Neuralgia and the Diseases that Resemble it. Anstie Francis Edmund

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      The foci of pain in intercostal neuralgia are always found in one or more of the points, already enumerated, at which sensory nerves become superficial. In long-standing cases acutely tender points are developed in one or more of these situations; not unfrequently the most decided of these spots is where it gets overlooked, namely, opposite the intervertebral foramen. H. G., a young woman aged twenty-six, who applied to me at Westminster Hospital, had suffered for twelve months from an irregularly intermitting but very severe neuralgia at the level of the seventh intercostal space of the left side. The violence of the pain was sometimes excessive, and when the paroxysm lasted longer than usual it generally produced faintness and vomiting. This patient had no sign of tenderness anywhere in the anterior or lateral regions, though the pain seemed to gird round the left half of the chest as with an iron chain, but an exquisitely tender spot, as large as a shilling, was found close to the spine; pressure on this always induced a strong feeling of nausea.

      As an illustration of the herpetic variety of dorso-intercostal neuralgia, running a severe but not protracted course, I may relate the case of a medical man whom I formerly attended. This gentleman was about thirty-two years of age, and a highly neurotic subject: inter alia, he had already suffered from a severe and protracted sciatica; and, very shortly before the herpetic attack, had been jaundiced from purely nervous causes. His nervous maladies were undoubtedly caused by over-brain-work. In this case the neuralgia developed itself during the latter half of the eruptive period, which was rather unusually lengthened. It occupied the seventh, eighth, and ninth intercostal spaces of the side affected with herpes, and was very violent and acute, so that the patient expressed himself as almost "cut in two" with it. The pain ceased even before the vesicles had perfectly healed; a rather unusual occurrence in my experience. I shall refer to this case hereafter, as an example of what I believe to be the effect of a particular method of treatment in lessening the tendency to after-neuralgia. The result of my experience is certainly this – that if a case of herpes in an adult, or still more in an aged person, be left to itself, the amount of after-neuralgia will very closely correspond with the severity of the eruptive symptoms.

      There is a variety of intercostal neuralgia which is of more importance than the commoner kinds. Occurring mostly in persons who have passed the middle age, it possesses the characters of obstinacy and severity which belong to the neuralgias of the period of bodily decay. It is at first unattended with any special cardiac disturbance. By-and-by, however, it begins to attract more careful attention from the fact that the severer paroxysms extend into the nerves of the brachial plexus of the affected side, so that pain is felt down the arm. In the midst of a paroxysm of intercostal and brachial pain, it may happen that the patient is suddenly seized with an inexpressible and deadly feeling of cardiac oppression, and, in fact, the symptoms of angina pectoris, such as they will be described in a future chapter, become developed. A case of this kind is at present under my care at the Westminster Hospital. The patient is a man only fifty-six years of age, but whose extreme intemperance has produced an amount of general degeneration of his tissues such as is rarely seen except in the very aged; he has the most rigid radial arteries, and the largest arcus senilis, I think, that I ever saw. This man has long been subject to attacks of violent intercostal neuralgia, and a recent access assumed the type of unmistakable angina. It is very probable that his coronary arteries have now become involved in the degenerative process. In this case, before the development of any marked anginal symptoms, the paroxysmal pain, from being merely intercostal, had come to extend itself into the left shoulder and arm.

      Intercostal neuralgia not unfrequently accompanies, and is sometimes a valuable indication of, phthisis. I do not mean to say that the vague pains in the chest-walls, which are so very common in phthisis, are to be indiscriminately accounted neuralgia; on the contrary, they are, in the large majority of instances, merely myalgic, and arise from the participation of the pectorals, or intercostals, or both, in the mal-nutrition which prevails in the organism generally. But it happens, sometimes that a distinctly intermitting neuralgia occurs as an early symptom of phthisis; in fact, where there is a predisposition to neurotic affections, I believe that this is not very uncommon. The subjects are generally women; they are mostly of that class of phthisical patients who have a quick intelligence, fine soft hair, and a sanguine temperament. I have had one male patient under my care: this was a young gentleman aged eighteen, in whom a neuralgic access came on with so much severity, and caused so much constitutional disturbance, that the idea of pleurisy was strongly suggested. The paroxysms returned at irregular intervals for a considerable period: they were quite unlike myalgic pains, not only in their character, but more especially with respect to the circumstances which were found to provoke their recurrence. They were the first symptoms which lead to any careful examination of the chest; it was then found that there were prolonged expiration and slight dulness, at one apex. At this period, wasting had not seriously commenced; but, on the other hand, there was an extraordinary degree of debility for so early a stage of phthisis. I am inclined to think that self-abuse was the principal cause both of the phthisis and the neuralgia, acting doubtless on a predisposed organism, for his family was rather specially beset with tendencies to consumption. I may add here, that it has appeared to me that young persons with phthisical tendencies are specially liable to neuralgic affections as a consequence of self-abuse.

      A special variety of intercostal neuralgia is that which attacks the female breast. The nerves of the mammæ are the anterior and middle cutaneous branches of the intercostals; and they are not unfrequently affected with neuralgia, which is sometimes very severe and intractable. Dr. Inman has very properly pointed out that a large number of the cases of so-called "hysterical breast" are really myalgic, and are directly traceable to the specific causes of myalgia; but there is no question in my mind that true neuralgia of the breast does occur, and indeed is frequent, relatively to the frequency of neuralgias generally. There are several kinds of circumstances under which it is apt to occur. In highly-neurotic patients it may come on with the first development of the breasts at puberty; and it may be added that this is especially apt to occur where puberty has been previously induced by the unfortunate and mischievous influences to which we had occasion to refer in speaking of certain other neuralgiæ. A neuralgia of the left breast occurred in a patient of mine, who attended the Westminster Hospital. She was only twelve years of age, and small of stature, but the mammæ were considerably developed. The face was haggard, there was an almost choreic fidgetiness about the child, and a very unprepossessing expression of countenance; the result of inquiries left no doubt that the patient was much addicted to self-abuse; and it seemed probable that to this was due the fact that menstruation had come on, and was actually menorrhagic in amount.

      A very painful kind of mammary neuralgia is experienced by some women during pregnancy; but more commonly the mammary pains felt at this period are mere throbbings, not markedly intermittent in character, and plainly dependent on mechanical distention of the breast: such affections are not to be reckoned among true neuralgiæ. A true neuralgia of a very severe character is sometimes provoked by the irritation of cracked nipples. I have seen a delicate lady, of highly-neurotic temperament, and liable to facial neuralgia, most violently affected in this way. Vain attempts had been made for several consecutive days to suckle the infant from the chapped breast; when suddenly the most severe dorso-intercostal neuralgia set in. The attacks lasted only a few seconds each, but they recurred almost regularly every hour, and were attended with intense prostration, and sometimes with vomiting. Discontinuance of suckling was found necessary, for even the application of the child to the sound breast now sufficed to arouse a paroxysm of pain. Complete rest, protection of the breast from air and friction, and the hypodermic injection of morphia, rapidly relieved the sufferer.

      (e) Dorso-lumbar Neuralgia.– The superficial branches of the spinal nerves emanating from the lumbar plexus are considerably less liable to be affected with severe and well-marked neuralgia than are the dorso-intercostal nerves. Pains in the abdominal walls, which are a good deal like neuralgia, are not uncommon; but the majority of them will be found, on careful observation, to be myalgia. At least, this has been the case in my own experience.

      When true neuralgia of the superficial branches of the lumbo-abdominal nerves occurs, it develops itself in one or more of the following foci: (1) Vertebral СКАЧАТЬ