Part 1 — CHAPTER I. (continued 2)

The sufferers from this variety of sciatica are mostly, as already said, of middle age or more; but this statement must be understood to be made in the comparative sense, which refers rather to the vital status of the individual than to the mere lapse of years. Many of these people have hair which is prematurely gray, and in some the existence of rigid arteries, together with arcus senilis, completes the picture of organic involution, or senile degeneration. In particular cases, where depressing influences have been at work for a long time, or unusually active, these appearances rectify the false impression we should otherwise derive from learning the mere nominal age of the person; this is especially often the case with regard to patients who have for a long time drunk to excess. The prematurely and permanently gray hair (it will be seen hereafter that permanency of grayness is an important point), together with well-marked inelasticity of arteries, very often tells a tale which is most useful in informing us, not only of the vital status of the patient, but of the kind of sciatica under which he labors; and also influences our prognosis seriously. There is otherwise a somewhat deceptive air about the appearance of many of these degenerative cases; for instance, a ruddy complexion is not uncommon, nor the retention of considerable, or even great, muscular strength. It is probable that these appearances deceived Valleix and many others, or they could hardly have failed, as they have, to observe the frequency of the degenerative type among the most numerous group of sciatic patients, namely, those between thirty and fifty years of age. These persons are not truly "robust," although at a hasty glance they might at first seem to be so. It would be a serious mistake to omit the search for the important vital evidences which have been referred to, since these therapeutic and prognostic indications are of the highest value.

A prominent feature in this kind of sciatica is its great obstinacy and intractability. Another, equally marked, is the tendency to the development of spots around the foci of severest pain which are intensely and permanently tender, and the slightest pressure on which is sufficient to set up acute pain. This is a symptom much less developed, if developed at all, in the variety of sciatica which we first discussed. The places which are especially apt to present this phenomenon of tenderness are as follows: (1) A series, or line of points, representing the cutaneous emergence of the posterior branches, which reaches from the lower end of the sacrum up to the crista ilii; (2) a point opposite the emergence of the great and small sciatic nerves from the pelvis; (3) a point opposite the cutaneous emergence of the ascending branches of the small sciatic, which run up toward the crista ilii; (4) several points at the posterior aspect of the thigh, corresponding to the cutaneous emergence of the filets of the crural branch; (5) a fibular point, at the head of the fibula, corresponding to the division of the external popliteal; (6) an external malleolar, behind the outer ankle; (7) an internal malleolar.

I have already mentioned that in sciatica the pain frequently spreads in a reflex manner to nerves which are connected, by their origin from the plexus, with the sciatic. It will be remembered, also, that I related cases in which the formation of tender points, in the course of the nerves thus secondarily affected, was even more distinct and remarkable than anywhere in the branches of the sciatic itself.

Another circumstance which distinguishes the form of sciatica which we are now describing is, the degree in which (above all other forms of neuralgia) it involves paralysis of motion. [The subject of the complication of neuralgia will be treated in a general manner farther on; but it seems necessary to note here the special liability of sciatic patients to this and to the most material complications]. By far the largest part of the motor nervous supply for the whole lower limb passes through the trunk of the great sciatic; it might therefore be naturally expected that a strong affection of the sensory portion of the nerve would produce, in a reflex manner, some powerful effect upon the motor element. This effect is most frequently in the direction of paralysis. Complete palsy is rare, but in a large proportion of cases which have lasted some time there will be found, independently of any wasting of muscles, a positive and considerable loss of motor power. It is of course necessary to avoid the fallacy which might be produced by neglecting to observe whether movement was restricted merely in consequence of its painfulness. Not long since, I had occasion to test the electric sensibility in a case of sciatica, in which there was extremely severe pain, affecting chiefly the peroneal region of the leg, and great weakness of the leg, amounting to inability for walking. The gastrocnemius could hardly be got to contract at all, when the most powerful Faradic current was directed upon the nerve in the popliteal space of the affected limb, though the muscle of the sound side reacted with great vigor.

Anæsthesia is also a common complication of sciatica, far commoner, I venture to think, than it has been represented either by Valleix, or Notta. It is necessary, however, to be explicit on this point. In the early stages, both of this form of sciatica, and of the milder variety previously described, there is almost always partial numbness of the skin previous to the first outbreak of the neuralgic pain, and during the intervals between the attacks. By degrees this is exchanged, in the milder form, for a generally diffused tenderness around the foci of neuralgic pain, while other portions of the limb remain more or less anæsthetic. In the severer forms it sometimes happens that, besides an intense tenderness of the skin over the painful foci, there is diffused tenderness over the greater part or the whole of the surface of the limb. But it is important to remark that both in the anæsthetic and the hyperæsthetic conditions (so called) the tactile sensibility is very much diminished. I have made a great many examinations of painful limbs, in sciatica, and have never failed to find (with the compass points) that the power of distinctive perception was decidedly lowered.

Convulsive movements of muscles are met with in a moderate proportion of cases of sciatica in middle and advanced life, in which affection they are entirely involuntary. They differ from certain spasmodic movements not unfrequently observed in the milder form (and especially in hysteric women), for these are more connected with morbid volition, and are in truth, not perfectly involuntary. In several cases of inveterate sciatica I have seen violent spasmodic flexures of the leg upon the thigh. Cramps of particular muscles are occasionally met with. I have seen the flexors of the toes of the affected limb violently cramped, and in one case there was agonizing cramp of the gastrocnemius. It is chiefly at night, and especially when the patient is falling asleep, that this kind of affection is apt to occur.

A third variety of sciatica is the rather uncommon one so far as my experience goes, in which inflammation of the tissues around the nerve is the primary affection, and the neuralgia is mere secondary effect, from mechanical pressure on the nerve, which, however, is not apparently itself inflamed. I believe that these cases are sometimes caused by syphilis, and sometimes by rheumatism. One of the most violent attacks of sciatic pain which ever came under my notice was in a syphilized subject, a discharged soldier, who had been the victim of severe tertiary affections, and had been mercilessly salivated into the bargain. This unfortunate man suffered dreadful agony, which was aggravated every night, but was never totally absent. The pain started from a point not far behind the great trochanter: pressure here caused intolerable darts of pain, which ramified into every offshoot of the sciatic nerve, as it seemed, and made the man quite faint and sick. Large doses of iodide of potassium, together with the prolonged use of cod-liver oil, completely removed the pain and tenderness. It need hardly be said that cases of this kind are essentially different, and require perfectly different principles of treatment from neuralgias in which the disturbance originates within the nervous tissues themselves.

The chronic rheumatism does also, occasionally, affect the sheath of the nerve in such a manner as to produce a deposit which sets up neuralgic pain, must also be admitted, although I believe the number of such cases to be preposterously over-estimated by careless observers. It has several times happened that a patient has come under my care with so-called "rheumatic affection of the nerves" of the thigh and leg, and that on examination one has found all the symptoms and clinical history of a neurosis, but not the slightest valid argument for a diagnosis of the rheumatic diathesis. Indeed, upon this point, I think it is time that a decided opinion should be expressed. I firmly believe that a large number of sciatic patients have their health ruined by treatment directed to a supposed rheumatic taint which is purely imaginary. The state of medical reasoning, suggested by the way in which too many practitioners decide that such and such pains are rheumatic in their origin, is a melancholy subject for reflection. Nearly always it will be found, on cross-examination, that the state of the urine has been made the basis of a confident diagnosis; the practitioner will tell you that the urine was loaded, i. e., with lithtaes. He ignores the fact that nothing is more common, in neurotic patients who are perfectly guiltless of rheumatic propensities, than a fluctuation between lithiasis and oxaluria, neither of which phenomena, under the circumstances, indicates any more than a temporary defect of secondary assimilation of food, produced by nervous commotion. I may perhaps find room, on a future page, for a few further remarks on the subject; at present I only put in a caution against too ready an acceptance of the rheumatic hypothesis.

II. Visceral Neuralgias.

Uterine and Ovarian Neuralgia.—This is an important group of neuralgic affections, and one which I cannot help thinking is strangely misappreciated, very often, in a therapeutic point of view. In one aspect these affections possess a special interest, namely this, that they are more frequently dependent on peripheral irritation for their immediate causation than any other group of neuralgias. If we consider the great copiousness of the nervous supply to the uterus and ovaries, and the powerfully disturbing character of the functional processes which are periodically occurring in these organs, we shall be at no loss to understand how this may be. The amount force of the peripheral influence and which are brought to bear upon the central nervous system by the functions of the uterus and ovaries are greater than any that emanate from the diseases and functional disturbances of any other organ in the body.

The most common variety of peri-uterine neuralgia is that which attends certain kinds of difficult menstruation. It would be hardly correct to give the name of neuralgia to the pain existing in these very numerous cases of dysmenorrhœa in which the suffering is apparently altogether dependent on the mere retention or difficult escape of the menstrual fluid, although the character of the pain often resembles the neuralgic type. There is another group of dysmenorrhœal affections however, in which the pain may fairly be called neuralgic, since it is apparently independent of the circumstances of the discharge of menstrual fluid, and simply attends the process, seemingly on account of a naturally-exaggerated irritability of the organs concerned. There is a large class of young women in whom, and more especially before marriage, the time of menstruation is always marked by the occurrence of more or less severe pain. Formerly I used to believe that this pain was relieved on the occurrence of the discharge, but I have seen too many cases of a contrary nature to retain this opinion. I now believe that the subjects of the kind of menstrual pain to which I am referring are naturally endowed with a very irritable nervous apparatus of the pelvic organs, and that there is a certain character at once of immaturity and excitability in their sexual organs, especially in the virgin condition. So far from these females being disposed to sterility, as is too often the case with those dysmenorrhœal subjects whose troubles depend upon occlusion, distortion, or narrowing of the outlets, they are often extremely apt to the generative function; and, what is more, the full and natural exercise of the sexual function appears necessary to the health of their organs, as is shown by the fact that these menstrual pains lose their abnormal character, completely or in great part, after marriage, and especially after child-bearing. The contrast between the two types of dysmenorrhœal patients is sharply brought out by the two following cases:

Case I.—S. M., a housemaid, aged twenty-three when first under my notice, was the picture of physical health and strength, very intelligent, and a girl of excellent character and most industrious habits. At every menstrual period, however, she suffered, for some hours previously to the occurrence of the flow, from severe pain in the uterine region, which was tumefied and tender. Hot hip-baths gave some relief, apparently by hastening the discharge; as soon as the latter was established, the pain rapidly subsided. This young woman married a healthy and vigorous young man, but has never had any children, and at the date of my last inquiries still suffered periodically from her old troubles.

Case II.—Mrs. B. was married at the age of twenty-six. Up to the date of her marriage she used to suffer the most severe pain at every menstrual period; the pain, however, bore no relation to the freedom of the discharge, but always lasted about the same length of time, under any circumstances, or was only less or more according as the general bodily vigor was greater or less at the moment. From the date of marriage these troubles steadily declined; a child was born at the end of twelve months, and the menstrual troubles have never resumed a serious shape up to the present time, a period of nearly nine years. This lady is herself a neuralgic subject, liable to migraine in circumstances of fatigue, and suffering horribly from it during her pregnancies; and she comes of a family in whom the nervous temperament is strongly developed.

It must not always be concluded, because the menstrual pain is very severe before the discharge and is relieved at or soon after its appearance, that the case is one of occlusion, and not of neuralgia. There is a class of cases in which the affection appears to be a very severe ovarian neuralgia, attended with a vaso-motor paralysis which causes great engorgement of the ovary and consequent difficulty of "ovulation." I have seen several instances which I could not explain in any other way.

Case III.—One patient I particularly remember, from the fact that she was always attacked with dreadful pain, which was sometimes seated in one groin and sometimes in the other, but was regularly attended with large and palpable tumefaction of the ovary, which began to subside when the discharge commenced. This woman married rather late, but her menstrual troubles immediately became less, and she became pregnant and was happily delivered, nearly as soon as was possible. She, too, was a decidedly neuralgic subject, independently of her tendency to dysmenorrhœal ovarian pain.

In some women who remain single long after the marriageable age, ovarian or uterine neuralgia becomes a constantly-recurring torment, not only at the menstrual period, but at various other times when they are depressed or fatigued in body or mind. As might be expected, this tendency is greatly aggravated in the rarer cases where the patient's mind dwells in a conscious manner on sexual matters, especially if by an evil chance she becomes addicted to self-abuse. Among the many reproaches that have been thrown upon the indiscriminate use of the speculum in examining unmarried women, it has often been urged that it tends to excite sexual feelings. I do not for a moment doubt that this is the case, or that the indiscriminate use of the instrument is altogether indefensible. But I expect that neuralgic pain of the uterus or ovaries, in unmarried women, connected with an already irritable condition of the sexual organs, has often been the reason why such women have applied for advice and have consequently been examined with the speculum; and that the same thing has frequently happened in the case of women who have been left widows at a time of life when the sexual powers were still in full vigor. These patients deserve great pity.

The peripheral irritation which gives rise to peri-uterine neuralgia is not always originally seated in the organs of generation. The following are various sources of external irritation which I have known to produce the affection:

1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman, aged thirty-four, single, was under my care in King's College Hospital many years ago, under suspicions of ulcerated cervix. On examination, no lesion could be detected. It was discovered that the rectum was infested with ascarides, and, after the use of appropriate vermifuges and tonics, the patient entirely lost the uterine pains and also a tormenting pruritus vaginæ, from which she suffered. This woman had at various times suffered from neuralgic headache a good deal.

2. Profuse and intractable leucorrhœa, whether associated or not with ulceration of the cervix, may produce peri-uterine neuralgia, even of great severity, when there are strongly-marked neurotic tendencies. It must be noted, however, that many cases of pain in leucorrhœal subjects, which superficially bear the aspect of neuralgia, turn out on closer investigation to be merely examples of myalgia of the abdominal muscles or aponeuroses.

3. Calculus in the kidney, or in the ureter, sometimes causes intolerable ovarian neuralgia. In the case of a woman who was under my care at the Chelsea Dispensary, some years ago, this was the unsuspected origin of severe neuralgic pains in the left ovary, which recurred several times a day, and which certainly contributed to the patient's death by the exhaustion which they produced. A calculus was found tightly impacted in the ureter, near the kidney.

4. Prolapsus uteri sometimes gives rise to severe peri-uterine neuralgia, or what appears to be such; though it is difficult here to draw the line between neuralgia and myalgia. The commonest kind of pains from prolapsus uteri are not neuralgic in their nature at all, but are of a "bearing down" character, and probably depend upon actual contractile movement of the walls of the uterus.

5. The presence of tumors, either cancerous or fibroid, in the uterus or its appendages, gives rise, frequently, to severe and indeed almost intolerable pains of a distinctly intermittent character. In the early stages of cancerous diseases these pains are usually felt at the lower part of the back; in the later stages they are felt also in the hypogastric region, and are then much more severe.

6. Ulcer of the cervix, of a non-malignant kind, probably sometimes gives rise to neuralgic pain of the uterus, though this is not so severe as in cancer.

7. Large masses of scybalous fæces, impacted in the rectum, will occasionally, by the pressure which they exert on nerves, set up violent neuralgia of uterus or ovaries, the true nature of which is accidentally discovered by the use of aperients which unload the intestine and put an end to the suffering. No doubt it is chiefly in persons with neuralgic predisposition that this effect is produced; for, common as is the occurrence of extreme constipation in women, it is comparatively very rare for us to hear of distinctly neuralgic pain being caused by it.

8. The condition known as "irritable uterus," ever since Gooch's classical description of it, is always attended with uterine pain, which is continuous, but is liable to periodical exacerbations of great severity. In this disorder there is no recognizable physical disease of the pelvic organs, and the patient will generally be found to have suffered neuralgia in other parts of the body on previous occasions. [There is some difference of opinion about this affection: some authors (e. g., Hanfield Jones) considering it as distinct from the true neuralgias.]

9. Reflex irritation, the source of which is in some quite distant part of the body, has in many recorded instances occasioned uterine neuralgia, in highly-predisposed persons. I have seen one case in which severe pain of this kind was clearly proved to have been excited by the presence of a carious tooth which was itself little, if at all, painful, but the removal of which at once cured the pelvic pain.

Neuralgia of the urethra is an affection which is occasionally seen, both in males and females. I have observed it three times; all these cases were apparently traceable to the effects of excessive self-abuse. The male subject was an unmarried man, aged forty-two, of cadaverous appearance, much emaciated, with clammy, perspiring skin, and habitual coldness of the extremities; he suffered much from dyspepsia and palpitation of the heart. The pain ran along the under side of the penis, which was very large, with an elongated prepuce. The paroxysms were severe, and came on chiefly in the morning, soon after he awoke. No remedies did this man any permanent good, and he passed out of my sight, being at that time in a condition of wretched feebleness, and with symptoms of threatened dementia. Of the female subjects, one was a married woman, who accused her husband of impotence, and from her account it would certainly appear that effective connection had never taken place; the hymen was completely destroyed, however. The neuralgic pains recurred nightly in several paroxysms, and were especially severe about the time of the monthly periods. In this case the patient was, she stated, induced to give up her malpractices; at any rate, the pain subsided in a manner which could not be well accounted for by any direct influence of the medicinal treatment. The other female patient was a widow in whom the morbid habit was suspected from her general appearance, and from the existence of enlarged clitoris and other signs of irritation about the external parts: she became rather rapidly phthisical, and suffered severely from neuralgic headaches.

Neuralgia of the bladder has been specially described by various writers; the pain is usually spoken of as seated at the neck of the bladder, and as accompanied by frequent desire to micturate. I have seen two cases, both in women: the first was eventually discovered to be an instance of malignant disease of the fundus of the bladder; the other was apparently the result of a long-continued menorrhœal flux, which had greatly impaired the health, and produced extreme anæmia. In neither of these instances was the pain referred to the external meatus, as in the female patients above mentioned who were suffering from urethral neuralgia. I have never seen the extreme examples of vesical neuralgia described by some writers, in which actual paralysis of the coats of the bladder was secondarily produced; but the reflex influence of the neuralgic affection in both the examples just mentioned appeared to produce great weakening of the muscular power of the rectum, occasioning most obstinate and troublesome constipation.

It would appear, from recorded cases, that both the bladder and the uterus are liable to be affected with neuralgia from malarious influences; but I have never chanced to see any such cases.

Neuralgia of the kidney is spoken of by several writers, and I suppose there is no doubt that it may exist as a special neurotic disease with obvious organic cause. For my own part, I cannot say that I have ever seen it except in instances where there was either the certainty, or a very strong suspicion, that the cause was the mechanical pressure and irritation of a calculus within the kidney. The diagnosis of the simple functional disorder must be excessively perplexing; for in the first place there is the greatest difficulty in making sure that the pain is not external, and seated either in the muscles of the back, or in the superficial dorsal or lumbar nerves, and certainly I am strongly inclined to suspect that this has been really the case in many examples of so-called renal neuralgia. That neuralgia of the kidney may arise secondarily, as a reflex extension of pelvic neuralgia, does, however, appear probable enough; for it is almost certain that in the latter affection at least, the vaso-motor nerves of the kidneys must be strongly influenced in a reflex manner; since the crisis or acme of a paroxysm of pelvic pain is not unfrequently attended with a copious secretion of pale urine.

Neuralgia of the rectum has been carefully described by Mr. Ashton, but is probably not often seen except by practitioners who possess special opportunities of observing rectal diseases. In the one pure case which has fallen under my notice the patient complained of acute paroxysmal cutting pains extending about one inch within the anus, and, as these were greatly increased by defecation I suspected the existence of fissure. Nothing of the kind, however, was found on examination; and the pain ultimately yielded to repeated subcutaneous injections of atropine. This patient had got wet through, and had sat in his damp clothes, getting thoroughly chilled; the pain came on with great suddenness and severity, and the tenderness which has been mentioned was developed very quickly. Probably the influence of cold and wet is among the commonest causes of the complaint. Mr. Ashton also reckons as causes, reflex irritation from other parts of the alimentary canal, and the influence of malaria. He observes that the subjects of the affection are most frequently anæmic, and of a generally excitable and deranged susceptibility, and that females, who, from menorrhagia, or frequent child-bearing with much hæmorrhage, have lost a great deal of blood, are specially predisposed.

Neuralgia of the testis (as an independent affection and not a mere extension of lumbo-abdominal neuralgia) is fortunately a much less common malady than the corresponding affection of the ovary; as might indeed be expected, from the much less degree of functional perturbation to which, in ordinary physiological circumstances, the former organ is exposed than the latter. Except from actual growths within the testis, of which it was a mere symptom, I have never seen neuralgia of the testis save from one of three causes. In one remarkable example it was produced as a reflex effect of severe herpes preputialis. Secondly, it is sometimes observed as a symptom of calculus descending the ureter. And, thirdly, I have seen it several times undoubtedly produced by excessive self abuse.

The occurrence of testicular neuralgia, in one case of epilepsy, as to the cause of which I had been previously much puzzled, led to the discovery of the real origin of the fits. I should observe here that I do not believe that self-abuse is ever more than an immediately exciting cause of epilepsy, a predisposition to the disease having previously existed in all cases. In the patient just referred to, there was a family history of epilepsy, but it was difficult to explain the exciting cause until this was suggested by the occurrence of neuralgic pain in the testicle. The patient relinquished his habit, and both the pain and the epilepsy ceased, and, for some twelve months during which I had him under observation, had not recurred at all. A medical friend has informed me of an instance in which the same habit had produced a neuralgia of the testis so severe as to strongly tempt the patient to castrate himself, and he would probably have done so but that he was too much of a coward with regard to physical pain. The attacks of pain were so severe as frequently to produce vomiting and the greatest prostration.

Hepatic Neuralgia.—It must be allowed that the evidence even for the existence of neuralgia of the liver is at present in an unsatisfactory state. At the same time, there are carefully-recorded cases, by Trousseau and other[7] writers of unquestionable authority, which leave no doubt in my mind, corroborated as they are by a certain amount of experience of my own, that such a form of neuralgia really exists. I must, of course, be understood to refer to something altogether different from the spasmodic pain which is produced by the difficult passage of a gall-stone toward the bowel. I have now seen several cases in which, as it appeared to me, there was sufficient evidence of neuralgic pain seated in the liver itself, and not dependent either on gall-stone or any so-called organic diseases of the viscus.

The subjects of hepatalgia are probably never troubled only by pain in the liver; they are persons of a nervous temperament, in whom a slight shock to, or fatigue of, the nervous system, habitually provokes neuralgic attacks; the pain localizing itself sometimes in the branches of the trigeminal, sometimes in those of the sciatic, sometimes in the intercostal nerves, etc. In one instance which has been under my observation, the attacks of hepatalgia alternated with cardiac neuralgia assuming the type of a rather severe angina pectoris. In another case the patient, a man aged sixty-seven, was very liable to attacks of intermittent abdominal agony, in which one could hardly doubt that the pain was located in the colon, and was attended with paralytic distention of the bowel; the peculiar feature of the case being the sudden way in which the symptoms would appear and depart, independently of any recognizable provocation or the use of any remedies. On two separate occasions this patient was attacked with pain of a precisely similar kind, but limited to the right hypochondrium, attended with great depression of spirits, and followed by a well-pronounced jaundice. So remarkable was the conjunction of symptoms in these two attacks that a strong suspicion of biliary calculus was raised, but not the slightest confirmation of this idea could be obtained; and indeed one symptom—vomiting—which nearly always attends the painful passage of a biliary calculus, was altogether absent.

Putting aside a considerable number of cases in which "pain in the liver" was vaguely complained of by patients who were plainly hypochondriacal, and whose account of their own sufferings could not be relied on, I have altogether seen five instances of what I regard as genuine hepatalgia. The first of these was very remarkable in its history and in all its features. The patient was a respectable girl of eighteen, subject to migraine, who had reason to fear that she had become pregnant, though this proved, ultimately, not to be the case. Under these circumstances she was attacked with intermittent pains, in the right hypochondrium, of intolerable severity; resembling, in fact, the pain of biliary calculus, but without the sense of abdominal constriction, and without any vomiting. These recurred daily at about the same hour in the morning, for about ten days; when rather suddenly, a jaundiced tint appeared upon the face, and very shortly the whole skin was colored bright yellow; there was intense mental apathy; the urine was loaded with bile-pigment, and the fæces clay-colored. This state of things lasted only about a week and then very rapidly disappeared; but as the jaundice subsided there was a partial recurrence of the neuralgic pains, which, for a day or two, were as severe as they had ever been; The other four cases of hepatalgia which I have seen, including that of the man above mentioned, have all been in persons in advanced life; but, except the latter, neither of them displayed any symptoms of disordered biliary secretion; and the diagnosis (as to situation, for the character of the attacks was manifestly neuralgic) rested mainly on the fact that the pain radiated to the shoulder.

There remains to be noticed one clinical feature of the disease, which, I believe, is characteristic; namely, the peculiar mental depression which attended all the cases I have seen, but was most marked in the two in which jaundice occurred. In the girl above referred to, the apathy, during the period when there was jaundice but no pain, was even alarming; it reminded one of the mental state in commencing catalepsy; during the painful stages it was more like the gloom of suicidal melancholia. Of course, the acute mental anxiety which this patient had suffered would account for a good deal of this; but the symptom was as distinct, though less severe, in the case of an elderly lady, whom I have attended on another occasion for migraine; here there was no recognizable source of anxiety; and, on the other hand, there was no reason to suspect the retention of bile-elements in the blood. It seems, therefore, as if an essentially depressing influence on the mind was excited by hepatic neuralgia; or else, that emotional causes are the chief source of the malady.

Neuralgia of the Heart.—If there be any hesitation in treating this disease as exactly conterminous with angina pectoris, it can, I think, be only reasonably justified on two grounds: In the first place, it may be urged that acute pain of the neuralgic type is not always present in angina pectoris; and, secondly, it may be urged that many cases of painful neurosis of the heart have been observed, in which the recurrence of pain with some amount of cardiac embarrassment has gone on for years, whereas the popular conception of true angina almost necessarily involves rapid fatality.

There is doubtless some force in these objections, especially in the second, for it does seem rather inconvenient to call by the same name so deadly a disorder as the worst form of angina, and so comparatively harmless a malady as some of those instances of chronic tendency to spasmodic pain of the heart which are not very uncommon, and in which the patient survives, perhaps, to an old age. Yet, after all, there is the greatest difficulty in drawing any rational line of distinction; for the basis of the affection seems the same in every case, whether pain or spasm be the predominant feature, and whether the course of the disease be long or short. All that appears to be necessary for its production is a certain originally neurotic temperament (with possibly some congenital weakness or some post-natal disease of that part of the spinal-cord centres which Von Bezold has described as furnishing three-fourths of the propulsive power of the heart) and the presence of almost any kind of difficulty or embarrassment of the action of the heart. The most common source of this embarrassment is perhaps failure of nutrition in the muscular walls of the heart, from disease of the coronary arteries. Indeed, it is not known that any organic change of the heart or great vessels, even of the slightest kind, is necessary to the production of angina; on the contrary, there is every reason to think that mere fatigue and depression may bring on the attacks in persons of a strongly nervous temperament. For my own part, I am inclined to believe, however that there really always is disease somewhere in the cardiac centre of the spinal cord, though that disease may consist in no more than a disposition to minute interstitial atrophy. But we shall say more about this presently.

It is at any rate certain that cardiac neuralgia is always a most grave complaint, from the almost total uncertainty whether succeeding attacks will not involve a fatal amount of spasm. As for the expression angina pectoris, it is just one of those mischievous terms which, arising out of the mystified ignorance in which the elder physicians found themselves as to the pathology of internal diseases, have since been attached in turn to various definite organic changes, with none of which they had any essential connection; and it is therefore much to be wished that it could be altogether done away with. At the same time, there is so much that is peculiar in the case of cardiac neuralgia, owing to the importance of the organ affected, that it will be necessary here to treat not merely its symptoms, but also its diagnosis, prognosis, etiology, pathology, and treatment, in a separate and continuous manner.

Clinical History and Symptoms.—Cardiac neuralgia usually shows itself for the first time with considerable abruptness. The patient may or may not have been consciously ill before the actual seizure, but it rarely happens, even when the heart has notoriously been the subject of some organic disease, that there has been any thing to lead him to expect the kind of attack from which he now suffers. In the midst of some little unusual effort, or even without this kind of provocation, suddenly the patient is attacked with severe pain, usually at the lower part of the sternum; this pain darts through to the back and left shoulder, and nearly always runs down the left arm. Sometimes, indeed, it is felt acutely over a large area of the chest, and runs down both arms; this is the case in a patient now under my care, in whom the affection is more obviously a neurosis, and less attended with coarse organic changes, than is usually the case. Along with the pain, which is always very distressing, but varies greatly in severity in different cases, there is a variable amount of another sensation which can be compared to nothing but cramp, or rather compression; the patient usually describes it as feeling as if some one were grasping the heart in his hands, and, when this sensation is at all prominent, the idea of impending death is most strongly impressed on the sufferer's mind. His outward appearance seems to confirm the idea. In cases where the sense of compression is great, the face is of an ashen gray; the lips white, with a faint livid tinge; the pulse small, feeble, and unrhythmical, or imperceptible, at the wrist; cold perspiration breaks out upon the face; in short, all the signs of approaching dissolution are present. In cases where the suffering is chiefly or entirely confined to severe pain, of a darting or burning character, the state of the circulation is often different. The heart bounds against the ribs, in rapid and painful palpitation, the face is flushed deep crimson, the pulse at the wrist is large, bounding, but very compressible; in fact, the outward appearance of the patient is so different from that of one who suffers from the more depressing kind of angina, that it is difficult to consider the two affections as essentially similar. But there can be no question, if we carefully examine the matter, that they are mere varieties of the same disorder, especially as they both may successively occur in the same person.

The course of cardiac neuralgia varies extremely. Supposing the malady to be purely neurotic, and not complicated with organic disease, which forms a constant source of cardiac embarrassment, then the patient may only experience one or two attacks, under some special circumstances of exhaustion, which may never recur; or, on the other hand, he may develop a strong tendency to cardiac neuralgia which may beset him during almost any number of years. In the latter case, it is an even chance whether the patient will at last sink from the anginal affection; for, even supposing him to escape any fatal intercurrent disease of an independent nature, the fatal event may be at last produced by cerebral softening, or by apoplexy, or other central nervous disease. In fact, the frequency with which the latter kind of termination occurs is very significant of the essential nature of the disease.

The manner in which cardiac neuralgia commences varies very greatly. In the celebrated case of Dr. Arnold, the first attack did not occur till he was forty-seven years of age; it at once assumed full intensity, and proved fatal in two hours and a half. There is also reason to believe that Dr. Arnold's father died in a first attack of angina. I have myself known a first attack prove fatal in the course of an hour; there was very considerable ossification of the coronary arteries and fatty degeneration of the heart-walls. Again, there are many cases which commence gradually, and with great mildness, and with little appearance of danger to life in the first attacks; but the subsequent attacks are progressively more severe and dangerous up to a fatal result, after weeks, months, or years. On the other hand, I have known three instances in which the first attacks of spasmodic heart-pain very nearly proved fatal, but the subsequent fits were milder (in one there was no second attack): all those patients are living, six, eight, and three years respectively, after their first attacks.

It can hardly be doubted that neuralgic spasm is the true cause of sudden death in some cases of stenosis of the aortic orifice, which, but for some accidental circumstances, would not have died suddenly at all, but would have gone through a long and gradual course of deterioration. I particularly remember an instance in which extreme and calcareous constriction of the aortic orifice, in a boy not yet come to puberty, was entirely unsuspected, until one day, in running fast, he screamed out and fell down, and was almost instantaneously dead. I remember another case very similar, in which extreme mitral constriction produced almost as sudden death, apparently from painful spasm, under the same kind of exertion. On the other hand, sudden death, when produced by the form of heart-disease which (as Dr. Walshe points out) is most likely to cause such a catastrophe, viz., aortic regurgitation pure, without hypertrophy, does not seem to be due to painful spasm, but to simple and complete failure of the muscular power, and is perhaps partly of the nature of paralysis from a syncopal condition of the brain, the unhypertrophied heart having become for the moment unable to supply blood enough to the brain to carry on nervous function at all.

A good instance of the form which angina takes, when the element of organic cardiac change is well pronounced, was afforded by the case of a young gentleman recently under my care. He was twenty-one years of age, and from early boyhood had been accustomed to a great deal of muscular exercise; in fact, it is probable that he had undermined his health by the frequent and extraordinarily long walks which he took, for his frame was particularly small and slight, and the muscles small and soft. He came of a family in whom the tendency to neurotic disorders is obviously very strong; both his father and his brother are subject to bad attacks of migraine, and he had himself repeatedly suffered from the same thing. The family disposition, altogether, is highly nervous and excitable. The remarkable circumstance in this young gentleman's case is, that although he had taken for years an extraordinary amount of pedestrian exercise (including mountain-climbing), and latterly had exchanged this for the even more trying exertion of rowing, he had never suffered from any noticeable symptom of cardiac distress up to the very day of his anginal attack. For some months, however, he had been growing thin and pale, and I had given him certain cautions, and had made him take cod-liver oil and steel, as I entertained some fears of his becoming phthisical. On the day of the attack there was nothing particular in his appearance, but he complained of a slight cold, and had no appetite for his six o'clock dinner. He retired to rest at eleven o'clock, having taken a small dose of laudanum and chloric ether for his cold. In less than half an hour he awoke out of his sleep in fearful agony; so severe and prostrating was the anginoid pain that he had the greatest difficulty in crawling out of bed to unlock his door. I found him bathed in cold sweat, pale as a sheet, and with livid lips. He groaned with pain, which he described as "cutting him across" from the sternal notch to the nipple, and going down the left arm; and there was so marked a catching of the breath as to make it almost certain that there was diaphragmatic spasm; in fact, it was this which alarmed him, and made him say that he was certainly dying. The heart, however, appeared to be pushed up somewhat, and it was thought that this might be partly due to stomachic distention, but a mustard emetic produced little effect. The heart-sounds were so weak that the presence or absence of bruit could not be safely predicated; meantime, the pulsations intermitted in a most alarming manner. Large doses of brandy and sulphuric ether at length (after several relapses) seemed to subdue the pain and spasm, and in an hour and a half from the commencement of the attack the patient, though utterly worn out, sank into a tolerably quiet sleep. The spasms did not recur, but for the next three or four days he was in a state of great exhaustion. When his tranquillity of mind had been somewhat restored, a careful physical examination was made, and it was discovered that there was a moderately loud and somewhat thrilling systolic bruit at the site of the aortic valves, and extending some distance into the vessels. The pulse still remained strikingly intermittent, and, though of fair volume, was very compressible. Percussion indicated considerable enlargement of the heart, and the physical signs pointed, on the whole, to dilatation without hypertrophy. Some doubtful signs of consolidation were observed at both apices of the lungs.

It is remarkable that, notwithstanding the serious degree of cardiac mischief indicated by the above signs, the patient, a very few days later, took a walk of some ten miles, and, though much exhausted, suffered no recurrence of his formidable spasmodic symptoms in consequence of this imprudence. He was sent to the mild climate of Mentone, and subsequently to Nice; the angina never recurred, but the patient remained weak, and liable to more or less dyspnœa for fifteen or sixteen months; now he lives an ordinary life, doing his duty as a Swiss citizen and officer. The cure of some hæmorrhoids, about twelve months after the anginal attack, seemed greatly to benefit him. What the future of this case may be it is impossible to say, but of course there is no security against the angina recurring on extraordinary excitement or over-exertion.

Of the purely neurotic variety of angina it is impossible to determine the frequency; but it seems certain that the affection is common, and I suspect that it occurs more often than is supposed, as a sequel to asthma. The probable relationship between the two affections was long ago indicated by Kneeland.[8] I have certainly seen several cases of asthma in which spasmodic pain of the heart has occurred on various occasions after or during a very severe asthmatic paroxysm. One case was that of a gentleman, of a highly delicate and neurotic temperament, who had suffered for fifteen or sixteen years from well-marked spasmodic asthma: this case is remarkable as an illustration of several points which will be dwelt upon in other parts of this volume. For some time before the outbreak of cardiac neuralgia, he had suffered repeatedly from severe facial neuralgia, and these attacks on more than one occasion culminated in facial erysipelas, or what was entirely indistinguishable from that affection. He then began to suffer from cardiac pain and spasm after his asthmatic paroxysms, and these new symptoms speedily assumed the form of a very severe intermittent angina: in several of the attacks he appeared about to die. The pain in these attacks is very severe; it occupies a large area in the centre of the chest, and runs down both arms; and, what is strange, the arms become remarkably swollen and hot after an unusually long bout of pain, I presume from vaso-motor paralysis. At present (nearly five years from the commencement of the cardiac neuralgia) the cardiac attacks, though of frequent occurrence, are decidedly more tolerable than they were at first, and the sense of squeezing or pressure, though never quite absent, does not amount to the dreadful sort of feeling which used to convince the patient that he was at the point of death. In this case, the heart has been repeatedly explored without any positive result, and the pulse has been frequently tested by the sphygmograph. The latter instrument is the only mode of examining by which I have been able to elicit even suspicious evidence that there is any organic change of the heart; by means of it I have lately obtained some grounds for suspecting that there is slight dilatation of the heart, but it is uncertain whether anything of the kind existed at the commencement of the anginal symptoms. In this case I am inclined, on the whole, to doubt whether the angina will ever prove fatal, unless the bronchitis, with which the patient's asthma has for some time past been liable to be complicated, should occur in a severe form; in that case it is likely that the additional embarrassment of the heart's action may bring on fatal spasms.

One of the best examples I ever saw of cardiac neuralgia (ultimately proving fatal) was one of which the origin was entirely nervous. It occurred in a gentleman in the prime of life, and naturally of a powerful physique, whose very active and capacious mind had been greatly overwrought. The whole weight of responsibility for an undertaking of national importance, and which involved great difficulties and much anxiety, for a long time rested on his shoulders. Under these influences he broke down, and never effectually recovered himself. At first, the symptoms were those of mere ordinary nervous exhaustion, but after a time he became subject to frequently recurring attacks of agonizing spasmodic heart-pain, with a sense of impending dissolution; from these he was invariably relieved by the inhalation of a small amount of chloroform. Not the slightest organic heart mischief could be detected, either during life or after death.

Pathology.—Angina stands in so peculiar a position that I deem it well to discuss it as a whole, and not merely its clinical history, in this place. As I have already said, there is nothing in the morbid appearances found after death which is characteristic of fatal angina, and in the milder kinds of cardiac neuralgia we are driven back upon the general probabilities which we deal with in reasoning as to the origin of neuralgias in general. As to morbid changes, it is impossible to say any thing more exhaustive of the facts known than the following words of Dr. Walshe:[9] "First, there are few, if any, structural diseases either of the heart, its orifices, and its nutrient arteries, or of the aorta, found recorded in the narratives of the post-mortem examination of different victims of angina pectoris. Secondly, there is no conceivable disease of these structures and parts which has not in various individuals reached the highest point of development, without anginal paroxysms, even of a slight kind, having occurred during life; to this proposition extensive calcification of the coronary arteries perhaps furnishes a solitary exception. Thirdly, the organic changes most frequently met with have been fatty atrophy and flabby dilatation of the heart; obstructive disease of the coronary arteries by atheroma and calcification of the orifice and arch of the aorta. Fourthly, the rarest have been hypertrophy and hypertrophy with dilatation. In truth, it may be doubted whether these conditions in their genuine form, without any combination of fatty atrophy, have ever been the sole morbid states present." From all this Dr. Walshe concludes that the fundamental mischief of angina is neurotic; and, while he believes that some textural change in the heart is necessary as an irritant to generate this neurotic susceptibility to dynamic disturbance from slight causes, he recognizes only one common quality in these various cardiac lesions, viz., that they indicate mal-nutrition and weakened power. Dr. Walshe does not appear to believe the neurotic disturbance can arise without the kind of irritation which is kept up by such cardiac changes. In spite, however of the great authority of this author, it certainly seems very probable that organic cardiac change is by no means necessary to the occurrence of angina, and this for two reasons: In the first place, though full reliance may be placed on the details of the post-mortem examinations made by Dr. Walshe himself, they are very few (twelve or fourteen) in number; and other observers who have recorded cases are as little trustworthy, considering their evident tendency to find some disease where none exists, as the older narratives which Dr. Walshe naturally distrusts were unreliable when they declared that no morbid change was present. And, secondly, his view hardly takes it into account that there are still two other alternatives, even supposing that one or other of the above changes is always present: (a) it is possible that the neurotic disturbance and the cardiac lesions might both be the result of a common cause; and (b) it is even possible that the alterations of tissue in the heart and vessels are due to a morbid influence proceeding from a diseased nervous centre, either spinal or sympathetic.

As for the state of the muscular fibre which immediately causes death, Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and he urges in favor of this view the fact that in his large experience he has never known the pulse to intermit during the attack—it was always regular, however feeble. In this respect he is in opposition to some distinguished authors, however, and, as he allows that he has not seen original attacks in their height, but only when they were subsiding, it would be possible that the spasm stage had subsided. However Dr. Walshe admits that there may be exceptional cases in which spasm, or cramp (i. e., spasm with rupture or dislocation of fibre), really occurs, and suggests that this is very probable in the rare cases where death is attended by general tetanic spasm of the muscles. As far as my own opinion is worth anything, I could insist that at least Dr. Walshe must be right as against Dr. Latham and Dr. Inman, in affirming that cardiac cramp, if it occurs, is the consequence and not the cause of the neuralgic pain.

Causes.—In some respects it is impossible to deal with the etiology of angina apart from the pathology, just as we remarked with regard to neuralgias in general. But there are certain special features in the causation of angina pectoris which require separate notice, just as there are special features in its pathology.

Of predisposing causes, the majority are the same as those of which we have spoken in our general remarks on the etiology of neuralgia. A family history of a tendency to the graver neuroses is I believe universal, and, indeed, direct inheritance of angina from father to son, as in Arnold's case, has happened in many recorded instances. A very remarkable fact is the time of life at which the disease originally appears: Walshe says it is rare before the age of fifty, but excessively rare before forty. This is very interesting, as placing angina in the same category with the severe and intractable forms of facial and other neuralgias which are so highly characteristic of the period of bodily degeneration. One may even gather a suspicion, though it goes but a short way toward proof, that the essence of angina is an atrophy either of the cardiac plexus or of the nucleus of the vagus, or of that part of the spinal cord, already mentioned, which seems to be the centre of the major part of the propulsive force of the heart.

On the other hand, there is a fact, even more remarkable than the influence of age, which tells somewhat in a contrary direction. There is a most extraordinary preponderance of males among the victims of angina. Sir John Forbes found eighty males among eighty-eight patients suffering from this disease. On the first blush it would seem natural, indeed almost necessary, to explain this by supposing that, as men take a much larger amount of strong physical exercise than women, they will furnish a much larger proportion of subjects in whom an ill-nourished heart will break down under its work and be seized either with paralysis or cramp (for the two states are, after all, not opposed to each other, but only varying shades of debility.) Upon this theory one would have to believe that the origin of angina was far more peripheral than central, if we are to suppose that spasm is the ordinary condition of the heart during the anginal paroxysm. But we do not know that this is the case; indeed, there are many arguments against it; and at any rate we must suppose that in a considerable number of cases the muscular state is one of relaxation from want of power. And certainly it is infinitely more probable that paralysis or spasm of a muscular viscus should occur as a reflex consequence of neuralgia occurring in a nerve whose central nucleus was closely connected with the motor centre of the organ, than that mere paralysis of the viscus should convey a reflex impression to sensitive nerves which should express itself in the form of acute pain. It must be confessed that the matter hangs in doubt; but the evidence is, on the whole, very strong for the belief that central nervous mischief is the most important element in angina.

Another very important class of predisposing causes of angina is the mental emotions. It is notorious that the disease is one not common in humble life; it chiefly assails the more cultivated class, and especially men who are much engaged in affairs in which great mental anxiety or emotion is mingled with severe toil of intellect. Thus the professional class has always shown a sad predominance in tendency to this disease; a large number of the victims have been found among overworked clergymen, lawyers, doctors, engineers, etc. The various forms of heart-lesion which have been already mentioned must doubtless be considered highly predisposing, when there is already a neurotic susceptibility, more especially those which, like fatty degeneration of the muscular structure, greatly enfeeble the heart's action. I do not believe that these diseases will cause angina in a person who is free from the peculiar nervous susceptibility.

The immediately exciting causes are very various. The most common of all is doubtless some exertion of body, or distress of mind, which at once agitates and embarrasses the heart's action; and, where the tendency to cardiac neuralgia has once declared itself by an actual attack, very slight excesses of this kind will usually suffice to re-excite the paroxysm. Sexual excitement is particularly provocative of the attacks, in the predisposed. But much slighter causes suffice, in those cases where the irritability of the cardiac nerves has become very intense: thus a mere puff of cold air upon the face, and other similar slight peripheral impressions, by acting in a reflex manner, have frequently produced the paroxysm. I have seen an extremely severe anginal attack brought on by the slight shock of the sudden slamming of a door. And it would even appear that some peripheral excitements of a powerful kind may operate with such force as to generate angina in persons who are merely in weak health, but who cannot be supposed to be specially predisposed to angina; it is in this way, I presume, that we must explain the extraordinary occurrence, reported by Guelineau,[10] of an epidemic outbreak of angina, in which numbers of men, belonging to a ship's crew, were simultaneously affected. The men had been badly fed, and their quarters were very unhealthy; but the powerful exciting cause seemed to be the rapid change from a very hot to a very cold climate. Not only were there many cases of severe angina, but other forms of neuralgia, and severe colics, were observed in others of the crew. Among the sources of peripheral irritation which ought to be particularly considered, in relation to angina, are the diseases and injuries which produce powerful irritation of the branches of the trigeminus. Lederer's cases[11] of violent vomiting and cardiac pain, from the operation of pivoting teeth, and Remak's instances[12] of violent palpitation and cardiac distress, produced by disease of the last molar tooth, seem to show that, both through the vagus and the sympathetic, the most powerful reflex action may be produced in the heart and stomach by irritation of the fifth cranial.

Another occasional excitant of angina is an interesting link in the chain of proof that angina is au fond a neuralgia, namely, the malarial poison, which has in a good many well-observed cases distinctly induced the disease.[13] Finally, the occasional influence of excessive tobacco-smoking in producing anginal attacks, in persons not affected with any discoverable organic heart-disease, affords the strongest corroborative evidence of the essentially neurotic character of angina pectoris. M. Beau[14] has recorded many serious, and some fatal, cases from this cause. Probably in both the malarial cases and those induced by tobacco-poisoning the special neurotic tendency existed already.

Diagnosis.—The diagnosis of angina pectoris, in those severe forms with which the popular idea of the disease is chiefly connected, can hardly be a matter of much difficulty. When we see an elderly man lying in a state of deathly collapse, which has suddenly come on, with cold sweats and nearly extinguished pulse, gasping for breath, and complaining of intolerable pain in the chest and arm, and a sense of oppression more dreadful, even, than the pain, we can hardly doubt that the case is angina in its worst form. On the other hand, when a young person, especially a young female, complains even of very severe pain in the cardiac region, together with breathlessness, especially if the heart be palpitating and the face flushed, the diagnosis, though not immediately certain, already very strongly indicates the probability that the case is not one of primary cardiac neuralgia at all. These are extreme instances, however. In more doubtful cases, the following are the principal materials for decision:

Affirmative Signs.Negative Signs.

1. Age over forty.1. Age under forty.

2. Male sex.2. Female sex.

3. Nervous temperament (personal and family) without marked hysteria or hypochondriasis.3. Temperament either not nervous at all, or markedly hysterical or hypochondriacal.

4. Existence of arterial degeneration.4. No signs of arterial degeneration.

5. Existence of valvular disease of the heart.5. No discernible valvular disease.

6. Extension of the pain to one or both arms.6. Heart sounds clear and strong.

7. Vivid sense of approaching dissolution.7. Pain fixed to one spot and increased or relieved by muscular movements of the painful parts.

8. Pain running round one side, but not extending to shoulder or arm.

It is scarcely necessary to say that no single one of the above signs is individually of positive worth for the decision, which must be made after a careful review of the comparative arguments, pro and con. The disorders with which angina is most likely to be confused are (1) Myalgia of the intercostal or pectoral muscles; (2) intercostal neuralgia; (3) acute commencing pleurisy. Either of these may very perfectly simulate the more formidable disease, as regards the two elements of acute pain and catching of the breath; but the condition of the circulation, taken together with the consideration of the above named points, will generally decide the question. Especially important is the deep persuasion of impending dissolution, when present, as a positively affirmative symptom.

It should be born in mind that, if we are summoned to a patient's assistance, and have no previous history to guide us, our diagnosis, to be useful, must be rapid; and it is always better to err on the side of angina than in other directions, and to employ remedies boldly in that sense, if there be any reasonable ground for believing the case to be of that nature. A more mature and careful diagnosis may be made when the patient has recovered from the severe symptoms of the paroxysm.

Prognosis.—The prognosis of cardiac neuralgia is at best doubtful, and, in many cases, positively bad in the highest degree. If the attacks occur for the first time in a patient who has passed middle life, and is physiologically old for his age, i. e., shows tendency to degenerative changes of vessels, arcus senilis, gray hair etc., they are of very gloomy import; more especially if any signs exist which make a fatty change in the ventricle probable, or if there be serious valvular lesions. The probability here is greatly in favor of a speedy fatal termination; if the first attack does not kill, a second or third very probably will; at any rate, the patient is not likely to survive any considerable number. If the attack occurs in a younger person, in whom there is not much likelihood that arterial degeneration has seriously commenced, or the heart-muscles become fatty, more especially if the attacks have been brought on by such an accidental circumstance as a very exhausting bout of mental or physical toil, then there is considerable reason to hope that the disease may soon wear itself out. Even patients who have serious valvular lesions may, with young and undegenerated tissues in their favor, quiet down again into a regular habit of semi-health, in which they may live for a long time without any recurrence of cardiac neuralgia. The more purely neurotic form, again, especially when it develops gradually out of some pre-existing chronic neurosis, such as asthma, is usually slow in its progress; and it may well happen, in such cases, that the danger to life is more on the side of serious nervous lesions than from the anginal attacks themselves. At the same time, it must be remembered that, even in the milder cases, any very unusual excitement, bringing on an unwontedly severe attack, may produce fatal results at any period of the disease.

There is some reason to believe that cardiac neuralgia is occasionally produced in a reflex manner in consequence of a severe existing intercostal neuralgia. I cannot say that I have witnessed any thing which can be considered as completely proving this; but it certainly seems likely that, in some of the few cases of excessively painful herpes zoster which have proved fatal (of which I have given one example), cardiac spasm or paralysis may have been secondarily induced, and may have occasioned the catastrophe. It is likely enough that, if this was the case, the reflex irritation operated upon motor centres which themselves were predisposed to take on the morbid action; but this again is a fresh illustration of the uncertainties to which prognosis is liable in a disease like angina, the very fundamental character of which is that, upon increase of the irritation, the gravity of the resulting functional affection is liable to be indefinitely and most rapidly increased.

Treatment.—The treatment of cardiac neuralgia is (1) prophylactic, and (2) palliative of the attacks.

As regards the prophylactic treatment, it is unnecessary to repeat the remarks which we have made elsewhere upon the general principles of tonic and nutritive medication in neuralgias of every kind. One especial prophylaxis, in the case of this formidable variety of neuralgia, is concerned with the preservation of the heart from certain disturbing influences which would render the occurrence of the fit more probable. All violent emotions and all strong physical exercise (but especially such forms of it as, like boating, are well known to "pump" the heart severely) are to be carefully avoided. Even indigestion and flatulence are to be carefully guarded against since these are quite capable of embarrassing the action of the heart to a degree which, though it might be trivial in the case of ordinary health, may prove fatal by exciting a flabby ventricle to irregular and embarrassing contraction. It is even possible that the strong irritation set up by some varieties of indigestible food might propagate an irritation to the spinal cord which would produce an interbitory paralysis at once.

But besides these obvious precautions against interference with the regular and tranquil action of the heart, there are some special medicinal remedies which deserve particular notice. Whether we really possess any means of so influencing the nutrition of the muscular tissue of the heart as to prevent its lapsing into a fatty degeneration, it is impossible to say; but this may be affirmed with some confidence, that, in cases where awkward threatenings of cardiac neuralgia have occurred, and simultaneously it has been noticed that the heart-sounds become weak and the circulation languid, a most marked improvement has been produced in all respects by the administration of iron and strychnia. I usually give tincture of sesquichloride of iron, ten minims, and strychnia, one-fortieth of a grain, three times a day. Still better, where it can be borne, is the syrup of the triple phosphate of quinine, iron, and strychnia, which undoubtedly has an extraordinary influence upon tissue nutrition, as exemplified in its remarkable effects in many cases of phthisis. It must be observed, however, that it is not every neuralgic patient who will bear the combination of quinine with iron; it has occurred to me to meet with several in whom the union of these two remedies proved violently disturbing to the nervous system, causing distressing headache and palpitation of the heart, which could not be attributed to any want of care in the apportioning of the dose, or in the mode of administration. Iron is more especially indicated, of course, in cases where there is anæmia; but there are some cases in which strychnia given alone seems to produce a very beneficial influence. (vide Chapter V., on "Treatment.")

By far the most important prophylactic tonic against cardiac neuralgia, however, is arsenic. That this drug should prove useful in cardiac neuroses might readily be anticipated from its very great utility in many cases of asthma, a disease which, as already remarked, has a close relationship to the former. Dr. Philipp has recently recorded a case which is perhaps an extreme instance of this beneficial influence of arsenic, but is none the less encouraging, especially as it only corroborates what has been advanced by other observers. Given in doses of from three to five minims of Fowler's solution, twice or thrice daily, arsenic is an invaluable remedy in cardiac neuralgia; the one objection to it being that some neurotic patients possess such an irritable intestinal canal that the remedy cannot be borne, as it produces diarrhœa. Even here we may sometimes succeed by combining it with very small doses of opium. It is more especially with regard to those cases in which the neurotic character of the disease is very prominent—i. e., in which the nervous temperament of the patient betrays itself in other ways besides the tendency to spasmodic embarrassment of the heart's action, that arsenic holds such a very high place as a remedy. And it should be carefully remarked that the prophylaxis of angina extends itself, in such cases, beyond the limits of actually-declared and well-defined angina, which is, of course, an uncommon disease. This remedy is important, and may be most usefully employed in the far larger group of cases in which a marked tendency to spasmodic pain in the chest, on the occurrence of some comparatively trifling excitement, is observed in patients who either have some organic heart-disease, or who are liable to severe attacks of asthma. It cannot be too often repeated that there is no intelligible separation, except one of degree, between these cases and the malignant forms of angina. It may be added that, in my experience, I have found the whole group of cases to be bound together in a singular way by the tolerance of arsenic which, with certain exceptions already referred to, they display. Commencing with the small doses above mentioned, I have found it possible, in many cases, to advance to the administration of twice or thrice the quantity, and to continue this medication for months together, not only with no evil effect, but with the best results.

Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but little. Truth to say, it is a nervine tonic of occasional great value, but which, on the whole, I have found so unreliable that I am somewhat prejudiced against it; and perhaps have not given it a fair trial in those milder cases of cardiac pain to which it might be suited. It does appear, however, to have some preferential action on the vagus, and might therefore be possibly more useful than I am at present inclined to think it.

The treatment of the acute neuralgic stage itself is a matter in which we are sadly limited by the exigencies of the case. Relief must be excessively rapid if we are to save life in the most threatening cases, or to deliver the patient from a most prostrating agony, which might have lasted for hours, in other instances.

The remedy which the highest authority, Dr. Walshe, seems to put first in efficacy is opium; and he directs the dose to be measured by the intensity of the pain, as much as forty to sixty drops of laudanum being given in a severe case. He says, however, that it should be given with an antispasmodic, such as brandy, or ether, or sal-volatile; and I confess that I believe the antispasmodic treatment to be by far the most important. Indeed, so marked is the success which I have found to attend the use of ether in the paroxysm, that till lately I scarcely cared to make further experiments, with drugs, for the relief of the patient at this stage. One teaspoonful of ether in two ounces of thickish mucilage should be given at once, and repeated in a short time if the patient does not rally.

In a few instances, angina seems to be provoked by the irritation of indigestible food, and when there is good reason to suspect this an emetic should be given. I strongly recommend that mustard should be used for this purpose, for the effect of a mustard-emetic is by no means merely to empty the stomach, it has a powerfully rousing influence on the heart.

Upon the subject of the inhalation of chloroform for cardiac neuralgia, I have only to say that, though I have seen it usefully employed, I should not, with my present experience, ever think of employing it myself. Every possible advantage which it could give is obtained by the internal use of ether, and many serious dangers are avoided, which would attend the use of chloroform. For it must be remembered that the only kind of chloroform inhalation which would be useful would be that in which a carefully measured small dose of a weakly impregnated atmosphere should be inhaled, and, without large experience in the administration of chloroform, the practitioner will be unable to secure this effect with certainty. And the effect of a powerfully-charged atmosphere, breathed only once or twice even, would be instantaneously fatal.

Hot epithems to the epigastrium are probably of some use, and besides this the temperature of the body should be carefully kept up by hot bottles to the feet, hot tins to the epigastrium, etc. Brandy should be freely administered during the attack, if we cannot immediately obtain either ether or a remedy now to be mentioned. I refer to the nitrite of amyl, which, at the time when the first part of this chapter was written, I had not had the opportunity of testing.

Nitrite of amyl is a highly-vaporizable fluid, which possesses the following remarkable physiological action: the inhalation even of a very small quantity is followed, after a minute or so, by a sudden acceleration of the heart's action, accompanied by intense crimson congestion of the vessels of the face and conjunctiva, and a sense of enormous fulness in the head; these phenomena are extremely fugitive, passing away completely in two or three minutes, unless the inhalation is renewed. These characteristic effects had for some years been experimentally exhibited by Dr. Fraser and others, but the practical application of amyl to the treatment of angina was first suggested, I believe, by Dr. Brunton, in the case of a patient under the treatment of Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The angina was in this case symptomatic, there being advanced valvular disease of the heart. Comparative examinations with the sphygmograph, during the intervals and during the paroxysms, made strikingly manifest the fact that, during the attacks, there was an increase of arterial tension which was directly proportionate to the severity of the pain and cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that nitrite of amyl, by relaxing the systemic arteries, might remove the unnatural tension, and give relief to the pain; and the result confirmed this hope. Doses of five and ten drops were inhaled from a towel, with the uniform result of at once quieting the pain; it might return in a few minutes, but a second dose usually removed it entirely for many hours. Various other cases have since been reported, in which similar relief was obtained, and I had occasion to employ it myself in one instance. The gentleman whose case has been related above (see page 101), as an example of the relief obtainable by the use of ether began to suffer rather more severely from his attacks than had been the case for some time, toward the end of the year 1869. I now determined to try the amyl, and accordingly left a small bottle containing half an ounce of it in his possession, with exact instructions to the following effect: On the first symptoms of a paroxysm of angina, he was to get the bottle open, and as soon as their character was fully declared he was to put the bottle to one nostril (closing the other with the finger, and keeping the mouth shut) and take one long, powerful inspiration. The result of his first experiment was very remarkable: the first sniff produced, after an interval of a few seconds, the characteristic flushing of the face and sense of fulness of the head; the heart gave one strong beat, and then at once he passed from the state of agony to one of perfect repose and peace, and at his usual bedtime slept naturally. This experience was repeated on several occasions, and for a considerable time the patient retained such full confidence in the remedy that he discarded all use of ether, and greatly reduced his allowance of stimulants, with very marked benefit to his appetite and general health. The new remedy did not lose any of its power by repetition, but unfortunately the patient at last conceived a horror of it, which caused him to abandon its use. So distressing and alarming to him was the sense of fulness in the head produced by the amyl, that, notwithstanding his certain knowledge that he could at once cut short a paroxysm, he could not persuade himself to continue its use, and for some time past he has returned to the use of the ether and (though in less quantities than previously) of the brandy, for this purpose. And here it must be remarked that this objection, although probably needless in the case of this particular patient, may have real importance in certain circumstances. The admirable physiological researches of Dr. Brunton leave no doubt that the effect of inhalation of amyl is to relax, very suddenly, the tonic contraction of the systemic arteries, and in the case of the brain it would appear that a serious strain must be suddenly thrown upon the capillary net-work. This being the case, it appears likely that, where the atheromatous change has considerably invaded these delicate vessels, they might prove too brittle to stand the sudden distention, and a rupture and consequent cerebral hæmorrhage might ensue. This suspicion, then, that such pathological changes exist, ought to seriously affect our judgment as to the administration of amyl; and this suspicion ought to be always entertained, prima facie, in the case of patients who have much passed the age of fifty, more especially if they have gray hair and an arcus senilis, or if the sphygmograph yields a pulse-trace of the decidedly square-headed type, or if they have been long addicted to alcoholic intemperance. In such patients I should be disinclined to allow the use of amyl.

[Although I have thought fit here to give an outline of angina pectoris as a connected whole, I shall have occasion to recur to the subject again under the heads of Pathology and Treatment of Neuralgias in General.]

Gastralgia.—Neuralgia seated in the stomach itself is not to be distinguished with accuracy from neuralgic pains occupying one or other of the neighboring nervous plexuses. It must be remembered that not merely is the stomach itself copiously supplied by the pneumogastric nerves with afferent fibres, but the great solar plexus is close behind it, the cœliac plexus springs from the fore part of the latter, and these, with the coronary and superior mesenteric plexus, may all be said to be well within the region in which "gastralgic" pain is felt. It is not particularly important, however, in my opinion, to make any very exact diagnosis here, as to the site of the pain, since all these neuralgias must be considered to belong to the pneumogastric nerve, the branches supplied from which are probably the sole means by which these plexuses become the seat of neuralgia.

Abdominal pneumogastric neuralgia is an extremely distressing and occasionally a very intractable disorder. The subjects of it are almost invariably in a state of marked and evident debility, and inquiry generally elicits the fact that they have suffered at other times from neuralgia elsewhere than in its present seat. By far the most common history of previous affections of this kind is that of trigeminal neuralgia, especially of the supra-orbital branch; and it has several times occurred to me to observe the direct sequence of a gastralgia upon a unilateral browache. Anæmia is a specially frequent attendant of gastralgia, more so than of other neuralgias. Women are, by the general consent of authors, more liable to gastralgia than men.

The special mark of true neuralgic pain in the abdominal pneumogastric, as distinguished from other deep-seated pains in the epigastrium, is the remarkably direct relation of its severity to the patient's exhaustion, particularly in regard to the weakness induced by want of food. While the great majority of dyspeptic pains are increased by filling the stomach, gastralgia, on the contrary, is invariably relieved by food, often most strikingly and completely. Pressure from without, also, while it aggravates most pains dependent on local organic mischief, nearly always more or less relieves gastralgia. Equally striking is the comfort given by stimulants, especially by hot brandy-and-water; in this respect gastralgia resembles colic. There is something special in the degree of mental depression which attends gastralgic pain. In this it resembles the pains of hypochondriasis, but there is a resilience of the spirits when the pain has been relieved which is not seen in the latter affection. A very frequent complication of gastralgia is severe palpitation of the heart, but during the paroxysm itself the pulse, whether rapid or not, is commonly small, at first tense, and afterward soft, but not acquiring any considerable volume till the pain has ceased.

So severe is the pain, and so complete the mental and physical prostration in bad attacks of gastralgia, that the first aspect of the patient might suggest—indeed often has suggested—the occurrence of gastric or duodenal perforation; but, as soon as the paroxysm is over all the alarming appearances vanish, leaving only a certain amount of tenderness on deep pressure. In the more typical cases there are no signs of dyspepsia whatever, no fulness nor excessive redness of the tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the neuralgic affection is complicated with more or less gastric catarrh; but this is a much rarer occurrence, in my experience, than some writers would lead one to believe; and, moreover, where a certain amount of organic disorder of the stomach is observed, it is usually a mere secondary result of the neuralgia. The most severe example of gastralgia which I ever saw was entirely unaccompanied by dyspepsia; this patient absolutely attempted suicide to escape from his agonizing pains, which recurred with the greatest frequency and obstinacy, but were at last entirely removed by strychnia. In another patient whose very interesting case will be again alluded to under the head of Complications of Neuralgia, violent abdominal pneumogastric pain was succeeded by a severe attack of trigeminal neuralgia, accompanied by inflammation of the eye, which inflicted irreparable damage; here, too, the gastralgia was entirely uncomplicated by any other stomach-symptoms.

Cerebral Neuralgia.—We enter, here, on an extremely obscure and doubtful subject: Can there be pain in the central masses of the encephalon? There are undoubtedly a not inconsiderable number of cases of pain, neuralgic in type on the whole, in which the suffering cannot be referred to any recognizable superficial nerve. It seems deeply situated within the cranium. I have also quoted cases of Dr. Hillier's in which not merely was there deep-seated headache in children, but there was something like a characteristic general change observed in the brain-tissues after death, viz., a great moisture and softness of texture. Notwithstanding all this, I am not convinced, nor indeed much disposed to believe, that pain is ever felt in the structure of the brain; I rather believe that, in the cases where this seems to occur, the pain is either in the intracranial portion of the nerve trunks, or, far more probably, in the twigs of nerves that are distributed to the cerebral membranes. In that case they are, strictly speaking, only varieties of neuralgia of the fifth nerve, and might have been properly discussed under that heading; but it is more convenient to speak of them apart, since their phenomena present considerable differences from those of the external neuralgias of the head and face.

I have now seen several of these cases of intracranial neuralgias, and very perplexing and (at first sight) alarming they certainly are. The first of these cases came under my care in 1868. The patient was a single lady who had greatly over-tasked an intellect that was not, perhaps, originally very strong, by trying to do hack literature on conscientious principles; insisting, for instance, on knowing something about every subject she wrote upon. Her age was thirty-eight when she applied to me; menstruation was scanty but regular; and, on the whole, she could not be said to have passed an unhealthy life, although "nervous-headaches" and "sick-headaches" had occasionally beset her. This time the trouble seemed to be more serious. Ten days before applying to me, she had awaked in the morning with a feeling that something was very wrong in her head; there was not so much pain as a dull, brooding sort of weight, felt deeply within the cranium, and rather anteriorly. This had not lasted many hours when she was seized with a sensation of intense cold, amounting almost to rigors, and then before long was suddenly attacked with acute splitting pain in the same situation as the feeling of weight already mentioned had occupied. This pain, which came and went, or rather intensified and remitted, without ever completely ceasing, lasted about two hours, and then rather suddenly disappeared, leaving the patient with a deep "bruised and sore feeling in her brains." The pain recurred about the middle of the next day, lasting for several hours, and again leaving behind it the sore feeling. Day by day the paroxysms returned, and, on the day before her visit to me, the patient had, she told me, been driven frantic by her sufferings and had become actually delirious. Her appearance, when I first saw her, was wretched; the face haggard, both eyes sunken and surrounded with deep rings of dusky pigment, both conjunctivæ bloodshot, the whole face almost earthy in its pallor. At that hour (11 a. m.) the pain had not positively recommenced, but she was in momentary dread of its recurrence. She complained of giddiness, muscæ volitantes, and great feebleness of vision, and dreaded attempting to read, as the mere effort of fixing her eyes on anything intently caused flashes of fire before them. It was difficult at first to believe that there was not some serious organic brain-mischief; but on the whole I concluded that there was an absence of any genuine symptoms of such disease. At the same time, the pain was decidedly not referred to any cutaneous sensory nerve; and on the whole it appeared probable that the affection was intracranial. There remained the diagnosis of meningeal neuralgia, and to this I provisionally made up my mind. The opinion that the pain did not depend on any fixed organic disease was decisively justified by the results of treatment. One-sixth of a grain of morphia was injected on the occasion of the first visit, and this was repeated every day, and sometimes twice a day, for a fortnight; by this sole means, with rest, quietude, and light nourishing food, the patient was brought to comparative convalescence. The injections were then gradually discontinued, and she got quite well.

In a second case, which presented itself in the out-patient room at Westminster Hospital, a young man of markedly-nervous temperament, who had been somewhat given to drink, complained of similarly deep-seated intermittent pain, which he referred, however, to a point nearer the back of the head. He suffered, also, from vertigo, especially after unusually long paroxysms. Blisters to the nape of the neck, and a few subcutaneous injections of morphia, removed the pain and the vertigo completely.

A third example was that of a gentleman, aged thirty-four, who was sent over from the neighborhood of Sydney, Australia, to see me. Here, also, there was deep-seated intracranial neuralgic pain of the most severe kind, which greatly alarmed his local medical attendants; and it was only after a great many remedies had been tried that one medical man gave the opinion that the disease was "neuralgia of the membranes of the brain," and employed the hypodermic injection of morphia. This treatment at once gave great relief, though the pain had been so severe as to cause delirium on several occasions. In order to get thoroughly re-established, he was sent to England, and desired to consult me. As was expected, the voyage proved of the greatest service, as he hardly suffered at all while on the water. On arriving in England he was at first well, but in a week or two began to feel somewhat below par, and one morning, feeling an attack of pain coming on, he came to me. He was a tall and strongly-built man, with nothing peculiar in his appearance except a certain languor and heaviness of the eyes. He appeared to have lived somewhat freely and to have smoked decidedly to excess. His description of the attacks left no doubt of their neuralgic character, and in other respects they seemed quite analogous to the other cases mentioned above, except in one thing, that there seemed a good deal of evidence tending to show a bad local influence in the air of that part of Australia where he usually resided. Almost any change from that had always done him good, though nothing had done anything like so much as the voyage to England. On the occasion of his first visit to me I injected him with one-sixth grain acetate of morphia, thereby stopping the pain. I prescribed muriate of iron and minute doses of strychnia, which he took for some little time, but the pain never recurred during his stay in England and on the Continent. Unfortunately, as he was anxious to return to Australia, I permitted him to do so, after a stay in the Old World of only three or four months; but, very shortly indeed after his return to Sydney, his old complaint attacked him. This time, unhappily, the hypodermic morphia has proved merely palliative, and I have latterly heard very bad accounts from him; still, there has been nothing to throw doubt on the neuralgic character of the disease.

In reflecting upon the anatomy of the nervous branches to the dura mater, I have formed the opinion that there are two situations, one anterior and the other posterior, in which intracranial neuralgia may occur; the former at the giving off of Arnold's recurrent branch from the ophthalmic division, near the sella turcica, the other in the peripheral twigs of this same branch, distributed to the tentorium cerebelli.

Pharyngeal Neuralgia.—A rather common and extremely troublesome form of neuralgia is that which attacks the pharynx. It is very much more common in women than in men, and especially in hysterical persons. The pain commonly commences in a not very acute manner; it may be felt for some days, or even weeks, as a dull aching, coming and going pretty much in accordance with the patient's state of fatigue, or of reinvigoration after meals, etc. Some trivial circumstance, such as a slightly extra degree of exhaustion, or the influence of some depressing emotion, will then change the type to that of decided neuralgia, which may become extremely severe. Nothing is more annoying, and even distressing, than the suffering itself, besides which there are abnormal sensations in the throat which almost irresistibly compel the patient to believe that there are severe inflammation and ulceration, and that the throat is in danger of being closed up. Although the pain is usually one-sided, it sometimes affects both sides, and is felt also at the back of the pharynx. The act of swallowing being painful, there is the greater suspicion of inflammation or ulceration, but careful observation shows that a large bolus of food is swallowed with as little, if not less, pain than a small mouthful of solids or even liquids.

Pharyngeal neuralgia must, I think, be considered mainly an affection of the glosso-pharyngeal nerve; the evidence for this is found in the distribution of the pain. A slight degree of the neuralgia will only involve some one or two points in or behind the tonsil; but, when the pain is strongly developed, it will be found to radiate into the tongue, in one direction, and into the neck (following the course of the carotid) in another, besides spreading well into the region occupied by the pharyngeal plexus. One disagreeable reflex effect of severe pharyngeal neuralgia consists in involuntary movements of the muscles of deglutition, another is seen in the copious outpouring of thick mucus similar to that which collects in the pharynx and œsophagus when a foreign substance has become impacted.

Laryngeal neuralgia concentrates itself mainly in the twigs of the superior laryngeal branch of the pneumogastric which are distributed to the arytæno-epiglottidean folds, the epiglottis, and the chordæ vocales; more rarely a neuralgia is developed lower down, within the cavity of the larynx, apparently in one or more of the scanty twigs to the mucous membrane supplied by the recurrent laryngeal.