disturbance occasionally ensues; trophic changes in the skin and joints have been de scribed, but it is very doubtful whether nutrition suffers except in consequence of considerable secondary neuritis. The course

of traumatic neuralgia is often tedious, sometimes most prolonged, and it has been known to last to the end of life, in spite of every medical and surgical measure that could be devised for its relief. When it ceases, it is prone to recur under the influence of general depressing influences.

Occupation Neuralgias.-These are pains, more or less neuralgic in character, brought on by some habitual act. They are the sensory forms of occupation neuroses.

Herpetic Neuralgia.-Herpes zoster, whatever its seat, is usually accompanied by pain of a neuralgic character. The explanation of this is found in the conclusive evidence that the eruption is the effect of nerve irritation, probably always inflammatory in character. It always corresponds in area to the distribution of certain nerves, and, post-mortem, inflammation has been found in the nerve (Haight) and in the ganglia of the posterior roots (Bärensprung, Charcot, etc.). The neuralgic pain is thus "symptomatic," the result of organic changes in the nerves. Sometimes herpes occurs in the area of a nerve which has long been the seat of neuralgic pain, and hence is regarded as an occasional trophic effect of neuralgia, but it is an extremely rare consequence, and probably only occurs in cases in which the pain is the expression of organic changes in the nerve, and is not a consequence of simple idiopathic neuralgia.

In cases of ordinary zoster, pain may occur before or after the eruption. The initial pain precedes the appearance of the eruption for a few hours or days, is usually moderate in severity, and commonly (but not always) subsides as the cutaneous lesion is developed. Sometimes this pre-herpetic pain is absent, especially in the young, although even then there is usually an initial sensation of tingling in the part. The pain that succeeds herpes is more constant. It comes on usually during the decline of the eruption, and its occurrence bears no relation to the seat of the herpes. The most common situations for neuralgia are those in which herpes is most common: the side of the trunk, the forehead, neck, and leg. The pain has the distribution of the eruption, corresponding to the nerve or nerves affected. It varies in degree, but is usually acute, lancinating, and for a time severe, and is accompanied by great tenderness of the skin. The same tender points are met with as in ordinary neuralgia in the same area. There is an

important relation between the age of the patient and the severity and duration of the pain. In old persons it constitutes one of the most severe and persistent forms of neuralgia, often continuing for months and even years before, at last, it slowly lessens. Occasionally, it persists in unmitigated intensity to the end of life. Sir William Jenner, in his lectures, was accustomed to illustrate the obstinate persistence of this pain in the old, by the instance of a man who, before the days of anaesthetics, endured the excision of the skin to which the pain was referred, in the hope of relief, but found none, and then, unable to bear the continuous agony, he shot himself.

Hysterical Neuralgias.-Neuralgic pains are common in hysteria, but a distinction must be drawn between those which are merely associated with, and those which are due to, the general neurosis. Of associated forms, every variety of true neuralgia may be met with, due to the neuropathic disposition, which is also the cause of the hysteria, and they present the characteristic distribution, tender points, etc., of the ordinary form. Anæmic neuralgias are also common in hysterical patients, in whom the nerve disturbance is often due to poorness of blood. Of the neuralgic pains that are due to hysteria, some are in the cerebro-spinal system, some in that of the sympathetic. Certain local pains in the head are very common, but these differ from ordinary neuralgia in being confined to one small spot, instead of following the course of nerves, and the local pain has a sharp stabbing or boring character, as if a nail were being driven in, and hence has received the name of "clavus hystericus." It is important to remember that a similar pain may be met with apart from hysteria, especially in anæmic persons. Pains in the spine are also extremely common, sometimes very local, and of various characters. Other pains referred to the trunk are usually associated with local tenderness, in the so-called "hysterogenic points." The most important neuralgias of hysteria are those of the viscera, ovarialgia (not necessarily in the ovary itself), and gastralgia, being the most frequent. Pains in the joints and muscles are also common. The visceral neuralgias, and those associated with parietal tenderness, are usually persistent, but the local boring pains, and those in the joints and muscles, are often fugacious and migratory, and this constitutes a diagnostic point of considerable importance.

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