LITMIR.BIZ

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which she described as resembling "iron teeth" tearing the flesh. The pains recurred many times daily; her life was a perfect burden to her, and always had been during these attacks. This patient was under my observation, on various occasions, during several years, and I established the fact that cod-liver oil always did very great good. But it was evident that nothing would remove the tendency to the recurrence of the pains. I should mention, as additional proof of the extent to which the mercurial poison had shattered the nervous system of this woman, that she had violent muscular tremors at the time of her first attack, and on several subsequent occasions. A more completely ruined life was never seen; the poor woman had been on the highway to promotion in the service of a nobleman when she was mercurialized, but her whole prospects were blighted by the serious danger to her health which was caused by the preposterous antiphlogisticism of her medical attendant.

      I do not know that the poisonous action of any other metallic poison than mercury has been distinctly shown to produce neuralgic pains of superficial nerves. The action of lead is well known to produce colic, a disease which will be specially dwelt on elsewhere. And undoubtedly a certain amount of aching pain sometimes attends certain stages of lead-palsy of the extensor muscles of the forearm. But I know of no facts pointing to a true saturnine neuralgia. And the chronic poisonous effects of arsenic on the nervous system seem to produce sensory paralysis, rather than pain.

      We come now to the consideration of the local varieties of neuralgia. The primary subdivision of them may be made as follows:

      I. Superficial Neuralgias. II. Visceral Neuralgias.

      I. Superficial Neuralgias.

      Of superficial neuralgias a further classification may be made:

      (a) Neuralgia of the fifth (trigeminal, or trifacial).

      (b) Cervico-occipital neuralgia.

      (c) Cervico-brachial neuralgia.

      (d) Intercostal neuralgia.

      (e) Lumbo-abdominal neuralgia.

      (f) Crural neuralgia.

      (g) Sciatic neuralgia.

      This arrangement is that of Valleix, and appears to me substantially correct.

      (a) Neuralgia of the Fifth. – The most important group of neuralgias are those of the fifth cranial nerve.

      Neuralgia of the fifth nerve always exhibits itself in the especial violence in certain foci, which Valleix was the first to define with accuracy. These foci are always in points where the nerve becomes more superficial, either in turning out of a bony canal, or in penetrating fasciæ. In the ophthalmic division of the nerve the following possible foci are noticeable: (1) The supra-orbital, at the notch of that name, or a little higher, in the course of the frontal nerve; (2) the palpebral, in the upper eyelid; (3) the nasal, at the point of emergence of the long nasal branch, at the junction of the nasal bone with the cartilage; (4) the ocular, a somewhat indefinite focus within the globe of the eye; (5) the trochlear, at the inner angle of the orbit.

      In the superior maxillary division the following foci may be found: (1) The infra-orbital, corresponding to the emergence of the nerve of that name from its bony canal; (2) the malar, on the most prominent portion of the malar bone; (3) a vague and indeterminate focus, somewhere on the line of the gums of the upper jaw; (4) the superior labial, a vague and not often important focus; (5) the palatine point, rarely observed, but occasionally the seat of intolerable pain.

      In the inferior maxillary division the foci are: (1) The temporal, a point on the auriculo-temporal branch, a little in front of the ear; (2) the inferior dental point, opposite the emergence of the nerve of that name; (3) the lingual point, not a common one, on the side of the tongue; (4) the inferior labial point, only rarely met with.

      Besides these foci in relation with distinct branches of the trigeminus, there is one of especial frequency which corresponds to the inosculation of various branches. This is the parietal point, situated a little above the parietal eminence. It is small in size – the point of the little finger would cover it. It is the commonest focus of all.

      Neuralgia may attack any one, or all, of the three divisions of the nerve; the latter event is comparatively rare. Valleix, indeed, holds a different opinion; but this seems to me to arise from the fact that his definition of neuralgia was too narrow to include a large number of the milder cases of neuralgia, which are, nevertheless I believe, decidedly of the same essential character with the severer affections. The most frequent occurrence is the limitation of the pain to the ophthalmic division, and incomparably the most frequent foci of pain are the supra-orbital and the parietal.

      The most common variety of trigeminal neuralgia is migraine, or sick-headache, as it is often called. This is an affection which is entirely independent of digestive disturbances, in its primary origin, though it may be aggravated by their occurrence. It almost always first attacks individuals at some time during the period of bodily development. Under the influences proper to this vital epoch, and often of a further debility produced by a premature straining of the mental powers, the patient begins to suffer headache after any unusual fatigue or excitement, sometimes without any distinct cause of this kind. The unilateral character of this pain is not always detected at first; but, as the attacks increase in frequency and severity, it becomes obvious that the pain is limited to the supra-orbital and its twigs, with sometimes also the ocular branches. In rare cases, as in all forms of neuralgia, the nerves of both sides may be affected; I have already observed that this seems to be relatively more common in young children. If the pain lasts for any considerable length of time, nausea, and at length vomiting, are induced. This is followed at the moment by an increase in the severity of the pain, apparently from the shock of the mechanical effect; but from this point the violence of the affection begins to subside, and the patient usually falls asleep. The history of the attacks negatives the idea that the vomiting is ordinarily remedial. This symptom merely indicates the lowest point of nervous depression; but it may happen that a quantity of food which has been injudiciously taken, lying as it does undigested in the stomach, may of itself greatly aggravate the neuralgia, by irritation transmitted to the medulla oblongata. In such a case vomiting may directly relieve the nerve-pain. When the patient awakes from sleep, the active pain is gone. But it is a common occurrence – indeed it always happens when the neuralgia has lasted a long time – that a tender condition of the superficial parts remains for some hours, perhaps for a day or two. This tenderness is usually somewhat diffused, and not limited with accuracy to the foci of greatest pain during the attacks.

      Sick headache is not uncommonly ushered in by sighings, yawning, and shuddering – symptoms which remind us of the prodromata of certain graver neuroses, to which, as we shall hereafter see, it is probably related by hereditary descent. In its severer forms, migraine is a terrible infliction; the pain gradually spreads to every twig of the ophthalmic division; the eye of the affected side is deeply bloodshot, and streams with tears; the eyelid droops, or jerks convulsively; the sight is clouded, or even fails almost altogether for the time, and the darts of agony which shoot up to the vertex seem as if the head were being split down with an axe. The patient cannot bear the least glimmer of light, nor the least motion, but lies quite helpless, intensely chilly and depressed, the pulse at first slow, small and wiry, afterward more rapid and larger, but very compressible. The feet are generally actually, as well as subjectively, cold. Very often, toward the end of the attack, there is a large excretion of pale, limpid urine.

      Another variety of trigeminal neuralgia which infests the period of bodily development is that known as clavus hystericus: clavus, from the fact that the pain is at once severe, and limited to one or two small definite points, as if a nail or nails were being driven into the skull. These points correspond either to the supra-orbital or the parietal, or, as often happens, to both at once. But for the greater limitation of the area of pain in clavus, that affection would have little to distinguish it from migraine, for the former is also accompanied with nausea and vomiting when the pain continues long enough; and in both instances it is obvious that there is a reflex irritation propagated from the painful nerve. The adjective hystericus is an improper and inadequate definition of the circumstances under which clavus arises. The truth is, that the subjects of it are chiefly females who are passing through the trying period of bodily development; but there

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