WL T253t 1834 > ,0l ,l \ ♦ •• k „ * * • '■fa I- <+'A- av ., /■ ■* 6 tV <~ vtta&v&8& ON NEURALGIC DISEASES, DEPENDENT UPON IRRITATION OF THE SPINAL MARROW AND GAN- GLIA OF THE SYMPATHETIC NERVE. BY THOMAS PRIDGIN TEALE, MEMBER OF THE ROYAL COLLEGE OF SURGEONS IN LONDON, OP THE ROYAL MEDICAL SOCIETY OF EDINBURGH, SENIOR SURGEON TO THE LEEDS PUBLIC DISPENSARY, &6. WOODSTOCK, VT: PUBLISHED BY N AHU M HASKELL. 183^. l * POWER PRESS. f- C. K. SMITH & CO.....Printer*. COIVTE^TS. Page, Introduction . . . . . .5 Irritation of the Spinal Marrow . . 17 Case I. Neuralgia of the scalp . . .26 II. Intermittent neuralgia of the scalp . 26 III. Intermittent neuralgia of the scalp . 27 IV. Neuralgia of the upper extremities and thoracic parietes . . .29 V. Neuralgia of the mamma, or "irritable breast" . . . .30 VI. Neuralgia of the mamma and arm . 32 VII. Intercostal neuralgia . . .35 VIII. Neuralgia of the abdominal parietes and lower extremities . . .37 IX. Neuralgia of the knee . . .38 Irritation of the Ganglia of the Sympathetic Nerve 41 Neuralgia of the heart . . . .45 Neuralgia of the stomach . . . .49 Physiological and pathological observations . 58 Case X. Palpitations, dyspnoea, neuralgia of the upper extremities . . .75 XI. Palpitations, neuralgia of the arms and scalp . . . .77 XII. Palpitations, neuralgia of the arm, gas- trodynia, cjfc. . '. .77 XIII. Dyspepsia, pulsation in the epigastrium, &c......80 XIV. Extreme flatulence, neuralgia of tbe thor- acic parietes . ,82 IV CONTENTS. Case XV. Flatulence, pyrosis, neuralgia of thoracic parietes . . . .84 XVI. Flatulence &c. , .85 XVII. Flatulence, &c. ... 86 XVIII. Palpitations, flatulence, neuralgia of the upper and lower extremities, and of the thoracic parietes . . .86 XIX. Palpitations, affection of the stomach, leu- corrhoea, &.c . . .89 Angina Pectoris . . . . .92 Uase XX. Angina, neuralgia of the left arm, flatu- Fence, fyc. .... 108 XXI. Angina, neuralgia of the left arm, palpi- tations, dyspepsia . . .111 XXII. Angina, neuralgia of the left arm and breast, flatulence, &.c. . 0 114 Colica Pictonum . . . . .116 Conclusion . . . . . .118 INTRODUCTION. The term Neuralgia, which was originally employed to designate certain affections of nerves attended with severe pain, has of late, with great propriety, been ex- tended, from its original and literal signification, to many other morbid affections of nerves, which are not characterized by pain, but by some other perverted state of their functions. Neuralgia includes within its range a great variety of diseases, presenting an endless diversity both in their symptoms and in the parts -where they are seated. That such variety should exist, ceases to excite surprise, when we consider how varied are the functions of the different nerves, and how diversified the tissues and organs to which they are distributed. To the attentive observer of disease, neuralgic affec- tions, under this more extended signification, must re- peatedly present themselves. The skin, for instance, may be the seat of every degree of exalted or diminished sensibility, from the slightest uneasiness to the most acute suffering, and from the most trivial diminution of sen- sibility to complete obliteration of feeling—symptoms not dependant upon disease affecting the different tissues of the part, but solely referable to a morbid condition of the sentient nerves. The voluntary muscles may, in like manner, indicate, in a variety of ways, a morbid con- dition of the nerves with which they are supplied. They may be affected with weakness, spasms, tremors, or a A 6 INTRODUCTION. variety of other disordered states included within the two extremes of convulsion and paralysis. The involutary muscles may have the harmony of their actions inter- rupted, from a morbid condition of their nerves; the heart may be affected with palpitations; the vermicular motion of the stomach, or the peristaltic action of the intestines may be subject to irregularity. The sensibil- ity of the internal organs may likewise be affected, the heart, the stomach, the intestines being the seat of pain, referable to their nerves, and independant of inflamma- tion, or any alteration of structure. The secretions may also undergo alterations, both in quantity and in quality, from a perverted agency of the nerves upon which they depend. Such is a very imperfect recital of the various morbid affections which may be included under the term Neuralgia, and so frequent is their occurrence, that they must be familiar to every practitioner. They are however, often perplexing in their treatment, and not ^infrequently exhaust the patience of the afflicted suffer- er, and also of the medical attendant. The difficulty and embarrassment which have attend- ed the diagnosis and treatment of these affections, I am inclined to believe, has principally arisen from mistaken views of their pathology. They have too often been regarded as actual diseases of those nervous filaments which are the immediate seat of the neuralgia instead of being considered as symptomatic of disease in the larger nervous masses from which those filaments are derived; hence the treatment has too frequently been ineffectually ap- plied to the seat of neuralgia, instead of being directed to the more remote and less obvious seat of disease. It is now pretty generally admitted as a pathological axiom, that disease of the larger nervous masses, as the brain and spinal marrow, is not so much evinced by INTRODUCTION. 7 phenomena in the immediate seat of disease, as in those more remote parts to which the nerves arising from the diseased portion are distributed. In the more severe forms of disease, this principle is readily admitted and recognized. When for instance, one half of the body shall have lost its sensibility, and th^ corresponding muscles their power of action, the skin and the muscles are not regarded as the seat of disease, but the brain is immediately referred to. In the slighter forms of dis- ease of the brain and spinal marrow, such as do not completely obliterate, but merely impair or pervert the functions of the nerves—such as do not paralyze the sentient and muscular powers of the part, but produce weakness, tremors, spasms, &c. in the muscular system, and numbness, prickings, pains, and other morbid feel- ings in the nerves of sensation, this important principle, which as strictly obtains as in the former instance, is too often entirely overlooked: and a numerous class of com- plaints of very frequent occurrence, are regarded as nervous or spasmodic diseases of the part affected, in- stead of being considered as actual diseases of that por- tion of the brain or spinal marrow from which the nerves of the part are derived. The same pathological principle is, I believe, equally applicable to the sympathetic system of nerves; and al- though it may be difficult to establish this opinion by ac- tual experiment, yet I think it may be rested upon a well-grounded analogy, which will justify us in regard- ing the nervous masses of the ganglionic system as bear- ing the same relation to the nerves derived from them, as the large nervous masses of the cerebro-spinal system bear to their respective nerves. Hence, many nervous affections of the visrera ought not to be considered as diseases of the vis ei a themselves, but as syms tomatic 8 INTRODUCTION. of disease in those particular ganglia whence their nerves are derived. Influenced by such considerations, I have, for a few years, been in the habit of treating many of these ner- vous affections as diseases of some portion of the spinal marrow or ganglia; and have been still further confirm- ed in my opinion, by the frequent and almost uniform co-existence of tenderness on pressing some portion of the vertebral column, and the circumstance of the ten- der portion of the spine being in the particular situation where the nerves of the affected part originate. During the early part of the year 1828, I was engag- ed in preparing for publication some observations on this subject, and had proceeded so far as to have arrang- ed this treatise almost in its present form, when I was much gratified by the appearance of an interesting Es- say, by Dr. Brown, on"Irritation of the Spinal Nerves."' About a year after the publication of Dr. Brown's Essay, a valuable communication on "Some forms of Cerebral and Spinal Irritation," by Dr. Darwall, of Bir- mingham, was published in the Midland Medical Re- porter; and I have lately seen a short exposition of similar views, by Mr, Player, of Malmsbury, in a letter addressed to the editor of the Quarterly Journal of Sci- ence, as early as the year 1821. I shall lake the liberty of quoting largely from these authors, being glad to avail myself of their concurrent testimony in corroboration of the opinions which I have now to advance. On the appearance of Dr. Brown's Essay, I at first relinquished the idea of publishing, as another had taken preccedence of me in a somewhat sim- ilar course of observations. Having, however, at my leisure moments, taken into the fullest consideration what has been thus presented to the public,, and be-In £ INTRODUCTION. 9 daily more convinced of the importance of the subject, I feel justified in attempting to reduce the facts which my own experience has afforded, in some definite form, and in deducing such practical conclusions as the phenome- na of the various diseases dependant upon the causes ad- verted to, seem to warrant. Mr. R. P. Player,* in his letter to the editor, "On Irritation of the Spinal Nerves," dated December 10, 1821, makes the following remarks:—"I take the liber- ty to submit to your notice a pathological fact, which has not to the best of my knowledge, been generally remarked, and attention to which, as far as my own ex- perience goes, promises some diminution of those diffi- culties with which the healing art has to contend. Most medical practitioners who have attended to the subject of spinal disease, must have observed that its symp- toms frequently resemble various and dissimilar mala- dies, and that commonly the function of every organ is impaired whose nerves originate near the seat of the disorder. The occurrence of pain in distant parts for- cibly attracted my attention, and induced frequent ex- amination of the spinal column; and after some years' attention, I considered myself enabled to state, that in a great number of diseases, morbid symptoms may be discovered about the origins of the nerves which proceed to the affected parts, or of those spinal branches which unite with them; and that if the spine be examined, more or less pain will commonly be felt by the patient on the application of pressure about or between those vertebrae from which such nerves emerge. This spinal affection may, perhaps, be considered as the consequence of diseases, but of its existence at their ^Quarterly Journal of Science, vol. xii. p. 428. A* 10 INTRODUCTION. commencement any one may satisfy himself; and this circumstance, combined with the success which has at- tended the employment of topical applications to the tender parts above the vertebrae, appears to indicate that the cause may exist there. Prejudice sometimes operates against the idea of connexions so remote; but in many instances patients are surprised at the discovery of tenderness in a part, of whose implication in disease they had not the least suspicion." Dr. Brown* proposes, in his Essay, to offer a few ob- servations on the symptoms and treatment of some diseases of the spine, which he considers to be by no means of rare occurrence, but which appear to be occa- sionally overlooked or neglected. "I allude (says Dr. B.) chiefly to those morbid affections of the spinal nerves so often met with in young females, and occa- sionally also, although much less frequently, in women of more advanced life, and in males. "In most instances, certainly, this irritated state of the nerves is not entitled to the name of a serious dis- ease, since the symptoms are not acute, and since they are easily removed or prevented; but when it is allowed to remain for any considerable length of time, it oflerc produces nervous complaints and general bad health,. and, of course, it becomes infinitely more unmanageable. "I find some difficulty in giving a name to this dis- ease, but as it consists, perhaps, in a state of increased irritability in some of the spinal nerves, we may name it spinal irritation." *On Irritation of the Spinal Nerves, by Thomas Brown, M. D. Senior Physician to the Royal Infirmary of Glasgow. Glasgow Medical Journal, May, 1828. Dr. Brown adds this note:—Five years since, viz. in January. 1823, the following Essay, nearly, was real o the Medic il Socie- ty of this city." INTRODUCTION. n The following case is related in illustration. "Miss C set. 17, (Sept. 1822) of a robust make, and appa- rently in good health, for more than a year has corn- plained of pain situated below the left mamma. This has been fixed to one spot for nearly the whole time. It is a gnawing bruised feeling, increased materially by fatigue of any kind, and, after fatigue, it is attended with restlessness. It is relieved by reclining in the horizontal posture. It is not sore to the touch. The complaint has been treated by a surgeon in the country as rheumatism. She has been bled and blistered for it without any good effect, and at last it has occasioned so much anxiety in the minds of her relations, that she is brought to Glasgow, from a considerable distance, for the benefit of further medical advice. On examin- ing the spine, it is found to be perfectly of the natural shape and appearance, but when pressure is made on it, about the seventh or eighth dorsal vertebra, she com- plains of a considerable feeling of tenderness, amount- ing even to pain; and she finds that the uneasy sensa- tion shoots forward exactly to the affected part of the breast. She bad not paid any attention to this affected part of the spine, indeed she had not any idea that there was any thing faulty there, till her attention was called to it by the examination." "When the affection of the spinal nerves is situated about the middle of the lumber vertebrae, it is apt to occasion severe pain in some part of the abdomen. I have seen it of a spasmodic nature, attended with flatu- lency, and occupying apparently the arch of the colon; and in one case it seemed to be fixed in the caput coli. In these cases the severity of the complaint may appear to call for powerful evacuations, from the apprehension that inflammatiom exists; Avhereas, if the attention be 12 INTRODUCTION. directed to the share which nervous irritation from the spine has in increasing the acuteness of the pain, very active depletion will not appear necessary." Dr. Brown thus divides these affections of the spinal nerves into two classes:— "1. Those in which there is merely a morbid sensi- bility of a single nerve. "2. Those in which there is a more general and constitutional irritability, in which the irritation is apt to affect different parts of the spine in succession, and to occasion a whole train of singular symptoms:" "Occasionally, disorder of the stomach and bowels is joined to this affection of the spinal nerves, and ap- pears to arise from it, since it yields, if the irritation of the spine is removed, and returus whenever this irrita- tion is renewed." "There is no part more frequently pained from ner- vous irritation, than the pericranium or scalp. The pain is often acute, and if we examine the parts mi- nutely we find that it shoots along the various nerves which are ramified over this tendinous membrane. If we press immediately behind the mastoid process, the pain passes upwards along the cervical nerve which takes that direction, and ramifies even as far forwards as the forehead." Dr. Brown proceeds to comment at considerable length on the nature of these affections, and several interesting cases and observations are recorded. A short time after the publication of Dr. Brown's Essay, a well marked case of spinal neuralgia came under the notice of Mr. Allen, which is thus related by him in the Glasgow Medical Journal. "Marv Durand, a single woman, aet. 24, applied to me on the 25th of June last for relief, complaining of pain INTRODUCTION* w in the left side, under the mamma, not in the gland. The pain was much aggravated by pressing with the fingers against the ribs, but sometimes, she said, it extended down the side as far as the crest of the ilium. It was accompanied with pain at the top and towards the back part of the left shoulder, which she described as a sensation of burning, not interfering with the movements of the joint, but so tender to the touch was the part, that she could not rest on that side in bed, and always awoke in severe pain if she happened to turn upon it." "Having perused Dr. Brown's paper on irritation of the spinal nerves, I was led to examine her spine, when I found that there were three or four of the middle dorsal vertebrae, the most moderate pressure upon which gave her considerable pain in the part, and increased that in her side. She had never previously felt pain in that part of her back, although the tenderness was too unequivocal, and too distinctly limited in extent, to leave any doubt as to its reality." Dr. Darwall,* in the interesting essay already alluded to, after adverting to the recent discoveries relative to the functions of the nerves, proceeds to remark, "If however, the nervous system is more or less connected with every function of the animal body: if the circula- tion of the blood, the phenomena of respiration, and the operations of intellect, cannot be carried on without its intervention, the manner in which it is disregarded, cannot but be a most important defect. It has perhaps. in great measure, arisen from always contemplating the brain as acted upon by the circulation, and never re- versing the order of review." •Observations upon some forms of Spinal and Cerebral irritation. By John Darwall, M. D. Midland Medical and Surgtcal Re- porter, May, 1 &-19. 14 INTRODUCTION. Before entering more particularly into the considera- tion of the affections he is about to describe, Dr. Dar- wall considers the following circumstance ought to be referred to, "That disorders attacking the origins of nerves, or their attachment to the central mass whether this be the brain or spinal chord, always disturb the functions of the organs to which such nerves are des- tined." The author then relates cases in which palpi- tations of the heart formed the prominent symptom, which were relieved by the application of blisters to the spine, after the usual remedies had failed, and in one case, after leeches had been applied to the region of the heart without benefit. The following is the description given by Dr. Dar- wall of a form in which cerebral and spinal irritation is frequently exhibited, particularly in young females. "It is attended by severe and constant pain in one or both hypochondria, extending to the shoulder and arm of the affected side, not always aggravated by pressure, and ceasing immediately upon or in a short time after lying down. It is this pain of which the patients gene- rally complain, and it frequently endures for several years. It is generally attended with much constitu- tional disturbance- There is headache, with great heat in the external surface of the head, severe throbbing of the temples, and pain in the nape of the neck. The temper is capricious, and the spirits very variable ; and at the catamenial periods, the depression in m.my cases is excessive. The tongue, after some time, is furred, and the back part greatly tuberculated. The stomach suffers under the various forms of dyspepsia, gastro- dynia, flatulence, pyrosis, &c ; the bowels are in many instances much distended, and there is continual clangor intestinorum. Palpitation of the heart, more INTRODUCTION. 15 ©r less, is present, and often dyspnoea attends. The most common disturbance, however, is in the uterine function, and I have scarcely seen an instance in which this has not occurred. Most commonly there is me- norrhagia ; in some few cases the catamenia are di- minished, or they are completely suppressed. But whether they are increased or diminished, leucorrhaea almost invariably attends, and is generally more or less profuse, in proportion to the duration of the general disorder. When the catamenia are profuse, they are usually, in the earlier part of the period, dark-colored and grumous, and are accompanied with severe pain. The urine for the most part deposits a light-colored sediment, and varies much in quantity, being occasion- ally very copious and limpid. The bowels are consti- pated, and yet no great relief is obtained by purging." Other circumstances attending these affections are also noticed, as " pain on the side in the course of the descending colon ;" " difficulty of breathing, which is sometimes so great as to induce great fear of organic mischief having taken place in the lungs, especially when, as indeed is generally the case, it is attended by frequent cough. The stethoscope, in these cases, is a great assistant in the diagnosis; the respiratory murmur is heard in every part of the chest, and is even puerile; indeed, this heightening of the respiiatory murmur is very characteristic of the disorder in question." It is, however, impossible for me to do justice to Dr. Darwall by quotation. To be fully appreciated, his essay must be read entire. I would also recommend to those who may feel interested in the subject, a careful perusal of the essay by Dr. Brown, which contains many interesting observations and facts. 16 INTRODUCTION. From the various testimonies which have now been offered, it is evident that numerous disorders are de- pendant upon some morbid affection of the large ner- vous masses which give origin to the nerves of the affected parts. I shall therefore proceed to describe, according to my own oppoitunities for observation, va- rious morbid phenomena exhibited by the spinal nerves, under the head of "Irritation of the Spinal Marrow," and several affections of the organs which derive their nerves from the sympathetic system, under " Irritation of the Ganglia of the Sympathetic." I shall defer any pathological discussion of these dis- «ases, until the phenomena, by which they are charac- terized, have been described. IRRITATION OF TIE SPIXAL MARROW, The symptoms of this affection consist in an infinite variety of morbid function of the nerves of sensation and volition which have their origin in the spinal mar- row, and the parts in which these morbid functions are exhibited, of course, bear reference to the distribution of the spinal nerves. The morbid states of sensation include every variety, from the slightest deviation from the healthy sensibility of any part, to the most painful neuralgic affections on the one hand, and to complete numbness or loss of feel- ino- on the other; including pains which may be fixed or fugitive, or darting in the direction of the nerves, prickling and tingling sensations, a sense of creeping in the skin, of cold water trickling over it, and numerous other states of perverted sensation, of which words are inadequate to convey a description. In the muscular system we find weakness or loss of power, tremors, spasms or cramps, and sometimes a.tendency to rigidity. These symptoms sometimes exist in so slight a degree, that the patient considers them unworthy of notice, and only admits their existence when particular inquiry i« made respecting them; the only complaint which he anak.es, being of an unaccountable sense of weakness 18 IRRITATION OF SPINAL MARROW. and inability of exertion. In other cases the tremors have excited alarm; sometimes the neuralgic pain in the scalp, or the fixed pain in the muscles, particularly when it occurs in the intercostal muscles, have suggest- ed the idea of serious disease in the brain or in the lungs; and when the pain is seated in the muscles of the abdo- men, a fear that some organic disease of the abdominal viscera has taken place, harrasses the mind of the pa- tient. The muscular weakness, in some cases tending to paralysis, often suggests the fear of apoplexy, or par- alysis from cerebral disease. The affection is often of very protracted duration, undergoing alternate variations from the sanitive pow- ers of the constitution, and the different exciting causes of disease. There are many individuals in whom the complaint has existed, in varying degrees of intensity, for a series of years, without its real nature having been suspected; the patients and their medical attendants having regarded it throughout as a rheumatic or a ner- vous affection. Many individuals, as young females and mothers of families whose domestic duties require the complete exertion of their energies, are often unjustly accused of indolence, when labouring under the state of muscular debility to which I have alluded. They have felt an un- conquerable disinclination to exertion, and a desire for sedentary pursuits, without even themselves being aware of the cause of this inertness. In this complaint, tenderness in the portion of the vertebral column, which corresponds to the origin of the affected nerves, is generally in a striking and une- quivocal manner evinced by pressuie. In some instan- ces the tenderness is so great that even slight pressure TRRITATION OF SPINAL MARROW. 19 can scarcely be borne, and will often cause pain to strike from the spine to the seat of spasm or neuralgia. This affection of the spinal marrow occasionally exists throughout its whole extent; more frequently, however, it is confined to some particular portion, and occasion- ally is seated in different and remote portions at the same time; the particular symptoms, and the tender- ness on pressure, indicating the affected part. The symptoms, of course, vary considerably, accord- ing to the particular part of the spine which is affected, and bear reference to the distribution of the different spinal nerves. When the upper cervical portion of the spinal mar- row is diseased, we frequently find neuralgic affections of the scalp; the pain strikes in various directions over the posterior and lateral parts of the head; sometimes the twigs in the neighborhood of the ear, sometimes those which ascend over the occiput to the superior part of the scalp, are more particularly the seat of the complaint; the nervous twigs distributed to the integuments of the neck, are occasionally affected, the pain darting across the neck to the edge of the lower jaw, and sometimes encroaching a little upon the face.* These neuralgic diseases frequently assume an intermittent form, the paroxysms generally occurring in the evening. A stiff neck, or impaired action of the muscles moving the head, frequently attend the affection of the upper cer- vical portion of the spinal marrow; and occasionally the * Vertigo frequently attends this neuralgia of the scalp, and it is sometimes accompanied with tinnitus aurium. These symptoms, however, are, I think, more properly attributable to a concomitant affection of the neighboring nerves of the sympathetic system.— Violent throbbing of the temples, and incioased heat of the scalp, often attend the paroxysm. 20 IRRITATION OF SPINAL MARROW. voice is completely lost or suffers alteration, and the' act of speaking is attended with pain or difficulty.* Irritation of the lower cervical portion of the spinal marrow gives rise to a morbid state of the nerves of the upper extremities, shoulders, and integuments at the upper part of the thorax. Pains are felt in various parts of the arm, shoulder, and breast; sometimes the pain takes the course of the anterior thoracic branches of the brachial plexus, occasionally the pain is fixed at some point near the clavicle scapula or shoulder-joint, at the insertion of the deltoid, or near the elbow, or shoots along the course of some of the cutaneous nerves. Frequently one or both of the mammas became exqui- sitely sensible and painful on pressure, and some de- gree of swelling occasionally takes place in the breast, attended with a knotty and irregular feel, when the neuralgic pains have existed a considerable time in that part. Prickling and numbness, tingling and creeping sensations are often felt in the upper extremities; and often a sensation of cold water trickling over the sur- face. On rubbing the hand over the part affected, a soreness is frequently felt, which is described as not merely situated in the integuments, but also in the more-deep-seated parts. In the muscular system are observed most frequently, a weakness of the upper ex- tremities, sometimes referred particularly to the wrists, tremors and unsteadiness of the hands; also cramps and spasms of various degrees of intensity. Occasionally there is an inability to perform complete extension of ^Difficulty of speaking and swallowing frequently depends, ac- cording to Portal, on "engorgement" iu the cervical poi-tioa of the: spinal marrow. IRRITATION OF SPINAL MARROW. 21 the elbows, the arm appearing restrained by the tendon of the biceps; pain and tightness being produced in this part when extension is attempted beyond a certain point. As far as I have observed, the pains and other morbid feelings in the upper extremities and chest, are felt more frequently and more severely on the left than on the right side. Females of sedentary habits appear particularly sub- ject to these affectionsof the upper extremities, and it is not uncommon for them to complain of being scarcely able to feel the needle when it is held in their fingers, and that their needle or their work frequently drops from their hands. When the upper dorsal portion is affected, in addition to various morbid sensations similar to those in the ex- tremities, there is often a fixed pain in some part of the intercostal muscles, to which the name pleurodynia has been assigned; and when this pain has existed a long time, there is tenderness on pressing the part. When the lower dorsal half of the spinal marrow is the seat of this irritation, or subacute inflammation,the pleurodynia when is exists, is felt in the lower intercostal muscles: frequently there is also a sensation of a cord tied round the waist; and oppressive sense of tightness across the epigastrium and lower sternal region; and soreness along the cartilages of the lower ribs, or in the course of insertion of the diaphragm. Various pains, fixed and fugitive, are also felt in the parietes of the abdomen, throughout any part of the abdominal and lumbar mus- cles; the pain is frequently fixed in some portion of the rectus muscle, and not unfrequently in the oblique mus- cle or transversalis, a little above the crest of the ilium, particularly when the origin of two or three of the low- est dorsal nerves is diseased. B* 22 IRRITATION OF SPINAL MARROW. The affection of the lumber and sacral portion of the spinal cord often produces a sensation of soreness in the scrotum and neighboring integuments; and the lower extremities become the seat of various morbid sensa- tions, spasms, tremors, &c for the most part resembling those which have been described as occurring in the up- per limbs. The patients also complain of a sense of in- security or instability in walking; their knees totter, and feel scarcely able to support the weight of the body. In some cases very considerable relief is found from recumbency, the pain frequently being diminished as soon as the patient retires to bed, independently of any paroxysmal remission. This irritation, or subacute inflammatory state of the spinal marrow, is not necessarily connected with any deformity of the spine, or disease in the vertebras. It may co-exist with these as well as with any other dis- eases, but it so repeatedly occurs without them, that they cannot be regarded as dependant upon each other. Where, however, inflammation and ulceration of the vertebrae or intervertebral cartilages exist,it is probable they may predispose to, and, in some instances, act as an exciting cause of an inflammatory state of the ner- vous structures which they contain; for we not unfre- quently find inflammatory affections of the vertebrae in conjunction with symptoms of irritation of the spinal marrow. But these two affections, although co-exist- ing, bear no regular relation to each other; and, during the progress of the vertebral disease, the affection of the nervous structures is subject to great changes and fluctuations. The local remedies employed for arresting the disease in the bones, often alleviate the affection of the spinal marrow at the very commencement of IRRITATION OF SPINAL MARROW*. 2& the treatment, long before the vertebral disease is sus- pended; but as the neighbouring inflammation in the bones appears to predispose or excite the nervous mass which they contain, to disease, relapses of the nervous affections are repeatedly occurring during the whole course of the complaint. The affections of the spine, termed lateral curvature and excurvation, appear to have no necessary connexion with the disease which I have been describing; and the proportion of cases in which they are found united, is so small, that lateral curvature can scarcely be con- sidered even as predisposing to this disease. The most extreme degrees of deformity frequently are observed without any affection of the nerves; and when lateral curvature does occasionally co-exist, local antiphlo- gistic treatment will often speedily remove the nervous symptoms, while the curvature remains unrelieved. Hence there is an impropriety in considering these nervous symptoms as a result of the deformity, and in explaining them upon the mechanical principle of pres- sure and stretching, to which the nerves supposed to be subjected as they issue from the intervertebral fo- ramina. If the pressure and stretching produced by the curvature, were the cause of the nervous symptoms, they ought to continue as long as the deformity remains. Symptoms of affection of the brain frequently occur in conjunction with these diseases of the spinal marrow. These however must be regarded as the result of exten- sion of disease from one part to the other, most pro- bably through the medium of the membranes. I shall however, purposely avoid touching upon these subjects, as it would be foreign to my present purpose to enter upon the discussion of cerebral neuralgiae. Treatment.—When the different neuralgic symptom* 24 IRRITATION OF SPINAL MARROW. Which have been enumerated, can be traced to this morbid state of some portion of the spinal marrow, the treatment that ought to be pursued, is readily decided upon Local depletion of leeches or cupping, and counter irritation by blisters to the affected portion of the spine, are the principal remedies. A great numj ber of cases will frequently yield to the single appli- cation of any of these means. Some cases, which have even existed several months, I have seen peefectly re- lieved by the single application of a blister to the spine, although the local pains have been ineffectually treated by a variety of remedies, for a great length of time. A repetition of the local depletion and blistering is how- ever often necessary after the lapse of a few days, and sometimes is required at intervals for a considerable length of time. In a few very obstinate cases issues or setons have been thought necessary; and where the disease has been very unyielding, a mild mercurial course has appeared beneficial. It is of course necessary that proper attention be paid to the regular functions of the bowels, and to the treat- ment, by appropriate means, of any other affection which may co-exist. It is needless, in this form of dis- ease, to offer any directions respecting diet, as the judg- ment of every medical man will enable him to decide best on the general management of the case immedi- ately under his notice. When my attention was first directed to this subject, I considered recumbency a necessary part of the treat- ment; it is, for a moderate length of time, undoubtedly beneficial, and frequently very much accelerates reco- very; but subsequent observation has convinced me that it is by no means essential. I have seen several in- stances of the most severe forms of these complaints* IRRITATION OF SPINAL MARROW. 25 occurring in the poorer classes of society, where con- tinued recumbency was impracticable, which have, nevertheless, yielded without difficulty to the other means of the treatment, whilst the individuals were pur- suing their laborious avocations. These observations, however, are not intended to apply to those cases in which there is actual disease of the vertebrae. When there exists a tendency to relapse, I have thought it advantageous to continue the use of some stimulating liniment to the spine for a few weeks after the other means of treatment had been discontinued. A liniment consisting of one part of spirit of turpen- tine, and two of olive oil, is what has generally been employed. In illustration of these observations, a series of cases will be recorded from my note books, and my object will be, not so much to swell their number as to select a few which may exhibit the principal varieties of these com- plaints. In relating them I shall adhere as much as pos- sible to the anatomical order, commencing with the affec- tions of the upper portions of the spinal chord, and gra- dually proceeding to those seated in the lower parts of it. I shall endeavour, in each case, to give a full de- scription of the symptoms as they were observed at the first consultation, but shall avoid the tedious detail of daily reports, by condensing, as much as possible, the subsequent history, not however, omitting a careful record of the effect of remedies, and of such peculiari- ties as some instances may present. 26 CASES OF IRRITATION. Case I. Neuralgia of the Scalp. June 5th, 1827. Mr. L., aet. 26, complains- of a feeling of indisposition, having suffered for a few days from stiffness of the neck, and pain at the back of the head, extending laterally towards the ears, and up- wards over the back part of the scalp; perspires much at night; feels languid and unable to attend to business. About four weeks ago he was exposed to the wet and cold, and has ever since been affected with these symp- toms. On pressing the spine there is tenderness in the first cervical vertebra, but no pain whatever is produced by firm pressure on any other part of the spine. Leeches to be applied to the neck. June 10th. The pains in the scalp were immediately relieved, on the application of the leeches, and the per- spirations have gradually ceased. The spine bears pressure without any uneasiness. Case II. Intermittent Neuralgia of the Scalp. June 18th, 1827. Mrs. B., a week after her ac- couchment, complained of pain in the head occur- ring in the afternoons in a violent degree. It was de- scribed as a dull, aching pain, principally seated in the occipital region, but extending from that part over the parietal bones towards the temples, and in the neigh- bourhood of each ear there was a small space more acutely painful than the rest; there were also pains OF THE SPINAL MARROW. 27 darting over the scalp and along the upper part of the neck transversely towards the cheeks, and terminating along the edge of the lower jaw. She complained of violent pulsating sensations in the head, accompanied with distressing sounds, which she compared to the "beating of hammers*" In other respects she was as well as her situation could admit of. She had suffered in a slighter degree from these symptoms for some time previous to her confinement. Leeches had been ap- plied to the temples, but the paroxysms returned with equal or greater violence on the two following days. On examining the spine, very great tenderness was detected on pressing the two upper cervical vertebrae, of which she had not been previously aware. Leeches were applied over the cervical vertebrae, and immediate relief was obtained. No further return of the paroxysms was experienced. In this case it should be observed that leeches had been applied to the seat of neuralgia without benefit, but the relief was immediate when they were applied near the origin of the affected nerves. Case III. Intermittent Neuralgia of the Scalp. August 10th, 1829. W. S., a stout healthy-looking young man, complains of pain in the head and giddiness. The pain is described as a dull, heavy sensation at the back of the head, frequently extending over the crown to the forehead. He also suffers from acute pains, which frequently dart fron the occipital region to the front part of the head. Occasional feeling of weariness 23 CASES OF IRRITATION. and aching about the shoulders. These uneasy sensa- tions occur in paroxysms, generally in the mornings, which continue about two hours. Vertigo occurs fre- quently, not only during the paroxysm of pain, but also in the intervals. These complaints have been gradually increased for several weeks. The bowels are regular, appetite good, and in other respects he is in good health. Tenderness in the third and fourth cervical vertebras. Leeches to be applied to the tender part. 14th. Much better. The pain returns at the usual time, but in a very slight degree. The vertigo is di- minished, but still continues rather troublesome. Blister to be applied to the neck. 18th. On the day after the blister had been applied, the vertigo was greatly diminished, and has since en- tirely disappeared. No tenderness on pressure is now perceived. Similar cases of affections of the scalp might be multiplied to a great extent; they are of frequent occurrence, not only in these simple forms, but also in conjunction with other diseases. The pains in the head which occur in fevers, will often be found to be of this neuralgic character, and altogether independent of any cerebral affection. A few leeches to the tender vertebrae of the neck will generally produce immediate relief of this distressing symptom. OF THE SPINAL MARROW. 29 Case IV. ■Neuralgia of the Upper Extremities and Thoracic Parietes. December 10th, 1827. Mrs. B., aet. 53, mother of a large family, represents herself as having been severely afflicted with rheumatism'during the greater part of her life. She now suffers from pain in the neck and head, pains about the clavicles, difficulty in moving the arms, which feel fixed at the shoulder joints. The pain in the neck and between the shoulders is fixed and constant, being nearly the same both day and night; it is a little alleviated by supporting the back against a chair. There are also darting pains extending from the cervical por- tion of the spine upwards over the occiput, and down- wards across the neck and over each shoulder. Both arms are affected with aching pains over their whole extent, and with a sense of soreness on pressing or rubbing the skin; prickling sensations, cramps, and numbness in the fore-arms, hands, and fingers. Diffi- culty in moving the arms, and in using her fingers in sewing or knitting. Frequent sudden "twitching" pains in the neck, arms, and trunk; occasional pains in the abdominal muscles, relieved by recumbency. No affection of the lower extremities; appetite poor; no fever; no cough or difficulty of breathing; catamenia ceased about six years ago. She has always considered the disease to be rheuma- tism, and has tried a great variety of remedies usually employed in that disease, but without much benefit. Tenderness in the two lower cervical and six upper dorsal vertebrae. Leeches were directed to be applied to the tender portion of the spine, and on the following evening a c 30 CASES OF IRRITATION, blister to the same part. Recumbency was also recom- mended. The blister produced an unusual degree of inflamma- tion in the skin, which continued several days, and was accompanied with considerable fever. During the febrile state the neuralgic symptoms were rather aggravated, but as the fever subsided, they gradually disappeared. On the 29th of December I took leave of her, as she was then perfectly well; she felt a degree of muscular power, particularly in the upper extremities, which she had not been accustomed to for several years; she was quite free from pain. June 20th, 1829. Since the last report, she has en- joyed good health, with the exception of occasional returns of the pain .during winter, which were so slight as to produce but little inconvenience, and were soon relieved by leeches and the application of turpentine liniment to the spine. These last attacks were attended with flatulence. Case V. Neuralgia of the Mamma or "Irritable Breast." Mrs.----, aet. 48, but without having experienced any change in the catamenia, of a healthy appearance, and mother of a large family, had suffered about seven years from a painful affection of the left breast. On examination it was found to be exquisitely sensitive to the slightest touch; it was somewhat increased in size, and irregularly indurated, having a knotty feel, and an obscure sense of tumours as if the glandular structure were enlarged at different parts. The integuments and cellular substance between the breast and clavicle, and OF THE SPINAL MARRtfW. 31 towards the axilla, were thickened. There was a Con- stant sense of uneasiness in the part, but her chief sufferings arose from its highly sensible state, which constantly exposed her to pain from the irritation of her dress, or any accidental contact. Her spirits were de- pressed, and an apprehension that the disease would prove cancerous, although she was repeatedly assured of the contrary, was a source of great anxiety. Leeches, evaporating lotions, and warm fomentations had been employed, and medical treatment had been particularly directed to the digestive organs; these means were oc- casionally productive of slight alleviation, but never of permanent benefit. The complaint varied in degree, being sometimes less severe for a few weeks, without any obvious cause for the temporary amendment. Whilst in this state (September, 1827,)- she became subject to pains in the scalp, and vertigo, attended with flatulence. The symptoms directed my attention to the spine, which on examination was found to be tender in several parts. The most painful vertebrae were the se- cond cervical, the seventh cervical, and two upper dor- sal. Leeches were applied to these parts, with consid- erable relief to the pains in the scalp and vertigo. Since that time she has been occasionally in the habit of apply- ing leeches, a blister, or a sinapism, of her own accord, when there has been any return of uneasiness in the head. On making inquiry (August 10, 1829,) respecting the complaint in the breast, of which 1 had not heard any mention for several months, she tells me that from the time of her commencing the treatment by local applica- tions to the spine, the affection of the breast has disap- peared. The pain and swelling are removed, and the breast re-iembles the oilier in every respect. 32 PA-SES OF IRRITATION. The circumstance of finding a portion of the spine tender, and the removal of the tenderness by suitable remedies being unexpectedly accompanied with relief of the fulness and pain in the breast, could not fail to pro- duce a powerful impression on my mind, and to excite a suspicion that this irritable affection of the breast was a neuralgia of that part dependant upon disease of the spinal marrow. Case VI. Neuralgia of the Mamma and Arm. August 28th, 1828. Miss L., aet. 30, consulted me respecting an affection of the right breast. The breast is considerably enlarged, and has an irre- gular knotted feel, particularly in the portion next the axilla. The slightest touch or pressure produces acute suffering. There is a constant gnawing sensation in the breast, shoulder, and arm. "Sharp darting pains" are often felt in the breast and arm. The right arm feels numb; is a little tumefied. The whole arm feels weak, particularly the wrist, so that she is scarcely able to sew. On suddenly touching the tips of the fingers pains are sometimes felt to strike up the arm to the neck and head and down to the breast. In other respects the health seems tolerably good. She is sometimes subject to indigestion, and the bowels are generally confined. The catamenia regular and un- attended with pain in the lumbar or pelvic regions. For a few years she has had more or less of the pain in the breast, and irregular knotty induration, particu- larly at the menstrual periods; the affection, however> OF THE SPINAL MARROW. 33 has seldom been very severe, until within the last four weeks, when the pain has become much more intense, and the swelling greater; and the usual subsidence of these symptoms after the catamenial period has not ta- ken place. Slight pressure on the fourth cervical and three upper dorsal vertebrae, produces great uneasiness. August 28th. Eight leeches to be applied to the tender vertebrae, and a mixture of salts and senna to be taken until the bowels are moved. 29th. Pains rather less acute, but the tumefaction continues. Bowels have acted freely. A blister to be applied to the upper part of the spine. 30th. Has passed a bad night from the irritation of the blister; slight fever; affection of the breast and arm much the same. Take an effervescing draught every four hours. September 3d. The irritation produced by the blister has subsided, and she feels much better. The breast bears pressure without inconvenience, and the tumefac- tion has considerably diminished. She can move the arm with rather more freedom. 10th. The pains in the breast and arm have a little increased. Ordered another blister to the same part of the spine. 17th. The pains have entirely ceased during this week, and the breast has nearly returned to its natural size; she has attempted to sew, and can move the arm with considerable facility. August 2Gth, 1829. I called upon this patient to-da y to make inquiry respecting these complaints. She has not had any return of the affection of the breast, but occasion- ally feels a weakness and numbness in the right arm. c* 34 CASES OF IRRITATION A few weeks ago, when at a distance from home, f was consulted by a lady respecting a painful affection of the left breast, which was enlarged and indurated in one part towards the axilla; the tumour appeared to have been produced by a simple enlargement of the glandular structure; the whole surface of the breast was painful on pressure, and she suffered from frequent pains dart- inS&t"- ' ,~J