§ 1. Tic Douloureux.—This disorder usually affects the branches of the fifth pair ; it is described as a darting pain which thrills along the course of the nerve to its remotest branches. Sometimes limited to one, sometimes extending to all of the main divisions of the nerve, its momentary shock seizes the individual without warning under a variety of exciting causes. The pain is intense, though transient, leaving an aching for some few minutes after it has passed ; it recurs again and again on the occasion of any fresh stimulus, whether speaking, eating, a draught of air, or a touch, or even without apparent cause. Its associations are so numerous as to defy classification; it is enough here to say, that in many instances treatment directed to correcting general disor dered states of system is successful in its removal; and we are therefore called upon to investigate all the correlative symptoms, not as an aid to diagnosis, which is generally only too unmistaka ble, but as a guide to rational treatment. The most intractable cases are those in which there is coexisting disease at the root of the nerve; they present to us the same problem as epilepsy, so difficult of solution, why an abiding cause of irritation should only manifest itself in paroxysms.
§ 2. Henzicrania.—Much more diffuse than tic, its paroxysms are not nearly so intense, but they are of very much longer dura tion; like it, they very generally entirely subside for a time, to return at no long interval; but in this disease there is very fre quently a marked regularity or periodicity in the recurrence; in such caps its popular name is brow ague. Its situation is not so much in the face and the course of the fifth nerve, as generally over one side of the head, referredially to the forehead, and frequently affecting the eyeball. associated, as it often is, with a debilitated or exhausted condition of the body, it is less distinctly periodic, and easily curable by means calculated to remedy the general health; in its purely intermittent form it is only a manifestation of malarious poison.
§ 3. Sciatioa.—It is very often difficult to make out whether a patient be suffering from chronic rheumatism or sciatica; but the distinction in such cases is of less importance, as this form of neuralgia is very frequently of rheumatic origin. In a well marked case, the pain is described as extending from the sciatic notch down the back of the thigh and leg; and the effect of counter-irritants in its treatment seems to prove that the pain is due to subacute inflammation of the neurilemma. But it is often much more diffuse; and then it is quite as likely that the ultimate filaments of the nerve are the seat of irritation, as its main trunk. This is especially the case when the pain is more sensibly felt in the proximity of the joints; it is probable, in such cases, that those are its real seat, although not spoken of by the patient„ whose description is so vague that it can only be determined by the effect of movement; forced flexion of the joints is always painless in sciatica, voluntary motion gives pain alike in both diseases. In sciatica the pain is not increaser as it usually is in
rheumatism, by the patient bearing his weight on the limb; local disease of the joints can hardly lead to any perplexity, as pain is is perhaps the best place to con sider a _f which all that we know is that it is accompanied by intense pain, referred to the cardiac region, and doubtless experienced in the nerves of the heart itself; while it also sympa thetically extends down the left arm, sometimes as far as the terminations of the ulnar nerve in the two last fingers. The cir cumstances which prove its cardiac origin, are its sudden and apparently causeless occurrence, its independence of feelings of dyspncea, the sensation of extreme faintness, and, what is some times so well described by the patient, a sensation as if the heart had stood still. These points are quite sufficient to establish its diagnosis; and as yet we must rest satisfied with the knowledge of its spasmodic character.
In most cases of angina, disease of the heart exists; sometimes such as may be detected by the stethoscope, frequently of such a character as escapes observation, or can only be inferred from general indications, such as fatty disease and ossific deposits, especially in the coronary arteries. There can be no question that such conditions predispose to it; but neither do they of neces sity produce it nor are they essential to it; patients with organic disease hays no angina, others bare angina in whom there is no reason to believe that the heart is diseased. This leads us to classify it among the neuralgias as being especially characterized by spasmodic pain, and as leaving behind it after death no definite record of its existence.
It is liable to be confounded with the palpitation produced by dyspepsia, and especially that which in nervous persons accom panies flatulent distension of the stomach. Such a mistake can only occur with those who are hasty in their conclusions, and who do not inquire accurately into the mode of incursion of every disorder; the one almost always makes its first attack during exertion, or in consequence of sudden and violent emotion; the other most generally awakes the patient out of a troubled sleep, and has been preceded by a continuance of dyspeptic symptoms. The amount of anxiety and distress, and the duration of the attack do not correspond in the two affections; the one is momentary, and of such intensity that the patient feels he could not survive its duration, if prolonged for ever so short a time; the other is much less violent, and more continuous.