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CHAPTER II.
SPINAL IRRITATION

I retain this phrase, not because it is an absolutely good one, but because it has become so familiar that it is difficult to dispense with it. We have taken a useful step, however, in separating the true neuralgias from the somewhat indefinite group of diseases to which this title has been given. I think the reader who has carefully studied Part I. of this work will not deny that the latter disorders present a very clear and definite common outline which distinguishes them essentially from the vaguer affections to be described under the present heading.

Spinal irritation, in my sense, includes all those conditions in which, without any special mental affection, and without any single nerve being definitely affected, there are sensations varying between mere cutaneous tenderness, often of a large and irregular surface, and acute pain approaching neuralgia in character, together with fixed tenderness of certain vertebræ on deep pressure. A very large majority of the phenomena are such as would be popularly included (now that they are known not to be of an inflammatory character) under the term "hysterical." That unhappy word crosses our path at every turn in a most embarrassing manner, and yet it can hardly at present be said that we could afford to do without it.

The more typical cases of so-called "hysterical hyperæsthesia" present the following phenomena: Along with the general symptoms of the hysterical temperament (tendency to causeless depression, variable spirits, sensation of globus, semi-convulsive attacks terminated by the discharge of a great quantity of pale, limpid urine) there is commonly a marked superficial tenderness of the surface everywhere, and an exaggeration of reflex irritability. The general tenderness is so far merely cutaneous that deep pressure is ordinarily borne better than the lightest finger-touch. But besides this there are usually one or several spots in which the tenderness is more profound and genuine. There is almost sure to be some point in the spinal column where firm pressure not merely evokes a complaint of pain, but also induces secondary objective phenomena connected with distant organs, such as nausea and vomiting when the cervical vertebræ are tender, severe gastric pain when the dorsal vertebræ are tender, etc. In such cases there is not only spinal tenderness, but very usually also a well-marked tenderness in the epigastrium and the left hypochondrium, the trepied hysterique of Briquet. The reader must, however, be warned that the whole of these three tender points may be merely myalgic, and it is necessary very carefully to observe whether local movements do or do not seriously aggravate the pain in them. And, on the other hand, the spinal tender point may be merely the "point apophysaire" of a true neuralgia which exhibits no other symptoms of the so-called hysteric constitution.

The kind of hysteria that is joined with the existence of fixed tender spots in definite points of the vertebral column is not commonly distinguished by the occurrence of cutaneous anæsthesia; but those writers are certainly wrong in saying that such a combination never takes place. I have seen examples of the most marked union of the two classes of symptoms in the same person.

These cases of so-called spinal irritation with general hysteric manifestations are very commonly attended with paroxysmal pains that approach true neuralgia in character. Nor is it to be denied that we sometimes meet with the combination of general hysteria, spinal tenderness in definite points (with secondary spasmodic or paralytic phenomena always following pressure exerted on the latter), and true neuralgia limited to one nerve. But the more typical spinal irritation cases are merely complicated with a tendency to vague pains which are shifting both in character and position, not with definite unilateral neuralgia always haunting the same nerve and exhibiting more or less of the same type. In fact, as far as one can judge in the absence of any precise information as to the condition of the nervous centres in such cases, it would seem likely that the ordinary cases of spinal irritation differ from the true neuralgias chiefly in this – that the injury, or inherited weakness of organization, or both, which is at the root of the malady, is at once slighter in degree, and spread over a larger tract of the nervous centres, than that which produces a true neuralgia. I believe that Dr. Radcliffe is right in supposing it to be probable that a blow or other injury to the back producing general spinal shock, is the original but unsuspected cause of a large proportion of these cases. One of the most perfect examples of spinal irritation that I have ever seen (and which also contrasts keenly with the commoner hysteric affections on the one hand, and the true neuralgiæ on the other) was that of a girl whom I examined together with Dr. Walshe, Dr. Reynolds, and Dr. Bridge. This young lady was a most intelligent person, and not in the slightest degree inclined to the apathy and idleness so often seen in hysterical people. She had received what was thought at the time to be a very slight contusion in a railway collision, in which, however, her sister, who was in the same carriage, had been severely injured. She nursed this sister assiduously, and it was not till three or four months later that her own health began to fail seriously; but she then became anæmic and extremely depressed. About six months after the accident it was quite casually discovered that there was a spot over the lowest cervical vertebra, pressure on which gave her exquisite pain and a sensation of extreme nausea; and the very curious observation was made that such pressure instantaneously produced extinction of the right pulse, the left pulse remaining unaltered. In this case it cannot be doubted that a serious shock had been communicated to a lateral segment of the cord involving chiefly the vaso-motor nerve fibres, in which probably some decided material lesion had been gradually set up; and besides this there was probably slighter damage to the spinal cord generally, as there was great general feebleness of movement, though no actual paralysis of the limbs.

Along with the phenomena of fixed spinal tenderness, without distinct neuralgia of any particular nerve, we not unfrequently observe the development of more or less decided tenderness of some of the internal surfaces of the body. I have recently had under my care a young woman in whom a very tender point was developed over the second cervical vertebra, and who suffered from such persistent tenderness of the whole posterior part of the pharynx, that I was for some time seriously apprehensive of the existence of spinal caries and post-pharyngeal abscess. The general character of her symptoms, however, induced me to hope that the case was one of spinal irritation merely, and the event proved that this was the case, for under the use of iron and small doses of strychnia she recovered completely in about three weeks. In another patient who came under my care about twelve months ago, there was extraordinary sensitiveness of the gastric mucous membrane, causing exquisite pain after she had eaten almost any thing: there was only occasional vomiting, however, and there had never been any hæmorrhage, so that the evidence for gastric ulcer, which I otherwise inclined to think existed, was insufficient. I discovered that pressure on the third or the fourth dorsal vertebra gave great pain, and produced a strong inclination to vomit; this made it probable that the affection was spinal, and accordingly all treatment addressed to the stomach was abandoned. Flying blisters to the neighborhood of the painful spinal points quickly relieved all the symptoms.

Another distressing class of symptoms, which is very commonly observed in connection with these cases of spinal irritation, is that of abnormal arterial pulsations: I am not sure whether even severe neuralgia produces more distress than does this pulsation. I have repeatedly seen abnormal pulsation of the carotids in connection with fixed tender-points over the cervical or the upper dorsal vertebræ; and still more commonly pulsation of the abdominal aorta in connection with tenderness over one or two of the upper dorsal vertebræ. Spasmodic cough and spasmodic dyspnœa frequently accompany tenderness of points in the upper half of the spinal column; and in one instance I have seen pressure on the lowest cervical vertebræ produce a paroxysm which looked alarmingly like angina pectoris. A case of singularly prolonged and obstinate spasmodic hiccough which came under my notice was distinguished by the presence of a fixed tender spot over the third dorsal vertebra.

Prolonged spastic contraction of voluntary muscles, going on, sometimes for weeks, and even months, is a phenomenon that has often been observed; it may attack the arm only, or may affect all the limbs, and the muscles of the trunk and of the neck: it is for the most part symmetrical, but is occasionally unilateral. It begins in the extremities, and is very commonly limited to them; it is much more gentle than tetanic spasm, and is also painless, or nearly so; but the contraction is often strong enough to resist very vigorous efforts at artificial extension.

Paralyses, both of bowel and bladder, have been recorded among the occasional phenomena of spinal irritation with fixed tender points; but I cannot say that I have ever seen such an occurrence. On the whole, I must say that by far the most frequent phenomena of spinal irritation that I have seen have been somewhat diffuse cutaneous or mucous tenderness and irritability (without acute pain) and the presence of tormenting arterial throbbings; also a marked tendency to aggravation of some symptoms, especially the gastric, when firm pressure is made upon the tender spinal points. For a further and fuller account of the phenomena of spinal irritation I may refer the reader to the able article of Dr. Radcliffe,⁴⁸ and the work of the brothers Griffin, already quoted; adding the suggestion, however, that both these authorities, and especially the Griffins, appear to me not to draw a sufficiently clear distinction between the class of cases that I have been attempting to describe and the true neuralgias.

After what has been said, there is no need to draw out a formal list of the points of diagnosis between spinal irritation and neuralgia. It must be admitted, moreover, that the two forms of diseases have a strong connection in the fact that they are each of them most frequently developed in the descendants of neurotic families. It is by the more generalized character of the symptoms, and the absence of the tendency to perpetual recurrence of paroxysmal pain in one definite nerve, that spinal irritation is mainly distinguishable from true neuralgia. I may add that there is a marked distinction, also, in the results of treatment.

The treatment of spinal irritation is, it must be confessed still in an unsatisfactory position; and I believe that a good deal of unnecessary discouragement has been occasioned to physicians by their failures to cure supposed neuralgias which really belonged to the spinal irritation class. I would assuredly by no means assert that genuine neuralgia is not frequently intractable, or even incurable; but it is certainly much more curable than spinal irritation; and for this reason, mainly as I believe – that there is much more possibility of aiming our remedies at the actual seat of the disease. On the other hand, in spinal irritation we are confused and distracted with a variety of phenomena for which even the most subtle analysis will frequently fail to trace a common origin. It is true that the existence of definite tender spots in the spine apparently suggests a strictly local application of remedies; and it true also that medication based upon this fact is sometimes very effective; but this is, in my experience, only an occasional result, and the practitioner who trusts to local measures will frequently be disappointed. And, on the other hand, the general tonic treatment, and the use of special medicines, like quinine and arsenic, or the hypodermic injection of morphia oratropia, have nothing like the extensive utility in the treatment of spinal irritation that they possess in that of true neuralgia. Of internal remedies, by far the most useful in my hands have been sesquichloride of iron with small doses of strychnia, and the milder vegetable bitters, especially calumba.

There is one special phase, however, of spinal irritation which is very amenable to the direct, treatment, viz., cutaneous and mucous tenderness. Whatever the "hyperæsthetic" part is within reach, so that we can apply Faradization, we can almost certainly eradicate the morbid sensibility very quickly. The secondary current of an electro-magnetic or volta-electric induction apparatus is to be employed; the conductors should be of dry metal and the negative one, which is to be applied to the painful surface, should be in the form of the wire brush. The positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backward and forward over the sensitive skin, a pretty strong current being employed. The process is painful so much so that it will often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the Faradization. A very few daily sittings of four or five minutes length will generally remove the morbid tenderness completely. Where the tender part is within one of the cavities, at the rectum, bladder, vagina, or pharynx, we must of course use a solid negative conductor of appropriate form, and must content ourselves with applying it steadily to one point after another of the sensitive surface.

The fact that Faradization proves so remarkably useful, in these cases of spinal irritation with diffuse cutaneous or mucous tenderness, is in itself a strong diagnostic between this sort of affection and the true neuralgiæ, which, as I have stated are seldom benefited, and are often made worse, by the interrupted current, though the constant current frequently mitigates or cures them.

Sometimes where it is not possible to apply the remedy directly to the sensitive surface, we may nevertheless do great good by sending the interrupted current through it. Thus, in gastric sensitiveness connected with spinal tenderness in the upper dorsal region, I have seen very great relief afforded by sending a current from the positive pole, placed on the tender vertebræ, to a broad, negative conductor placed on the epigastrium. And similarly, I have seen an acutely sensitive condition of the neck of the bladder greatly soothed by the passage of a current from a painful lumbar vertebra to the perinæum immediately behind the scrotum.

Undoubtedly, however, the more serious cases of spinal irritation will yield only (if they yield at all) to a prolonged treatment in which very skilful use is made of general hygienic measures, and especially of morbal influences. As the brothers Griffin long ago pointed out, although rest is useful in the early stages of this malady, if the disease does not quickly yield to this and to appropriate tonic medication, and perhaps local applications to the spine, it will not do to keep the patient recumbent and confined to the house; on the contrary at whatever cost of immediate discomfort, he (or she for these patients are by far the most frequently females) must be roused up, and persuaded or compelled to take out-door exercise, and if possible to travel, and divert the mind by complete change of scene. When such expensive remedies are out of the question, it seems better that patients, even seemingly very feeble, should take to their ordinary avocations in life again, and fight down the tendency to invalidism. But of course, the decision on such a point must rest with the tact and judgment of the practitioner in each individual case, for there are, doubtless, instances in which the attempt to carry out such a plan, even moderately, would break down the remaining strength, and make matters worse than they were before.

In the worse case of spinal irritation that I ever saw, that of a young lady, aged twenty-eight, there were pronounced anæmia and general feebleness, the true hysteric trepied of tender points, painful irritability of the stomach, which baffled all medical advisers and resisted almost every possible form of tonic and nervine medicines, counter-irritation to the spine, and, in fact every thing that one dared attempt with so feeble-looking a patient, but at once cleared up and was quite cured after marriage. And there can be no question that a very large proportion of these cases in single women (who form by far the greater number of subjects of spinal irritation) are due to this conscious or unconscious irritation kept up by an unsatisfied sexual want. In some patients there cannot be a doubt that this condition of things is indefinitely aggravated by the practice of self abuse; but it would be most unjust to think that this is a necessary element in the causation; on the contrary, it is certain that very many young persons (women more especially) are tormented by the irritability of the sexual organs without having the least consciousness of sensual desire, and present the sad spectacle of a vie manquee without ever knowing the true source of the misery which incapacitates them for all the active duties of life. It is a singular fact, that in occasional instances one may even see two sisters inheriting the same kind of nervous organization, both tormented with the symptoms of spinal irritation, and both probably suffering from repressed sexual function, but of whom one shall be pure-minded and entirely unconscious of the real source of her troubles, while the other is a victim to conscious and fruitless sexual irritation.

I have already causally alluded to the danger of mistaking mere myalgia for spinal irritation and must again enforce this consideration upon the reader. Myalgic tender points in the region of the spine are common enough; and it would be easy without careful attention, to mistake them for the deeper-seated vertebral tenderness which is truly characteristic of spinal irritation. Hence the utmost care must be taken to ascertain the true history of the commencement of the disorder whether it succeeded to great and long continued fatigue of particular sets of muscles, and whether it is specially aggravated by contractions of those muscles, and relieved by their full extension. The differences of treatment which depend on the diagnosis are too obvious to need dwelling upon.

The question of administering remedies with the direct intention of procuring sleep, for patients suffering from spinal irritation, often becomes an important and a very difficult one. It is, for the most part, highly objectionable to commence the use of such remedies; and yet sleeplessness is a very distressing symptom with many patients, and is, of course in itself exhausting and deleterious. For as long as we possibly can, we should content ourselves with efforts to produce sleep by the timely administration of nourishment. The same general rule of a very generous (though not very stimulating) diet to be enforced as carefully as in the case of sufferers from neuralgia. But it is especially advisable in spinal irritation; that the patient should take some food shortly before bedtime; and it is well, also to place food within reach at the bedside, so that if he wakes up he may take some. If, however, we are absolutely driven to employ hypnotics, we must commence with the very mildest. The popular remedy of a pillow stuffed with hops will sometimes suffice; and a better way of administering the volatile principle of hops is to scatter a few hops on hot water in an inhaler, and let the patient breathe the steam. Hot foot-baths, with mustard, are also very useful. If these fail, chloral, in moderate doses is probably the best and safest remedy, and, with care not to give too much, we may go on using the same dose without increase for a good many times.